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Spiral CT Angiography of the Pulmonary Circulation¹

¹ From the Department of Radiology, Hospital Calmette, Boulevard Jules Leclerc, 59037 Lille, France. Received October 6, 1998; revision requested November 24; revision received January 5, 1999; accepted April 6. Address reprint requests to M.R.J. (e-mail: mremy-jardin@chru-lille.fr).

View larger version (139K): [in a new window]   Figure 1. Spiral CT scan (2-mm collimation, pitch of 2, 24% iodinated contrast agent) obtained at the level of the right upper lobe in a 65-year-old patient with acute onset of dyspnea. There are multiple partial filling defects at the level of the anterior (arrowhead) and posterior (arrow) segmental arteries of the right upper lobe. Note the additional presence of bilateral pleural effusion.

View larger version (111K): [in a new window]   Figure 2. Spiral CT scan (2-mm collimation, pitch of 2, 24% iodinated contrast agent) obtained at the level of the lower lobes in a 70-year-old patient with a previous history of severe chronic obstructive pulmonary disease and acute dyspnea at the time of diagnosis. There is a partial filling defect (arrow) at the level of a subsegmental branch of the anterior segmental artery of the right lower lobe.

View larger version (83K): [in a new window]   Figure 3a. Spiral CT scans obtained in a 41-year-old patient with previous history of recurrent left upper lobe hemoptysis. (a) Spiral CT scan (2-mm collimation, pitch of 2, 30% iodinated contrast agent, scanning delay of 15 seconds) obtained at the level of the left main bronchus shows the nonopacification of a small left interlobar pulmonary artery (arrow). Note the mediastinal shift to the left due to a small left lung. (b) Spiral CT scan obtained at the same level during the same session with a longer scanning delay (scanning delay, 22 seconds; other parameters same as in a). The opacification of the left interlobar pulmonary artery (arrow) at the systemic phase confirms that the focal hypoattenuation previously observed was related to retrograde left-to-right shunting, itself related to left pulmonary venous atresia. Note the enlargement of bronchial and intercostal arteries (arrowheads) and extensive left pleural thickening. (c) Stacking of eight 2-mm-thick sections of the right lower lobe from the same data set demonstrates an additional atresia of the right inferior pulmonary vein ().

View larger version (92K): [in a new window]   Figure 3b. Spiral CT scans obtained in a 41-year-old patient with previous history of recurrent left upper lobe hemoptysis. (a) Spiral CT scan (2-mm collimation, pitch of 2, 30% iodinated contrast agent, scanning delay of 15 seconds) obtained at the level of the left main bronchus shows the nonopacification of a small left interlobar pulmonary artery (arrow). Note the mediastinal shift to the left due to a small left lung. (b) Spiral CT scan obtained at the same level during the same session with a longer scanning delay (scanning delay, 22 seconds; other parameters same as in a). The opacification of the left interlobar pulmonary artery (arrow) at the systemic phase confirms that the focal hypoattenuation previously observed was related to retrograde left-to-right shunting, itself related to left pulmonary venous atresia. Note the enlargement of bronchial and intercostal arteries (arrowheads) and extensive left pleural thickening. (c) Stacking of eight 2-mm-thick sections of the right lower lobe from the same data set demonstrates an additional atresia of the right inferior pulmonary vein ().

View larger version (63K): [in a new window]   Figure 3c. Spiral CT scans obtained in a 41-year-old patient with previous history of recurrent left upper lobe hemoptysis. (a) Spiral CT scan (2-mm collimation, pitch of 2, 30% iodinated contrast agent, scanning delay of 15 seconds) obtained at the level of the left main bronchus shows the nonopacification of a small left interlobar pulmonary artery (arrow). Note the mediastinal shift to the left due to a small left lung. (b) Spiral CT scan obtained at the same level during the same session with a longer scanning delay (scanning delay, 22 seconds; other parameters same as in a). The opacification of the left interlobar pulmonary artery (arrow) at the systemic phase confirms that the focal hypoattenuation previously observed was related to retrograde left-to-right shunting, itself related to left pulmonary venous atresia. Note the enlargement of bronchial and intercostal arteries (arrowheads) and extensive left pleural thickening. (c) Stacking of eight 2-mm-thick sections of the right lower lobe from the same data set demonstrates an additional atresia of the right inferior pulmonary vein ().

View larger version (104K): [in a new window]   Figure 4a. Spiral CT scans obtained over 16 months in a 27-year-old woman with acute PE who presented with right-sided chest pain at the initial diagnosis. (a) Spiral CT scan (5-mm collimation, pitch of 1, 30% iodinated contrast agent) obtained at the level of the right bronchus intermedius at the time of initial diagnosis shows a complete obstruction of the right interlobar pulmonary artery (arrow). (b) Follow-up spiral CT scan (3-mm collimation, pitch of 1.7, 25% iodinated contrast agent) obtained at the same level as a, 16 months later, shows the dramatic reduction in diameter of the right interlobar pulmonary artery (arrow), partially recanalized.

View larger version (79K): [in a new window]   Figure 4b. Spiral CT scans obtained over 16 months in a 27-year-old woman with acute PE who presented with right-sided chest pain at the initial diagnosis. (a) Spiral CT scan (5-mm collimation, pitch of 1, 30% iodinated contrast agent) obtained at the level of the right bronchus intermedius at the time of initial diagnosis shows a complete obstruction of the right interlobar pulmonary artery (arrow). (b) Follow-up spiral CT scan (3-mm collimation, pitch of 1.7, 25% iodinated contrast agent) obtained at the same level as a, 16 months later, shows the dramatic reduction in diameter of the right interlobar pulmonary artery (arrow), partially recanalized.

View larger version (116K): [in a new window]   Figure 5. Spiral CT angiogram (2-mm collimation, pitch of 1, 30% iodinated contrast agent) obtained at the level of the left upper lobe bronchus in a 50-year-old woman with progressive dyspnea, 3 years after treatment of a breast carcinoma. There is a thick hypoattenuated area (arrows) around the medial border of the narrowed left interlobar pulmonary artery. An endoscopic biopsy of endobronchial abnormalities at the level of the posterior wall of the left upper lobe bronchus revealed left hilar invasion from adenocarcinoma.

View larger version (136K): [in a new window]   Figure 6. Preoperative spiral CT angiogram (3-mm collimation, pitch of 1.7, 30% iodinated contrast agent) obtained at the level of the lower lobes in a 63-year-old patient evaluated for right hilar carcinoma. There is tumoral invasion of the right venoatrial junction and of the right border (arrowheads) of the left atrium.

View larger version (151K): [in a new window]   Figure 7a. Postoperative spiral CT angiography (2-mm collimation, pitch of 2, 24% iodinated contrast agent) performed in a 72-year-old patient treated by means of left pneumonectomy for lung carcinoma. (a) Spiral CT scan obtained at the level of the left pulmonary artery stump shows an endoluminal filling defect (arrowhead). (b) Spiral CT scan obtained at the level of the bronchus intermedius. Note the additional presence of a partial filling defect (arrow) at the level of a subsegmental branch of the anterior segmental artery of the right upper lobe.

View larger version (127K): [in a new window]   Figure 7b. Postoperative spiral CT angiography (2-mm collimation, pitch of 2, 24% iodinated contrast agent) performed in a 72-year-old patient treated by means of left pneumonectomy for lung carcinoma. (a) Spiral CT scan obtained at the level of the left pulmonary artery stump shows an endoluminal filling defect (arrowhead). (b) Spiral CT scan obtained at the level of the bronchus intermedius. Note the additional presence of a partial filling defect (arrow) at the level of a subsegmental branch of the anterior segmental artery of the right upper lobe.

View larger version (122K): [in a new window]   Figure 8a. Postoperative spiral CT angiography (3-mm collimation, pitch of 1.7, 24% iodinated contrast agent) performed in a 51-year-old patient, 10 days after left lung transplantation for idiopathic pulmonary fibrosis. (a) Spiral CT scan obtained at the level of the left main pulmonary artery suggests either an anastomotic stenosis or a postoperative kinking (arrowhead). (b) Oblique coronal reformation obtained along the main axis of the left pulmonary artery confirms the presence of an anastomotic stenosis (arrowhead). (c) Similar morphologic information to that shown in b is provided by means of the opacification of the balloon during the angioplasty procedure (the arrow points to the anastomotic stenosis).

View larger version (60K): [in a new window]   Figure 8b. Postoperative spiral CT angiography (3-mm collimation, pitch of 1.7, 24% iodinated contrast agent) performed in a 51-year-old patient, 10 days after left lung transplantation for idiopathic pulmonary fibrosis. (a) Spiral CT scan obtained at the level of the left main pulmonary artery suggests either an anastomotic stenosis or a postoperative kinking (arrowhead). (b) Oblique coronal reformation obtained along the main axis of the left pulmonary artery confirms the presence of an anastomotic stenosis (arrowhead). (c) Similar morphologic information to that shown in b is provided by means of the opacification of the balloon during the angioplasty procedure (the arrow points to the anastomotic stenosis).

View larger version (88K): [in a new window]   Figure 8c. Postoperative spiral CT angiography (3-mm collimation, pitch of 1.7, 24% iodinated contrast agent) performed in a 51-year-old patient, 10 days after left lung transplantation for idiopathic pulmonary fibrosis. (a) Spiral CT scan obtained at the level of the left main pulmonary artery suggests either an anastomotic stenosis or a postoperative kinking (arrowhead). (b) Oblique coronal reformation obtained along the main axis of the left pulmonary artery confirms the presence of an anastomotic stenosis (arrowhead). (c) Similar morphologic information to that shown in b is provided by means of the opacification of the balloon during the angioplasty procedure (the arrow points to the anastomotic stenosis).

View larger version (108K): [in a new window]   Figure 9a. Spiral CT angiography (2-mm collimation, pitch of 2, 24% iodinated contrast agent) performed in a 72-year-old patient. (a) Spiral CT scan obtained at the level of the right and left main pulmonary arteries shows bilateral endoluminal hypoattenuated areas (). Note the additional presence of a partial filling defect at the level of a subsegmental branch of the superior segmental artery (arrow) of the left lower lobe. (b) Spiral CT scan obtained at the same level as in a, 2 minutes after contrast material administration, shows heterogeneous enhancement of the right and left vascular regions () due to the presence of multicentric malignant histiocytofibroma (surgically confirmed).

View larger version (118K): [in a new window]   Figure 9b. Spiral CT angiography (2-mm collimation, pitch of 2, 24% iodinated contrast agent) performed in a 72-year-old patient. (a) Spiral CT scan obtained at the level of the right and left main pulmonary arteries shows bilateral endoluminal hypoattenuated areas (). Note the additional presence of a partial filling defect at the level of a subsegmental branch of the superior segmental artery (arrow) of the left lower lobe. (b) Spiral CT scan obtained at the same level as in a, 2 minutes after contrast material administration, shows heterogeneous enhancement of the right and left vascular regions () due to the presence of multicentric malignant histiocytofibroma (surgically confirmed).

View larger version (137K): [in a new window]   Figure 10a. Spiral CT angiography (2-mm collimation, pitch of 2, 24% iodinated contrast agent) performed in an asymptomatic 75-year-old patient This study was indicated for the evaluation of a right lung nodule incidentally identified on a postoperative chest radiograph. (a) Spiral CT scan obtained at the level of the right middle lobe shows a well-circumscribed enhancing nodule (arrow), corresponding to a false aneurysm of a right middle lobe peripheral artery induced by a Swan-Ganz catheter. (b) Spiral CT scan obtained at the same level after occlusion of a subsegmental branch of the medial segmental artery of the right middle lobe. There is absence of contrast enhancement at the level of the false aneurysm (thick arrow) after successful endovascular treatment (the thin arrow points to the deposited coils).

View larger version (111K): [in a new window]   Figure 10b. Spiral CT angiography (2-mm collimation, pitch of 2, 24% iodinated contrast agent) performed in an asymptomatic 75-year-old patient This study was indicated for the evaluation of a right lung nodule incidentally identified on a postoperative chest radiograph. (a) Spiral CT scan obtained at the level of the right middle lobe shows a well-circumscribed enhancing nodule (arrow), corresponding to a false aneurysm of a right middle lobe peripheral artery induced by a Swan-Ganz catheter. (b) Spiral CT scan obtained at the same level after occlusion of a subsegmental branch of the medial segmental artery of the right middle lobe. There is absence of contrast enhancement at the level of the false aneurysm (thick arrow) after successful endovascular treatment (the thin arrow points to the deposited coils).

View larger version (129K): [in a new window]   Figure 11a. Spiral CT scans of the lower lobes obtained in a 44-year-old asymptomatic volunteer. Note the striking difference in the identification of supernumerary vessels of normal pulmonary vasculature between (a) a 1-mm-thick section and (b) an 8-mm-thick slab generated from a focal spiral CT acquisition according to the STS MIP technique.

View larger version (126K): [in a new window]   Figure 11b. Spiral CT scans of the lower lobes obtained in a 44-year-old asymptomatic volunteer. Note the striking difference in the identification of supernumerary vessels of normal pulmonary vasculature between (a) a 1-mm-thick section and (b) an 8-mm-thick slab generated from a focal spiral CT acquisition according to the STS MIP technique.

View larger version (141K): [in a new window]   Figure 12. An 8-mm-thick slab of the right lower lobe generated from a focal spiral CT acquisition according to the STS MIP technique in a 29 year-old patient with Rendu-Osler-Weber disease. There are numerous pulmonary arteriovenous microfistulas in the periphery of the right lower lobe. On this STS MIP image, it is possible to demonstrate the vascular connections of the posterior microfistula, with a feeding artery (thin arrows) originating from the posterior segmental artery (thick arrow) and a draining vein (small asterisks) joining the superior segmental vein (large asterisk).

View larger version (126K): [in a new window]   Figure 13. Three-dimensional SSD of a right lower lobe pulmonary AVM evaluated with nonenhanced spiral CT angiography (3-mm collimation, pitch of 1.3, threshold value of -520 HU). Demonstrated is the simple angioarchitecture of the AVM consisting of a single feeding artery (arrow) and a single draining vein (arrowhead), both connected to the aneurysmal sac (open circles).

View larger version (91K): [in a new window]   Figure 14a. Spiral CT angiography (5-mm collimation, pitch of 1, 30% iodinated contrast agent, inferosuperior acquisition) indicated for the suspicion of a left superior vena cava in a 76-year-old patient with obstructive airway disease. (a, b) Spiral CT scans show the partial anomalous pulmonary venous drainage of the left upper lobe (arrow in a) into a vertical vein (arrow in b). (c) Coronal reformation confirms the confluence of the left upper lobe pulmonary veins (short arrows) into the left vertical vein (long arrow), which drains into the left brachiocephalic vein ().

View larger version (88K): [in a new window]   Figure 14b. Spiral CT angiography (5-mm collimation, pitch of 1, 30% iodinated contrast agent, inferosuperior acquisition) indicated for the suspicion of a left superior vena cava in a 76-year-old patient with obstructive airway disease. (a, b) Spiral CT scans show the partial anomalous pulmonary venous drainage of the left upper lobe (arrow in a) into a vertical vein (arrow in b). (c) Coronal reformation confirms the confluence of the left upper lobe pulmonary veins (short arrows) into the left vertical vein (long arrow), which drains into the left brachiocephalic vein ().

View larger version (100K): [in a new window]   Figure 14c. Spiral CT angiography (5-mm collimation, pitch of 1, 30% iodinated contrast agent, inferosuperior acquisition) indicated for the suspicion of a left superior vena cava in a 76-year-old patient with obstructive airway disease. (a, b) Spiral CT scans show the partial anomalous pulmonary venous drainage of the left upper lobe (arrow in a) into a vertical vein (arrow in b). (c) Coronal reformation confirms the confluence of the left upper lobe pulmonary veins (short arrows) into the left vertical vein (long arrow), which drains into the left brachiocephalic vein ().

View larger version (160K): [in a new window]   Figure 15a. CT and conventional angiographic evaluation of a scimitar syndrome diagnosed in a 29-year-old patient who presented with hemoptysis originating from the right lower lobe. (a) Transverse thin-section CT scan obtained at the level of the lower lobes shows numerous and abnormally dilated vascular structures within an area of ground-glass attenuation (arrowheads) in the right posterobasal segment and a large vascular structure (arrow) corresponding to the scimitar vein. (b) Hyperselective catheterization of the right inferior phrenic artery, obtained prior to embolization, demonstrates the abnormal systemic arterial supply to the right posterobasal segment (arrowhead). (c) Frontal MIP image generated from a focal spiral CT angiogram (5-mm collimation, pitch of 1.4, 30% iodinated contrast agent) of the lower lung zones provides an overall analysis of the scimitar vein (small ) draining into the inferior vena cava (large ) without stenosis at its distal portion. (d) Selective catheterization (frontal angiogram obtained during the hemodynamic evaluation of the scimitar syndrome) of the scimitar vein () confirms the absence of stenosis of the abnormal pulmonary venous drainage.

View larger version (154K): [in a new window]   Figure 15b. CT and conventional angiographic evaluation of a scimitar syndrome diagnosed in a 29-year-old patient who presented with hemoptysis originating from the right lower lobe. (a) Transverse thin-section CT scan obtained at the level of the lower lobes shows numerous and abnormally dilated vascular structures within an area of ground-glass attenuation (arrowheads) in the right posterobasal segment and a large vascular structure (arrow) corresponding to the scimitar vein. (b) Hyperselective catheterization of the right inferior phrenic artery, obtained prior to embolization, demonstrates the abnormal systemic arterial supply to the right posterobasal segment (arrowhead). (c) Frontal MIP image generated from a focal spiral CT angiogram (5-mm collimation, pitch of 1.4, 30% iodinated contrast agent) of the lower lung zones provides an overall analysis of the scimitar vein (small ) draining into the inferior vena cava (large ) without stenosis at its distal portion. (d) Selective catheterization (frontal angiogram obtained during the hemodynamic evaluation of the scimitar syndrome) of the scimitar vein () confirms the absence of stenosis of the abnormal pulmonary venous drainage.

View larger version (59K): [in a new window]   Figure 15c. CT and conventional angiographic evaluation of a scimitar syndrome diagnosed in a 29-year-old patient who presented with hemoptysis originating from the right lower lobe. (a) Transverse thin-section CT scan obtained at the level of the lower lobes shows numerous and abnormally dilated vascular structures within an area of ground-glass attenuation (arrowheads) in the right posterobasal segment and a large vascular structure (arrow) corresponding to the scimitar vein. (b) Hyperselective catheterization of the right inferior phrenic artery, obtained prior to embolization, demonstrates the abnormal systemic arterial supply to the right posterobasal segment (arrowhead). (c) Frontal MIP image generated from a focal spiral CT angiogram (5-mm collimation, pitch of 1.4, 30% iodinated contrast agent) of the lower lung zones provides an overall analysis of the scimitar vein (small ) draining into the inferior vena cava (large ) without stenosis at its distal portion. (d) Selective catheterization (frontal angiogram obtained during the hemodynamic evaluation of the scimitar syndrome) of the scimitar vein () confirms the absence of stenosis of the abnormal pulmonary venous drainage.

View larger version (102K): [in a new window]   Figure 15d. CT and conventional angiographic evaluation of a scimitar syndrome diagnosed in a 29-year-old patient who presented with hemoptysis originating from the right lower lobe. (a) Transverse thin-section CT scan obtained at the level of the lower lobes shows numerous and abnormally dilated vascular structures within an area of ground-glass attenuation (arrowheads) in the right posterobasal segment and a large vascular structure (arrow) corresponding to the scimitar vein. (b) Hyperselective catheterization of the right inferior phrenic artery, obtained prior to embolization, demonstrates the abnormal systemic arterial supply to the right posterobasal segment (arrowhead). (c) Frontal MIP image generated from a focal spiral CT angiogram (5-mm collimation, pitch of 1.4, 30% iodinated contrast agent) of the lower lung zones provides an overall analysis of the scimitar vein (small ) draining into the inferior vena cava (large ) without stenosis at its distal portion. (d) Selective catheterization (frontal angiogram obtained during the hemodynamic evaluation of the scimitar syndrome) of the scimitar vein () confirms the absence of stenosis of the abnormal pulmonary venous drainage.

View larger version (98K): [in a new window]   Figure 16a. Suspicion of a right upper lobe pulmonary AVM in a 60-year-old man. (a) Three-dimensional SSD (inferosuperior view, threshold of +150 HU) and (b) vertical MIP image, both generated from the same focal spiral CT angiogram (2-mm collimation, pitch of 1.5, 24% iodinated contrast agent), show the abnormal route of a right upper lobe pulmonary vein (arrows in a, • in b), mimicking a pulmonary AVM. (c) The venous phase of the hyperselective right upper lobe angiogram (frontal view) confirms the abnormal route of the right upper lobe pulmonary vein (arrows) without abnormal connection (the arrowhead points to the tip of the catheter).

View larger version (156K): [in a new window]   Figure 16b. Suspicion of a right upper lobe pulmonary AVM in a 60-year-old man. (a) Three-dimensional SSD (inferosuperior view, threshold of +150 HU) and (b) vertical MIP image, both generated from the same focal spiral CT angiogram (2-mm collimation, pitch of 1.5, 24% iodinated contrast agent), show the abnormal route of a right upper lobe pulmonary vein (arrows in a, • in b), mimicking a pulmonary AVM. (c) The venous phase of the hyperselective right upper lobe angiogram (frontal view) confirms the abnormal route of the right upper lobe pulmonary vein (arrows) without abnormal connection (the arrowhead points to the tip of the catheter).

View larger version (141K): [in a new window]   Figure 16c. Suspicion of a right upper lobe pulmonary AVM in a 60-year-old man. (a) Three-dimensional SSD (inferosuperior view, threshold of +150 HU) and (b) vertical MIP image, both generated from the same focal spiral CT angiogram (2-mm collimation, pitch of 1.5, 24% iodinated contrast agent), show the abnormal route of a right upper lobe pulmonary vein (arrows in a, • in b), mimicking a pulmonary AVM. (c) The venous phase of the hyperselective right upper lobe angiogram (frontal view) confirms the abnormal route of the right upper lobe pulmonary vein (arrows) without abnormal connection (the arrowhead points to the tip of the catheter).

View larger version (68K): [in a new window]   Figure 17a. Spiral CT angiography (5-mm collimation, pitch of 1.7, 30% iodinated contrast agent) performed in a 61-year-old patient evaluated for left hilar enlargement. (a-d) Spiral CT angiograms enable recognition of the abnormal juxtahilar route of a left upper lobe pulmonary vein (•) draining into the left inferior pulmonary vein ( in d). (e) Three-dimensional SSD (lateral view, threshold of +150 HU) generated from the same data set provides an overall view of the sub- and retro-hilar route of the abnormal vein (•) and of its normal drainage into the left atrium ().

View larger version (75K): [in a new window]   Figure 17b. Spiral CT angiography (5-mm collimation, pitch of 1.7, 30% iodinated contrast agent) performed in a 61-year-old patient evaluated for left hilar enlargement. (a-d) Spiral CT angiograms enable recognition of the abnormal juxtahilar route of a left upper lobe pulmonary vein (•) draining into the left inferior pulmonary vein ( in d). (e) Three-dimensional SSD (lateral view, threshold of +150 HU) generated from the same data set provides an overall view of the sub- and retro-hilar route of the abnormal vein (•) and of its normal drainage into the left atrium ().

View larger version (76K): [in a new window]   Figure 17c. Spiral CT angiography (5-mm collimation, pitch of 1.7, 30% iodinated contrast agent) performed in a 61-year-old patient evaluated for left hilar enlargement. (a-d) Spiral CT angiograms enable recognition of the abnormal juxtahilar route of a left upper lobe pulmonary vein (•) draining into the left inferior pulmonary vein ( in d). (e) Three-dimensional SSD (lateral view, threshold of +150 HU) generated from the same data set provides an overall view of the sub- and retro-hilar route of the abnormal vein (•) and of its normal drainage into the left atrium ().

View larger version (76K): [in a new window]   Figure 17d. Spiral CT angiography (5-mm collimation, pitch of 1.7, 30% iodinated contrast agent) performed in a 61-year-old patient evaluated for left hilar enlargement. (a-d) Spiral CT angiograms enable recognition of the abnormal juxtahilar route of a left upper lobe pulmonary vein (•) draining into the left inferior pulmonary vein ( in d). (e) Three-dimensional SSD (lateral view, threshold of +150 HU) generated from the same data set provides an overall view of the sub- and retro-hilar route of the abnormal vein (•) and of its normal drainage into the left atrium ().

View larger version (133K): [in a new window]   Figure 17e. Spiral CT angiography (5-mm collimation, pitch of 1.7, 30% iodinated contrast agent) performed in a 61-year-old patient evaluated for left hilar enlargement. (a-d) Spiral CT angiograms enable recognition of the abnormal juxtahilar route of a left upper lobe pulmonary vein (•) draining into the left inferior pulmonary vein ( in d). (e) Three-dimensional SSD (lateral view, threshold of +150 HU) generated from the same data set provides an overall view of the sub- and retro-hilar route of the abnormal vein (•) and of its normal drainage into the left atrium ().