Pulmonary varices: a case report and review of the literature

Rare and potentially lethal case of a round lesion in the lung

A pulmonary venous aneurysm (PVA) is extremely rare. A PVA can be either congenital or acquired. Possible symptoms include thoracic pain, dyspnoea, haemoptysis and palpitations but can also occur asymptomatically. Treatment can be conservative or surgical depending on growth and risk of rupture or development of mitral insufficiency, symptoms and thrombus formation. Only a few cases have been described in the literature. A recent case study and a literature review are described below.

A lung cyst harbouring a congenital pulmonary varix

A non-smoker man in his second decade presented to a medical centre with intermittent haemoptysis over 2 years. The haemoptysis was infrequent initially to be ignored, but later, the episodes increased in amount and frequency. Routine blood tests including coagulation profile showed normal results. The chest radiography and echocardiography were normal. The contrast-enhanced CT scan of the chest showed a cystic lesion with intracystic abnormality and surrounding ground-glass opacity in the left upper lobe. The CT pulmonary angiography and invasive pulmonary angiography showed the abnormality to be a dilated pulmonary vessel draining into the left atrium, thereby confirming the diagnosis of congenital pulmonary varix contained within a lung cyst. The patient underwent a successful lobectomy following which he experienced no further haemoptysis.

A Diagnostic Conundrum: Progressive Tubular Lung Mass in Asymptomatic Young Woman

CASE PRESENTATION

A 39-year-old female avid marathon runner presented with an abnormal chest radiograph obtained during preoperative evaluation prior to bilateral knee replacement because of osteoarthritis. As shown in Figure 1, chest radiograph revealed a focal nodular opacity in the middle lobe. She did not have any prior imaging for comparison.

Comprehensive Cross-sectional Imaging of the Pulmonary Veins

The pulmonary veins carry oxygenated blood from the lungs to the heart, but their importance to the radiologist extends far beyond this seemingly straightforward function. The anatomy of the pulmonary veins is variable among patients, with several noteworthy variant and anomalous patterns, including supernumerary pulmonary veins, a common ostium, anomalous pulmonary venous return, and levoatriocardinal veins. Differences in pulmonary vein anatomy and the presence of variant or anomalous anatomy can be of critical importance, especially for preoperative planning of pulmonary and cardiac surgery. The enhancement or lack of enhancement of the pulmonary veins can be a clue to clinically important disease, and the relationship of masses to the pulmonary veins can herald cardiac invasion. The pulmonary veins are also an integral part of thoracic interventions, including lung transplantation, pneumonectomy, and radiofrequency ablation for atrial fibrillation. This fact creates a requirement for radiologists to have knowledge of the pre- and postoperative imaging appearances of the pulmonary veins. Many of these procedures are associated with important potential complications involving the pulmonary veins, for which diagnostic imaging plays a critical role. A thorough knowledge of the pulmonary veins and a proper radiologic approach to their evaluation is critical for the busy radiologist who must incorporate the pulmonary veins into a routine "search pattern" at computed tomography (CT) and magnetic resonance imaging. This article is a comprehensive CT-based imaging review of the pulmonary veins, including their embryology, anatomy (typical and anomalous), surgical implications, pulmonary vein thrombosis, pulmonary vein stenosis, pulmonary vein pseudostenosis, and the relationship of tumors to the pulmonary veins. Online supplemental material is available for this article. ^©RSNA, 2017.

Pulmonary venous varix associated with mitral regurgitation mimicking a mediastinal mass: A case report and review of the literature

Pulmonary vein varix is an unusual cause of a mediastinal mass on a chest radiograph. It may be found as an isolated malformation or as a sequela of pulmonary venous hypertension. We encountered a case presenting with left hemiparesis and a past medical history of rheumatic heart disease. The chest radiograph revealed a well-defined mediastinal mass that turned out to be a hugely dilated pulmonary vein on contrast enhanced computed tomography of the chest. The computed tomography of the brain and upper abdomen revealed bilateral cerebral infarction and splenic infarction. In the literature, one-third of the reported cases of pulmonary vein varix are acquired secondary to mitral valve disease.

Generalized Malperfusion Due to Systemic Embolization From a Large Thrombosed Pulmonary Vein Aneurysm

We report the case of a 61-year-old patient who presented with generalized malperfusion due to systemic embolization from a large, partially thrombosed aneurysm of the left upper pulmonary vein. When the patient arrived at our center, large thrombus formations were detected in the left atrium and the abdominal aorta, as well as the renal, iliac, and femoral arteries. Renal, splenic, and mesenteric ischemia was diagnosed with computed tomography. The patient was in shock, acute kidney failure, and in high vasopressor need. The case highlights the risk of intraluminal thrombus formation in pulmonary vein aneurysms and underlines the need for systemic anticoagulation therapy and surgical therapy, if diagnosed in time.

Pulmonary venous aneurysm: Forming a glove balloon-like shape

INTRODUCTION

Pulmonary venous aneurysm (PVA) is a candidate for surgery because of the risk of rupture and continued growth even if the patient does not develop mitral valve disorders.

PRESENTATION OF CASE

We report the case of PVA that continued to increase in size throughout a 17-year observational period.

DISCUSSION AND CONCLUSION

The location and form of the aneurysm are important to consider when choosing the surgical approach. If the aneurysm forms a "glove balloon-like shape," lobectomy is necessary because end-to-end anastomosis is difficult to perform in such cases.

Pulmonary varix: A case report

The authors report a case of multiple pulmonary varices, a rare disease characterized by aneurysmatic venous dilatations, which can be present at any age and without gender predominance, occurring in isolation or associated with obstruction of the pulmonary veins. This condition usually manifests as a lung mass with variable clinical consequences.

A complex pulmonary vein varix -- diagnosis with ECG gated MDCT, MRI and invasive pulmonary angiography

A case of an asymptomatic 32-year-old male with a complex congenital pulmonary vein varix is reported herein. Chest X-ray incidentally revealed a tubular opacity passing from the periphery of the left lingula to the mediastinum. ECG gated multidetector computed tomography showed the opacity to be a vessel emptying into the left atrium via the left superior pulmonary vein. In addition, a second vascular structure was noted within the posterior mediastinum that was emptying into the same pulmonary vein. These findings were also confirmed by magnetic resonance imaging, 4D magnetic resonance angiography and invasive arterial angiography. Based on multimodality imaging findings the diagnosis of complex congenital pulmonary venous varix with posterior mediastinal extension was established.

[Pulmonary varix inside a bulla]

Pulmonary varices are uncommon vascular abnormalities that are usually asymptomatic and so they are normally diagnosed by chance from a chest x-ray. They often present as a pulmonary nodule and can be either congenital or acquired. If acquired, they are associated with pulmonary venous hypertension, usually as a result of mitral valve disease. Pulmonary arteriography provides a definitive diagnosis, although the use of new noninvasive imaging techniques is spreading. Treatment is not normally required unless serious complications arise. We present the case of a pulmonary varix located within a pulmonary bulla. This form of presentation has not been previously reported.

A rare case of dilatation of pulmonary veins and pulmonary emphysema in both lower lobes

A 34-year-old man was admitted to hospital because of persistent shortness of breath and diffuse vascular dilation at both lower fields of his CXR. Bronchiectasis had been suspected during childhood because of abnormal chest shadows. However, a chest CT scan obtained on admission failed to show bronchiectasis, but rather there was a dilation of blood vessels and low attenuation areas in both lower lobes. A pulmonary angiogram showed normal pulmonary arteries in the arterial phase and diffuse dilated veins in the venous phase. Although the patient also had liver cirrhosis type B with portal hypertension, no association could be found between his liver cirrhosis and the lung lesions. This is a rare case of possible congenital or idiopathic diffuse dilatation of the pulmonary veins.

Echocardiographic diagnosis of pulmonary vein varix

Pulmonary vein varix is a rare abnormality, often resembling a pulmonary or mediastinal mass on chest radiographs, and pulmonary angiography has been the mainstay of diagnosis. An unusual case of pulmonary vein varix was clearly defined by echocardiography performed in a 47-year-old woman with chest discomfort who had been found to have an abnormal structure behind the cardiac silhouette on a chest radiograph. The diagnosis of left lower pulmonary vein varix was noninvasively confirmed by transthoracic echocardiography and transesophageal echocardiography.

Large pulmonary vein varix diagnosed by transesophageal echocardiography: an unusual site for thrombus in atrial fibrillation

An elderly man with pulmonary vein varix and atrial fibrillation is described. The diagnosis of pulmonary varix, a localized dilatation of pulmonary vein, was made by transesophageal echocardiography. The patient had chronic atrial fibrillation, and transesophageal echocardiography demonstrated thrombus in the pulmonary varix. In patients with atrial fibrillation, pulmonary varix may be an unusual site for thrombus formation.

Pulmonary varices presenting as a solitary lung mass in a patient with end-stage liver disease

A man undergoing evaluation for liver transplantation was found to have an asymptomatic chest mass, which further evaluation revealed to be pulmonary varices. The left hilar lesion was discovered on a screening chest x-ray film and confirmed by a computed tomographic scan of the thoracic cavity. Bronchoscopy was nondiagnostic, and a thoracotomy was required to diagnose the vascular lesion and exclude carcinoma. The pathophysiology of this pulmonary venous anomaly appeared to be related to portal hypertension, since esophagogastric and colonic varices also were present and the pulmonary varices resolved after liver transplantation. This is the first reported case of pulmonary varices caused by portal hypertension.

Pulmonary varix: magnetic resonance findings

The magnetic resonance appearance of a confluent-type pulmonary varix is correlated with computed tomography and angiographic findings. This case demonstrates the usefulness of magnetic resonance in the evaluation of cardiovascular lesions.