A 39-year-old female with a history of chest discomfort and persisting breathlessness

A 39-year-old female with a history of chest discomfort and persisting breathlessness

  • A 39-year-old female with a history of chest discomfort and persisting breathlessness.
  • A) MIP image displaying an abrupt cut-off of the left pulmonary artery with mild soft tissue thickening (yellow bent arrow).
  • B) Plain CT image revealing calcification (white bent arrow) corresponding to the noted soft tissue thickening.
  • Non-visualization of segmental and sub-segmental branches of the descending interlobar artery (yellow arrow).
  • Diffuse mosaic attenuation (yellow arrow) observed in both lungs. Additionally, there is volume loss of the left lung (black arrow) with associated crowding of ribs.
  • A) Dilated main pulmonary artery (yellow arrow) and right pulmonary artery (green arrow) are observed.
  • B) Moderate pericardial effusion is visible (black arrow).
  • A) Dilated right ventricle (yellow arrow) with prominent trabeculation, straightening of the interventricular septum, and a moderately dilated right atrium (black arrow) are evident.
  • B) Early reflux of contrast in the hepatic veins is observed, indicative of right heart strain.
  • Oblique Volume Rendering Technique (VRT) images confirming the abrupt cut-off of the left pulmonary and segmental arteries (yellow arrow) due to focal narrowing.


  • Chronic Pulmonary Thromboembolic Pulmonary Hypertension (CTEPH) with resultant right heart failure.


  • Chronic pulmonary thromboembolism (CPTE) represents the long-term consequences of pulmonary emboli, often manifesting as a complex interplay of vascular and parenchymal changes.
  • A radiologist's comprehensive evaluation is crucial for recognizing both vascular and parenchymal signs.

Radiological Evaluation
1) Vascular signs:
a) Complete occlusion: vessel cut off.
b) Partial occlusion: look for 

  • Webs, bands, or focal stenosis
  • Areas of irregular thickening of the vessel wall
  • Calcified thrombus or crescent-shaped defect

c) Collateral vessels 

  • Bronchial artery dilation (> 2 mm) and tortuosity 
  • Non-bronchial arteries: In pleural, intercostal, phrenic, internal mammary areas

2) Signs of Pulmonary Hypertension (PH) 

  • Main pulmonary artery dilation (> 33 mm)
  • Ratio of main pulmonary artery diameter to ascending aorta diameter >1.1:1

3)Right ventricular signs:

  • Enlargement and hypertrophy
  • Ratio of right ventricle diameter to left ventricle diameter >1:1
  • Bowing of the interventricular septum toward the left ventricle

4) Lung parenchymal signs:
a. Scars from prior pulmonary infarctions

  • Bands, irregular peripheral linear opacities
  • Wedge-shaped opacities with pleural thickening

b. Mosaic lung attenuation

Treatment and Management:

  • Pulmonary endarterectomy (PEA) is the treatment of choice in CTEPH patients.
  • Understanding radiological features is crucial for diagnosis, severity assessment, and treatment planning.
  • Clinic radiological correlation ensures accurate diagnosis, helps determine disease severity, and guides the selection of suitable treatments, be it surgical (PEA), medical, or interventional (Balloon Pulmonary Angioplasty). 
  • Regular follow-up imaging is essential for monitoring disease progression and treatment effectiveness.

Chronic Pulmonary Thromboembolism (Without Pulmonary Hypertension):

  • Marked by vascular changes like irregular vessel walls and webs.
  • Distinguishing it from cases with associated pulmonary hypertension is crucial.
  • Pulmonary endarterectomy, a potentially curative surgery, is reserved for CTPEH patients.

Pulmonary Vasculitis:

  • Wegener's: Localized inflammation in a specific pulmonary artery or branches.
  • Indicators: Inflammatory changes in the vessel wall, leading to irregularities and stenosis.

Congenital Anomalies in Pulmonary Arteries:

  • Hypoplasia or agenesis, often coexisting with congenital cardiovascular disorders.
  • Examples: Tetralogy of Fallot, septal defects.


  • Nishiyama, K. H., Saboo, S. S., Tanabe, Y., Jasinowodolinski, D., Landay, M. J., & Kay, F. U. (2018). Chronic pulmonary embolism: diagnosis. Cardiovascular Diagnosis and Therapy, 8(3), 253–271. doi:10.21037/cdt.2018.01.09
  • Castañer, E., Gallardo, X., Ballesteros, E., Andreu, M., Pallardó, Y., Mata, J. M., & Riera, L. (2009). CT Diagnosis of Chronic Pulmonary Thromboembolism. RadioGraphics, 29(1), 31–50. doi:10.1148/rg.291085061

Dr. Faizel Abdul Khader 
Consultant Radiologist.
Manipal Hospital, Varthur road, Bengaluru.

Dr. Nanda Gopal
Cross sectional fellow.
Manipal Hospital, Varthur road, Bengaluru.