CTICasesPulmonary Vein Occlusion after Pulmonary Vein Ablation with Pseudo-PE Phenomenon
Imaging findings
CT pulmonary angiography in a patient with prior radiofrequency ablation for atrial fibrillation demonstrates complete absence of left-sided pulmonary veins entering the left atrium consistent with bilateral pulmonary vein occlusion. The left lung shows septal thickening, chronic scarring, and round atelectasis from chronic venous obstruction. The left pulmonary artery demonstrates filling with unenhanced blood (smoke phenomenon) due to absent left venous outflow. On a repeat gated cardiac CT obtained for ablation planning, the smoke was misread as pulmonary embolism with propagation.
Key takeaways
Pulmonary vein stenosis or occlusion is a complication of radiofrequency ablation for atrial fibrillation. Obstructed pulmonary veins cause chronic unilateral or focal lung changes including septal thickening and round atelectasis. High resistance in the obstructed pulmonary vascular bed dramatically slows pulmonary artery flow, generating unenhanced blood (smoke) in ipsilateral pulmonary arteries that exactly mimics pulmonary embolism. 4D cardiac gating demonstrates the rhythmic ebb and flow of contrast-unenhanced blood within the obstructed system.
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