Top

Pediatric Radiology

Published in:

01-09-2009 | Original Article

MDCT evaluation of pulmonary embolism in children and young adults following a lateral tunnel Fontan procedure: optimizing contrast-enhancement techniques

Authors: Sanjay P. Prabhu, Soran Mahmood, Laureen Sena, Edward Y. Lee

Published in: Pediatric Radiology | Issue 9/2009

Abstract

Background

Pulmonary embolism (PE) is a life-threatening thromboembolic complication in patients who have undergone a Fontan procedure for augmenting pulmonary blood flow in the setting of single-ventricle physiology. In patients following a Fontan procedure, lack of proper contrast agent mixing in the right atrium and sluggish, low-velocity blood flow within the Fontan circulation often results in suboptimal contrast enhancement within the pulmonary artery for evaluating PE. Unfortunately, there is a paucity of information describing the optimal contrast-enhancement technique with multidetector CT (MDCT) for evaluating PE in children and young adults following a Fontan procedure.

Objective

We illustrate the MDCT imaging findings of suboptimal contrast enhancement within the pulmonary artery, which can be mistaken for PE, in patients following a lateral Fontan procedure, and we discuss MDCT techniques to optimize contrast enhancement within the pulmonary artery in these patients for evaluating PE.

Materials and methods

The MDCT imaging findings in pediatric and young adult patients following a lateral Fontan procedure and with clinically suspected PE are illustrated. We describe intravenous contrast agent injection techniques that can be used to optimize the contrast enhancement in the pulmonary artery in patients following a lateral Fontan procedure.

Results

The use of a suboptimal contrast-enhancement technique led to initial misdiagnosis and incomplete evaluation of PE in the three patients following a lateral Fontan procedure. Imaging in two patients showed that optimal evaluation of thrombosis in the Fontan pathway and PE in the pulmonary arteries can be successfully achieved with simultaneous upper- and lower-limb injections of contrast agent.

Conclusion

This series demonstrates that suboptimal contrast enhancement can result in misdiagnosis or incomplete evaluation of PE in children and young adults following a lateral Fontan procedure. Careful attention to optimizing contrast enhancement during MDCT examination for evaluation of PE in these patients is essential to prevent misdiagnosis and incomplete evaluation.

Bull K (1998) The Fontan procedure: lessons from the past. Heart 79:213–214PubMed

Monagle P, Karl TR (2002) Thromboembolic problems after the Fontan operation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 5:36–47PubMedCrossRef

Varma C, Warr MR, Hendler AL et al (2003) Prevalence of ‘silent’ pulmonary emboli in adults after the Fontan operation. J Am Coll Cardiol 41:2252–2258PubMedCrossRef

Russo V, Piva T, Lovato L et al (2005) Multidetector CT: a new gold standard in the diagnosis of pulmonary embolism? State of the art and diagnostic algorithms. Radiol Med 109:49–61; quiz 62–63PubMed

Singh HR, Forbes TJ, Humes RA (2008) CT artifact mimicking pulmonary embolism in a patient with single ventricle. Pediatr Cardiol 29:241–242PubMedCrossRef

Fontan F, Baudet E (1971) Surgical repair of tricuspid atresia. Thorax 26:240–248PubMedCrossRef

Coon PD, Rychik J, Novello RT et al (2001) Thrombus formation after the Fontan operation. Ann Thorac Surg 71:1990–1994PubMedCrossRef

Dobell AR, Trusler GA, Smallhorn JF et al (1986) Atrial thrombi after the Fontan operation. Ann Thorac Surg 42:664–667PubMed

Fletcher SE, Case CL, Fyfe DA et al (1991) Clinical spectrum of venous thrombi in the Fontan patient. Am J Cardiol 68:1721–1722PubMedCrossRef

10.

Rosenthal DN, Friedman AH, Kleinman CS et al (1995) Thromboembolic complications after Fontan operations. Circulation 92(9 Suppl):II287–293PubMed

11.

Jacobs ML (2005) The Fontan operation, thromboembolism, and anticoagulation: a reappraisal of the single bullet theory. J Thorac Cardiovasc Surg 129:491–495PubMedCrossRef

12.

Monagle P, Cochrane A, McCrindle B et al (1998) Thromboembolic complications after fontan procedures − the role of prophylactic anticoagulation. J Thorac Cardiovasc Surg 115:493–498PubMedCrossRef

13.

Balling G, Vogt M, Kaemmerer H et al (2000) Intracardiac thrombus formation after the Fontan operation. J Thorac Cardiovasc Surg 119:745–752PubMedCrossRef

14.

Fyfe DA, Kline CH, Sade RM et al (1991) Transesophageal echocardiography detects thrombus formation not identified by transthoracic echocardiography after the Fontan operation. J Am Coll Cardiol 18:1733–1737PubMed

15.

Jahangiri M, Ross DB, Redington AN et al (1994) Thromboembolism after the Fontan procedure and its modifications. Ann Thorac Surg 58:1409–1413; discussion 1413–1414PubMed

16.

Gottschalk A, Sostman HD, Coleman RE et al (1993) Ventilation-perfusion scintigraphy in the PIOPED study. Part II. Evaluation of the scintigraphic criteria and interpretations. J Nucl Med 34:1119–1126PubMed

17.

The PIOPED Investigators (1990) Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 263:2753–2759CrossRef

18.

Wells PS, Ginsberg JS, Anderson DR et al (1998) Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 129:997–1005PubMed

19.

Qanadli SD, Hajjam ME, Mesurolle B et al (2000) Pulmonary embolism detection: prospective evaluation of dual-section helical CT versus selective pulmonary arteriography in 157 patients. Radiology 217:447–455PubMed

20.

Remy-Jardin M, Pistolesi M, Goodman LR et al (2007) Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology 245:315–329PubMedCrossRef

21.

Stein PD, Hull RD (2007) Multidetector computed tomography for the diagnosis of acute pulmonary embolism. Curr Opin Pulm Med 13:384–388PubMed

22.

Winer-Muram HT, Rydberg J, Johnson MS et al (2004) Suspected acute pulmonary embolism: evaluation with multi-detector row CT versus digital subtraction pulmonary arteriography. Radiology 233:806–815PubMedCrossRef

23.

Gosselin MV, Rassner UA, Thieszen SL et al (2004) Contrast dynamics during CT pulmonary angiogram: analysis of an inspiration associated artifact. J Thorac Imaging 19:1–7PubMedCrossRef

24.

Gotway MB, Patel RA, Webb WR (2000) Helical CT for the evaluation of suspected acute pulmonary embolism: diagnostic pitfalls. J Comput Assist Tomogr 24:267–273PubMedCrossRef

25.

Shannon FL, Campbell DN, Clarke DR (1986) Right atrial thrombosis: rare complication of the modified Fontan procedure. Pediatr Cardiol 7:209–212PubMedCrossRef

26.

Frush DP, Herlong JR (2005) Pediatric thoracic CT angiography. Pediatr Radiol 35:11–25PubMedCrossRef

27.

Greenberg SB, Bhutta ST (2008) A dual contrast injection technique for multidetector computed tomography angiography of Fontan procedures. Int J Cardiovasc Imaging 24:345–348PubMedCrossRef

28.

Stumper O, Sutherland GR, Geuskens R et al (1991) Transesophageal echocardiography in evaluation and management after a Fontan procedure. J Am Coll Cardiol 17:1152–1160PubMed

29.

Takawira F, Ayer JG, Onikul E et al (2008) Evaluation of the extracardiac conduit modification of the Fontan operation for thrombus formation using magnetic resonance imaging. Heart Lung Circ 17:407–410PubMedCrossRef

30.

Matsushita T, Matsuda H, Ogawa M et al (1990) Assessment of the intrapulmonary ventilation-perfusion distribution after the Fontan procedure for complex cardiac anomalies: relation to pulmonary hemodynamics. J Am Coll Cardiol 15:842–848PubMedCrossRef

31.

Pruckmayer M, Zacherl S, Salzer-Muhar U et al (1999) Scintigraphic assessment of pulmonary and whole-body blood flow patterns after surgical intervention in congenital heart disease. J Nucl Med 40:1477–1483PubMed

32.

Tayama M, Hirata N, Matsushita T et al (1999) Pulmonary blood flow distribution after the total cavopulmonary connection for complex cardiac anomalies. Heart Vessels 14:154–160PubMedCrossRef

Title: MDCT evaluation of pulmonary embolism in children and young adults following a lateral tunnel Fontan procedure: optimizing contrast-enhancement techniques
Authors: Sanjay P. Prabhu
Soran Mahmood
Laureen Sena
Edward Y. Lee
Publication date: 01-09-2009
Publisher: Springer-Verlag
Published in: Pediatric Radiology / Issue 9/2009
Print ISSN: 0301-0449
Electronic ISSN: 1432-1998
DOI: https://doi.org/10.1007/s00247-009-1304-8

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

MDCT evaluation of pulmonary embolism in children and young adults following a lateral tunnel Fontan procedure: optimizing contrast-enhancement techniques

Abstract

Background

Objective

Materials and methods

Results

Conclusion

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Objective

Materials and methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 9/2009

Loeys-Dietz syndrome

PET/CT of fibrodysplasia ossificans progressiva

Is juvenile liver biopsy unsafe? Putting an end to a common misapprehension

Pediatric radiology in the Philadelphia region: a history of pedigrees and legacies

Pituitary stalk duplication with intrasellar dermoid and herniation of the third ventricle

Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed?