How I Do It: CT Pulmonary Angiography

doi:10.2214/AJR.06.1104

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How I Do It: CT Pulmonary Angiography

Conrad Wittram¹

¹ Department of Thoracic Radiology, Massachusetts General Hospital, Founders 202, 55 Fruit St., Boston, MA 02114.

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Fig. 1 —Transient interruption of flow of contrast material in 59-year-old woman. Coronal oblique reformatted image through right posterior basal segmental artery from CT pulmonary angiography shows segment of poor opacification (arrow) between areas of higher attenuation both proximally and distally. Interface between low- and high-attenuation areas is ill-defined.

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Fig. 2A —Localized increase in vascular resistance in 69-year-old woman with breast cancer who has right-sided talc pleurodesis. Staging CT was performed with injection of 65 mL of Isovue 370 (iopamidol, Bristol-Myers Squibb) at rate of 1.5 mL/s using scan delay of 35 seconds. Right lower lobe shows volume loss and consolidation. Note good opacification of left lower lobe pulmonary arteries (arrowheads). However, also note poor opacification of right lower lobe pulmonary arteries (arrows), indicating localized increase in vascular resistance in right lower lobe arteries.

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Fig. 2B —Localized increase in vascular resistance in 69-year-old woman with breast cancer who has right-sided talc pleurodesis. CT pulmonary angiogram 3 days after A using 110 mL of Isovue 370 at 4 mL/s and 22-second scanning delay. Note good opacification of right lower lobe pulmonary arteries (arrows). This image illustrates that peripheral vascular resistance can be overcome with large volume of contrast material injected rapidly and by acquiring images at very end of injection.

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Fig. 3 —Acute pulmonary embolism in 27-year-old woman. CT pulmonary angiogram shows thrombus (arrow) that expands diameter of right posterior basal subsegmental artery compared with pulmonary arteries of same order of branching (arrowheads).

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Fig. 4A —Acute pulmonary embolism in 27-year-old woman. Centrally located thrombus, in right posterior basal segmental artery, has well-defined margins and is completely surrounded by contrast material (arrow). Acute emboli are also noted in right lateral basal segmental and left posterior basal subsegmental arteries.

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Fig. 4B —Acute pulmonary embolism in 27-year-old woman. Curved reformatted image of posterior basal segmental artery of right lower lobe shows that central arterial filling defect (seen in A) cannot occur in isolation without embolism draping over vessel branch point or touching vessel wall at some point. Axial image of thrombus (A) was acquired at level of arrow.

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Fig. 5 —Acute pulmonary embolism in 28-year-old woman. Eccentrically located embolism (arrow) forms acute angle with vessel wall. Emboli are also noted in right lower lobar and left anteromedial basal segmental arteries.

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Fig. 6 —Chronic pulmonary embolism in 37-year-old woman. Curved coronal reformatted CT image viewed on lung window setting shows pouch defect (arrow) of anterior basal segmental artery of right lower lobe. Contracted or obliterated artery (arrowheads) is shown peripheral to site of chronic obstruction.

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Fig. 7 —Chronic pulmonary embolism in 60-year-old man. Axial CT image obtained at level of right lower lobe pulmonary artery shows broad-based, smoothly margined, eccentric filling defect (arrow) that forms obtuse angle with vessel wall.

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Fig. 8 —Chronic pulmonary embolism in 65-year-old man. Curved coronal reformatted CT image viewed on maximum intensity projection shows abrupt vessel narrowing that affects posterior basal segmental artery of right lower lobe. Note abrupt convergence of contrast material, leading to thin column of more distal IV contrast material (arrow). In addition, organized thrombus is identified surrounding column of contrast material (arrowheads).

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Fig. 9 —Chronic pulmonary embolism in 54-year-old man. Axial CT image of right lower lobe pulmonary artery shows band or web (arrow) surrounded by contrast material. Subcarinal and right hilar lymphadenopathy is also noted, which is associated with chronic pulmonary embolism.

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Fig. 10A —Acute right ventricle dilatation in 33-year-old woman with large acute pulmonary embolism clot burden. Maximum short-axis diameter (black rule) of right ventricle measures 5.2 cm.

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Fig. 10B —Acute right ventricle dilatation in 33-year-old woman with large acute pulmonary embolism clot burden. At more cephalad level, maximum short-axis diameter (black rule) of left ventricle measures 3.2 cm. CT pulmonary angiography right ventricle-to-left ventricle ratio equals 1.6.

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