CTICasesIn-Situ Pulmonary Artery Thrombus after Radiation
Imaging findings
A woman in her 70s with imaging findings of pulmonary hypertension (enlarged pulmonary arteries, dilated right heart with septal bowing/flattening and mild RV hypertrophy) has extensive thrombus filling the left pulmonary artery, misinterpreted elsewhere as pulmonary artery dissection. She had definitive chemoradiation for a stage 2B non-small cell lung cancer in this region about two years earlier, with associated radiation scarring and airway narrowing, and no history of PE. Perfusion is preserved on the right but drops out on the left, and recanalization channels are seen within the clot.
Key takeaways
Unilateral in-situ pulmonary artery thrombus can develop in a previously irradiated territory and should not be mistaken for the exceedingly rare pulmonary artery dissection (essentially confined to trauma or iatrogenic causes). The extensive one-sided thrombus with recanalization, in the setting of prior radiation injury and pre-existing pulmonary hypertension, is best managed with anticoagulation rather than endarterectomy, unlike classic chronic thromboembolic disease.
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