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In Situ Pulmonary Arterial Thrombosis-Literature Review and Clinical Significance of a Distinct Entity. AJR Am J Roentgenol 2023:1-12. [PMID: 36856299 DOI: 10.2214/ajr.23.28996] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Filling defects identified in the pulmonary arterial tree are commonly presumed to represent an embolic phenomenon originating from thrombi formed in remote veins, particularly lower-extremity deep venous thrombosis (DVT). However, accumulating evidence supports an underappreciated cause for pulmonary arterial thrombosis (PAT), namely, de novo thrombogenesis-where thrombosis arises within the pulmonary arteries in the absence of DVT. Although historically underrecognized, in situ PAT has become of heightened importance with the emergence of SARS-CoV-2 infection. In situ PAT is attributed to endothelial dysfunction, systemic inflammation, and acute lung injury, and has been described in a range of conditions including COVID-19, trauma, acute chest syndrome in sickle cell disease, pulmonary infections, and severe pulmonary arterial hypertension. The distinction between pulmonary embolus and in situ PAT may have important implications regarding management decisions and clinical outcomes. In this review, we summarize the pathophysiology, imaging appearances, and management of in situ PAT in various clinical situations. This understanding will promote optimal tailored treatment strategies for this increasingly recognized entity.
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Correlation between CT Value on Lung Subtraction CT and Radioactive Count on Perfusion Lung Single Photon Emission CT in Chronic Thromboembolic Pulmonary Hypertension. Diagnostics (Basel) 2022; 12:diagnostics12112895. [PMID: 36428955 PMCID: PMC9688979 DOI: 10.3390/diagnostics12112895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/09/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Lung subtraction CT (LSCT), the subtraction of noncontrast CT from CT pulmonary angiography (CTPA) without spatial misregistration, is easily applicable by utilizing a software-based deformable image registration technique without additional hardware and permits the evaluation of lung perfusion as iodine accumulation, similar to that observed in perfusion lung single photon emission CT (PL-SPECT). The aim of this study was to use LSCT to newly assess the quantitative correlation between the CT value on LSCT and radioactive count on PL-SPECT as a reference and validate the quantification of lung perfusion by measuring the CT value in chronic thromboembolic pulmonary hypertension (CTEPH). Methods: We prospectively enrolled 47 consecutive patients with CTEPH undergoing both LSCT and PL-SPECT; we used noncontrast CT, CTPA, and LSCT to measure CT values and PL-SPECT to measure radioactive counts in areas representing three different perfusion classes—no perfusion defect, subsegmental perfusion defect, and segmental perfusion defect; we compared CT values on noncontrast CT, CTPA, and LSCT and radioactive counts on PL-SPECT among the three classes, then assessed the correlation between them. Results: Both the CT values and radioactive counts differed significantly among the three classes (p < 0.01 for all) and showed weak correlation (ρ = 0.38) by noncontrast CT, moderate correlation (ρ = 0.61) by CTPA, and strong correlation (ρ = 0.76) by LSCT. Conclusions: The CT value measurement on LSCT is a novel quantitative approach to assess lung perfusion in CTEPH and only correlates strongly with radioactive count measurement on PL-SPECT.
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Clinical Presentations and Multimodal Imaging Diagnosis in Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2022; 11:jcm11226678. [PMID: 36431155 PMCID: PMC9698386 DOI: 10.3390/jcm11226678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but life-threatening pulmonary vascular disease caused by the presence of a prolonged thrombus in the pulmonary artery. CTEPH is a distinct disease entity classified as group 4 pulmonary hypertension according to the World Symposium on Pulmonary Hypertension. It is the only potentially curable cause of pulmonary hypertension. However, timely diagnosis and treatment are often hampered by nonspecific symptoms and signs and a lack of physician awareness regarding the condition. Thus, it is important to be familiar with the clinical features of CTEPH and the associated diagnostic processes. Herein, we cover the diagnostic approach for CTEPH using multimodal imaging tools in a clinical setting.
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Patel N, Hyder SN, Michaud E, Moles V, Agarwal PP, Rosenfield K, Abe K, Haft J, Visovatti SH, Cascino TM, Auger WR, Mclaughlin VV, Aggarwal V. Interventional Imaging Roadmap to Successful Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100429. [PMID: 39132377 PMCID: PMC11307535 DOI: 10.1016/j.jscai.2022.100429] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 08/13/2024]
Abstract
Balloon pulmonary angioplasty (BPA) is an evolving treatment modality for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are not candidates for pulmonary endarterectomy. Although several imaging modalities currently exist for evaluating CTEPH, their individual use, specifically in the clinical practice of BPA, has not been well described. In this article, we provide a preprocedural, intraprocedural, and postprocedural interventional imaging roadmap for safe and effective BPA performance in routine clinical practice. Preprocedural assessment includes transthoracic echocardiography for right ventricular assessment, ventilation/perfusion scan to identify pulmonary segments with the highest degree of hypoperfusion, cross-sectional chest imaging excluding alternative causes of mismatched defects and providing anatomic and perfusion imaging concurrently, and nonselective invasive pulmonary angiography for risk stratification of individual lesion subtypes. Intraprocedural assessment includes subselective segmental angiography (SSA) for delineating segmental and subsegmental branch anatomy, lesion identification, and vessel sizing. Intravascular ultrasound and optical coherence tomography serve as adjunctive intraprocedural tools for more accurate vessel sizing and lesion characterization when SSA alone is insufficient. Postprocedural considerations include chest radiography to monitor for immediate postprocedure complications and echocardiography for the interval assessment of the right ventricle on longer-term follow-up.
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Affiliation(s)
- Nimai Patel
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Syed N. Hyder
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Erinleigh Michaud
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Victor Moles
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Prachi P. Agarwal
- Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Kenneth Rosenfield
- Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kohtaro Abe
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jonathan Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Scott H. Visovatti
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Thomas M. Cascino
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - William R. Auger
- Division of Pulmonary Medicine, Department of Internal Medicine, University of California San Diego, San Diego, California
| | - Vallerie V. Mclaughlin
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Vikas Aggarwal
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Section of Cardiology, Department of Internal Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan
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Liu W, Xie S, Liang T, Chang F, Liu M, Zhai Z. Clinical and imaging risk factors for the persistence of thromboembolism following acute pulmonary embolism. Quant Imaging Med Surg 2022; 12:4047-4058. [PMID: 35919067 PMCID: PMC9338360 DOI: 10.21037/qims-21-753] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Abstract
Background Predicting the progression of acute pulmonary embolism to chronic pulmonary thromboembolism (CPTE) disease is essential to monitoring and improving the long-term prognosis of pulmonary embolism. We explored the risk factors for chronic persistence of thromboembolism after acute pulmonary embolism. Methods Cases with newly onset acute pulmonary embolism in the China-Japan Friendship Hospital from November 2016 to November 2019 were retrospectively analyzed. The clinical characteristics, serological examination results, and treatment strategies of acute pulmonary embolism patients were obtained through the electronic medical record system (Goodwill E-Health Info Co., Ltd.). Imaging parameters on computed tomography pulmonary angiography (CTPA) images at the onset of the acute pulmonary embolism were measured and counted. Notably, we propose a new parameter based on CTPA images: the ratio of Sd (sum of residual segmental pulmonary artery diameter) to MPAd (the main pulmonary artery diameter) (Sd/MPAd). After 3 months of regular treatment for acute pulmonary embolism, patients were classified into a CPTE group or a non-CPTE group based on the presence of residual embolus. All data were compared between the CPTE group and non-CPTE group. Furthermore, logistic regression analysis was used to investigate risk factors for the progression of acute pulmonary embolism to CPTE. Results A total of 77 cases (male:female = 1:1.26) were included in the study. There were 43 cases (55.84%) in the CPTE group and 34 cases in the non-CPTE group (44.16%). The results of univariate analysis showed that there were statistically significant differences between the 2 groups in risk stratification (χ2=8.043; P=0.005), protein S activity (χ2=5.551; P=0.018), the ratio of sum of residual segmental pulmonary artery diameter to the main pulmonary artery diameter (Sd/MPAd; t=–2.103; P=0.039), Mastora score (U=362.500; P<0.001), and embolus location (χ2=16.969; P<0.001). However, there were no statistically significant differences between the 2 groups in treatment options (P=0.381). According to multivariate logistic-regression analysis, protein S activity <55% (P=0.025), Sd/MPAd ≥1.97 (P=0.011), and an embolus being located in the central pulmonary artery (P<0.001) were independent risk factors for chronic persistence of thromboembolism following acute pulmonary embolism. Conclusions The protein S activity, location of the embolus, and Sd/MPAd on CTPA at the onset of acute pulmonary embolism may suggest the progression of acute pulmonary embolism to CPTE.
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Affiliation(s)
- Weifang Liu
- Department of Radiology, Civil Aviation General Hospital, Beijing, China
| | - Sheng Xie
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Tian Liang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Feiyan Chang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
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Lashari BH, Kumaran M, Aneja A, Bull T, Rali P. Beyond Clots in the Pulmonary Circulation: Pulmonary Artery Tumors Mimicking Pulmonary Embolism. Chest 2022; 161:1642-1650. [PMID: 35041833 DOI: 10.1016/j.chest.2022.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/02/2022] [Accepted: 01/10/2022] [Indexed: 10/19/2022] Open
Abstract
Pulmonary embolism (PE) is the most common filling defect seen on CT scan pulmonary angiography. Pulmonary artery (PA) tumors can mimic PE on imaging and clinical presentation. One classic feature of tumors is failure to improve on anticoagulation. PA tumors, particularly malignant ones, have radically different treatments and usually have a grim prognosis. Thus, it is essential that PA tumors, when suspected, receive an expedited confirmatory diagnosis followed by multidisciplinary treatment at an expert center. In this review, we present clinical, imaging, and histopathologic features of benign and malignant PA tumors, emphasizing differentiating features from PE. We also describe available diagnostic and treatment methods for PA tumors.
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Affiliation(s)
- Bilal Haider Lashari
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA.
| | - Maruti Kumaran
- Department of Radiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Amandeep Aneja
- Department of Pathology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Todd Bull
- Department of Medicine, Pulmonary Sciences and Critical Care, University of Colorado, Aurora, CO
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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Chronic Thromboembolic Pulmonary Hypertension. Lung 2022; 200:283-299. [DOI: 10.1007/s00408-022-00539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
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Naranje P, Shera T, Bhalla A, Meena P, Kabra S, Gupta A, Kandasamy D. Role of computed tomography angiography in the evaluation of haemoptysis in children: Decoding the abnormal vessels. Indian J Med Res 2022; 155:356-363. [DOI: 10.4103/ijmr.ijmr_3271_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
Pulmonary CTA is a ubiquitous study interpreted by radiologists with different levels of experience in a variety of practice settings. Pulmonary embolism (PE) can range from an incidental and clinically insignificant finding to a clinically significant thrombus that can be managed on an outpatient basis to a potentially fatal condition requiring immediate medical or invasive management. Accordingly, a clear and concise pulmonary CTA report should effectively communicate the most pertinent findings to help the treating medical team diagnose or exclude the diagnosis of PE and provide information to guide appropriate management. In this expert panel narrative review, we discuss the purpose of the radiology report for pulmonary CTA, the optimal report format, the relevant findings that need to be addressed and their clinical significance.
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Al Abri Q, Lu AJ, Ramchandani MK. Chronic Thromboembolic Pulmonary Hypertension: A Comprehensive Review and Multidisciplinary Approach to Surgical Treatment. Methodist Debakey Cardiovasc J 2021; 17:e18-e28. [PMID: 34377353 PMCID: PMC8331206 DOI: 10.14797/iqtu6714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 04/04/2021] [Indexed: 11/08/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed and undertreated sequelae of acute pulmonary embolism. In this comprehensive review, we provide an introductory overview of CTEPH, highlight recent advances in its diagnostic imaging, and describe the surgical technique for pulmonary thromboendarterectomy (PTE), the only established curative treatment for CTEPH. We also discuss the emerging role of balloon pulmonary angioplasty, both independently and combined with PTE, for patients with inoperable, residual, or refractory pulmonary hypertension post PTE. Finally, we stress the importance of a specialized multidisciplinary team approach to CTEPH patient care and share our approach to optimizing care for these patients.
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Fathala A, Aldurabi A. Frequency of computed tomography abnormalities in patients with chronic thromboembolic pulmonary hypertension: a comparative study between lung perfusion scan and computed tomography pulmonary angiography. Multidiscip Respir Med 2021; 16:753. [PMID: 34322231 PMCID: PMC8273626 DOI: 10.4081/mrm.2021.753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/31/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of pulmonary hypertension. Diagnosis of CTEPH can be established using various imaging techniques, including ventilation-perfusion scintigraphy (VQ) and multidetector computed tomography pulmonary angiography (CTPA). The aim of this study was to determine the frequency of direct pulmonary vascular, parenchymal lung, and cardiac abnormalities on CTPA in patients with CTEPH and to compare the diagnostic accuracy of both VQ scan CTPA in detecting CTEPH. Methods We retrospectively included 54 patients who had been referred for pulmonary hypertension service (20 males, 34 females). All patients had VQ scan and CTPA within 15 days and underwent pulmonary artery endarterectomy (PEA) thereafter. VQ scans were reported according to modified PIOPED (Prospective Investigation of Pulmonary Embolism Diagnosis) criteria. CTPA was considered as diagnostic for CTEPH if it showed presence of thrombus, webs, stenosis, or perfusion lung abnormalities. Results The mean age of the study population was 41±10 years. The mean pulmonary artery pressure was 53±13 mmHg. Fifty-three out of 54 patients in the study population had high probability VQ scan and one patient had intermediate probability. CTPA was suggestive of CTEPH in all patients. The most frequent CTPA findings in the central pulmonary arteries and peripheral arteries were presence of thrombotic materials, abnormal vessel tapering and abrupt vessels-cut off (76% vs 65%, 67% vs 48%, and 48% vs 22%), respectively. The mosaic lung perfusion was present in 78% of the patients, and various cardiac morphology abnormalities were present and most common was abnormal right to left ventricle ratio (69%). Conclusion Our findings indicate that both VQ scan and CTPA are highly sensitive for the detection of CTEPH confirmed by PEA. Most CTEPH patients had several pulmonary vascular, parenchymal lung and cardiac abnormalities. There was no sign with 100% sensitivity on CTPA for CTEPH detection.
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Affiliation(s)
- Ahmed Fathala
- Department of Radiology, Nuclear Medicine and Cardiovascular Imaging, King Faisal Specialist Hospital and Research Center, Riyadh
| | - Alaa Aldurabi
- Department of Radiology, College of Medicine, Qassim University, Buraidah, Saudi Arabia
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Schüßler A, Richter M, Tello K, Steiner D, Seeger W, Krombach GA, Roller FC. Evaluation of Diagnostic Accuracy and Radiation Exposure of Dual-Energy Computed Tomography (DECT) in the Course of Chronic Thromboembolic Pulmonary Hypertension (CTEPH). ROFO : FORTSCHRITTE AUF DEM GEBIETE DER RONTGENSTRAHLEN UND DER NUKLEARMEDIZIN 2021; 193:1318-1326. [PMID: 34139779 DOI: 10.1055/a-1502-7541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study was to assess the diagnostic accuracy of computed tomography pulmonary angiogram (CTPA) including dual energy and reconstruction of iodine maps for diagnosing CTEPH. This method for detecting embolisms and perfusion failures was compared with V/Q-SPECT. An additional purpose was to compare the applied radiation dose of both techniques. MATERIALS AND METHODS 71 patients (49 women) with suspected CTEPH were included in this prospective study. The patients received a V/Q-SPECT and a dual-energy CTPA. Iodine maps were reconstructed from the data set. CTPA and the iodine maps were read by an experienced radiologist unaware of the clinical information as well as the results of the V/Q-SPECT. Results were compared to the V/Q-SPECT. DLP and the applied amount of radionuclides (MAA, Technegas) were obtained for comparison of radiation dose. RESULTS For the diagnosis of CTEPH, the sensitivity of DECT was 1.000, specificity 0.966, PPV 0.867 and NPV 1.000, respectively. There was not a considerable difference in the x-ray exposure between the DECT examination and the V/Q-SPECT (1.892 mSv vs. 1.911 mSv; p = 0.6115). Both examination modalities were highly consistent regarding the classification of pathological segments (1177/1278 segments, 92,09 %, κ = 0,5938). CONCLUSION This study presents the DECT, in combination with reconstructed iodine maps, as a potential alternative to the current imaging technique of first choice, V/Q-SPECT. For creating future prospective diagnostic algorithms, the implementation of DECT screening with iodine maps should be considered. KEY POINTS · DECT correctly identified all CTEPH patients.. · There is substantial agreement between DECT and V/Q-SPECT in the classification of pathological segments.. · There is no significant difference in radiation exposure during DECT examination and V/Q-SPECT examination.. · Reduced radiation dose does not negatively impact image quality.. CITATION FORMAT · Schüßler A, Richter M, Tello K et al. Evaluation der diagnostischen Genauigkeit und der Strahlendosis der Dual-Energy-Computertomografie (DECT) bei chronisch thromboembolischer pulmonaler Hypertonie (CTEPH). Fortschr Röntgenstr 2021; DOI: 10.1055/a-1502-7541.
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Affiliation(s)
- Armin Schüßler
- Department of Diagnostic and Interventional Radiology, University Hospital Gießen, Justus Liebig University, Gießen, Germany.,Member of the German Centre for Lung Research (DZL), Germany
| | - Manuel Richter
- Member of the German Centre for Lung Research (DZL), Germany.,Department of Internal Medicine II, University Hospital Gießen, Justus Liebig University, Gießen, Germany
| | - Khodr Tello
- Member of the German Centre for Lung Research (DZL), Germany.,Department of Internal Medicine II, University Hospital Gießen, Justus Liebig University, Gießen, Germany
| | - Dagmar Steiner
- Member of the German Centre for Lung Research (DZL), Germany.,Department of Nuclear Medicine, University Hospital Gießen, Justus Liebig University, Gießen, Germany
| | - Werner Seeger
- Member of the German Centre for Lung Research (DZL), Germany.,Department of Internal Medicine II, University Hospital Gießen, Justus Liebig University, Gießen, Germany
| | - Gabriele Anja Krombach
- Department of Diagnostic and Interventional Radiology, University Hospital Gießen, Justus Liebig University, Gießen, Germany.,Member of the German Centre for Lung Research (DZL), Germany
| | - Fritz Christian Roller
- Department of Diagnostic and Interventional Radiology, University Hospital Gießen, Justus Liebig University, Gießen, Germany.,Member of the German Centre for Lung Research (DZL), Germany
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Affiliation(s)
- Peter V. Dicpinigaitis
- Albert Einstein College of Medicine and Montefiore Medical Center, 1825 Eastchester Road, Bronx, NY 10461 USA
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