Radiologic Diagnosis of Heart Diseases

An Atlas of Cardiac X-rays

Part 2
Pulmonary vasculature

Dr. Khairy Abdel Dayem

Professor of Cardiology
Ain Shams University
 Content

Pulmonary vasculature
 The normal pulmonary vasculature
 Pulmonary congestion
 Pulmonary Plethora
 Pulmonary Oligemia
 Pulmonary embolism and Infarction
 Pulmonary Hypertension
 The Lung Fields
The Normal Pulmonary Vasculature

Characteristics of the Normal Pulmonary Vasculature

The normal pulmonary vessels include, (Fig. 11):

a) The pulmonary arterial tree starts at the hilum with the right and
left main pulmonary arteries. Each artery divides repeatedly until
very small terminal branches are seen in the peripheral third of the
lung fields.

b) The pulmonary veins drain the lung and end into four main
pulmonary veins that run alongside the arteries and open into the
left atrium.
 The pulmonary vessels to the lower lung fields are slightly larger than
those of the upper lung fields because gravity aids the flow of blood the
lower half of the lungs.

Fig. (11): Left: Normal distribution of pulmonary blood flow. Note that the vessels in the
lower lung zone (3) are larger than those of the upper lung zone (1).
Middle: Redistribution (inversion of flow) in case of pulmonary congestion.
Right: Increased but balanced flow distribution (pulmonary plethora) resulting
from left to right shunt
 c-The major pulmonary arteries accompany the major bronchi.
When seen in cross section they are equal in size.

Abnormalities in the Pulmonary Vasculature

Four types of pathological changes in the pulmonary vasculature
must be recognized:
A. Pulmonary Congestion (Fig. 12):
When the venous return from the lungs is interfered with,
pulmonary congestion results. The pressure in the pulmonary
veins and capillaries rises and this pressure elevation is
passively transmitted to the pulmonary artery raising its
pressure. Its most common causes are:
 Left ventricular failure
 Mitral stenosis
Fig. (12): Left: vasoconstriction of the pulmonary arterioles supplying the lung bases in
response to congestion (redistribution or cephalization of flow).
Right: Radiological signs of pulmonary congestion: (1) hilar veiling, (2) small
pleural effusions, (3) thickened transverse fissure, (4) Kerely’s B lines, (5)
dilated upper lobe veins, (6) hemosiderosis.
The X-ray shows the following:
1. Pulmonary arteriolar vasoconstriction occurs early and starts first in
the lower lobes of the lungs because congestion is more severe in the
base. The vasoconstriction diverts blood from the lower lobes to the
upper lobes. The lower lungs zones become more radiotranslucent in
the X-ray relative to the upper zone. The upper lobe veins dilate. This
is called redistribution or cephalisation of the pulmonary vasculature,
(Fig. 12, 13 & 14).
2. Transudation of fluid in the interstitial septa between lung lobules
renders them thick. They become visible in the X-ray as short
transverse lines near the base (Kereley’s B lines).
3. Transudation of fluid around the bronchi causes a radio opaque ring
around the air filled bronchus. This is called bronchial cuffing, (Fig.
15). Bronchi with thick congested walls may be seen along their
course as longitudinal lines running towards the hilum (Kereley’s A
lines).
Fig. (13): Pulmonary congestion: in a case mitral stenosis showing increased
translucency of both lung bases with dilated upper pulmonary veins (A)
Interstitial edema of the right hilum makes its components difficult to
recognize individually. Kerley’s B lines are apparent in the right costophrenic
angle.
Fig. (14): Pulmonary congestion in mitral valve disease showing: radiotransluscent
bases and dilated pulmonary veins draining the upper lobe.
Fig. (15): Left: the wall of normal bronchus is invisible or very thin.
Right: pulmonary congestion causing thickened bronchial wall
(bronchial cuffing)
4. In extreme cases transudation of fluid occurs in the pulmonary alveoli
and round the main bronchi causing picture of acute pulmonary edema
which characteristically results in butterfly opacities extending from the
hila of both lung fields, (Fig. 16 & 17).

Fig (16): Pulmonary edema in an adult shown diagrammatically (left) and PA

view of x-ray (right).
Fig. (17): Butterfly or bat-wing appearance of pulmonary edema in PA
view in an infant.
5. Pleural effusion may be seen as obliteration of right or left
costophrenic angles. Effusion may also fill the interlobar fissure
(interlobar effusion). When it is absorbed it leaves a thickened
transverse fissure (Fig. 18).
6. Multiple very small extravasations of red cells in the interstitial tissue
of the lungs lead to collections of hemosiderin particles resulting in
foreign body reaction. In the X-ray this is seen as miliary shadows in
both lung fields (hemosiderosis) (Fig. 19).

Fig. (18): Case of mitral stenosis and pulmonary Fig. (19): Mitral stenosis and pulmonary
congestion showing small pleural effusions in congestion showing miliary small nodules of
both costophrenic angles hemosiderosis
B. Pulmonary Oligemia:
The amount of blood flowing into the pulmonary vessels is reduced
in cases of:

 Pulmonary stenosis

 Pulmonary hypertension

 Pulmonary embolism

 Right ventricular failure

The X-ray signs consist of rapid or sudden narrowing (pruning) of

the peripheral branches of the pulmonary artery which become very
thin and invisible in the peripheral third of the lung fields. The lungs
become more radiotranslucent (Fig. 20). Pulmonary oligemia may be
accompanied by right ventricular enlargement and right atrial dilatation,
(Fig. 21).
Fig. (20): Valvular pulmonary stenosis showing pulmonary
oligemia and poststenotic dilatation of the pulmonary artery
Fig. (21): Pulmonary Oligemia: No vascular markings can be recognized in
the peripheral two thirds of the lung fields. The right ventricle and the
atrium are dilated
C. Pulmonary Plethora:
Increased arterial blood flowing in the lungs is called plethora. The
pulmonary vessels dilate to accommodate the excessive flow. When the
flow exceeds twice the normal the pulmonary blood pressure starts to
rise because of overfilling.

Pulmonary plethora always results from shunt of blood from the

arterial to the venous side of the circulation as in cases of:

 Atrial septal defect

 Ventricular septal defect

 Patent ductus arteriosus

X-ray Picture:
1. The main pulmonary artery and its branches in the hilum are
enlarged.
2. The peripheral pulmonary arteries are larger than normal and are
well seen in the outer third of lung field. When seen in cross section
the pulmonary artery is larger than accompanying bronchus, (Fig. 22
& 23).

Fig. (22): Pulmonary plethora in a case of

ventricular septal defect. A catheter
was introduced from an arm vein to
the superior vena cava then to the
right ventricle and through the defect
to the left ventricle and aorta. The
pulmonary arteries are over-filled.
Fig. (23): 3 degrees of severity of pulmonary plethora: mild
(a), moderate (b) and severe (c).
D. Pulmonary Embolism:
Small pulmonary emboli produce no pathological effects apart from
obstruction of small arteries in the lungs. Moderately large emboli may
produce pulmonary infarction that occurs only in 10% of cases because
the lungs have double blood supply from both the pulmonary artery and
the bronchial arteries. Massive pulmonary embolism may obstruct one
or both of the main pulmonary arteries (Fig. 24).

Fig. (24): Effects of pulmonary emboli of different

sizes: (1) single very small embolus, (2)
bigger emboli cause pulmonary infarction,
(3) massive embolus obstructing the main
pulmonary artery and its branches, (4)
repeated pulmonary emboli cause right
ventricular hypertrophy
The radiologic signs depend on the pathologic effects of the embolism,
Fig. (24):
a. There may be no radiologic signs in cases of small emboli.
b. Large emboli may cause abrupt cut-off or sudden tapering of one pulmonary
artery associated with radiotranslucency in the corresponding lung zone due
to absent or decreased blood flow (Westermark’s Sign).
c. Signs of pulmonary infarction are:
i. The infarcted area is seen in the X-ray either as a triangular radio-
opaque shadow with its base towards the chest wall and its apex at the
site of the embolus or as “Hampton’s Hump”: a homogenous, wedge-
shaped density in the peripheral field, convex to the hilum, Fig. (25).
ii. The copula of the diaphragm is high on the side of infarction.
iii. There may be a small pleural effusion.
iv. After healing, fibrosed and contracted infarction may show as a linear
opacity.
d. Signs of pulmonary hypertension and right ventricular enlargement.
 Fig. (25): Case of Pulmonary embolism causing pulmonary infarction. Hampton’s
Hump is seen in the lower zone of the right lung. The right copula or the diaphragm is
elevated and the right atrium is dilated
E. Pulmonary Hypertension:
The basic mechanism of pulmonary hypertension is increased
pulmonary vascular resistance. This can be due to one of the two main
causes:
1. Pulmonary arteriolor vasoconstriction which occurs most commonly
as a response to longstanding pulmonary venous congestion or to
increased pulmonary arterial flow (pulmonary plethora).
2. Organic obliteration or destruction of pulmonary arterioles causing
obstruction to blood flow. This may be:
a. Primary (primary pulmonary hypertension), or
b. Due to lung disease as extensive fibrosis or emphysema
(chronic obstructive pulmonary disease), or
c. Obliteration of pulmonary vessels by clots or emboli
(thromboembolic pulmonary hypertension) or bilharzia ova.
The X-ray may show the following, (Fig. 26):

1. Signs of pulmonary vasoconstriction and pulmonary oligemia.

These consist of narrowing of the peripheral branches of the
pulmonary artery which become very thin or even invisible in the
peripheral third of the lung fields. The lungs become more
radiotranslucent.

2. Dilatation of the main pulmonary artery and of its proximal

branches. The dilated main pulmonary artery is seen as a
prominence of the left border of the heart at the medial end of
the second left intercostal space anteriorly. Its main branches
are seen dilated in the hila.

3. Signs of right ventricular hypertrophy.

4. Right atrial dilatation causes outwards displacement of the right

border of the heart.
Fig. (26): Two cases of aneurysmal dilatation of the main pulmonary
artery and its right branch and pulmonary oligemia in bilharzial
pulmonary hypertension