Objective-To compare the visualisation of bronchopulmonary collaterals and bronchopulmonary collateral blood flow in patients with chronic thromboembolic pulmonary hypertension and primary pulmonary hypertension.Setting--Referral centre for cardiology at an academic hospital. Patients-Nine patients with chronic thromboembolic pulmonary hypertension and 17 with primary pulmonary hypertension. Interventions-Bronchopulmonary collaterals were visualised by selective bronchial arteriography or thoracic aortography. Bronchopulmonary collateral blood flow was estimated by injecting indocyanine green into the ascending aorta and sampling below the mitral valve from the left ventricle. Results-The degree ofpulmonary hypertension was comparable in the two groups. Large bronchopulmonary collaterals were visualised in all the patients with thromboembolic pulmonary hypertension who had bronchial arteriography or aortography or both. None of the primary pulmonary hypertension group studied by aortography had bronchopulmonary collaterals (P << 0 001). All the patients with chronic thromboembolic pulmonary hypertension had significant bronchopulmonary collateral blood flow, which was (mean (SD)) 29-8 (18.6)% of the systemic blood flow. There was no recordable collateral blood flow in 11 of 15 patients with primary pulmonary hypertension. In the remaining four patients the mean value was 1-1 (1l8)% of the systemic blood flow (P << 0.001).Conclusions-Visualisation of bronchopulmonary collaterals by thoracic aortography or by bronchial arteriography, or the demonstration of an increased bronchopulmonary collateral flow, helps to distinguish patients with chronic thromboembolic pulmonary hypertension from those with primary pulmonary hypertension. (Heart 1997;78:171-176) Keywords: pulmonary thromboembolism; primary pulmonary hypertension; bronchial arteries; heart catheterisation The recognition of chronic thromboembolic obstruction of the central, lobar, and segmental pulmonary arteries resulting in pulmonary hypertension is important since this is potentially curable by pulmonary thromboendarterectomy.' On the other hand, the management of the majority of patients with primary pulmonary hypertension continues to be disappointing despite advances in pharmacotherapy and transplantation.2-5 At present, the differentiation of chronic thromboembolic pulmonary hypertension from primary pulmonary hypertension depends mainly on the perfusion-ventilation lung scan and pulmonary angiography. 2 6 7 The risk of pulmonary angiography in patients with severe pulmonary hypertension and the precautions during angiography need special emphasis.1 7 More recently high resolution computerised tomography,8 magnetic resonance imaging,8 pulmonary intravascular imaging,9 and transoesophageal echocardiography'0 have been used for the detection of pulmonary thrombi. The separation of thromboembolic pulmonary hypertension from primary pulmonary hypertension is at times difficult, and made more so by the development of in situ thrombosis of the p...

Expanded bronchopulmonary circulation did not prevent the development of infarction in the embolised region of the lung with impaired pulmonary venous outflow. Development of collateral bronchopulmonary circulation was not influenced by previously impaired pulmonary venous outflow.

We describe a percutaneous method of balloon occlusion of surgically created femoral arteriovenous fistulae (AVF) after thrombectomy for acute iliofemoral venous thrombosis. The technique was successful in permanent obliteration of the AVF in 25 of 27 patients. Complications were few, minor, and limited to the developmental period of the procedure. No patient required surgical intervention. The procedure provides an opportunity to angiographically evaluate the results of previous thrombectomy.

Pulmonary arteriovenous fistula (PAVF) is a rare vascular malformation of the lung that may lead to cyanosis, epistaxis, hemoptysis, and neurological deficits or cerebral abscess. The purpose of this study is to assess the effectiveness of percutaneous transcatheter embolization of PAVF in pediatric patients. Transcatheter embolization of PAVF using spring coils was performed in three patients (two males and one female) who presented between 1989 and 1999. The age at presentation ranged from 8 months to 3 years (mean 19.6 months). All patients had cyanosis and clubbing. Neurological, dermatological, or other cardiac manifestations were absent. The arterial oxygen saturations at presentation ranged from 60 to 72% (mean 64%). During eight procedures, multiple coils (total of 41 coils, average 14 coils per patient) were delivered to occlude the fistulas successfully. There was complete occlusion of the fistulas in all patients after the multiple interventions. The aortic saturations increased from a mean of 66% to a mean of 95%. Chest radiographs demonstrated dramatic regression of the pulmonary shadows in all three patients. There were no complications encountered during the procedures or during follow-up. Transcatheter coil embolization of PAVF is a safe and effective method of treatment in the pediatric age group. Patients may require multiple procedures to completely occlude the fistulas. Long-term follow-up is essential to ensure absence of recurrence due to recanalization.

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