Wittram et al.

C a rd i a c I m ag i n g • P i c t o r i a l E s s ay
Angiography and CT of
Pulmonary Emboli
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A C E N T U
R Y O F Acute and Chronic Pulmonary
Emboli: Angiography–CT
MEDICAL IMAGING
Correlation
Conrad Wittram1 OBJECTIVE. The objective of our study was to review the classic direct and indirect angio-
Mannudeep K. Kalra graphic signs of acute and chronic pulmonary embolism (PE) and correlate these findings with MDCT.
Michael M. Maher CONCLUSION. CT and angiography have complementary roles in the accurate diagno-
Alan Greenfield sis of acute and chronic thromboembolic disease. Conventional angiography should be used as
Theresa C. McLoud a problem-solving technique after CT angiography has been performed because CT angiogra-
phy is less invasive.
Jo-Anne O. Shepard
Wittram C, Kalra MK, Maher MM, Greenfield ulmonary embolism (PE) is the consequences of a false-positive or false-
A, McLoud TC, Shepard J-AO
P third most common acute cardio-
vascular disease, after myocar-
dial infarction and stroke, and is
negative diagnosis can be rapidly fatal. In
this pictorial essay, we review the classic
pulmonary angiographic findings of acute
a major public health problem [1]. Accurate and chronic PE and correlate these signs
diagnosis of PE is important because the with MDCT.

Keywords: cardiovascular disease, conventional

angiography, CT angiography, embolism, lung,
thromboembolic disease

DOI:10.2214/AJR.04.1955

Received December 23, 2004; accepted after revision

March 14, 2005.

1All authors: Department of Thoracic Radiology,

Massachusetts General Hospital, Founders 202, 55 Fruit St.,

Boston, MA 02115; and Harvard Medical School, Boston,
MA. Address correspondence to C. Wittram A B
(cwittram@partners.org). Fig. 1—Acute pulmonary embolism (PE) in 78-year-old woman.
A, Pulmonary angiogram of right pulmonary artery shows complete obstruction of right posterior basal segmental
AJR 2006; 186:S421–S429 artery. Trailing edge or concave filling defect (arrow) is shown within column of contrast material. Perfusion defect
within right posterior basal segment artery (arrowhead) is also detected.
0361–803X/06/1866–S421 B, Illustration of complete obstruction due to acute PE as seen on angiography. Trailing edge of thrombus forms
concave filling defect within column of contrast material at level of obstruction.
© American Roentgen Ray Society (Fig. 1 continues on next page)

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C D
Direct Signs of Acute PE
Complete Obstruction
On pulmonary angiograms, the diagnostic
sign of acute PE with complete obstruction is a
concave filling defect or “trailing edge” that
should be seen within the contrast material at
the level of the obstruction [2, 3] (Fig. 1). CT is
able to show thrombus distal to the obstruction
that cannot be seen on an angiogram. At the site
of the thrombus, the diameter of the pulmonary
artery may be increased because of impaction
of the thrombus by pulsatile flow [4] (Fig. 1).
Nonobstructive Filling Defect
A nonobstructive filling defect may be
central or eccentric in location. On angiog-
S422
Wittram et al.
raphy, a central filling defect is completely
surrounded by contrast material [2, 3]
(Fig. 2). On CT, this finding is seen as a
well-defined central filling defect in either
an axial or a longitudinal plane with respect
to the vessel [4] (Fig. 2).
A nonobstructive central filling defect
cannot float within the center of the lumen
without physically touching the vessel wall
and will be attached to either a nonobstruc-
tive eccentric filling defect or the thrombus
of complete obstruction. In acute PE, a non-
obstructing eccentric filling defect forms
acute angles with respect to the vessel wall
when seen on angiography or CT [4]
(Fig. 2).
Fig. 1 (continued)—Acute pulmonary embolism (PE) in
78-year-old woman.
C, Curved coronal reformatted CT image shows acute
thrombus within right posterior basal segment and
branch vessels (arrow). Obtained more distal to
obstruction, this CT image is able to show expansion of
vessel with acute thrombus (arrowheads).
D, Illustration of coronal reformatted CT image of acute
PE shows expansion of diameter of involved vessel
distal to point of obstruction (arrow).
E, Axial CT image shows impacted thrombus distal to
point of occlusion (arrow) that expands vessel
diameter.
Indirect Sign of Acute Thromboembolic
Disease: Nonuniform Arterial Perfusion
Oligemia, or a decrease in flow rate, due
to acute PE is often identified on angiogra-
phy [2, 3] (Fig. 1A). In our experience, this
finding is more often seen on angiography
than on CT. Nonuniform arterial perfusion
due to acute PE can uncommonly manifest
as a mosaic pattern of attenuation on CT.
Occasionally, a large acute central PE can
cause oligemia and a decrease in vessel di-
ameter, which is reversible, can be seen on
CT (Fig. 3). The differential diagnosis of
the indirect radiologic sign of nonuniform
pulmonary arterial perfusion consists of
congenital or acquired causes including
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 Angiography and CT of Pulmonary Emboli
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A B C

D E F
Fig. 2—Acute pulmonary embolism (PE) in 78-year-old woman (same patient as shown in Fig. 1).
A, Left pulmonary angiogram shows central filling defect (arrow) within posterior segment of left upper lobe. In this patient, all three segmental arteries of left upper lobe
arise directly from main pulmonary artery. Nonuniform arterial perfusion (arrowhead) is seen on arteriogram.
B, Curved coronal reformatted CT image shows central nonobstructive filling defect (arrow). CT also shows more proximal nonobstructive thrombus (arrowhead) within main
pulmonary artery, more easily seen on CT than on angiogram (A).
C, Illustration shows that eccentric acute thrombus (arrow) makes acute angles with vessel wall.
D, Axial CT image shows central filling defect within posterior segmental artery (arrow) of left upper lobe.
E, Illustration shows acute PE central filling defect on CT image viewed perpendicular to plane of thrombus; well-defined central thrombus is completely surrounded by
contrast material.
F, Illustration shows acute PE central filling defect on CT image viewed in long axis of thrombus. Contrast material can be seen on either side of well-defined thrombus forming
the “railroad track sign.”
(Fig. 2 continues on next page)

chronic PE, emphysema, infection, com- Direct Signs of Chronic PE with respect to the contrast material and has
pression or invasion of a pulmonary artery, Complete Obstruction been described as a “pouch” defect [5]
atelectasis, pleuritis, and pulmonary venous On angiography, complete vessel cutoff (Fig. 4). This differs from the appearance of a
hypertension [2]. due to chronic embolism has a convex margin complete obstruction caused by acute PE in

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 Wittram et al.

Fig. 2 (continued)—Acute pulmonary embolism (PE) in

78-year-old woman (same patient as shown in Fig. 1).
G, Axial CT image, obtained more cephalad than D,
shows eccentric filling defect within pulmonary artery
(arrow).
H, Illustration shows acute PE eccentric filling defect on
CT image viewed perpendicular to plane of thrombus;
well-defined thrombus (arrow) forms acute angles with
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vessel wall.

G H

Fig. 3—Acute pulmonary embolism in 55-year-old man.

A, Right pulmonary artery angiogram shows large filling defect in right pulmonary
artery (arrow). Nonuniform arterial perfusion is shown affecting majority of right lung
with sparing of anterior segmental artery of right upper lobe. There is reflux of
contrast material into left pulmonary artery. Unusual pulmonary artery catheter
course due to azygos continuation of anomalous inferior vena cava is also seen.
B, CT image obtained distal to large thrombus shows pulmonary arteries to have
decreased in vessel diameter (arrows) with respect to adjacent bronchi and
contralateral vessels.
C, Obtained 3 weeks after embolectomy, CT image shows pulmonary arteries
(arrows) have returned to their normal diameter.
A

B C

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A B C

Fig. 4—Chronic pulmonary embolism (PE) in 40-year-old woman.

A, Angiogram shows complete obstruction (arrows) is affecting subsegmental vessels of posterior segment of left
upper lobe and anterior and posterior basal segmental arteries. Resultant nonuniform arterial perfusion
(arrowheads) is also well shown.
B, Line drawing shows complete obstruction of vessel with convex margin with respect to contrast material. This
is the “pouch” defect of chronic PE seen on angiography.
C, Curved coronal reformatted CT image viewed on lung windows shows pouch defect of anterior basal segment
of right lower lobe (arrow). Contracted artery (arrowheads) is smaller than adjacent bronchus.
D, Illustration of reformatted CT image of complete obstruction in chronic PE shows contracted thrombus (arrow)
distal to pouch defect.
D

that a concavity can be seen within the con-
trast material due to the trailing edge of
thrombus [2] (Fig. 1B). On CT, an additional
finding is a decrease in the diameter of the
vessel distal to the complete obstruction [4].
This permanent reduction in vessel diameter
is due to contraction of thrombus in chronic
PE (Figs. 4C and 4D).
Nonobstructive Filling Defects
The organized thrombus of chronic PE can
cause intimal irregularities, bands and webs,
and abrupt vessel narrowing; any of these can
lead to a pulmonary artery stenosis.
Intimal Irregularities
Intimal irregularities are broad-based,
smooth, margined abnormalities that create

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 Wittram et al.

obtuse angles with the vessel wall. They
may be unilateral or bilateral [4–6] (Fig. 5).
Pulmonary artery intimal irregularities can
also be due to plaques secondary to pulmo-
nary hypertension.
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Abrupt Vessel Narrowing
Abrupt vessel narrowing, often the result
of recanalization, manifests angiographi-
cally as an abrupt convergence of contrast
material that leads to a thin column of intra-
vascular contrast material distally [5]. This
include mycotic aneurysms secondary to sep-
tic emboli or adjacent pulmonary infection,
pseudoaneurysms resulting from extra- or en-
dovascular trauma (e.g., pulmonary artery
catheterization), Behçet disease, and Taka-
yasu’s arteritis.

Bands and Webs nonreversible finding can also be detected

A band is defined as a delicate ribbonlike
structure anchored to the vessel wall at two
ends with a free unattached mid portion. A
band generally ranges from 0.3 to 2 cm in
length and from less than 0.1 to 0.3 cm in
width. It is often orientated in the direction of
blood flow along the long axis of the vessel
[7]. A web is a descriptive term for bands that
have branches and form networks of varying
complexity [7]. Bands and webs are seen as
thin lines surrounded by contrast material on
angiography [5] or CT (Fig. 6).
on CT images, which can be used to identify
the cause of the stenosis [4] (Fig. 7).
Indirect Signs of Chronic
Thromboembolic Disease
Poststenotic Dilatation
Poststenotic dilatation or aneurysm com-
monly occurs as a manifestation of chronic
thromboembolic disease [5] (Figs. 5A, 5B,
and 5D). The differential diagnosis includes
congenital causes—for example, Marfan syn-
drome—or acquired causes. Acquired causes
Tortuous Vessels
Tortuous pulmonary vessels have been
well described in patients with pulmonary ar-
tery hypertension. This radiologic sign is also
seen in patients with pulmonary artery hyper-
tension secondary to chronic thromboembo-
lic disease [8] (Figs. 5A and 5B).
Enlargement of the Main Pulmonary Artery
Enlargement of the main pulmonary ar-
tery, greater than 33 mm [9], occurs in pa-
tients with precapillary, capillary, and post-

A B
Fig. 5—Chronic pulmonary embolism (PE) in 60-year-old man.
A, Right pulmonary angiogram shows multiple intimal irregularities (straight arrows). Poststenotic dilatation (arrowhead) is shown affecting posterior segment of right upper
lobe. Also noted within right lower lobe is tortuous vessel (curved arrow).
B, Coronal reformatted CT image shows organized thrombus (arrows) as cause of intimal irregularities. In addition, poststenotic dilatation (arrowhead) is shown affecting
posterior segmental artery. Again shown within right lower lobe is tortuous vessel (curved arrow).
(Fig. 5 continues on next page)

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C D

E F
Fig. 5 (continued)—Chronic pulmonary embolism (PE) in 60-year-old man.
C, Illustration of intimal irregularity of chronic PE as seen on angiography. This broad-based, smooth, margined abnormality can affect one or both sides of vessel; it forms
obtuse angles with vessel wall (arrow).
D, Axial CT image obtained at level of poststenotic aneurysm shows that posterior segment of right upper lobe (arrow) is affected.
E, Axial CT image obtained at level of right lower lobe pulmonary artery shows eccentric chronic thrombus (arrow).
F, Illustration of intimal irregularity of chronic PE viewed in axial plane. This broad-based, smooth, margined, eccentric filling defect forms obtuse angles with vessel wall (arrow).

capillary causes of pulmonary artery
hypertension. This radiologic finding is
commonly identified in patients with pulmo-
nary artery hypertension secondary to
chronic thromboembolic disease [8].
Enlargement of Bronchial Arteries
Enlarged bronchial arteries are often identi-
fied in patients with chronic thromboembolic
disease. Other causes of this finding include con-
genital vascular anomalies, bronchiectasis, acute
or chronic lung abscesses, and mycobacterial
and fungal infections. Enlargement of the bron-
chial artery collateral supply is easily seen on CT
angiography but cannot be identified on conven-
tional angiography of the pulmonary artery.
Nonuniform Arterial Perfusion
Chronic PE can cause a nonuniform arterial
perfusion pattern identifiable on angiography
and can manifest as a mosaic pattern of lung at-
tenuation on CT [4] (Fig. 8). In addition, on CT
one can see that the affected pulmonary arteries
are permanently small relative to the accompa-
nying bronchi [4, 6] (Figs. 4C and 8B) and that
unaffected arteries are often larger than their ac-
companying bronchi. The mosaic pattern of
lung attenuation has two other major causes:
small airways disease, in which the mosaic pat-
tern of lung attenuation is accentuated by expi-
ratory CT, and ground-glass opacification, in
which it is not.
Summary
The direct radiologic signs, shown on an-
giography or CT angiography, are required to
make the diagnosis of acute or chronic pulmo-
nary thromboembolic disease. The indirect
signs are helpful as indicators of the sites of the
direct radiologic signs of PE. Both CT angiog-
raphy and angiography have complementary

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 Wittram et al.
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A B C
Fig. 6—Chronic pulmonary embolism (PE) in 51-year-old man.
A, Oblique view of left-sided pulmonary angiogram shows abrupt vessel narrowing (arrow) and complete obstruction of posterior basal segment of left lower lobe
(arrowhead). It was difficult to see vascular band or web in this patient.
B, Axial CT image obtained near origin or posterior basal segmental artery of left lower lobe shows band or web (arrow).
C, Illustration of nonobstructive filling defect of chronic PE. Band or web can be identified as thin dark line surrounded by contrast material, often orientated in direction of blood flow.

Fig. 7—Chronic pulmonary embolism (PE) in 65-year-old man.

A, Abrupt vessel narrowing (arrow) is shown affecting posterior basal subsegmental artery of right lower lobe.
B, Curved coronal CT image shows similar appearance, with abrupt convergence of contrast material leading to
thin column of more distal intravascular contrast material. In addition, organized thrombus (arrows) is identified
adjacent to column of contrast material.
C, Illustration of abrupt vessel narrowing of chronic PE as seen on angiography. This finding is recognized by
abrupt convergence of contrast material leading to thin column of intravascular contrast material.

A B C

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A B
Fig. 8—Chronic pulmonary embolism in 60-year-old man.
A, Left-sided pulmonary angiogram shows complete occlusion of left lower lobe with nonuniform arterial perfusion and large perfusion defect affecting left lower lobe
(arrowheads).
B, Axial CT image viewed on lung window settings shows occluded, contracted left lower lobe pulmonary artery (arrowhead). There is decrease in lung attenuation of left
lower and right upper lobes, and more normally perfused lung contributes to mosaic pattern of lung attenuation (arrows). Incidental note is made of centrilobular emphysema.

roles in the accurate diagnosis of acute and
chronic thromboembolic disease. Conventional
angiography should be used as a problem-solv-
ing technique after CT angiography because
CT angiography is less invasive.
Acknowledgments
We thank Susan Loomis for the illustra-
tions and Sally Pinho for the image recon-
struction processing.
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