Work

The pulmonary embolism that wasn’t: a case of pulmonary pseudosequestration

Year: 2018

Type: article

Abstract: A 68-year-old male patient was referred for coronary CT angiogram (CCTA) to evaluate an episode of non-anginal chest pain. He had a 10-year history of anticoagulation for pulmonary embolism based on multiple ventilation perfusion scans (V/Q scans) showing persistent V/Q mismatch. CCTA showed non-obstructive coronary disease but also found an incidental worm-like plexus of arterial vessels posterior to the left atrium (Panel A). On further investigation of the arterial plexus as a potential cause for the V/Q mismatch, a dedicated contrast CT scan of the chest demonstrated a small left lung (Panel B). The descending branch of the left pulmonary artery was absent on contrast CT and contrast magnetic resonance imaging (MRI) angiography (Panel D, red arrowhead). A large plexus of arterial vessels originating from the coeliac trunk supplied the lower lobe of the left lung (Panel B). Decreased contrast density was noted in the left pulmonary veins due to increased transit time via the systemic arterial network (Panel C). The tracheobronchial tree was normal. First pass contrast perfusion MRI revealed significantly delayed perfusion to the left lower lung consistent with supply in the systemic arterial phase, thus explaining the V/Q mismatch (Panel E, pulmonary arterial phase; Panel F, systemic arterial phase; see Supplementary material online, Video). CCTA and downstream evaluation led to the correct diagnosis of pulmonary pseudosequestration—a congenital anomaly. This allowed discontinuation of inappropriate anticoagulation which might help avoid potential bleeding complications. This case highlights the importance of non-cardiac findings on CCTA and pursuing alternate plausible diagnoses for V/Q mismatch. AA, ascending aorta; DA, descending aorta; LA, left atrium; MPA, main pulmonary artery.

Source: European Heart Journal - Cardiovascular Imaging

DOI: 10.1093/ehjci/jey094

Authors: Tushar Acharya, W Patricia Bandettini, Andrew E Arai, Marcus Y Chen

Institutions: National Institutes of Health, National Heart, Lung, and Blood Institute

Language: English

Topic: Congenital Heart Disease Studies

Subfield: Epidemiology

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: hybrid

Estimated APC paid: $5,203