Journal of Veterinary Cardiology (2015) -, -e-

www.elsevier.com/locate/jvc

Pulmonary artery dissection in eight dogs

with patent ductus arteriosus*
Brian A. Scansen, DVM, MS a,*, Elaine M. Simpson, DVM a,h,
Jordi López-Alvarez, LltVet, MRCVS b,c,
William P. Thomas, DVM d, Janice M. Bright, BSN, MS, DVM e,
Bryan D. Eason, DVM f, John E. Rush, DVM, MS g,
Joanna Dukes-McEwan, BVMS, MVM, PhD, MRCVS b,
Henry W. Green III, DVM f, Suzanne M. Cunningham, DVM g,
Lance C. Visser, DVM, MS a,i, Agnieszka M. Kent, DVM, MS a,j,
Karsten E. Schober, DVM, PhD a
a
Department of Veterinary Clinical Sciences, The Ohio State University College of
Veterinary Medicine, Columbus, OH, USA
b
Small Animal Teaching Hospital, School of Veterinary Science, University of Liverpool,
Leahurst, Chester High Road, Neston, Cheshire, UK
c
Department of Clinical Science and Services, Royal Veterinary College, London, UK
d
Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of
California-Davis, Davis, CA, USA
e
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical
Sciences, Colorado State University, Fort Collins, CO, USA
f
Department of Veterinary Clinical Sciences and the Veterinary Teaching Hospital,
College of Veterinary Medicine, Purdue University, West Lafayette, IN, USA
g
Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts
University, North Grafton, MA, USA

Received 12 September 2014; received in revised form 4 December 2014; accepted 5 December 2014

*
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unique to this paper which is indicated at the end of the manuscript.
* Corresponding author.
E-mail address: scansen.2@osu.edu (B.A. Scansen).
h
Dr. Simpson’s current address is: Veterinary Teaching Hospital, Colorado State University, Fort Collins, CO, USA.
i
Dr. Visser’s current address is: Department of Medicine & Epidemiology, School of Veterinary Medicine, University of California-
Davis, Davis, CA, USA.
j
Dr. Kent’s current address is: Newtown Veterinary Specialists, Newtown, CT, USA.

http://dx.doi.org/10.1016/j.jvc.2014.12.001
1760-2734/ª 2014 Elsevier B.V. All rights reserved.

Please cite this article in press as: Scansen BA, et al., Pulmonary artery dissection in eight dogs with patent ductus arteriosus,
Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
2 B.A. Scansen et al.

KEYWORDS Abstract Objectives: To describe a series of dogs with pulmonary artery dissec-
Angiography; tion and patent ductus arteriosus (PDA).
Canine; Animals: Eight dogs.
Congenital heart dis- Methods: Retrospective case series.
ease; Results: Pulmonary artery dissection was diagnosed in 8 dogs, 3 were Weimaraners.
Echocardiography Four dogs presented in left-sided congestive heart failure, 4 presented for murmur
evaluation and without clinical signs, and 1 presented in right-sided congestive
heart failure. In 7 dogs the dissection was first documented concurrent with a diag-
nosis of uncorrected PDA. In the other dog, with pulmonary valve stenosis and PDA,
the dissection was observed on autopsy examination 17 months after balloon pul-
monary valvuloplasty and ductal closure. Median age at presentation for the 7 dogs
with antemortem diagnosis of pulmonary artery dissection was 3.5 years (range,
1.5e4 years). Three dogs had the PDA surgically ligated, 2 dogs did not undergo
PDA closure, 1 dog failed transcatheter occlusion of the PDA with subsequent sur-
gical ligation, 1 dog underwent successful transcatheter device occlusion of the
PDA, and 1 dog had the PDA closed by transcatheter coil delivery 17 months prior
to the diagnosis of pulmonary artery dissection. The 2 dogs that did not have the
PDA closed died 1 and 3 years after diagnosis due to heart failure.
Conclusions: Pulmonary artery dissection is a potential complication of PDA in dogs,
the Weimaraner breed may be at increased risk, presentation is often in mature
dogs, and closure of the PDA can be performed and appears to improve outcome.
ª 2014 Elsevier B.V. All rights reserved.

causes (cardiac catheterization or angiography),

Abbreviations
ACDO Amplatz Canine Duct Occluder
PDA patent ductus arteriosus
RVp right ventricular pressure
Introduction
Dissection of an elastic artery, such as the aorta or
pulmonary artery, is defined as a tear in the tunica
intima and subsequent infiltration of blood into the
vessel wall, resulting in separation of tunica intima
from the tunica media.1 The incidence of aortic
dissection in people is reported as 3e5 per 100,000
humans in western countries, with chronic hyper-
tension representing the underlying cause in w75%
of cases.1 In small animal medicine, sporadic case
reports exist of aortic dissection in hypertensive
cats,2,3 2 dogs suspected to have elastin dyspla-
sia,4 an older dog with an aortic aneurysm,5 and in
a dog secondary to tumor infiltration.6
In humans, pulmonary artery dissections appear
to be rarer than aortic dissections. Fewer than 100
human cases of pulmonary artery dissection have
been described, with most diagnosed post-
mortem.7,8 Pulmonary artery dissections in people
result from chronic pulmonary hypertension in
nearly all reported cases (either primary or secon-
dary to congenital heart disease) although iatrogenic
infection, inflammatory disease, or Marfan’s syn-
drome have also been described as potential etiol-
ogies.8,9 Three prior descriptions of pulmonary
artery dissection in the dog have all been associated
with concurrent aortic dissection.6,10,11 Recently, a
pulmonary artery dissection was appreciated in a
dog with an anomalous vessel between the ascending
aorta and main pulmonary artery.12 The aim of this
case series is to describe pulmonary artery dissection
in 8 dogs, each with a patent ductus arteriosus (PDA).
Animals, materials and methods
Case records from 8 dogs with echocardiographic,
angiographic, or autopsy diagnoses of pulmonary
artery dissection were retrospectively reviewed from
7 different veterinary hospitals throughout the Uni-
ted States and United Kingdom. Case details, imaging
findings, treatment attempted, and outcome (if
available) were compiled for all dogs (Table 1).
Results
Signalment and clinical presentation
The signalment and clinical details for the 8 cases
of this report are listed in Table 1. All of the dogs

Please cite this article in press as: Scansen BA, et al., Pulmonary artery dissection in eight dogs with patent ductus arteriosus,
Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
 Table 1 Case information from 8 dogs with pulmonary artery dissection and patent ductus arteriosus.

Pulmonary artery dissection in dogs

Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
Please cite this article in press as: Scansen BA, et al., Pulmonary artery dissection in eight dogs with patent ductus arteriosus,

Case number 1 2 3 4 5 6 7 8
Breed Boston Terrier Weimaraner Shih Tzu Weimaraner Mixed breed Weimaraner Bearded Collie Cavalier King
Charles spaniel
Gender Male castrated Male castrated Female spayed Male intact Female spayed Female spayed Female spayed Male intact
Age at 4 3.5 1.5 3.5 2.5 4 3 0.4; PA
presentation dissection
(years) diagnosed at 1.8
years of age
Weight (kg) 10.9 43.3 4 33.5 15.2 23.2 16.7 4.6
Presenting Murmur Labored Labored Labored Ascites Lethargy; Murmur Murmur
complaint evaluation breathing breathing breathing murmur evaluation evaluation
evaluation
Auscultation Grade IV/VI left Grade V/VI left Grade V/VI left Grade V/VI left Grade III/VI left Grade IV/VI left Grade IV/VI left Grade V/VI left
basilar basilar basilar basilar basilar systolic basilar basilar basilar
continuous continuous continuous continuous murmur continuous continuous continuous
murmur, Grade murmur; S3 murmur murmur murmur murmur murmur
III/VI systolic gallop
right-sided
murmur
Femoral pulse Hyperkinetic Hyperkinetic Hyperkinetic Hyperkinetic Hyperkinetic Hyperkinetic Hyperkinetic Hyperkinetic
quality
Diagnostics TTE, TEE, TXR, TTE, TEE, TXR, TTE, TEE, TXR, TTE, TXR, TTE, TXR, TTE, TXR, TTE TTE, TXR,
performed cardiac cath cardiac cath cardiac cath cardiac cath, cardiac cath cardiac cath cardiac cath
CTA
Additional Overcirculation L-CHF L-CHF L-CHF ReCHF; None
Pulmonary Pulmonary valve
findings of right lung hypovascularity hypertension stenosis (severe)
lobes on TXR of left lung lobes (estimated 61/
41 mmHg)
Therapy None Transcatheter Surgical ligation Surgical ligation Transcatheter Surgical ligation None Transcatheter
attempted ACDO failed; ACDO placed coil; balloon
surgical ligation pulmonary
successful valvuloplasty
Outcome Euthanized for Resolution of LV No PDA flow Alive, no ReCHF resolved Resolution of LV Euthanized for Died suddenly at
L-CHF 3 years volume overload noted post- symptoms 4 with ACDO and volume overload ReCHF 1 year home 17 months
after diagnosis after ligation; operatively; lost years after medical after ligation; after diagnosis after diagnosis;
alive and to follow-up surgery therapy; alive asymptomatic 1 PA dissection
without and without year after noted on
symptoms 4 symptoms 4 diagnosis; lost to autopsy
years after months after further follow-
surgery diagnosis up
ACDO ¼ Amplatz Canine Duct Occluder; Cath ¼ catheterization; CTA ¼ computed tomography angiography; L-CHF ¼ left-sided congestive heart failure; LV ¼ left ventricle;
PA ¼ pulmonary artery; PDA ¼ patent ductus arteriosus; ReCHF ¼ right-sided congestive heart failure; TEE ¼ tranesophageal echocardiography; TTE ¼ transthoracic echocardiography;

3
TXR ¼ thoracic radiographs.
4 B.A. Scansen et al.

presented in this report were young to middle age. Echocardiographic studies

The 7 dogs diagnosed with pulmonary artery dis-
section at the time of presentation had a median
age of 3.5 years, ranging from 1.5 to 4 years in age.
Breeds affected included 3 Weimaraners, and 1
each of Boston terrier, Shih Tzu, Bearded Collie,
Cavalier King Charles spaniel, and mixed breed.
Reasons for cardiac evaluation were respiratory
signs secondary to left-sided congestive heart
failure (cases 2, 3, 4) or murmur evaluation (cases
1, 6, 7, 8). One dog presented for evaluation of
ascites and right-sided congestive heart failure
(case 5). The gender distribution was equal, with 4
male and 4 female.
Cardiac auscultation revealed a continuous
heart murmur at the left base in all cases, except
the dog in right heart failure (case 5), which
presented with a systolic left basilar heart mur-
mur. In all dogs the femoral pulse quality was
hyperkinetic.
Thoracic radiography
Thoracic radiographs were performed in all cases,
revealing left heart enlargement, pulmonary over
circulation, and dilation of the main pulmonary
artery segment. In 2 cases (cases 1 and 5), hypo-
perfusion of the left lung lobes was suspected with
increased perfusion to the right lung (Fig. 1). Pul-
monary edema secondary to left-sided congestive
heart failure was noted in 3 cases (cases 2, 3, 4).
Transthoracic echocardiography revealed the
presence of a left-to-right shunting PDA in all dogs,
except for case 5 in which the PDA was diagnosed
during diagnostic catheterization. In each of the 7
dogs with antemortem diagnosis of pulmonary
artery dissection, turbulent flow was noted to
enter the main pulmonary artery, but not reach
the pulmonary valve due to a dissecting membrane
and aneurysmal false lumen (Fig. 2; Video 1). In
cases 1 through 7, the membrane resulted in a
variable degree of supravalvular pulmonary
stenosis, which in case 5 resulted in right ven-
tricular hypertrophy, septal flattening, right atrial
dilation, and the presenting clinical signs of right-
sided congestive heart failure. Antegrade flow
through the true lumen of the main pulmonary
artery into the branch pulmonary arteries was
variably obstructed, preferentially directed
toward the right branch pulmonary artery due to
the dissecting membrane (Fig. 2, Video 1). In case
8, the presenting echocardiogram did not identify
a dissecting membrane, rather, this dog was diag-
nosed with pulmonary valve stenosis characterized
by a thickened, doming, and fused valve with a
peak instantaneous systolic pressure gradient
across the pulmonary valve of 150 mmHg. Color
flow and spectral Doppler were not suggestive of
pulmonary hypertension except in case 7, with
peak tricuspid regurgitation velocity estimating a

Figure 1 Right lateral (A) and ventrodorsal (B) thoracic radiographs from a 4-year-old Boston terrier (case 1) with
pulmonary artery dissection. Note the mild left atrial enlargement, prominence of the aortic isthmus (arrow), and
increased vascularity of the right lung as compared to the left.

Please cite this article in press as: Scansen BA, et al., Pulmonary artery dissection in eight dogs with patent ductus arteriosus,
Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
Pulmonary artery dissection in dogs 5

Figure 2 Right parasternal short axis echocardiographic images from 4 dogs with pulmonary artery dissection. The
dissecting membrane is shown by the arrow (A, C, E, F). Panels A & B: Gray scale (A) and color Doppler (B) images from
a 4-year-old Boston terrier (case 1) showing laminar flow (blue) across the pulmonary valve and left-to-right turbulent
flow (green) from the patent ductus arteriosus (PDA) entering the false lumen of the pulmonary artery dissection.
Panels C & D: Gray scale (C) and color Doppler (D) images from a 3-year-old Bearded Collie (case 7) showing laminar
flow (blue) within the true lumen of the pulmonary artery and turbulent left-to-right flow (red-green) from the PDA
entering the false lumen of the pulmonary artery dissection. Panel E: Gray scale image from a 1.5-year-old Shih Tzu
(case 3) showing a large aneurysmal false lumen (FL) nearly obstructing the true lumen of the pulmonary artery. Panel
F: Gray scale image from a 2.5-year-old mixed breed dog (case 5) with pulmonary artery dissection after placement of
an Amplatz Canine Duct Occluder (arrowhead) into the ductal ampulla with the pulmonary artery disc within the
false lumen of the pulmonary artery. Ao ¼ aortic valve; PV ¼ pulmonary valve.

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Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
6 B.A. Scansen et al.
systolic right ventricular pressure (RVp) of at least
61 mmHg and end-diastolic pulmonary insuffi-
ciency velocity estimating a diastolic pulmonary
arterial pressure of 41 mmHg. Case 7 lived at an
altitude of 4984 feet, which may have contributed
to the development of pulmonary hypertension in
this dog.
Transesophageal echocardiography was per-
formed in 3 dogs (cases 1, 2, 3), which confirmed
the ductal anatomy, dissecting membrane, and
aneurysmal false lumen (Video 2).
Cardiac catheterization and angiography
Cardiac catheterization and angiography were
performed in all but 1 dog (case 7). Contrast
injections in the descending aorta confirmed duc-
tal flow entering the false lumen created by the
dissecting membrane in cases 1 through 5 (Fig. 3,
Video 3). Right ventricular selective angiography
was performed in cases 1, 3, 4, 5, and 6, showing a
narrowing of the contrast stream in the main pul-
monary artery and around the pulmonary dis-
section (Fig. 3, Video 3). A mild increase in systolic
RVp consistent with supravalvular stenosis was
reported in case 1 (systolic RVp ¼ 37 mmHg) and
case 4 (systolic RVp ¼ 35 mmHg). An Amplatz
Canine Duct Occluder (ACDO) was successfully
placed within the ductus of case 5, having the
pulmonary artery disc deployed within the pul-
monary artery false lumen, resulting in resolution
of ductal flow (Videos 3 and 4). Transcatheter
closure of case 2 with an ACDO was attempted,
with deployment of the pulmonary arterial disc
within the true lumen of the pulmonary artery in
an attempt to pull the dissecting membrane
adjacent to the PDA ostium. Upon release, the
ACDO embolized to the right pulmonary artery.
Case 8, the dog with PDA and pulmonary valve
stenosis, underwent PDA occlusion with a Gian-
turco stainless steel coil after balloon pulmonary
valvuloplasty.
Computed tomography angiography was per-
formed in case 4 to further characterize the
anatomy of the branch pulmonary arteries as
asymmetric size was noted on angiography with
the right pulmonary artery substantially larger
than the left (Fig. 4). Non-selective bolus-tracking
computed tomography through the great vessels
revealed a severely dilated right pulmonary artery
and a membrane that separated the main pulmo-
nary artery longitudinally. The PDA was in a normal
position, but entered the false lumen of the main
pulmonary artery, prior to flow exiting preferen-
tially toward the right pulmonary artery. The left
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Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
pulmonary artery was visualized and was of normal
size, though no flow from the ductus entered the
left pulmonary artery due to the dissecting mem-
brane. No tapering of the PDA at the pulmonary
ostium could be appreciated.
Surgery
Cases 3, 4, and 6 underwent PDA ligation through a
standard left lateral thoracotomy following diag-
nostic catheterization. Case 2 also underwent
surgical ligation of the PDA following embolization
of the ACDO, which was left at the embolized
location within the right branch pulmonary artery.
Cases 1 and 7 did not have definitive therapy for
the PDA attempted and were managed medically
after diagnosis of the pulmonary artery dissection.
Follow-up
The PDA was successfully closed in all dogs, except
cases 1 and 7. No perioperative complications from
the dissection were observed, with the exception of
the device embolization in case 2. Case 1 was
euthanized 3 years after diagnosis for left-sided
congestive heart failure, following treatment with
furosemide and enalapril by the referring veter-
inarian. Case 2 had mild mitral insufficiency, trace
tricuspid insufficiency, mild pulmonary insuffi-
ciency, and mild obstruction of the left pulmonary
artery secondary to the dissecting membrane
reported on echocardiography 1 month after surgi-
cal ligation with no residual flow through the ductus.
The dog remains alive and without clinical signs of
heart disease 4 years after surgery. Case 3 had mild
flow turbulence in the main pulmonary artery
around the dissecting membrane on post-operative
echocardiography the day after surgery, but no flow
through the PDA was appreciated and the dog was
then lost to follow-up. Case 4 was tapered off all
cardiac medications and the dissecting membrane
was challenging to visualize on echocardiography 1
month post-operatively. Case 4 was alive and
asymptomatic 4 years after surgical ligation of the
PDA. Case 5 had no residual flow through the PDA,
the membrane appeared torn and mobile, and a 60%
reduction in the flow velocity across the supra-
valvular stenosis was noted on repeat echo-
cardiography 1 month after ACDO implantation
(Video 4). Case 5 had resolution of clinical signs
associated with right-sided heart failure and was
receiving furosemide and enalapril 4 months after
PDA occlusion. Case 6 was rechecked 1 year after
PDA ligation and was asymptomatic. Echocardiog-
raphy showed that the dissection was still present,
Pulmonary artery dissection in dogs 7

Figure 3 Angiography from 2 dogs with patent ductus arteriosus (PDA) and pulmonary artery dissection. Panels A &
B: Aortic (A) and right ventricular (B) angiography from a 4-year-old Boston terrier (case 1) showing ductal flow into
the false lumen (FL), not reaching the pulmonary valve (PV). The FL is seen as a filling defect during right ventricular
(RV) injection at the cranial aspect of the pulmonary artery, which narrows the true lumen (TL) of the pulmonary
artery distal to the PV. A marker pigtail catheter is present in the esophagus to allow for calibrated measurements.
Panels C & D: Similar findings in a 1.5-year-old Shih Tzu (case 3), with a larger FL and more narrowed TL creating
supravalvular pulmonary stenosis.

though it was no longer causing right ventricular
outflow tract obstruction. There was no residual
flow through the PDA following surgical ligation and
the dog was lost to follow-up after this visit. Case 7
was euthanized 1 year after diagnosis because of
severe right-sided heart failure. Case 8 was
rechecked 1 month after balloon pulmonary valvu-
loplasty and PDA occlusion, with no residual PDA
flow observed and a peak instantaneous systolic
pressure gradient across the pulmonary valve of
50 mmHg. A second recheck exam 10 months after
catheterization showed a peak instantaneous sys-
tolic pressure gradient across the pulmonary valve
of 26 mmHg. The dog then died suddenly at home 17
months after cardiac catheterization. The dog had
no signs of heart disease at the time of death.

Please cite this article in press as: Scansen BA, et al., Pulmonary artery dissection in eight dogs with patent ductus arteriosus,
Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
8 B.A. Scansen et al.

Figure 4 Computed tomography angiography images from a 3.5-year-old Weimaraner (case 4) with pulmonary
artery dissection and a patent ductus arteriosus (PDA). Axial images in the transverse plane during peak arterial
opacification progress from cranial (A) to caudal (C) through the pulmonary artery. Both the ascending aorta (AAo) and
descending aorta (DAo) are opacified and contrast enters the false lumen (FL) of the dissection through PDA with flow
preferentially directed to the right pulmonary artery (RPA). The true lumen of the main pulmonary artery (MPA) is
seen above the pulmonary valve (PV and arrow) and flow from the right ventricle is directed preferentially through the
true lumen of the MPA to the left pulmonary artery (LPA). The dissecting membrane is shown in panels A and B by
arrowheads.

Autopsy findings The main pulmonary artery was severely dilated

and, when opened, a rent in the endothelium was
Postmortem evaluation of case 7 was performed present and the tunica intima was circumferentially
after the dog was euthanized for severe right-sided separated from the tunica media (Fig. 5A). The
congestive heart failure. A large PDA was visible. pulmonary artery dissection extended from the

Figure 5 Gross pathologic images from 2 dogs with pulmonary artery dissection. Panel A is from a 4-year-old
Bearded Collie examined after euthanasia for right-sided heart failure. The main pulmonary artery and right ventricle
(RV) are dilated and a dissecting membrane (arrowheads) is seen within the main pulmonary artery, separating the
lumen in two with a false lumen (FL) seen at the cranial aspect. The ostium (arrow) of a patent ductus arteriosus (PDA)
is seen entering the FL of the pulmonary artery dissection. Similar findings are seen in panel B from a 1.8-year-old
Cavalier King Charles spaniel examined after sudden death. A thickened and dysplastic pulmonary valve (PV) in this
dog was consistent with the antemortem diagnosis of pulmonary valve stenosis.

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Pulmonary artery dissection in dogs
sinotubular junction of the pulmonary valve
throughout the length of the main pulmonary artery
and into the left branch pulmonary artery. A long
circumferential rent in the endothelium was also
found in the descending aorta, traversing the PDA
and extending the length of the thoracic aorta.
There was no evidence of aortic or pulmonary
arterial rupture. Lung histopathology revealed
changes indicative of pulmonary vascular damage
from chronic over-perfusion including pulmonary
muscular and elastic arteries that were thickened
by marked medial hypertrophy, intimal fibrosis, and
concentric elastosis. Histopathologic pulmonary
changes secondary to chronic left-sided congestive
heart failure were also noted. Cystic medial
degeneration with proteoglycan deposits separat-
ing and disrupting the elastin fibers were seen on
histopathologic examination of the aorta. Similar
findings were seen in the main pulmonary artery.
Postmortem evaluation of case 8 was performed
following sudden death and revealed concentric
hypertrophy of the right ventricular wall with a
thickened and dysplastic pulmonary valve. The
free edges of the mitral valve were mildly thick-
ened and there was a small PDA present with the
coil still in the proper position in the ductal
ampulla with fibrous closure of the pulmonary
ductal ostium. There was moderate pulmonary
artery dilation and the vessel was separated into
two layers directly adjacent to the PDA and distal
to the pulmonary valve, creating a false lumen and
consistent with a pulmonary artery dissection.
There was a small 2 mm  2 mm circular tear in
the tunica intima of the pulmonary artery directly
adjacent to where the ductal ampulla entered the
main pulmonary artery. The false lumen extended
from this tear towards the pulmonary valve and
circumferentially around the main pulmonary,
encompassing 30% of the vessel circumference.
The dissecting aneurysm in the main pulmonary
artery was not ruptured and there was no evidence
of hemorrhage at the site of the dissection
(Fig. 5B). There was no evidence that the pulmo-
nary artery dissection was the cause of death on
postmortem examination. Lung sections revealed
moderate diffuse alveolar histiocytosis with mod-
erate pulmonary edema. A cause of death was not
identified, but was speculated to be a fatal
arrhythmia.
Discussion
This case series describes 8 dogs with pulmonary
artery dissection, all in association with PDA. Most
human cases of pulmonary artery dissection have
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Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
9
been associated with chronic pulmonary hyper-
tension or saccular aneursyms of the pulmonary
artery.7,8 As in all dogs of this report, the site of the
dissection in 80% of human cases is the main pul-
monary artery.7 Congenital heart disease accounts
for roughly half of all reported human cases of
pulmonary artery dissection,7,8 though in nearly all
cases severe pulmonary hypertension (e.g., Eisen-
menger’s physiology) is speculated as the under-
lying cause of the dissection. Congenital heart
diseases reported with pulmonary artery dissection
include PDA,13e20 aortopulmonary window,21 dou-
ble outlet right ventricle,22 atrial septal defect,23
and ventricular septal defect.24e26 Consequences
of pulmonary artery dissection in people involve
rupture and bleeding into the pericardial space;
however, bleeding into the lungs, mediastinum, or
pleural space has been reported.8,27
The pathophysiology of pulmonary artery dis-
section is not fully elucidated. It is thought that
dilation of the pulmonary artery, typically due to
pulmonary hypertension in people, results in
medial degeneration and fragmentation of the
elastic fibers with subsequent weakening of the
vessel wall.7,28 As degeneration and fragmentation
progress, the vessel wall weakens and the
increased pulmonary artery pressure and sheer
stress on the vessel wall result in intimal tearing
and dissection. Blood then separates the tunica
intima from the tunica media, creating a dissecting
membrane and predisposing to a complete tear in
the vessel wall.7 While aortic dissection often
leads to separation of the tunica intima from the
tunica media and propagation of the dissection
along the aortic length, the thin wall of the pul-
monary artery in people appears less likely to
dissect with an intimal flap and more likely to
rupture, increasing the mortality risk for pulmo-
nary artery dissections.21
Pulmonary artery dissection is a rare finding in
veterinary medicine. Aortic rupture and dissection
with extension to the pulmonary artery has been
described in several horses, particularly of Friesian
ancestry.29,30 Pulmonary artery dissection and
rupture has also been reported in cattle with
fibrillin deficiency and a syndrome comparable to
the human Marfan syndrome.31
The authors are aware of 4 cases reported in the
literature describing pulmonary artery dissections
in dogs.6,10e12 In the first 3 cases, the pulmonary
artery dissection was associated with a concurrent
aortic dissection either traversing a PDA,10 spanning
the ligamentum arteriosum,11 or communicating in
an uncertain location.6 In the most recent report,
the pulmonary artery dissection was associated
with an anomalous vessel between the ascending
10
aorta and main pulmonary artery, the embryology
of which was uncertain.12
In the prior case of pulmonary artery dissection
with PDA, the dissection was speculated to origi-
nate in the aorta and traversed the PDA into the
main pulmonary artery.10 Given the cases descri-
bed here, we speculate that the dissection
described in this prior report may have instead
originated in the pulmonary artery and propagated
across the PDA to the aorta. The dog presented in
right heart failure secondary to the supravalvular
pulmonary stenosis resulting from the dissecting
membrane, similar to case 5 of this report, and the
diagnosis of aortic and pulmonary artery dissection
was made by echocardiographic and postmortem
examination.10 Similar to the cases reported here,
the dog of the prior report describing PDA and
pulmonary artery dissection presented at 3 years
of age for labored breathing.10
The second case reported was an iatrogenic
pulmonary artery dissection that occurred during
cardiac catheterization.11 The dissection occurred
after resistance was felt upon advancement of an
aortic catheter and resulted in the dog dying sud-
denly during the procedure. On autopsy, the dis-
section extended from the intima of the aortic
arch to the pulmonary artery via the ligamentum
arteriosum.
The third case involved a dog with an obstruc-
tive chondrosarcoma of the aortic arch in which
multiple tears in the aortic intima were appre-
ciated, as well as a periaortic hematoma that
compressed the right pulmonary artery.6 An inti-
mal tear was identified in the main pulmonary
artery, though communication to the aortic dis-
section could not be located.6
In the dogs reported here, aortic dissections
were not apparent by echocardiography, conven-
tional angiography, or computed tomography
angiography. However, case 7 did have evidence of
aortic dissection on autopsy evaluation, which had
not been appreciated on echocardiographic stud-
ies performed antemortem. Without postmortem
evaluation of all cases, the occurrence of aortic
dissection with pulmonary artery dissection in
these dogs is unknown.
The most recent report of pulmonary artery
dissection occurred in a young dog that presented
in left-sided congestive heart failure, comparable
to cases 2, 3 and 4 in this series.12 The dog was
diagnosed with a congenital vascular anomaly and
the pulmonary artery dissection was observed on
computed tomography and selective fluoroscopic
angiography. This recent report utilized computed
tomography and magnetic resonance angiography
to characterize aneurysmal dilatation of the main
Please cite this article in press as: Scansen BA, et al., Pulmonary artery dissection in eight dogs with patent ductus arteriosus,
Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
B.A. Scansen et al.
pulmonary artery, as well as the pulmonary artery
dissection, which closely parallels the condition
described in the dogs of our series, albeit from an
anomalous vessel and not a PDA. In contrast to our
series, this dog was 1 year of age at the time of
presentation.
The dogs described in this report (excluding
case 8 which did not have a dissection at pre-
sentation) presented at a mature age for PDA
evaluation, with a median age of 3.5 years. This is
in contrast to the typical age at presentation for
dogs with PDA, reported as a median age of 5
months in a series of 520 cases.32 Sufficient time
may be necessary for the pulmonary artery to
dilate or undergo degenerative changes in the wall
to result in dissection. Although speculative, the
dissections observed in these dogs likely occurred
secondary to the high velocity PDA flow, secondary
pulmonary artery aneurysm, and the increased
shear stress on the pulmonary arterial wall for
months to years. There was also a difference in sex
predilection in this series (equal number of male
and female dogs affected) when compared to large
series of dogs with PDA where the proportion of
female to male was nearly 3:1.32 It is unknown if
males carry a greater risk for pulmonary artery
dissection or if the numbers in this series are too
small to adequately reflect a sex bias. Three of the
dogs in this series were Weimaraners, a breed not
commonly associated with PDA,32 suggesting an
increased risk for pulmonary artery dissection in
the breed.
In human medicine, pulmonary artery dis-
sections are usually fatal and present as cardio-
genic shock or sudden death.7,8 In a literature
survey of pulmonary artery dissections, 63 human
cases were described, though only 8 were diag-
nosed antemortem.7
In contrast, only case 8 was associated with
sudden death in this series and the cause of death in
that dog could not be directly related to the dis-
section, as no rupture was apparent. This contrast
may reflect the different etiologies of pulmonary
artery dissection in humans versus dogs. While
nearly all people with pulmonary artery dissection
have chronic pulmonary hypertension,7,8 this find-
ing was only apparent in 1 of the dogs of this report.
Aneurysmal dilatation of the pulmonary artery
associated with PDA in these dogs may have been
sufficient to dissect the arterial wall, but both
elevated pulmonary arterial pressure and secon-
dary degenerative cystic wall changes may be
necessary to ultimately result in arterial rupture.
Aneurysmal dilatation of the main pulmonary artery
has been associated with PDA in people, though is
reported to occur in only 15% of humans with
Pulmonary artery dissection in dogs
uncorrected PDA.9 While aneurysmal pulmonary
artery dilatation associated with PDA has pro-
gressed to pulmonary artery dissection in people,
all cases had severe pulmonary hypertension sec-
ondary to uncorrected PDA,13e20,22 which is in
contrast to most of the dogs reported here.
Case 8 is unique in that pulmonary artery dis-
section was not documented prior to sudden death
and autopsy evaluation. While it is possible that
the dissection was present at the time of cathe-
terization, a review of the echocardiographic and
angiographic images failed to find any evidence of
a dissecting membrane at that time or in the
follow-up period. It appears more likely that the
dissection occurred later in life, perhaps as a
result of the chronic pulmonary artery aneurysm
that remained after PDA closure and balloon pul-
monary valvuloplasty. The cranial aspect of the
pulmonary artery was presumably weakened in
this dog from PDA flow, as the dissection was
localized immediately opposite the prior ductal
ostium. It is also possible, however, that the dis-
section was created iatrogenically during the
catheterization procedure, either from trauma to
the arterial wall from guidewire or catheter pas-
sage or from balloon inflation during pulmonary
valvuloplasty. Iatrogenic trauma to the pulmonary
arterial wall resulting in hemorrhage, dissection,
or rupture has been reported during pulmonary
artery catheterization in people, most often dur-
ing placement of a Swan-Ganz catheter for
hemodynamic monitoring.33e35 Pulmonary artery
dissection secondary to balloon pulmonary valvu-
loplasty has also been reported in a child, which
was not diagnosed until 11 years after the proce-
dure was performed.36
The 2 dogs that did not have their PDA occluded
were euthanized due to progressive cardiac dis-
ease and left-sided (case 1) or right-sided (case 7)
congestive heart failure. Importantly, case 1 indi-
cates that progression of this syndrome may be
consistent with pulmonary over circulation and
left-sided volume overload as seen in uncorrected
PDA.32 Alternatively, case 7 indicates that signs of
right-sided congestive heart failure may develop in
this condition comparable to dogs with pulmonary
hypertension from other causes of increased vas-
cular resistance.37 However, right-sided congestive
heart failure may also develop in this condition
secondary to supravalvular pulmonary artery
obstruction as seen in case 5 and comparable to
other causes of acquired pulmonary artery stenosis
in dogs.38 Although follow-up was not available for
all dogs, the outcomes for cases 1 and 7 are in
contrast to the other cases with successful closure
and resolution of heart failure. This difference
Please cite this article in press as: Scansen BA, et al., Pulmonary artery dissection in eight dogs with patent ductus arteriosus,
Journal of Veterinary Cardiology (2015), http://dx.doi.org/10.1016/j.jvc.2014.12.001
11
suggests that ductal closure should be advised in
similar cases to reduce the risk of future compli-
cations and heart failure. Surgical ligation had the
highest success, though the result of case 5 sug-
gests that transcatheter closure of the PDA with an
ACDO can also be accomplished in the setting of
pulmonary artery dissection.
Conclusions
Pulmonary artery dissection should be considered
a potential complication of uncorrected PDA in the
dog. Dogs with this complication present at a
mature age and older than the typical dog diag-
nosed with PDA. While only 8 cases are described,
the proportion of Weimaraners in this sample
suggests that this breed may be at increased risk
for this complication. The dogs that underwent
surgical or transcatheter closure of their PDA did
well post-operatively; though care should be taken
when deploying an ACDO into this anatomical
structure given the risk for embolization. The dogs
in this report that had the PDA closed remained
clinically unaffected by their pulmonary dis-
sections for years, which is in contrast to human
reports of pulmonary artery dissection in which
rupture is common. However, the 2 dogs that did
not undergo PDA closure died from complications
related to their primary heart condition, and clo-
sure of the PDA under such circumstances is
therefore advised. Last, pulmonary dissection was
diagnosed 17 months after PDA closure in 1 dog,
and it remains uncertain if this was a result of
iatrogenic trauma or a consequence of pulmonary
artery aneurysm and reduced vessel integrity from
prior ductal flow.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
The authors wish to thank J. Fraser McConnell
BVMS, MRCVS for assistance during the acquisition
of, as well as Thomas Maddox BVSc, PhD, MRCVS
for his help retrieving the archived images of the
computed tomography angiography of case 4. The
authors gratefully acknowledge Greta M. Krafsur
DVM, MS and Paula A. Schaffer DVM, MS for pro-
viding the postmortem description and photograph
for case 7. Finally, the authors acknowledge Barret
J. Bulmer DVM, MS for clinical contributions to
12
case 2, Daniel F. Hogan DVM for clinical con-
tributions to case 5, and Adrian Boswood MA,
VetMB, MRCVS and Daniel J. Brockman BVSc,
CertVR for clinical contributions to case 6.
Supplementary data
Supplementary data related to this article can
be found at http://dx.doi.org/10.1016/j.jvc.
2014.12.001.
Video Table
Video 1 Compilation of transthoracic
echocardiographic images from 2 dogs
(cases 1 and 3) with pulmonary artery
dissection and patent ductus arteriosus.
An ¼ aneurysm; Ao ¼ aorta; CDI ¼ color
Doppler imaging; D ¼ ductal ampulla;
LA ¼ left atrium; LCLAX ¼ left cranial
long axis; LPA ¼ left pulmonary artery;
LV MM ¼ M-mode of left ventricle;
PV ¼ pulmonary valve; RPA ¼ right
pulmonary artery; RPLAX ¼ right
parasternal long axis; RPSAX ¼ right
parasternal short axis; RPSAX PV ¼ RPSAX
at the level of the pulmonary valve;
RV ¼ right ventricle; TTE ¼ transthoracic
echocardiogram
Video 2 Tranesophageal echocardiographic (TEE)
images of patent ductus arteriosus and
pulmonary artery dissection from a
1.5-year-old Shih Tzu (case 3). See Video 1
for key.
Video 3 Compilation of angiographic images from
3 dogs (cases 1, 3, and 5) with pulmonary
artery dissection and patent ductus
arteriosus. ACDO ¼ Amplatz Canine Duct
Occluder; LV ¼ left ventricular; RV ¼ right
ventricular; RVOT ¼ right ventricular
outflow tract.
Video 4 Post-operative transthoracic
echocardiographic images from
a 2.5-year-old mixed breed dog (case 5)
following transcatheter ductal occlusion.
See Videos 1 and 3 for key.
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