State-of-the-Art Imaging Techniques in Chronic
Thromboembolic Pulmonary Hypertension
Richard Coulden
Radiology Department, University Hospitals of Leicester, Leicester, United Kingdom
It is important to differentiate chronic thromboembolic pulmonary
hypertension (CTEPH) from other forms of pulmonary hypertension
(PH) to target treatment and optimize therapeutic outcome. Misdiagnosis is common, and high-quality imaging is essential if CTEPH
is to be diagnosed correctly. In addition to making a diagnosis,
imaging helps identify patients for surgery, aids surgical planning,
and provides postsurgical monitoring. Ventilation–perfusion scintigraphy and pulmonary angiography have been the mainstay of
diagnosis and surgical assessment for many years, but crosssectional techniques are rapidly taking over. Echocardiography is
used to confirm or refute the presence of PH and to identify cardiac
causes if PH is present. For patients with PH but no evidence of
cardiac disease, multislice computed tomography (CT) is the next
best step. CT distinguishes CTEPH from idiopathic arterial PH, evaluates underlying lung disease, and may help identify rarer causes of
PH. CT is quick, widely available, and inexpensive. There is, however,
a significant radiation burden, and it is unsuitable for serial examinations. Magnetic resonance (MR) involves no ionizing radiation and
makes an ideal alternative. When combined with techniques for
measuring ventricular function and blood flow, MR provides unique
insight into structure and function. CT and MR are complementary
techniques, and together they represent the future of imaging in
PH. How they might be used in routine clinical practice is presented
as a diagnostic algorithm developed at Papworth Hospital, the
United Kingdom’s national center for surgical treatment of CTEPH.
Keywords: chronic thromboembolic pulmonary hypertension;
computed tomography; diagnosis; echocardiography; magnetic
resonance angiography
Misdiagnosis in chronic thromboembolic pulmonary hypertension (CTEPH) is common because patients often present with
subtle or nonspecific symptoms. Clinical presentation typically follows one of two scenarios: (1) progressive dyspnea on exertion,
hemoptysis, and/or signs of right heart dysfunction (e.g., fatigue,
palpitations, and syncope) or (2) pulmonary hypertension after single
or recurrent episodes of overt pulmonary embolism (PE) (1).
Many patients experience a “honeymoon period” between
the acute event (PE) and the development of overt signs or symptoms. This may last from months to many years and may mask
the diagnosis. Lang (2) suggested that up to 63% of patients
give no history of acute PE. In these patients, the clinical course
of CTEPH is often indistinguishable from other types of pulmonary hypertension (PH), in particular idiopathic pulmonary arterial hypertension (IPAH), where symptoms may be just as severe. Accurate diagnosis is essential if treatment is to be targeted
and outcome optimized.
Imaging has become central to the diagnosis of CTEPH and in
monitoring subsequent treatment. Although a variety of imaging
modalities are available and of proven value, there is no benefit in using every test on every patient. This article describes a
rational approach to imaging in PH, how it is used in the diagnosis of CTEPH, and how it is used to assess operability when
CTEPH is present. All the techniques described are well established and form part of the routine imaging regime used at
Papworth Hospital, the United Kingdom’s national center for
surgical treatment of CTEPH.
IMAGING IN CTEPH
Initial Work-up
Patient evaluation must establish the presence and severity of
PH, identify its etiology when present, and, if thromboembolic
disease is the cause, determine whether surgical intervention
is appropriate. Initial work-up includes physical examination,
pulmonary function testing, and chest radiography. Findings from
the initial work-up usually indicate whether the patient’s symptoms are cardiac, pulmonary, or pulmonary–vascular in origin.
Patients with a normal chest X-ray and a low likelihood for
disease need no further investigation. Patients with a normal
chest X-ray and a strong history or a chest X-ray abnormality
suggesting PH (e.g., cardiomegaly, pulmonary vascular abnormality) should be investigated by echocardiography.
Echocardiography
Transthoracic echocardiography establishes whether resting PH
is present (estimate of pulmonary artery systolic pressure from
peak Doppler velocity of tricuspid regurgitant jet). It also assesses the right ventricle (RV) and left ventricle (LV), assesses
valve integrity, and examines overall cardiac anatomy for
underlying cardiac causes of PH (e.g., congenital heart disease
or valve disease). Depending on the stage of disease, atrial and
ventricular enlargement, RV and LV impairment, tricuspid regurgitation, flattening and displacement of the interventricular
septum, and pericardial effusion may be seen (3). If no cardiac
cause for PH is found, other imaging is needed.
Up to 1% of patients with acute PE go on to develop CTEPH,
although this is an area of controversy because many believe
that there is a higher prevalence (4). Routine echocardiography
6 wk after PE has therefore been suggested as a screening tool
to identify patients with persistent PH and/or RV dysfunction
(5). The ideal timing of the examination, the need for long-term
follow-up, whether it should be targeted to symptomatic or asymptomatic patients, and its cost-effectiveness overall has yet to be
determined.
(Received in original form May 15, 2006; accepted in final form May 18, 2006 )
Supported by an unrestricted educational grant from Actelion Pharmaceuticals.
Ventilation–Perfusion Scanning
Correspondence and requests for reprints should be addressed to Richard
Coulden, F.R.C.R., F.R.C.P., Radiology Department, University Hospitals of Leicester, Glenfield Hospital, Groby Rd., Leicester LE3 9QP UK. E-mail: richard.
[email protected]
For many years, ventilation–perfusion (V̇/Q̇) scintigraphy has
been the mainstay of diagnosis in PE. It can reliably distinguish
between large-vessel occlusive disease and small-vessel pulmonary vascular disease, and a normal V̇/Q̇ scintigram virtually
rules out CTEPH (1, 6–9). In patients with PH, one or more
mismatched segmental or larger defects generally indicates
Proc Am Thorac Soc Vol 3. pp 577–583, 2006
DOI: 10.1513/pats.200605-119LR
Internet address: www.atsjournals.org
578
CTEPH (8). A normal perfusion study or the presence of multiple, small, subsegmental defects make IPAH or another form
of small-vessel PH more likely (6). Occasionally, multiple mismatched defects are seen in pulmonary venoocclusive disease,
pulmonary capillary hemangiomatosis, fibrosing mediastinitis,
pulmonary vasculitis, or pulmonary artery sarcoma (1, 10–13).
Computed Tomographic Angiography
At Papworth Hospital, V̇/Q̇ scintigraphy has been largely superseded by multislice computed tomography (CT). Remy-Jardin
and colleagues (14) were the first to show that spiral CT reliably
demonstrates thromboemboli in second- to fourth-order pulmonary vessels and could therefore replace V̇/Q̇ scintigraphy in
suspected PE. Even then, with a single-slice CT scanner and
volume coverage limited to segmental vessels, the negative predictive value of pulmonary CT angiography (CTA) for acute PE
was 99% (15). With the advent of multislice CT and resolution
approaching 0.5 mm in all planes, results for CTA match those
obtained with conventional pulmonary angiography (16, 17).
The difference is that CTA is a three-dimensional technique.
The role of pulmonary angiography in providing a surgical “road
map” (18–20) is gradually being lost to cross-sectional methods.
Pulmonary CTA shows luminal thrombi, organized mural
thrombi, occlusions, and webs, just as might be seen with conventional angiography (21) (Figure 1). It is, however, noninvasive
and a fraction of the price of conventional angiography.
CT provides more than a vascular map. High-resolution CT
(HRCT) of the lung shows a mosaic pattern in CTEPH that is
virtually diagnostic (Figure 2) (22–25). The only important mimic
is air trapping, which can be seen in a variety of small-airway
diseases. The distinction is usually straightforward, but if the
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clinician is in doubt, expiratory images discriminate between the
two. HRCT is also helpful identifying other causes of PH. A
nodular ground-glass pattern is frequently seen in IPAH,
IPH-CREST (limited systemic sclerosis syndrome), and capillary
hemangiomatosis. The HRCT features of these conditions show
considerable overlap, and a specific diagnosis can rarely be made;
however, CTEPH can be differentiated from small-vessel PH.
Venoocclusive disease is distinct from other small-vessel diseases
in that its ground-glass nodules are frequently associated with interlobular septal thickening (26) (Figure 3). Mediastinal adenopathy
is a nonspecific but well recognized feature of IPAH, capillary
hemangiomatosis, and venoocclusive disease. It is not usually seen
in CTEPH and, if it is present, raises the possibility of associated
small-vessel disease or other causes of lymphadenopathy.
The timing of the intravenous contrast bolus for CTA should
opacify pulmonary and systemic circulations. This allows assessment of all cardiac chambers and the pulmonary vascular tree.
Although often ignored on chest CT, a number of cardiac features should be looked for as follows (27):
•
•
•
•
•
Cardiac chamber size
Position and shape of the interventricular septum
The presence or congenital cardiac abnormalities
Anomalous pulmonary venous drainage
Contrast reflux into the inferior vena cava (IVC) and hepatic veins indicating the presence and severity of tricuspid
regurgitation (28)
• Size and distribution of bronchial arteries and nonbronchial
systemic arteries
RV dilatation is easily assessed by CT, even without ECG
gating. Comparing RV and LV diameters at midventricular level,
an RV/LV diameter ratio greater than 1:1 indicates RV dilatation
Figure 1. Selective left pulmonary angiogram (A ) and matching three-dimensional reconstruction from a computed
tomography (CT) pulmonary
angiogram (B ) in a patient with
chronic thromboembolic pulmonary hypertension (CTEPH).
Tight webs, typical of CTEPH,
are shown on the conventional
angiogram and CT angiogram
(arrows).
Coulden: Imaging in CTEPH
Figure 2. High-resolution CT in a patient with CTEPH showing mosaic
perfusion (A ). Areas of pulmonary hyperperfusion are of high attenuation (dark arrows) and are associated with large vessels, whereas areas of
hypoperfusion are of low attenuation and contain small vessels. Coronal
reconstruction of the lung parenchyma from a patient with CTEPH (B )
shows that hyperperfused areas (arrows) correlate well with regions of
residual perfusion seen on perfusion scintigraphy (C ).
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Figure 3. High-resolution CT in idiopathic pulmonary arterial hypertension (A ) and venoocclusive disease (B ). In both conditions, there may be
ground-glass nodular shadowing tending to coalescence. Venoocclusive
disease is also associated with smooth interlobular septal thickening
(black arrows), mimicking left ventricular failure.
(Figure 4) (29). Planimetry of the RV blood pool on axial slices
has also been shown to give an accurate estimate of diastolic
volume when compared with that obtained by magnetic resonance (MR). Although the majority of patients with valve disease
580
Figure 4. CT images through the right ventricle (RV) in a patient with
CTEPH before (A ) and 3 mo after pulmonary thromboendarterectomy
(B ). Preoperatively, RV is dilated with right ventricular/left ventricular
(RV/LV) ratio 1 and a small pericardial effusion (white arrows). Pericardial effusions are common in pulmonary hypertension and carry a poor
prognosis. After surgery, RV returns to normal, and LV regains its normal
shape. The RV/LV ratio is normal at 1.0.
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nary tree. Because no ionizing radiation is involved, the technique is ideally suited to young patients and those requiring
serial assessment (e.g., for postoperative follow-up). The typical findings of CTEPH (intraluminal webs and bands, vessel cutoffs, and organized central thrombus) are well demonstrated
and can be seen in vessels to segmental level (Figure 5). Beyond
the segmental level, the higher spatial resolution of conventional
angiography makes it superior. Does this matter? Surgical intervention is largely limited to proximal and segmental vessels, and
in a study by Kreitner and colleagues (33), CEMRA correctly
predicted surgical success in 33 of 34 patients. Pulmonary MRA
also correlates well with CTA, but beyond the segmental level
the higher spatial resolution of CTA makes CTA superior (25,
34). Pulmonary MRA has similar accuracy to V̇/Q̇ scintigraphy
in distinguishing between patients with CTEPH and IPAH (35).
As with CT, there is more to MR than MRA. Pulmonary
MRA may be combined in the same examination with a variety
of cine techniques to gauge cardiac function and flow. Cine imaging allows qualitative and quantitative assessment of ventricular
function. Using planimetry of contiguous cine slices, end-systolic
volume, end-diastolic volume, stroke volume, ejection fraction,
and muscle mass can be determined. Numerous studies have
shown these measurements to be accurate and reproducible,
and, over recent years, MR has become the gold standard for
determining RV and LV function (36, 37).
Phase-contrast velocity mapping is the MR equivalent of
Doppler ultrasound. It has the advantage that it is independent of acoustic window and can measure absolute vessel flow in
addition to mean or peak velocity. In the setting of PH, its most
important applications include measurement of cardiac output
and pulmonary and systemic flow measurements in the estimation of right-to-left and left-to-right shunts. In patients with
CTEPH, phase-contrast imaging has been used to measure flow
in the ascending aorta and right and left pulmonary artery before
and after pulmonary thromboendarterectomy (PEA). As might
be expected from the ease of surgical access, postoperative blood
flow in the right main pulmonary artery increases significantly
more than left. The size of the bronchial artery shunt also falls
after surgery; the levels of decrease corresponding broadly to
the extent of revascularization (38).
Our experience at Papworth mirrors that described previously. As a consequence, pulmonary MRA has replaced conventional angiography as the surgical “road map” in patients
being considered for surgery. This has the added benefit that
the preoperative examination serves as a baseline for noninvasive postoperative follow-up of pulmonary vascular anatomy and
cardiac function. When MR is contraindicated, CT is used.
Pulmonary Angiography
or a congenital abnormality are identified on echocardiography, sinus venosus arterial septal defect (ASD), patent ductus
arteriosus, and anomalous pulmonary venous drainage can be
missed. It is important to look for these conditions even though
previous echocardiography may have been negative. Bronchial
artery dilatation is a well-recognized feature of CTEPH on conventional angiography (30) and has recently been described on
CTA (31, 32). Identifying bronchial artery dilatation is important
because a large bronchial blood supply can complicate surgery,
and its presence has been reported to be an indicator of poor
surgical outcome.
MR Angiography
Contrast-enhanced MR angiography (CEMRA) is an established alternative to CTA in all vascular beds beyond the coro-
Pulmonary angiography predates all the other techniques described and has been the cornerstone of managing patients with
CTEPH for many years. By identifying occlusions and intravascular webs, it confirms the diagnosis and gives an indication of
operability (18–20). Limited access, limited expertise, and a small
but definite patient risk favor newer, noninvasive methods. At
Papworth, pulmonary angiography is performed only in patients
being considered for PEA when an adequate surgical road map
has not been provided by CT or MR. In this situation, it is best
performed at the surgical center where it can be added to a
right-heart catheter examination with little additional risk. If
pulmonary angiography has to be done, two views of each lung
are essential to show pulmonary vascular anatomy in sufficient
detail for surgical planning.
Coulden: Imaging in CTEPH
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Pulmonary Angioscopy
Pulmonary angioscopy was developed in an era before CT and
MR as an adjunct to the preoperative evaluation of CTEPH
(39). It is invasive and expensive and carries a small but definite
risk. It is debatable whether this technique would have developed
had current noninvasive cross-sectional techniques been available at the time. Nonetheless, angioscopy provides excellent
views of chronic organized emboli and the intimal surface and
can identify bands or webs across the vascular lumen as a consequence of recanalization (39). Intimal plaques are nonspecific
and are seen in all types of PH, their extent and severity correlating with the level of PH, much as systemic atheroma may relate
to hypertension.
Depending on the expertise of the surgical center, angioscopy
is performed in up to 30% of patients with CTEPH being considered for PEA. Although it has been shown that angioscopy can
predict hemodynamic outcome in patients with relatively mild
PH and can confirm operability in patients with severe PH (40),
noninvasive methods providing similar information are increasingly becoming available.
CLINICAL CONDITIONS MIMICKING CTEPH
CTEPH is often misdiagnosed, and the true diagnosis may not
be made until autopsy (4). Table 1 lists some of the conditions
that mimic CTEPH and describes the imaging features that may
help in identifying them.
DIAGNOSING CTEPH: THE PAPWORTH ALGORITHM
Imaging is central to making the diagnosis and management of
CTEPH, but which test do you use, and when? The imaging
algorithm used at Papworth for CTEPH diagnosis is shown in
Figure 6. All the techniques described, with the exception of
angioscopy, are in routine use.
In summary, patients presenting with suspected PH have a
chest X-ray. Those with abnormal X-rays and those with normal
X-rays but a strong clinical history undergo echocardiography.
If PH is confirmed on echocardiography and no cardiac cause
is found, CTA is performed. This identifies CTEPH, lung disease,
and a variety of unsuspected shunts. If none of these is present,
TABLE 1. OVERVIEW OF CONDITIONS THAT MIMIC
CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION
AND DIAGNOSTIC FEATURES THAT MAY HELP IN
THEIR DIAGNOSIS
Conditions Mimicking
CTEPH
Fibrosing mediastinitis
causing obstruction
of the pulmonary
veins and arteries
Pulmonary artery sarcoma
Large-vessel arteritis
(or Takayasu’s arteritis)
Figure 5. Selective right pulmonary angiogram (A ) and matching threedimensional reconstruction from a magnetic resonance (MR) pulmonary
angiogram (B ) in a patient with CTEPH. Webs and occlusions, typical of
CTEPH, are shown on the conventional angiogram and MR angiogram
(arrows).
Techniques Used for Diagnostic Differentiation
Chest X-ray is rarely helpful. CT shows mediastinal
soft tissue obliterating fat planes and encasing
and compressing vascular structures (41).
Echocardiography, CT angiography, and MR have
difficulty distinguishing sarcoma from central
thrombus. Sarcoma may involve the pulmonary
valve and extend retrogradely into the RV
infundibulum, unlike thrombus (42, 43).
Contrast-enhanced MR may show tumor
enhancement, whereas thrombus will not (44).
Pulmonary angiography, angioscopy, and
aortography may not be helpful.
Cross-sectional CT or MR may identify
concentric inflammatory mural thickening.
FDG-PET shows intense uptake in active disease (45).
Definition of abbreviations: CT ⫽ computed tomography; FDG-PET ⫽ fluorodeoxyglucose positron emission tomography; MR ⫽ magnetic resonance; RV ⫽
right ventricular.
582
Figure 6. Algorithm used at Papworth Hospital for the investigation
of suspected pulmonary hypertension. CXR ⫽ chest X-ray; Echo ⫽
echocardiogram; IPAH ⫽ idiopathic pulmonary arterial hypertension;
L ⫽ left; PH ⫽ pulmonary hypertension; R ⫽ right.
HRCT often shows features suggesting IPAH, venoocclusive
disease, or papillary hemangiomatosis. V̇/Q̇ scintigraphy is not
routinely used. Although it can differentiate between CTEPH
and IPAH, it does not help in identifying other causes of PH,
such as unsuspected shunts, large-vessel pulmonary arteritis,
and primary pulmonary vascular tumors. If necessary, pulmonary
angiography and MR are used to problem-solve or to provide
a surgical road map in patients considered suitable for surgery.
CONCLUSIONS
CT, in combination with MR, represents the future for diagnosis
and management of patients with CTEPH. Both techniques detect postembolic obstructions at the lobar and segmental levels,
although at the subsegmental level the spatial resolution of
CT is superior to MR. Not every patient with PH has CTEPH;
imaging must identify patients with CTEPH, but it must also
provide alternative diagnoses when other causes of PH are
present.
Because multislice CT and cardiac-enabled MR scanners
are widely available, the proposed imaging algorithm should be
achievable in most hospitals. CT and MR have not reached the
peak of their development. Stress ventricular function imaging,
pulmonary flow waveform analysis, and MR lung perfusion are
just some of the techniques waiting to be explored further. We
are hopeful that as we move forward in our understanding of
CTEPH, we will no longer have to wait until autopsy to make
a diagnosis.
Conflict of Interest Statement : R.C. does not have a financial relationship with a
commercial entity that has an interest in the subject of this manuscript.
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