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MDCT Evaluation of Central Airway and Vascular Complications of Lung Transplantation

Ritu R. Gill1, Angeline C. Poh1, Phillip C. Camp2, Jean M. Allen1, Mark T. Delano1, Francine L. Jacobson1, Andetta Hunsaker1 and Yolonda L. Colson2

1 Department of Radiology, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.
2 Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA.


Figure 1
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  		Fig. 1 —Bronchial anastomotic dehiscence. Schematic diagram shows telescoped anastomosis (A). In B, blue arrow indicates infold or pseudodiverticulum (other blue arrows indicate air). Purple arrow shows contained leak, a small pocket of air trapped in omental wrap. Note that air pocket does not communicate with airway. Drawings C–E show development of dehiscence and its progression. Membranous part of trachea is the most vulnerable. Extraluminal air communicates with airway and progresses if not diagnosed early.

 

Figure 2
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  		Fig. 2A —60-year-old man who underwent double lung transplantation for idiopathic pulmonary fibrosis. Axial CT image of thorax shows bilateral pneumothoraces (horizontal arrows). Right main bronchus is minimally irregular (vertical arrow).

 

Figure 3
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  		Fig. 2B —60-year-old man who underwent double lung transplantation for idiopathic pulmonary fibrosis. Axial CT image in more cranial plane suggests irregular pocket of gas in region of right bronchial anastomosis (arrow).

 

Figure 4
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  		Fig. 2C —60-year-old man who underwent double lung transplantation for idiopathic pulmonary fibrosis. Coronal minimum-intensity-projection image clearly shows lobulated collection of gas measuring 0.8 x 0.4 cm just inferior to and communicating with right bronchial anastomosis (arrow) that is consistent with bronchial dehiscence.

 

Figure 5
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  		Fig. 2D —60-year-old man who underwent double lung transplantation for idiopathic pulmonary fibrosis. Volume-rendering model shows communication between gas pocket and right bronchial anastomosis (arrow). Despite attempts at conservative therapy, patient eventually required surgery to repair bronchial dehiscence. See also Figure S2, cine image, at www.ajronline.org.

 

Figure 6
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  		Fig. 2E —60-year-old man who underwent double lung transplantation for idiopathic pulmonary fibrosis. Volume-rendering model shows communication between gas pocket and right bronchial anastomosis (arrow). Despite attempts at conservative therapy, patient eventually required surgery to repair bronchial dehiscence. See also Figure S2, cine image, at www.ajronline.org.

 

Figure 7
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  		Fig. 2F —60-year-old man who underwent double lung transplantation for idiopathic pulmonary fibrosis. Volume-rendering model shows communication between gas pocket and right bronchial anastomosis (arrow). Despite attempts at conservative therapy, patient eventually required surgery to repair bronchial dehiscence. See also Figure S2, cine image, at www.ajronline.org.

 

Figure 8
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  		Fig. 3 —30-year-old man who underwent double lung transplantation. Axial CT image shows pneumothorax (straight green arrow), pneumomediastinum (curved green arrow), pneumatocele (blue arrow), and subcutaneous emphysema (white arrow).

 

Figure 9
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  		Fig. 4A —39-year-old man with pulmonary fibrosis who underwent double lung transplantation. Axial (A), coronal (B and C), and volume-rendered (D and E) CT images show pseudodiverticulum (arrow) along telescoped anastomosis on left. Insets (A–C) show pseudodiverticulum in different planes.

 

Figure 10
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  		Fig. 4B —39-year-old man with pulmonary fibrosis who underwent double lung transplantation. Axial (A), coronal (B and C), and volume-rendered (D and E) CT images show pseudodiverticulum (arrow) along telescoped anastomosis on left. Insets (A–C) show pseudodiverticulum in different planes.

 

Figure 11
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  		Fig. 4C —39-year-old man with pulmonary fibrosis who underwent double lung transplantation. Axial (A), coronal (B and C), and volume-rendered (D and E) CT images show pseudodiverticulum (arrow) along telescoped anastomosis on left. Insets (A–C) show pseudodiverticulum in different planes.

 

Figure 12
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  		Fig. 4D —39-year-old man with pulmonary fibrosis who underwent double lung transplantation. Axial (A), coronal (B and C), and volume-rendered (D and E) CT images show pseudodiverticulum (arrow) along telescoped anastomosis on left. Insets (A–C) show pseudodiverticulum in different planes.

 

Figure 13
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  		Fig. 4E —39-year-old man with pulmonary fibrosis who underwent double lung transplantation. Axial (A), coronal (B and C), and volume-rendered (D and E) CT images show pseudodiverticulum (arrow) along telescoped anastomosis on left. Insets (A–C) show pseudodiverticulum in different planes.

 

Figure 14
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  		Fig. 5 —22-year-old woman who underwent double lung transplantation. Axial CT image shows tracheal diverticulum (arrow).

 

Figure 15
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  		Fig. 6A —23-year-old woman who underwent double lung transplantation. Axial (A) and coronal (B) posttransplantation and coronal pretransplantation (C) CT images show tracheal bronchus (arrow) that was ligated and ends as blind pouch in mediastinum.

 

Figure 16
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  		Fig. 6B —23-year-old woman who underwent double lung transplantation. Axial (A) and coronal (B) posttransplantation and coronal pretransplantation (C) CT images show tracheal bronchus (arrow) that was ligated and ends as blind pouch in mediastinum.

 

Figure 17
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  		Fig. 6C —23-year-old woman who underwent double lung transplantation. Axial (A) and coronal (B) posttransplantation and coronal pretransplantation (C) CT images show tracheal bronchus (arrow) that was ligated and ends as blind pouch in mediastinum.

 

Figure 18
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  		Fig. 7A —25-year-old man with cystic fibrosis who underwent double lung transplantation. Patient developed shortness of breath several months after surgery. See also Figure S7, AVI images, at www.ajronline.org. Axial thoracic CT image shows collapse of right upper lobe and anterior displacement of oblique fissure (arrow).

 

Figure 19
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  		Fig. 7B —25-year-old man with cystic fibrosis who underwent double lung transplantation. Patient developed shortness of breath several months after surgery. See also Figure S7, AVI images, at www.ajronline.org. Axial (B) and coronal (C) CT images of thorax in more caudal plane show cause to be possible stricture (black and white arrows) at origin of right upper lobe bronchus and stenosis of bronchus intermedius.

 

Figure 20
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  		Fig. 7C —25-year-old man with cystic fibrosis who underwent double lung transplantation. Patient developed shortness of breath several months after surgery. See also Figure S7, AVI images, at www.ajronline.org. Axial (B) and coronal (C) CT images of thorax in more caudal plane show cause to be possible stricture (black and white arrows) at origin of right upper lobe bronchus and stenosis of bronchus intermedius.

 

Figure 21
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  		Fig. 7D —25-year-old man with cystic fibrosis who underwent double lung transplantation. Patient developed shortness of breath several months after surgery. See also Figure S7, AVI images, at www.ajronline.org. Coronal reformatted CT image after dilatation of right upper lobe stricture and stenting of bronchus intermedius shows improved patency (black arrow) and reexpansion of right upper lobe.

 

Figure 22
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  		Fig. 7E —25-year-old man with cystic fibrosis who underwent double lung transplantation. Patient developed shortness of breath several months after surgery. See also Figure S7, AVI images, at www.ajronline.org. Sagittal reformatted CT image after stenting shows patency of right upper lobe bronchus (arrow).

 

Figure 23
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  		Fig. 7F —25-year-old man with cystic fibrosis who underwent double lung transplantation. Patient developed shortness of breath several months after surgery. See also Figure S7, AVI images, at www.ajronline.org. Complementary virtual bronchoscopy images illustrate patency of right main bronchial anastomosis and right upper lobe bronchus. Image looking down from carina (F) into right mainstem bronchus (blue arrow) shows origin of right upper lobe bronchus and patency of bronchus intermedius. Image from trachea looking inferiorly at carina (G) shows patency of anastomosis of both right and left mainstem bronchi.

 

Figure 24
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  		Fig. 7G —25-year-old man with cystic fibrosis who underwent double lung transplantation. Patient developed shortness of breath several months after surgery. See also Figure S7, AVI images, at www.ajronline.org. Complementary virtual bronchoscopy images illustrate patency of right main bronchial anastomosis and right upper lobe bronchus. Image looking down from carina (F) into right mainstem bronchus (blue arrow) shows origin of right upper lobe bronchus and patency of bronchus intermedius. Image from trachea looking inferiorly at carina (G) shows patency of anastomosis of both right and left mainstem bronchi.

 

Figure 25
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  		Fig. 7H —25-year-old man with cystic fibrosis who underwent double lung transplantation. Patient developed shortness of breath several months after surgery. See also Figure S7, AVI images, at www.ajronline.org. Volume-rendered image shows patent right upper lobe bronchus (black arrow) and stent in bronchus intermedius (white arrow).

 

Figure 26
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  		Fig. 8A —54-year-old man who underwent single left lung transplantation for idiopathic pulmonary fibrosis. Patient had earlier developed left pulmonary artery anastomotic stenosis for which stent was placed. He became increasingly short of breath several weeks after stent was deployed. See also Figure S8, cine images, at www.ajronline.org. Coronal unenhanced axial CT scan of thorax reveals mass effect from pulmonary artery stent resulting in stenosis of left main bronchus (arrow).

 

Figure 27
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  		Fig. 8B —54-year-old man who underwent single left lung transplantation for idiopathic pulmonary fibrosis. Patient had earlier developed left pulmonary artery anastomotic stenosis for which stent was placed. He became increasingly short of breath several weeks after stent was deployed. See also Figure S8, cine images, at www.ajronline.org. Volume-rendered image clearly shows relationship of stent to left bronchial narrowing (arrow).

 

Figure 28
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  		Fig. 8C —54-year-old man who underwent single left lung transplantation for idiopathic pulmonary fibrosis. Patient had earlier developed left pulmonary artery anastomotic stenosis for which stent was placed. He became increasingly short of breath several weeks after stent was deployed. See also Figure S8, cine images, at www.ajronline.org. Curved reformation acquired after manually inserting cursor point in center of airways allows accurate measurement of stenoses, which are graded as mild, moderate, or severe. Additional cross-sectional measurements of airways at normal airway proximal, distal, and at level of stenosis, along with length of stenosis, are provided and aid in planning stent. 1 = trachea, 2 = point proximal to stenosis showing normal diameter of left main bronchus, 3 = diameter of stenotic segment.

 

Figure 29
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  		Fig. 8D —54-year-old man who underwent single left lung transplantation for idiopathic pulmonary fibrosis. Patient had earlier developed left pulmonary artery anastomotic stenosis for which stent was placed. He became increasingly short of breath several weeks after stent was deployed. See also Figure S8, cine images, at www.ajronline.org. Coronal CT image after bronchial stent placement clearly shows patent left main bronchus (black arrow). White arrow indicates pulmonary artery stent.

 

Figure 30
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  		Fig. 9A —54-year-old man who underwent left lung transplantation for idiopathic pulmonary fibrosis. CT image shows "frown sign" of tracheobronchomalacia (arrow). Marked collapse of trachea of more than 50% was seen incidentally on CT of thorax performed for evaluation of patient's pneumonia.

 

Figure 31
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  		Fig. 9B —54-year-old man who underwent left lung transplantation for idiopathic pulmonary fibrosis. Dynamic inspiratory (B) and expiratory (C) virtual bronchoscopy images confirm diagnosis of tracheobronchomalacia. Image from trachea looking inferiorly at right and left mainstem bronchi in inspiration (B) shows normal diameter of central airways. In expiration (C), note marked collapse and associated decrease in diameter of trachea, which is consistent with tracheobronchomalacia.

 

Figure 32
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  		Fig. 9C —54-year-old man who underwent left lung transplantation for idiopathic pulmonary fibrosis. Dynamic inspiratory (B) and expiratory (C) virtual bronchoscopy images confirm diagnosis of tracheobronchomalacia. Image from trachea looking inferiorly at right and left mainstem bronchi in inspiration (B) shows normal diameter of central airways. In expiration (C), note marked collapse and associated decrease in diameter of trachea, which is consistent with tracheobronchomalacia.

 

Figure 33
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  		Fig. 10A —40-year-old woman who underwent single left lung transplantation for emphysema. CT pulmonary angiography was performed for suspected pulmonary embolism. See also Figure S10, AVI images, at www.ajronline.org. Axial CT image shows complete occlusion of left pulmonary artery anastomosis (arrow).

 

Figure 34
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  		Fig. 10B —40-year-old woman who underwent single left lung transplantation for emphysema. CT pulmonary angiography was performed for suspected pulmonary embolism. See also Figure S10, AVI images, at www.ajronline.org. Maximum-intensity-projection axial (B) and coronal (C) images show occlusion of left pulmonary artery and no distal arterial supply. Left bronchial collaterals are also present (arrow).

 

Figure 35
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  		Fig. 10C —40-year-old woman who underwent single left lung transplantation for emphysema. CT pulmonary angiography was performed for suspected pulmonary embolism. See also Figure S10, AVI images, at www.ajronline.org. Maximum-intensity-projection axial (B) and coronal (C) images show occlusion of left pulmonary artery and no distal arterial supply. Left bronchial collaterals are also present (arrow).

 

Figure 36
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  		Fig. 10D —40-year-old woman who underwent single left lung transplantation for emphysema. CT pulmonary angiography was performed for suspected pulmonary embolism. See also Figure S10, AVI images, at www.ajronline.org. Pulmonary angiogram reveals abrupt cutoff at orifice of left main pulmonary artery that could not be cannulated. Turbulent retrograde contrast flow is shown at site of stenosis (white arrow). Pulmonary vein branches are seen in upper left chest (black arrow).

 

Figure 37
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  		Fig. 11A —54-year-old man who underwent single left lung transplantation for idiopathic pulmonary fibrosis. CT pulmonary angiography was performed for suspected pulmonary embolism. Axial CT image shows tight stricture at left pulmonary artery stenosis (black arrow). Note dilatation of central pulmonary arteries from recurrent pulmonary hypertension (white arrow).

 

Figure 38
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  		Fig. 11B —54-year-old man who underwent single left lung transplantation for idiopathic pulmonary fibrosis. CT pulmonary angiography was performed for suspected pulmonary embolism. Axial (B) and coronal (C) CT images of thorax after insertion of metallic Wallstent (arrow) show satisfactory positioning and patency of left main pulmonary artery.

 

Figure 39
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  		Fig. 11C —54-year-old man who underwent single left lung transplantation for idiopathic pulmonary fibrosis. CT pulmonary angiography was performed for suspected pulmonary embolism. Axial (B) and coronal (C) CT images of thorax after insertion of metallic Wallstent (arrow) show satisfactory positioning and patency of left main pulmonary artery.

 

Figure 40
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  		Fig. 11D —54-year-old man who underwent single left lung transplantation for idiopathic pulmonary fibrosis. CT pulmonary angiography was performed for suspected pulmonary embolism. Pulmonary angiogram confirms diagnosis of tight stricture (arrow) of left pulmonary artery anastomosis.

 

Figure 41
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  		Fig. 12A —46-year-old woman who underwent double lung transplantation 10 years previously for cystic fibrosis and who had history of repeated right subclavian vein line insertions. Patient developed painless right lower neck mass. Chest radiograph after attempted insertion of central venous catheter reveals right paratracheal opacity (arrow) causing deviation of trachea to right.

 

Figure 42
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  		Fig. 12B —46-year-old woman who underwent double lung transplantation 10 years previously for cystic fibrosis and who had history of repeated right subclavian vein line insertions. Patient developed painless right lower neck mass. Coronal contrast-enhanced CT image of neck and thoracic inlet shows focal dilatation of proximal right subclavian artery and mural thrombus (arrow).

 

Figure 43
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  		Fig. 12C —46-year-old woman who underwent double lung transplantation 10 years previously for cystic fibrosis and who had history of repeated right subclavian vein line insertions. Patient developed painless right lower neck mass. Right upper limb angiography confirms presence of pseudoaneurysm of proximal right subclavian artery (arrow). Pseudoaneurysm was removed surgically, and patient underwent grafting of right subclavian artery.

 

Figure 44
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  		Fig. 13A —34-year-old man who underwent double lung transplantation for cystic fibrosis. Patient also had acute shortness of breath, elevated D-dimer level, and new pulmonary hypertension. Axial (A) and coronal oblique (B) maximum-intensity-projection CT pulmonary angiography images show nonocclusive filling defect in left lower lobe pulmonary artery (white arrow). Black arrow (B) indicates mild stenosis involving left main pulmonary artery at vascular anastomotic site.

 

Figure 45
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  		Fig. 13B —34-year-old man who underwent double lung transplantation for cystic fibrosis. Patient also had acute shortness of breath, elevated D-dimer level, and new pulmonary hypertension. Axial (A) and coronal oblique (B) maximum-intensity-projection CT pulmonary angiography images show nonocclusive filling defect in left lower lobe pulmonary artery (white arrow). Black arrow (B) indicates mild stenosis involving left main pulmonary artery at vascular anastomotic site.

 

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