First evaluation by CT chest after lung transplantation: All that the radiologist should know.

Transcription

1 First evaluation by CT chest after lung transplantation: All that the radiologist should know. Poster No.: C-1018 Congress: ECR 2015 Type: Educational Exhibit Authors: R. M. Ruiz Peralbo, I. RIVERA, M. Alfageme Zubillaga, D. Petite, M. A. Francés Arpón, P. Servent Sáenz, A. Piazza, C. Gonzalez Hernando, V. Cuartero Revilla; Majadahonda/ES Keywords: Transplantation, Surgery, CT, Lung DOI: /ecr2015/C-1018 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 28

2 Learning objectives Identify normal post-surgical changes after lung transplantation, sometimes it is really difficult to define the border between them and possible early complications. Recognize chest CT imaging findings in post-transplant lung, usually non specific, so it is essential to correlate with the time course and symptomatology. Page 2 of 28

3 Background Lung transplantation represents the only treatment option in advanced stages of some lung diseases such as: chronic obstructive pulmonary disease emphysema (COPD) represents 38% of total (38% *), idiopathic pulmonary fibrosis (IPF) 35 % (19% *), cystic fibrosis 25% (16% *) and others: antitrypsin deficiency emphysema (8%), primary pulmonary hypertension (3'6%),sarcoidosis (2.8%), bronchiectasis(2.5%), lymphangioleiomyomatosis (1%), neoplasias (0.1%),... The distribution of the etiology of lung transplants at our center does not differ significantly from other series (* Percentage of our center). In our hospital, a referral center, an average lung transplants are performed annually, from 1991 to December 2014 were performed 615 lung transplants, so the radiologist is faced routinely to the evaluation of chest CT after lung transplantation, requiring knowledge of transplantation mode: bilateral, 60% (the most frequent, as in other reviews), unilateral, 40% (dependent receptor) and cardiopulmonary 0.5%; details of the surgical technique (approach, sutures..); usual postoperative changes (pleural effusion,..) and possible early complications (represent 10% of the rate of early mortality in our hospital): 10% related to surgery ( being the most common dehiscence of vascular sutures); 50% infections (bacterial, the most frequent) and 30% rejections. Page 3 of 28

4 Findings and procedure details Review of imaging findings in the first CT chest after lung transplantation. Following the clinical protocol used in our hospital,all patients before leaving the hospital after lung transplantation (mean hospital stay of one month) are performed a study of control.it consists of a multidetector CT angiography with intravenous contrast, according to protocol used for diagnosis of pulmonary embolism, multidetector system using a 64-detector with image acquisition in caudocranial direction 120kV and 200mA with an interval of collimation 0'625 and reconstruction 1 mm and after intravenous administration of 80ml nonionic contrast using the antecubital vein at a rate of 4 ml / s with a delay of 15 s and bolus tracking situated in main pulmonary artery.acquired images are reconstructed in three of the planes of space, with window soft-tissues / mediastinum (400) and window lung parenchimal (1500) and subjected to post-processing techniques (MPR). Radiological evaluation systematically examines imaging findings in relation to: 1.Chest wall hernias (fig5) subcutaneous cellular edem (fig6) collections (fig 23) 2.Sutures of sternotomy hernias (fig7) collections (fig8, fig9) 3.Anastomosis vascular hilar retraction (fig10) stenosis of the arterial anastomosis (fig10) stenosis of the venous anastomosis pulmonary embolism (fig11) vascular dehiscence (hemothorax) 4.Pleural effusion free (fig13) loculated (fig14) infected (empyema) hemothorax (fig15) Page 4 of 28

5 5.Airway pneumothorax (fig16, fig17,fig18, fig19) pneumopericardium (fig16, fig17, fig19) pneumomediastinum (fig17,fig18, fig19) subcutaneous tissue emphysema (fig17,fig18) airway dehiscence (fig19) endobronchial occupation (fig 20, fig21) 6.Parenchyma sutures (fig22) collapses (fig21) atelectasis preclinical infiltrates Early parenchymal complications infection (fig23, fig24) reperfusion edema acute rejection Sometimes it is difficult to draw a border between post-surgical changes and complications, because radiographic findings in CT chest post-transplant lung may be nonspecific and it is essential to know the time course and symptomatology to provide relevant information (1). Page 5 of 28

6 Images for this section: Fig. 5: Hernia lung parenchyma through 4th left costal arch Page 6 of 28

7 Fig. 6: Subcutaneous tissue edem of chest wall Page 7 of 28

8 Fig. 7: Hernia of the lung parenchyma through sternotomy suture Page 8 of 28

9 Fig. 8: Sternotomy suture: postsurgical collection retroesternal Page 9 of 28

10 Fig. 9: Collection retropectoral left in mammography and breast ultrasound left, which is not evident in the first post transplant chest CT performed 3 weeks prior. Page 10 of 28

11 Fig. 10: A-B. Retraction right hilum. Right pulmonary artery stenosis (coronal projection, postprocessing VRT). C-D-E. Anastomotic stenosis lower concentric right pulmonary artery 50% (CT in axial and coronal projection, correlation with MRI). Page 11 of 28

12 Fig. 11: Pulmonary embolism: filling defects in bilateral lobar arteries Page 12 of 28

13 Fig. 12: Repletion defect right main artery in relation to septic embolus of fungal origin Page 13 of 28

14 Fig. 13: Mild bilateral pleural effusion Page 14 of 28

15 Fig. 14: Moderate bilateral pleural effusion, partially loculated in right hemithorax, parenchymal collapse in both lung bases associated Page 15 of 28

16 Fig. 15: Apical small chamber of right hemothorax Page 16 of 28

17 Fig. 16: Pneumopericardium. Pneumothorax. Page 17 of 28

18 Fig. 17: Pneumothorax. Pneumomediastinum. Pneumopericardium. Emphysema in subcutaneous tissue. Page 18 of 28

19 Fig. 18: Emphysema in subcutaneous tissue. Pneumomediastinum. Pneumothorax. Page 19 of 28

20 Fig. 19: Left bronchial suture dehiscence (red arrow). Pneumomediastinum. Pneumopericardium. Page 20 of 28

21 Fig. 20: Pulmonary aspergillosis. Endobronchial occupation. Page 21 of 28

22 Fig. 21: Pulmonary aspergillosis. Endobronchial occupation. Collapse parenchymal. Page 22 of 28

23 Fig. 22: Suture in the parenchyma of the right lower lobe Page 23 of 28

24 Fig. 23: Retractable extensive parenchymal consolidation of the right lower lobe. Right prepectoral collection. Page 24 of 28

25 Fig. 24: Pulmonary aspergillosis. Peribronchovascular bilateral infiltrates with cavitation in left hemithorax. Page 25 of 28

26 Conclusion Correct interpretation of radiological findings of the first chest CT performed in the early postoperative period after lung transplantation as routine studio allows appropriate radiological assessment to recognize surgical success, identify normal postoperative changes and distinguish them of possible early complications, for that it is imperative to know the clinical and the postoperative evolution. In this way, the rapid handling of early complications contributes to reduce morbidity and mortality of these patients, and so increase the survival of these patients, that in our center reaches 79% in the first year, decreasing to 60% at five years after lung transplantation. Page 26 of 28

27 Personal information Page 27 of 28

28 References 1.Imaging of lung transplantation: Review. AJR,2009; 192:S1-13. Yuen Li Ng, Narinder Paul, Demetris Patsios, Anna Walsham, Tae-Bong Chung, Shaf Keshavjee, Gordon Weisbrod.(1) 2.Postoperative complications of lung trasnplantation: radiological findings along a time continuum. Krishnam MS, Suh RD, Tomasian A, et al Radiographics 2007;27: Imaging of the chest after lung transplantation. Journal of Thoracic Imaging,2002; 17: Collins J. 4.Computed tomography findings of postoperative complications in lung transplantation. J Bras Pneumol. 2009;35(3): B. Hochhegger et al. 5.Complicaciones del trasplante de pulmón: Manifestaciones radiológicas con correlación patológica. Experiencia en un centro de referencia terciario. SERAM P. Diez Martinez et al. 6.Findings in routine CT performed at 3,6,12 weeks after lung transplantation. ECR S. Tapia Concha et al. Page 28 of 28