PMC10311022_01
(A) Axial computed tomography pulmonary angiography (CTPA) of the chest in soft tissue windows demonstrating a chest wall low flow vascular malformation (yellow box) with the presence of phleboliths (blue arrows); (B) Axial fat saturated T1-weighted MRI post gadolinium image of the left lateral chest wall demonstrating a low flow vascular malformation with clustered vessels centered under the left latissimus dorsi muscle (yellow box) and large draining veins in the subcutaneous tissues (blue arrows).
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F1
Heart Association (NYHA) functional class II at the time of presentation. He was known to have a vascular malformation in the left chest wall (Figure 1).
Posterior view of ventilation (A) and perfusion (B) scintigraphy showing normal ventilation and a paucity of perfusion in the periphery of the lung (blue arrows) with no defined segmental or lobar lesions.
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F2
Ventilation-perfusion (VQ) scintigraphy that demonstrated a paucity of perfusion in the peripheral lung (Figure 2).
(A) Sagittal oblique reformat of a chest CTPA showing a subtle web (blue arrow) in the distal right lower lobe posterior basal segment; (B) Coronal oblique maximum intensity projection view of a chest CTPA demonstrating a subtle web-like lesion (blue arrow) in the anterior basal right lower lobe pulmonary artery at the subsegmental level. This is the lesion subsequently treated with balloon pulmonary angioplasty (BPA) (see Figure 4); (C) Axial CTPA of the chest in lung windows at the level of the left atrium demonstrating striking mosaic lung attenuation with geographic regions of hypoperfused lung (white asterisks) and normally perfused lung (black asterisks); (D) Axial CTPA lung subtraction iodine mapping (LSIM) at the lung bases demonstrating areas of low iodine concentration in the periphery of the lung detonated by black-purple coloration (white asterisk) and corresponding to perfusion defects on VQ scintigraphy (Figure 2). Red-orange coloration indicates normal lung perfusion.
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F3
On CTPA reformats, the patient was found to have a subtle web in the distal right lower lobe posterior basal segment (Figure 3A) and a subtle web-like lesion in the anterior basal right lower lobe pulmonary artery at the subsegmental level (Figure 3B). Lung subtraction iodine mapping (LSIM) highlighted perfusion defects in areas of pulmonary embolism (Figures 3C, D).
(A) Pulmonary angiogram pre-BPA of the anterior basal right lower lobe segmental pulmonary artery demonstrating significant impairment in flow due to a subtle web lesion (yellow arrow); (B) post-BPA pulmonary angiogram showing significant improvement in flow (blue arrow).
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F4
A 0.014 in x 185 cm PT2 microwire was used to selectively access the right lower lobe anterior basal segmental branch, with significant impairment in flow due to a subtle web lesion (Figure 4A). Significant improvement in flow was observed post-BPA (Figure 4B).