Pulmonary endarterectomy (PEA) is the definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH) by surgically removing obstructive material from the pulmonary arteries to reduce vascular resistance and relieve pulmonary hypertension. During surgery, ‘subacute’ thrombosis (days to weeks old) may represent a significant surgical challenge due to its strong adherence to the intima of the segmental arteries. As there is no fibrotic organization of the material yet, it can be very difficult to remove this fragile material sticking to the intima like glue. Routine radiological tests to identify patients with such ‘subacute’ thrombosis are unavailable to date. Magnetic resonance direct thrombus imaging (MRDTI) is a state-of-the-art imaging tool to directly visualize acute thrombosis without administration of intravenous contrast. By using inversion recovery prepulses and inversion times tailored to the relaxation time of acute thrombus, thrombi can be clearly visualized within hours after thrombus formation. This technique has been shown to accurately differentiate chronic thrombotic remains from acute deep vein thrombosis, but has never been applied to patients with CTEPH. We succeeded in performing MRDTI of the pulmonary artery. Here, we present MRDTI of a 39-year-old CTEPH patient, assessed 1 day before surgery. The coronal MRDTI view with a positive signal in the left main pulmonary artery (indicated by white arrow, left panel) is demonstrated, that correlated 1:1 with `fresh clot' upon histological examination of the surgical specimen (right panel). Such a positive signal was absent in the right pulmonary artery branches where only chronic fibrotic lesions were surgically removed. Not only is this the first successful MRDTI of CTEPH, it also uniquely provides proof-of-concept of the applied technique. We consider MRDTI to be a potential key tool to guide optimal timing of PEA. The authors thank Prof. E. Meier (Kerckhoff-Klinik GmbH, Bad Nauheim, Germany) and Dr. L.J.M. Kroft (Leiden University Medical Center, Leiden, the Netherlands) for their valuable contribution to this report.
No takes yet. Share an insight, caveat, or question.
Klok et al. (2018) studied this question.