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Chronic pulmonary embolism

Last revised by Mina Sameh Rizk on 28 Oct 2024

Citation, DOI, disclosures and article data

Citation:

Weerakkody Y, Rizk M, Elfeky M, et al. Chronic pulmonary embolism. Reference article, Radiopaedia.org (Accessed on 16 Mar 2025) https://doi.org/10.53347/rID-25000

DOI:

https://doi.org/10.53347/rID-25000

Permalink:

https://radiopaedia.org/articles/25000

rID:

25000

Article created:

27 Sep 2013, Yuranga Weerakkody ◉

Disclosures:

At the time the article was created Yuranga Weerakkody had no recorded disclosures.

View Yuranga Weerakkody's current disclosures

Last revised:

28 Oct 2024, Mina Sameh Rizk

Disclosures:

At the time the article was last revised Mina Sameh Rizk had no financial relationships to ineligible companies to disclose.

View Mina Sameh Rizk's current disclosures

Revisions:

20 times, by 12 contributors - see full revision history and disclosures

Systems:

Vascular, Chest

Tags:

cases

Synonyms:

Chronic pulmonary emboli
Chronic pulmonary thromboemboli
Chronic pulmonary thromboembolism
Chronic pulmonary emboli (CPE)
Chronic pulmonary thromboembolism (CPTE)
CPTE
Chronic PE

Chronic pulmonary emboli are mainly a consequence of incomplete resolution of pulmonary thromboembolism.

vascular CT signs include
- direct pulmonary artery signs
  - complete obstruction
  - partial obstruction
  - eccentric thrombus
  - calcified thrombus - calcific pulmonary emboli
  - pulmonary arterial bands/pulmonary arterial webs ^1,4,5
  - post-stenotic dilatation
- signs related to pulmonary hypertension
  - enlargement of main pulmonary arteries
  - the peripheral pulmonary arteries in affected segments may be narrowed ^{ref required}
  - pulmonary arterial calcification
  - tortuous pulmonary vessels
  - right ventricular enlargement/hypertrophy
- signs of systemic collateral supply
  - enlargement of bronchial and non-bronchial systemic arteries ^7,8
parenchymal signs (often non-specific on their own):
- scars
- mosaic perfusion pattern
- focal ground-glass opacities
- bronchial anomalies

Nuclear medicine: V/Q scan

Some publications suggest that V/Q scanning may be more sensitive ^6,9 but less specific⁹than CTPA in detecting chronic pulmonary embolic burden.

Complications

Increased vascular resistance due to obstruction of the vascular bed leads to pulmonary hypertension.

Differential diagnosis

Differential considerations on a CTPA include ⁵:

perivascular pulmonary edema
artifacts/interpretational errors
- motion: breathing artifact
- flow-related artifact
- streak artifact
- misinterpretation
  - due to incorrect window settings
  - misinterpretation of veins as arteries
pulmonary arterial catheter ⁵
intrinsic intraluminal tumor
- pulmonary arterial sarcoma

References

1. Castañer E, Gallardo X, Ballesteros E et-al. CT diagnosis of chronic pulmonary thromboembolism. Radiographics. 2009;29 (1): 31-50. doi:10.1148/rg.291085061 - Pubmed citation
2. Wittram C, Kalra MK, Maher MM et-al. Acute and chronic pulmonary emboli: angiography-CT correlation. AJR Am J Roentgenol. 2006;186 (6_supplement_2): S421-9. doi:10.2214/AJR.04.1955 - Pubmed citation
3. Muller NL, Silva CIS. Imaging of the Chest, 2-Volume Set. Saunders. ISBN:141604048X. Read it at Google Books - Find it at Amazon
4. Wijesuriya S, Chandratreya L, Medford AR. Chronic pulmonary emboli and radiologic mimics on CT pulmonary angiography: a diagnostic challenge. Chest. 2013;143 (5): 1460-71. doi:10.1378/chest.12-1384 - Pubmed citation
5. Wittram C, Maher MM, Yoo AJ et-al. CT angiography of pulmonary embolism: diagnostic criteria and causes of misdiagnosis. Radiographics. 2004;24 (5): 1219-38. Radiographics (full text) - doi:10.1148/rg.245045008 - Pubmed citation
6. Tunariu N, Gibbs SJ, Win Z et-al. Ventilation-perfusion scintigraphy is more sensitive than multidetector CTPA in detecting chronic thromboembolic pulmonary disease as a treatable cause of pulmonary hypertension. J. Nucl. Med. 2007;48 (5): 680-4. doi:10.2967/jnumed.106.039438 - Pubmed citation
7. Martine Remy-Jardin, Alain Duhamel, Valérie Deken, Nébil Bouaziz, Philippe Dumont, Jacques Remy. Systemic Collateral Supply in Patients with Chronic Thromboembolic and Primary Pulmonary Hypertension: Assessment with Multi–Detector Row Helical CT Angiography1. (2005) Radiology. 235 (1): 274-81. doi:10.1148/radiol.2351040335 - Pubmed
8. Shyamal Madhavani, Edison Gavilanes, Helaine Larsen, Brian Webber. Pulmonary Collateral Circulation in Recurrent Pulmonary Thromboembolic Disease. (2017) CHEST. 152 (4): A1025. doi:10.1016/j.chest.2017.08.1058
9. Meng Wang, Dayong Wu, Rongzheng Ma, Zongyao Zhang, Hailong Zhang, Kai Han, Changming Xiong, Lei Wang, Wei Fang. Comparison of V/Q SPECT and CT Angiography for the Diagnosis of Chronic Thromboembolic Pulmonary Hypertension. (2020) Radiology. doi:10.1148/radiol.2020192181 - Pubmed
10. Nishiyama KH, Saboo SS, Tanabe Y, Jasinowodolinski D, Landay MJ, Kay FU. Chronic pulmonary embolism: diagnosis. (2018) Cardiovascular diagnosis and therapy. 8 (3): 253-271. doi:10.21037/cdt.2018.01.09 - Pubmed

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Chronic pulmonary embolism

Citation, DOI, disclosures and article data

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Radiographic features

CTPA