From the Guidelines
Pulmonary angiography in children should be performed when less invasive imaging methods are insufficient to evaluate pulmonary vascular abnormalities, particularly in cases of suspected pulmonary embolism, congenital pulmonary vascular anomalies, or pulmonary hypertension requiring interventional procedures. The primary indications for pulmonary angiography include:
- Suspected pulmonary embolism unconfirmed by other imaging modalities
- Evaluation of congenital pulmonary vascular anomalies
- Assessment of pulmonary arteriovenous malformations
- Pre-surgical planning for complex congenital heart defects
- Evaluation of pulmonary hypertension, particularly when considering interventional procedures 1.
According to the American Thoracic Society clinical practice guideline, imaging should be performed as part of the initial diagnostic workup for chronic thromboembolic pulmonary hypertension (CTEPH), especially in the absence of significant lung disease 1. The procedure involves injecting contrast material through a catheter placed in the pulmonary artery while taking X-ray images to visualize the pulmonary vasculature. Due to radiation exposure and invasiveness, less invasive alternatives like CT angiography or MR angiography are typically tried first, especially in children 1.
The decision to perform pulmonary angiography should balance diagnostic necessity against risks including radiation exposure, contrast reactions, vascular injury, and the need for sedation or anesthesia in younger children. The procedure requires specialized pediatric interventional radiologists or cardiologists with experience in pediatric vascular procedures and appropriate pediatric facilities for safe performance and monitoring. Cardiac catheterization is recommended before initiation of PAH-targeted therapy, which may include pulmonary angiography, unless there are specific contraindications 1.
In cases of CTEPH, pulmonary angiography may be necessary to evaluate the extent of disease and plan for potential interventions like pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty 1. Overall, the use of pulmonary angiography in children should be guided by a thorough evaluation of the potential benefits and risks, with a focus on minimizing harm and optimizing outcomes.
From the Research
Indications for Pulmonary Angiography in Children
Pulmonary angiography is a diagnostic procedure used to evaluate pulmonary embolism (PE) in children. The decision to perform pulmonary angiography depends on various factors, including clinical suspicion, imaging findings, and patient risk factors.
- Clinical suspicion of PE, such as symptoms of chest pain, shortness of breath, or syncope 2
- Indeterminate lung scan or high-probability lung scan with a need for confirmation 2
- Massive PE with consideration for embolectomy or thrombolytic therapy 2
- Significant clinical evidence for an alternative diagnosis, such as pulmonary hypertension 2
Alternative Diagnoses
Pulmonary angiography can also detect alternative diagnoses in children with suspected PE.
- Pneumonia 3, 4
- Atelectasis 3
- Malignancy 3
- Congenital heart disease 3
- Pulmonary hypertension 3
- Pericardial effusion 3
- Pulmonary nodules 3
- Rib fractures 3
- Right atrial thrombus 3
- Fat embolism 3
Imaging Guidelines and Recommendations
Recent studies have emphasized the need for updated guidelines on the diagnostic approach to PE in children 5.
- Pulmonary CT angiography (CTA) is a commonly used imaging modality for evaluating PE in children 6, 4
- CTA can detect alternative diagnoses and is useful in patients with indeterminate lung scans or high-probability lung scans with a need for confirmation 3, 2
- Radiation dose reduction techniques, such as reduced mAs and automatic exposure control, should be employed when performing CTA in children 6