대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Pulmonary Vein Varix associated with Mitral Valvular Disease

Radiologic Findings

Chest radiographs revealed a round mass in the left paravetebral area (arrows). Straightening of the left cardiac border just below the pulmonary artery, double contour of the right cardiac border, and elevation of the left main bronchus were also noted. Contrast-enhanced CT scan shows fusiform dilation of the proximal left lower lobe pulmonary vein.
Varix of the central left inferior pulmonary vein was confirmed by operation.

Brief Review

In the literature a pulmonary vein varix has been described as a rare lesion consisting of a focal pathological enlargement of a segment of a pulmonary vein (1). Histologic sections of the varix suggest no intrinsic defect in the structure of the varix wall. Most patients with pulmonary varices are asymptomatic and come to medical attention due to the finding of a mass on chest roentgenogram. Complications associated with pulmonary varix include cerebral embolism unnecessary thoracotomy, and rupture of the varix into the pleural space or into a bronchus with hemoptysis. Pulmonary vein varices usually remain stable in the absence of pulmonary hypertension. Acute increase in varix size is indicative of elevation of left atrial pressure (2). The most common cardiac abnormality associated with pulmonary varix is acquired mitral valve disease, evident in one third of reported cases (3). Appropriate management involves mitral valve replacement rather than surgery of the varix itself. In case of hemoptysis in non-cardiac reason of the varix, lobe section can be necessary. An appropriate diagnosis of pulmonary vein varix should therefore be established to prevent unnecessary thoracotomy. Most pulmonary varices involve the right lower lobe pulmonary vein with the left upper lobe vein next in frequency. A pulmonary vein varix can be picked up on a routine chest radiography as a low-density, non-calcified opacity with well-defined edges. It can simulate a malignant lung tumor, or a mediastinal or paramediastinal mass. Definitive diagnosis rests on the demonstration of the following features on pulmonary angiography: normal pulmonary arteries without shunting; normal filling of the veins feeding the varix; delayed but direct drainage of the varix into the left atrium; and limitation of the varicosity to the proximal portion of the vein. Because of less invasive nature of CT, dynamic bolus CT or single-slice helical CT could be good alternative diagnositic tools. The CT finding of pulmonary vein varix is dilated pulmonary vein opacifying simultaneously with the left atrium (4). The disadvantage of the CT technique is that only a part of the lung can be imaged during optimal contrast enhancement in one single breath hold. The newly introduced multi-slice helical CT makes it possible to examine the entire lung with thin slices during optimal enhancement in a single breath hold, allowing better depiction of the pulmonary vascular tree (2).

References

1. Wildenhain PM, Bourekas EC. Pulmonary varix: magnetic resonance findings. Catheterization and cardiovascular diagnosis. 1991;24:268-270.
2. Vanherreweghe E, Rigauts H, Bogaerts Y, Meeus L. Pulmoanry vein varix: diagnosis with multi-slice helical CT. European radiology. 2000;10:1315-1317.
3. Narula J, Talwar KK, Bharani S, Mukhopadhyaya M, Rajani M, Bhatia ML. Pulmoanry varix associated with mitral valve disease. Catheterization and cardiovascular Diagnosis. 1987;13:411-13.
4. Godwin JD, Webb WR. Dynamic computed tomography in the evaluation of vascular lung lesions. Radiology. 1981;138:629-635.

Keywords

Vascular, Vascular,