대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Pulmonary Vein Varix with an Emphysematous

Radiologic Findings

Chest radiographs reveals 2 cm sized, well-defined, nodular density in left lower lobe. Preenhanced CT scan shows 2 cm sized, homogeneous, low density nodule with well-defined margin in left lower lobe. This nodule shows strong homogeneous enhancement identical to that of the adjacent pulmonary vein after contrast IV injection. A 3.7 cm sized bulla or air cyst is also noted in posterolateral portion of this nodule.

3D Gd-enhanced MRA and digital subtraction pulmonary arteriography demonstrates no abnormalities during the arterial phase but during the venous phase (fig 1b, 2b) revealed localized aneurysmatic dilatation of vein which drains into the left atrium through the inferior pulmonary vein. These are confirmative findings of pulmonary vein varix.

Brief Review

In the literature a pulmonary vein varix has been described as a rare lesion consisting of a focal pathological enlargement of a segmental pulmonary vein (1). This uncommon lesion usually presents as an asymptomatic, well-defined mediastinal or parenchymal mass on chest radiography (1).

Although most patients with pulmonary varices are asymptomatic, systemic embolization secondary to thrombosis of the varix, rupture of the varix into the pleural space or into a bronchus with hemoptysis could rarely occur (2). 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.

A pulmonary vein varix can be picked up on a routine chest radiography as a low-density, non-calcified opacity with well-defined edges. Because of resemblance to other lesions, such as malignant lung tumor, mediastinal or paramediastinal tumor (3), diagnostic work-up is important to avoid unnecessary investigations and surgical procedures. In the literature, the diagnosis of a pulmonary varix has been described using selective pulmonary angiography, computed tomography and magnetic resonance imaging. 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 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).

In the literature, there has been no report of a patient with a pulmonary vein varix which is associated with an emphysematous bulla. Yet there was one report described a case of a pulmonary artery aneurysm causing massive hemoptysis in a patient with bullous emphysema (5). In our case, it is not clear that the emphysematous bulla is an innocent bystander or an associated finding with the pulmonary vein varix
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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;13:411-413.

4. Godwin JD, Webb WR. Dynamic computed tomography in the evaluation of vascular lung lesions. Radiology 1981;138:629-635.

5. Bowler RP, Durham J, Schwarz MI. Massive hemoptysis from a pulmonary artery aneurysm associated with an emphysematous bulla. Chest 1998;113:1130-1131.

Keywords

Lung, Vascular, Vascular,