RADIOLOGY
Massive Pulmonary Emboli Diagnosed and
Followed in Progress by Lung Imaging and
Radionuclide Pulmonary Angiography
By E. W. KLEIN, M. D., KATHLEEN MCCARTEN, M.D., D. G. DiMCHEFF, M.D.,
AND J. T. COLVIN, M. S.
SUM MARY
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A dramatic case of occlusion of the right pulmonary artery is presented. The diagnosis was clearly
established by means of a lung scan and a radionuclide pulmonary angiogram. The entire course of the
disease process was followed by radionuclide studies with a gradual but persistent return to normal. Due to
the preciseness of the evidence presented, contrast angiography was not.thought necessary.
Additional Indexing Words:
Technetium 99m pertechnetate
THE MEDICAL literature
Saddle emboli
Technetium 99m microspheres
Case History
at this time contains
innumerable investigations for diagnostic evaluation of pulmonary emboli.`6 The present article
attempts to point out that radionuclide pulmonary
angiography can be utilized in the diagnosis of
massive pulmonary emboli. In the case presented, the
radionuclide pulmonary angiogram clearly showed
complete obstruction of the right main pulmonary
artery. Contrast angiography was felt unnecessary due
to the clarity of this particular study and the patient
was followed completely by radionuclide studies
thereafter.
The low frequency data (poor resolution) obtained
by radionuclide angiography will obviously not fit the
majority of pulmonary emboli cases; however, it is
suggested that in the more central, large-type
pulmonary emboli, the radionuclide pulmonary
angiogram is quite satisfactory as a diagnostic
procedure. The postembolic progress is easily
followed by this procedure, offering a much simpler
and less hazardous program than contrast
angiography.
Mrs. E. D., a 46-year-old woman, was admitted in March
of 1972 for a radical mastectomv due to carcinoma of the
breast. She was otherwise healthy, and except for the right
breast mass, her physical examination was normal. She was
premenopausal and on no hormone therapy.
Chest roentgenograms, electrocardiogram, and other
routine laboratory studies were normal.
A radical mastectomy was performed, and on the fourth
postoperative day, she complained of right groin pain. The
following day she developed fever, cough, severe right-sided
pleuritic chest pain and dyspnea. She was anxious,
diaphoretic, and the pulse was 120. Blood pressure was
100/70, respirations 30, and a few rales were heard at the
right base. Oxygen and heparin were given. Standard chest
roentgenogram showed elevation of the right hemidiaphragm. Arterial P02 in approximately 35% oxygen was
101. A calculated alveolar arterial gradient was significantly
widened (DA-a02 60-90 mm Hg).
The day after clinical embolism, a standard perfusion
lung scan using Technetium 99m microspheres revealed a
severe reduction in perfusion of the right lung with the exception of a small area above the diaphragmatic surface (fig.
1). The left lung perfused normally. Insofar as the perfusion
study indicated a major occlusion of the right pulmonary
artery, a radionuclide pulmonary angiogram was performed
to ascertain if this technique would provide sufficient data to
confirm a major obstruction of the pulmonary artery. The
resultant pulmonary angiogram (fig. 2) demonstrated
complete obstruction of the right pulmonary artery.
On delayed filming, some perfusion finally reached the
area of the lung above the right base. Chest X-rays at this
time showed bilateral volume loss and infiltrates at both
bases.
Six days after clinical pulmonary embolism, hypotension,
From the Department of Nuclear Medicine, St. Joseph Mercy
Hospital, Ann Arbor, Michigan.
Address for reprints: E. W. Klein, M.D., Department of Nuclear
Medicine, St. Joseph Mercy Hospital, Ann Arbor, Michigan 48104.
Received June 17, 1974; revision accepted for publication July 25,
1974.
1260
Circulation, Volume 50, December 1974
PULMONARY EMBOLI BY SCAN AND ANGIOGRAPHY
ant
poSt
rt
A
1261
Figure 1
rt
B
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dliaphoresis and tachycardia occurred. Blood pressure was
82/72, puilse 120. At the same time, wound infection had occurred and there was bleeding from the wouind, as well as
excessive vaginal bleeding during menstrual periods, which
was felt to he due to the heparin therapy.
On the elevenith postoperative day, the luing scan was
repeated showing essentially no charnge from the original
study. The ractiornuclide puilmonary angiogram, however,
showed slight irnprovement in the appearance of the right
ltrng.
On the nineteenth postoperative dav, the lung scan
revealed that approximately one-third of the right lung xxas
now perftusinig (fig. 3). She was discharged on the twentysixth postoperative day onr oral arnticoagulants.
She returned to the N uclear Medicine Department for
reevaluatiorn approximately three anid one-half monthis
following the embolic episode. At this time, the lung scai
vas remnarkabily improved (fig. 4), and the radionuclide
angiogram vas similarly improved (fig. 5).
Materials and Methods
Standard perfuision lung scans were obtained utilizing a
NLuelear Chicago IL. P. Gamma Caamera. A low energy,
r t.
rt
A
B
A) Xntrcrior lonPgscan itndicates virtuially
(omrplete lack of perfuision of the rig/it
long except fur a small area overlying the
/ecteited heniidiapl/liraign. B3) 1osterior
Ilong .scanri foirt/icr demonstrates lack of petfulsioni to the rig/ht lnnzg.
diverging collimator was uitilized. T'ro mCi of rechnetium
99m microspheres wxere injected intravenously, and imaging
was performed in the usual manner. The radionuclide
pLulmonary angiogram was performed on a Nuclear Chicago
H, P (;anima Camera with a high resolution, low energy
collimator. Fifteen mCi of Techtiuttim 99m pertechnetate
wx as injected intravenouisly tutilizing a modifiedl Lane
technique.'7 The gamma camera was peaked at the center of
the 140 Kev photopeak of Technetium 99m, uising a 25%
winclow The study. wxas recorded on 35 mm film, utilizing
0.5 sec framing, and (on magnietic disc (MDS Ntuclear
\ledicine computetr). Recording vas begtun as the bolus was
injected into the arm. Filminig xxas continued until the bolois
lhacl mad(le at least one complete pass throuigh the lung fieldl.
Discussion
At the present time, acute pulmonary emboli pose a
serious problem for the clinician.
Clinical manifestations are found to be deceptive in
varying degrees in both the less serious emboli as well
as those massive emboli associated with tissue infaretion.
C
Figure 2
X)nterior radionoclidc antgiograni s/iotws f/ice tail of the holiis to hi' in thc' rig/it sob,lauiani acdinc stipc rinor c'n,tia ccit-.ca
fTie'rc is goodfill of the right atriorni and rig/it v entricle. The pilniotiary outfloui trcack ts cllearly sc'cl. T/hc' lcft p1nlnionaiy
artery is well delineated and t/iere i.s excellent perfusiont of t/e left ilong. There is n1o fill of sign ifijiccic c, of t/ic rig/it
puilnionary artery. B) Radionticlcde pulmionary angiograrn (.5 sec latcer) con/iros cirtoal coniplctc obstroction of t/c
riglit pulmioncary artery. C) Illustrationi of flowi pattern in A atid B. SAC' = siipcrior renia ccti cia; RA = riglit at?rioill;
RV-= rig/it ventricle; PA = p)utlmontary artery; LL = left long.
C irculation, Volunme 50, De.emiber 1974
KLEIN, McCARTEN, DIMCHEFF, COLVIN
1262
ant
ant
rt
r
Figure 4
ILung scani performed 3½- mnonths follnowing t/h episode of right
piiloionarq arteryJ occlusion shows ainiost coniplete restoration of
t/he pc rfnision piattern in the right Intlg.
Figure 3
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Iung scan performned approxrrnatlil two weeks later shows mnarke.d
inmprovemenit in perfusion of t/ie right lower lobe region. T/e riglit
upper lulng shows, a persistent perfusion deftcit. The diaphragnm has
retiirned to a more normal /)ositiomi.
The chest radiograph joins the list of parameters in
which findings are essentially nonspecific. Multiple
studies to date have been performed, attempting to
correlate radiographic signs in pulmonary embolus
and frequency of appearance.8-"
The lung scan is generally considered to be more
sensitive and innumerable investigations have
demonstrated the relative safety and efficacy of this
diagnostic parameter.`2 i6 Xenon ventilation studies
have further improved the diagnostic capabilities of
the nuclear medicine approach.1 "20
Contrast pulmonary angiography has thus far been
considered the most specific diagnostic approach
available. Freeman et al.`2 very concisely and accurately stated that pulmonary scanning and
angiography are complementary. They should not be
considered "competitive." We also adhere to this
position. In general, the approach of this institution
includes a Xenon ventilation study followed
immediately by a lung scan. A PA chest X-ray is taken
and the three data acquisitions are interpreted
together. We have tried to reserve contrast pulmonary
angiography for the difficult diagnostic problems and
potential surgically corrective cases, due to the heavy
load on our angiography suite, and the inherent
complexities of the study itself.
The role of the radionuclide pulmonary angiogram
in pulmonary emboli is a minimal one at the present
time. Low frequency data preclude any definitive approach to pulmonary emboli except for the larger central problems. However, the radionuclide angiogram
offers at this time several distinct advantages. It can
be performed utilizing the standard 2-4 mCi lung
scan dose of technetium 99m microspheres. We have
performed several such studies using a high sensitivity
collimator with excellent results. In fact, we anticipate
that in selected cases this may become routine policy.
Thus the radionuclide angiogram and lung scan can
be obtained with a single, noninvasive injection. In
addition, the definition of the major vessels is quite
satisfactory and may, as in the case presented, negate
the need for pulmonary contrast angiography. Finally
those patients allergic to iodine containing contrast
media could be handled in this manner.
The authors sincerely hope that further interest will
be generated in determining the role of the
Figure 5
rt
rt
r
S
t ;,,'.
4;v^kS
A
B
X-\ .i te rio rcridionutclidc p1)idlni7onary
zangiogrami shows good filling of the rig/it
atrintoi riglit uenitriele arid puloouary
outflowc track. At this tinme there is equal
fillitig of the rigl/it pulmionary artery; and
left piilnonarij artery. B) Radionuclidle
p)liltmioiciry anigiogrami (0..5 sec Iciter),sh/ows
good uaisculcir supply to bo)ti luings.
Circulation, Vo/unie 50, December /974
PULMONARY EMBOLI BY SCAN AND ANGIOGRAPHY
radionuclide angiogram in the diagnosis and management of pulmonary emboli.
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Massive Pulmonary Emboli Diagnosed and Followed in Progress by Lung Imaging and
Radionuclide Pulmonary Angiography
E. W. KLEIN, KATHLEEN MCCARTEN, D. G. DIMCHEFF and J. T. COLVIN
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Circulation. 1974;50:1260-1263
doi: 10.1161/01.CIR.50.6.1260
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