So, I'm going to start by saying, I'm going to focus on the art of pulmonary angiography in somebody who is being suspected of chronic thromboembolic pulmonary disease. So we're not talking about doing a PA gram in general for an AV fistula or, you know, so what not. We're going to start with an anatomy refresher. So this is a pulmonary angiogram, the right and left main PA as you see marked, the lobar branches after that, the segmental trunks, and the sub-segmental branches. Now I want to introduce this concept and these slides thanks to my friend Vladimir, the perfusion zone concept. Very, very important to understand the anatomy. So when it comes to understanding pulmonary angiography, you almost have to read them backwards. You have to first look at perfusion and then identify the blood vessel or the segment associated. The right upper lobe, so what you see here is, so you see an ipsilateral view and a contralateral view, ipsilateral view, lateral medial, contralateral, anterior, posterior. The right upper lobe apical, so A1 segment, A3 segment anterior, the middle lobe, so A4 is lateral, A5 is medial, lower lobe, A8 is anterior, A7 is medial, and then there is an area of overlap and that's why you need orthogonal views because otherwise you will not be able to open up these overlaps. A2 is posterior, A6 is superior segment of the right lower lobe, which is essentially the posterior aspect of the right middle lobe, and then you have the lateral and the posterior right lower lobe segments. In the left lung it's almost similar, it's just that the A1 and A2 are oftentimes a combined zone. A3 is anterior as in the right. The superior lingular segment corresponds to the lateral middle lobe segment on the right side, inferior lingular corresponds to the medial segment of the middle lobe on the right side, then you have the A6 same, and then you have the anteromedial A8. The A7 segment of the left lung is largely a diminutive branch of the A8 segment because that part of the chest on the left side is largely occupied by the heart. And then you have A9 and A10 as you have it on the right. So important to get these basics right. So this is how I report my pulmonary angiograms, especially when I'm doing these for CTED or CTEF evaluations. I want to make a comment about the venous return, I want to make a comment about the level of disease, and we'll get into the weeds of that soon. So let's do that. So first things first. So let's get the diagnosis right. I'm going to let these videos play. So let everybody stare at them for a second. You see these arteries being nicely opacified and then have these cutoffs and these large chunked out perfusion defect. Here, here, and here. This is classic chronic thromboembolic disease. How about this? So you see this haziness inside the lumen, but the perfusion beyond that is not as bad as you saw in the previous pictures. This is acute pulmonary embolism. This one and this one. This is chronic disease here, acute disease here, and chronic disease here. This is acute and chronic disease. These two conditions are not mutually exclusive, we have to remember. So you have acute, you have acute and chronic, and you have chronic. How about this? So the pulmonary arteries are opacifying, the blood vessels go out all the way distally, but you see the zone of hypovascularity all the way at the end across on both sides of the lung. This is group 1 pulmonary arterial hypertension, this is not obstruction, this is vasculopathy. Another key to this being vasculopathy is that the pulmonary artery is dilated and the right heart cath will prove it. How about this? So you see where my arrow is, why is this contrast going from the pulmonary vein to the left atrium to the right atrium? Because there is an ASD in there. You see this connection? That's an anomalous pulmonary vein. If a patient like this is going to the operating room and we missed this, it's a problem. It needs to be fixed in the OR at the same time as the pulmonary endarterectomy. This one is key. You see the true and faux motion of this mass or this clot-like thing sitting in the main pulmonary artery. This is a pulmonary artery intimal sarcoma. This is not a clot. This is not chronic disease. You can't miss this because it's a whole different operation, a whole entire treatment approach. What about this? This is normal. All right. Let's focus on chronic thromboembolic pulmonary hypertension. This is a surgical specimen. We have to learn two things, how to identify the level of disease on an angiogram, and how to further describe the lesion. The level of disease is important for surgical accessibility. It's obvious this is level 1. It's in the main pulmonary artery on the right and the left. Let's look at level 2. You see the disease in the lobar branches. Let's look at these. It extends out. The disease starts in the segmental branches. It's all about where the disease starts. It's not about where most of the disease is because the surgeon can start there and direct me to wherever the disease starts. This is 3. This is subsegmental branches all the way out. This is 4. Right and left main PA is level 1, lobar branch 2, segmental branch 3, subsegmental branch is 4. Pulmonary angioplasty planning is why you need to understand lesion types. So this is easy. This is pre- and post-angioplasty. This is what we call a focal lesion. You see the difference between the two pictures in the venous return in the background. And you see this haziness right where the tip of the guide is. This is what we call as an intravascular web, pre- and post-angioplasty. Now you see this here and see this now. This is pre- and post-. Again, this is a subtotal occlusion. And here is a classic example of a total occlusion, pre- and post. This is so very important to know. This is what we call as a diffuse disease associated with the highest risk of complications. We've got to be careful. So when we are so intervening in these. This is an example of how a pouch lesion. So in a patient who's had a pulmonary angioplasty So in a patient who's had a pulmonary endarterectomy and the surgeon was trying to take it out and lost the tail of the endarterectomy specimen in the segmental branch, it would look. Again, a high risk lesion if you're going to do an angioplasty here. So I end this by saying we want to learn this together. And we want everybody to get used to and get familiar with this. This is not too complicated. Sky has been kind enough to allow us to post these things on their website. And then we also have a YouTube series. So please take advantage of these things. And if you have interest and want to know more, feel free to reach out. Thank you. So this is what I do. So I use a 7 French high flow pigtail in most cases. Some people use the Berman catheter. That's also fine. I like the pigtail because I can take it over the wire. It's easier. And I don't think the pictures are any inferior. As far as the settings go, there's a paper by UCSD, so Larry Yang, and Shami Mahmood, and Smitul is on it in the Journal of Invasive Scardiology that has a whole table for the contrast settings. I don't follow that. I started out by describing the paper before somebody else says there's a paper about it. So what I do is I do 20 cc's per second for a total of 40 cc's per injection. I dilute my contrast 50-50. So if the patient has CKD or they are super thin, and I take four pictures. Shallow ipsilateral, meaning RAO 20 for the right lung, so LAO 20 for the left lung. And a steeper is contralateral, meaning so LAO 40-50 for the right and RAO 40-50 for the left. Some people would say, just do apilateral. And that's fine. You can do apilateral. But if you have to do angioplasty in that patient, you can't use that lateral image as your reference, so you want to soak in all that radiation. So that's what I do.

pulmonary angiography

chronic thromboembolic pulmonary disease

angiograms interpretation

pulmonary embolism

pulmonary arterial hypertension