Download Free Medical Post Operative Chest Imaging PowerPoint Presentation

Post Operative Chest Imaging PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : Check out this medical presentation on Radiology and Imaging, which is titled "Post Operative Chest Imaging", to know about Post Operative Chest Imaging.

Tags : Radiology, Imaging, Post Operative Chest Imaging

Published on : Jul 28, 2021 | Views : 1503 | Downloads : 5

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

Post Operative Chest Imaging Dr Basant Regmi Resident ;Radiodiagnosis NAMS, Bir Hospital
Slide 2-

Overview THORACOTOMY PNEUMONECTOMY LOBECTOMY SEGMENTECTOMY COMPLICATIONS OF THORACOTOMY EARLY LATE CARDIAC SURGERY THORACIC COMPLICATIONS OF GENERAL SURGERY
Slide 3-

Introduction Intrathoracic surgery is performed most frequently for resection of all or part of lung, or for cardiac disease. So it is must for a radiologist to have the knowledge of acute and chronic radiological appearances of such surgical conditions and their complications.
Slide 4-

Thoracotomy With increasing use of thoracoscopic and minimally invasive surgery for lung resection, thoracotomy is typically reserved for procedures that require a larger surgical field, such as lobectomy and pneumonectomy. Lung resection usually through posterolateral 4th or 5th intercoastal space Part of rib resected or Periosteum stripped or Ribs simply spread apart. Fig. (A) Typical sharply truncated rib defect following right thoracotomy (right upper lobectomy for carcinoma). (B) Late postsurgical changes following periosteal stripping at time of left fifth interspace thoracotomy for mitral valvotomy. There is a wavy line of calcification below the affected rib(arrows) Fig: A
Slide 5-

An understanding of the expected post-thoracotomy appearance of the chest is essential, as postoperative complications can make imaging findings additionally complex. Accurate identification and timely diagnosis of complications is crucial in minimizing increased morbidity and mortality. Surgical route often not obvious on the CXR, or Marked by some narrowing of the intercoastal space Soft tissue swelling Subcutaneous emphysema
Slide 6-

Following Lobectomy The remaining lung should expand to fill the space of the resected lobes Immediately post operatively Pleural drains are kept to prevent accumulating pleural fluid Mediastinum may be shifted to side of operation Hyperinflation of the remaining lung – mediastinum returns to its normal position. When drains removed – small pleural effusion commonly occurs; usually resolves within a few days leaving residual pleural thickening
Slide 7-

Following Segmentectomy sub-segmentectomy With segmental resection cut surface of the lung is oversewn, and air leaks are fairly common – may cause persistent pneumothorax Wire sutures or staples at site of bronchial stump are visible. On CT, the presence of surgical material and changes in central lung anatomy are key to determining the type and location of limited lung resection. A peripheral suture line with intact segmental bronchi and vessels should suggest wedge resection, whereas central surgical clips and ligated bronchi and vessels indicate segmentectomy or lobectomy.
Slide 8-

Pneumonectomy Pneumonectomy is the treatment of choice for bronchogenic carcinoma and intractable end-stage lung diseases such as tuberculosis and bronchiectasis, but it is often followed by postoperative complications, which account for significant morbidity and mortality. Knowledge of the radiologic features of such complications is of critical importance for their early detection and prompt management.
Slide 9-

The overall incidence of complications after pneumonectomy has been reported to be as high as 20%–60% . although the associated morbidity and mortality have decreased in recent decades. The nature of these complications differs according to the length of time between pneumonectomy and the onset of the complications.
Slide 10-

Normal Postpneumonectomy Changes on Chest Radiographs Initial chest radiographs after pneumonectomy should demonstrate: midline position of the trachea, slight congestion in the remaining lung, and a postpneumonectomy space that contains gas and fluid. The rate of accumulation of fluid in the postpneumonectomy space is extremely variable . In most cases, within the first 4–5 postoperative days, approximately half of the space is filled with fluid. Figure 1a. Normal postoperative anatomy at chest radiography in a 55-year-old man who underwent left pneumonectomy for squamous cell carcinoma. (a) Radiograph on postoperative day 1 shows air in the postpneumonectomy space, a midline trachea, and slight congestion in the remaining right lung
Slide 11-

After the 1st week, the air-fluid level gradually rises. Thereafter, the mediastinum either remains stationary or gradually shifts toward the postpneumonectomy space as a result of hyperextension of the remaining lung as gas from the surgical site is reabsorbed. Progressive mediastinal shift and lung herniation into the postpneumonectomy space indicate continuing fluid reabsorption . Total obliteration of the postpnemonectomy space usually takes weeks to months. Figure 1b. Normal postoperative anatomy at chest radiography in a 55-year-old man who underwent left pneumonectomy for squamous cell carcinoma. (b)Radiograph on postoperative day 2 shows fluid in the lower one-third of the postpneumonectomy space.
Slide 12-

In the immediate postoperative period, a rapid mediastinal shift toward the remaining lung indicates : Atelectasis of the lung or An abnormal accumulation of air or Fluid in the postpneumonectomy space most often resulting from a bronchopleural fistula, hemorrhage, or empyema. In the late postoperative period, a mediastinal shift toward the remaining lung is indicative of a delayed complication.
Slide 13-

Figure 1c. Normal postoperative anatomy at chest radiography in a 55-year-old man who underwent left pneumonectomy for squamous cell carcinoma. (c)Radiograph on postoperative day 14 shows that the air- fluid level has risen in the postpneumonectomy space. Figure 1d. Normal postoperative anatomy at chest radiography in a 55-year-old man who underwent left pneumonectomy for squamous cell carcinoma. (d) Radiograph on postoperative day 30 shows total opacification of the postpneumonectomy space and elevation of the left hemidiaphragm.
Slide 14-

Post-thoracotomy complications following lung-resection Early postoperative complications Pulmonary edema •Acute lung injury/acute respiratory distress syndrome(ARDS) •Pneumonia •Hemorrhage/hemothorax Chylothorax Dehiscence of bronchial stump, formation of bronchopleural fistula Esophagopleural fistula Empyema •Lobar torsion •Cardiac herniation
Slide 15-

Late postoperative complications •Pneumonia •Disease recurrence (tumor, infection) •Dehiscence of bronchial stump,formation of bronchopleural fistula Esophagopleural fistula Empyema •Stricture of bronchial anastomosis •Pulmonary artery stump thrombosis Postpneumonectomy syndrome Herniation of lung or chest wall soft tissues via thoracotomy defect
Slide 16-

Pulmonary edema Postpneumonectomy pulmonary edema is a life- threatening complication of pneumonectomy, with a reported prevalence of 2.5%–5% and an associated mortality rate of 80%–100%. The causal mechanism of this complication remains largely undetermined. Increased hydrostatic pressure and altered permeability of capillaries are probably contributing factors . Predisposing factors include an excessive perioperative fluid load, transfusion of fresh frozen plasma, arrhythmia, marked postsurgical diuresis, and low serum colloidal osmotic pressure.
Slide 17-

Severe cases appears as increased opacity identical to that seen in ARDS . In less severe cases, the imaging findings resemble those in hydrostatic pulmonary edema: – The most frequently observed features include Kerley lines, peribronchial cuffing (ie, thickening of the bronchial wall), and ill- defined vessels. Fig : Pulmonary edema in a 58-year-old man after right pneumonectomy for multidrug-resistant tuberculosis. Chest radiograph on postoperative day 2 shows perihilar consolidation and an air bronchogram in the left lung.
Slide 18-

Bronchopleural Fistula Bronchopleural fistula is a potentially fatal complication of pneumonectomy, although its incidence has decreased over the years. An incidence of 0%–9% and an associated mortality rate of 16%–23% have been reported. The most common cause of death associated with this condition is Aspiration pneumonia with subsequent ARDS. Other predisposing factors are uncontrolled preoperative pleuropulmonary infection, trauma, preoperative radiation therapy, postoperative positive ventilation, and faulty closure of the bronchial stump.
Slide 19-

The radiographic features suggestive of a bronchopleural fistula in the postpneumonectomy patient can be summarized as follows: Failure of the postpneumonectomy space to fill, Persistent or progressive pneumothorax despite adequate tube drainage; Progressive subcutaneous or mediastinal emphysema; A 2-cm drop in the air-fluid level, with a shift of the mediastinum to the side opposite the postpneumonectomy space; And a sudden pneumothorax or reappearance of air in a previously opaque postpneumonectomy space.
Slide 20-

Bronchopleural fistula in a 65-year-old man after right pneumonectomy for large cell carcinoma. (a) Chest radiograph on postoperative day 18 shows near complete opacification of the postpneumonectomy space. Bronchopleural fistula in a 65-year-old man after right pneumonectomy for large cell carcinoma. (b) Chest radiograph on postoperative day 20 shows recurrent air-fluid levels in the middle of the postpneumonectomy space.
Slide 21-

Figure 3c. Bronchopleural fistula in a 65-year-old man after right pneumonectomy for large cell carcinoma. (c) Chest radiograph on postoperative day 22 shows tension hydro- pneumothorax, subcutaneous emphysema (*), and a leftward shift of mediastinal structures, including the trachea. A chest tube subsequently was inserted for drainage. Figure 3d. Bronchopleural fistula in a 65-year- old man after right pneumonectomy for large cell carcinoma. (d) Axial CT image demonstrates a fistula (arrow).
Slide 22-

Empyema Advanced surgical techniques and potent antibiotics have rendered empyema an uncommon complication of pneumonectomy. Reported incidence (1% and 10%. However, empyema remains a potentially fatal complication of pneumonectomy. The infection may be manifested in the early postoperative period or may develop months or even years after surgery. Empyema in the early post-op period >> attributed to intraoperative contamination or residual infection in the pleural cavity, whereas hematogenous spread is the usual cause of infections that occur at a later time after surgery.
Slide 23-

The radiographic features of postpneumonectomy empyema include : rapid filling of the postpneumonectomy space with fluid; a mediastinal shift toward the side opposite that of pneumonectomy; a decrease in the air-fluid level in the postpneumonectomy space, accompanied by communication to the outside via the bronchus or through the skin; and a new air-fluid level in a previously opacified postpneumonectomy space, indicative of a bronchopleural fistula or a gas-forming organism .
Slide 24-

Figure 4a. Empyema in a 74- year-old man after left pneumonectomy for sarcomatoid carcinoma. (a)Chest radiograph on postoperative day 21 shows a midline position of the trachea, mediastinum, and tracheostomy tube and total opacification of the postpneumonectomy space. Figure 4b. (b)Chest radiograph on postoperative day 50 shows a rightward deviation of the trachea with tracheostomy tube and of the mediastinum because of overexpansion of the postpneumonectomy space. Figure 4c. (c) Axial CT image on postoperative day 52 shows irregular pleural thickening in the postpneumonectomy space and an abscess (arrow) in the posterior chest wall, findings suggestive of empyema. A chest tube was inserted for drainage.
Slide 25-

ARDS and Acute Lung Injury Postpneumonectomy acute lung injury is a recognized complication with a likely fatal outcome. The overall incidence of ARDS and acute lung injury has been reported to be approximately 5% . Patients who develop ARDS after pneumonectomy have a very poor prognosis, with mortality of more than 80%, compared with overall mortality of 65% for all patients with ARDS . Although the precise mechanism that causes ARDS or acute lung injury after pneumonectomy remains unclear, it has been postulated that increased postoperative blood flow through the remaining lung may disrupt the capillary endothelial cell–alveoli barrier .
Slide 26-

The diagnosis of ARDS or acute lung injury is largely based on the observation of the characteristic pulmonary opacity on chest radiographs and a pulmonary artery wedge pressure lower than 18 mm Hg. Serial chest radiographs show the rapid development of diffusely increased opacity in the remaining lung . ARDS also may develop in combination with other postpneumonectomy complications, such as pneumonia and bronchopleural fistula with or without empyema .
Slide 27-

Figure 5a. ARDS in a 62-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph on postoperative day 6 shows mild peribronchial cuffing and ill-defined nodular areas of opacity in the left lung. Figure 5b. ARDS in a 62-year-old man after right pneumonectomy for squamous cell carcinoma. (b) Chest radiograph on postoperative day 19 shows increased opacification signifying progressive infiltration of the left lung. ARDS was diagnosed on the basis of clinical and radiographic findings.
Slide 28-

Pneumonia The reported incidence of pneumonia in the remaining lung after pneumonectomy is 2%–15%. Pneumonia after pneumonectomy is associated with a mortality rate of 25% . Aspiration (overt or silent) of gastric secretions and bacterial colonization of atelectatic lung tissue are the most common causes of postoperative pneumonia. Intubation and mechanical ventilation may contribute to the prevalence of aspiration with subsequent pneumonia. The transbronchial spill of fluid via a bronchopleural fistula is another possible cause of aspiration pneumonia.
Slide 29-

Features on chest radiographs vary, from foci of increased opacity or bronchopneumonia to lobar consolidation . CT is especially useful for the evaluation of aspiration pneumonia caused by transbronchial spill in patients with a bronchopleural fistula, because CT images can directly depict the fistula Fig : Pneumonia in a 72-year-old man after left pneumonectomy for adenocarcinoma. Chest radiograph on postoperative day 9 shows consolidation and an air bronchogram, findings suggestive of pneumonia, in the lower zone of the right lung.
Slide 30-

Cardiac Herniation Very rare postpneumonectomy complication, and it requires urgent reduction. The mortality rate among patients affected by this complication is 40%–50% . Most cases of cardiac herniation are the result of a prolapse of the heart muscle through the pericardial defect created for surgical exposure of the hilar vessels of the lung Patients typically manifest sudden hypotension, cyanosis, and circulatory distress . The triggering event may be a change in the patient’s position, coughing, extubation, or the connection of a chest tube to a negative pressure source . The immediate differential diagnosis includes :massive intrathoracic hemorrhage, atelectasis of the remaining lung, and acute cardiac tamponade .
Slide 31-

Postpneumonectomy Syndrome Postpneumonectomy syndrome is a delayed complication seen primarily in children and young adults within a year after surgery . Most cases of postpneumonectomy syndrome have been described as occurring after right pneumonectomy, when the powerful negative pressure of the involved hemithorax and over-expansion of the remaining lung move the mediastinum rightward. As the overexpanded lung further displaces the mediastinum toward the right side, the heart descends in the hemithorax and rotates counterclockwise along its main axis. The trachea also is displaced toward the right side, with resultant stretching of the left main bronchus, which is compressed downward by the aortic arch and the left main pulmonary artery .
Slide 32-

Chest radiographic findings include: Displacement of the heart and trachea toward the right side Abnormal narrowing of the distal part of the trachea and the left main bronchus because of compression of the airway between the pulmonary artery anteriorly and the aorta and spine posteriorly .
Slide 33-

Postpneumonectomy syndrome in a 34- year-old woman after right pneumonectomy for multidrug-resistant tuberculosis. (a) Chest radiograph at 11- month follow-up shows overexpansion and anterior herniation of the left lung and rightward deviation of the trachea. Postpneumonectomy syndrome in a 34-year- old woman after right pneumonectomy for multidrug-resistant tuberculosis. (b) Axial CT image depicts stretching of the left main bronchus, which is visible between the left pulmonary artery and the vertebral body.
Slide 34-

Esophagopleural Fistula Esophagopleural fistula is a devastating pathologic condition that occurs in 0.2%–1.0% of patients after pneumonectomy . This condition can result from at least three different mechanisms: surgical injury, mediastinal cancer recurrence, and chronic infection In the early postoperative period, the fistula is usually secondary to direct esophageal injury or compromise of the blood supply to the lower esophagus at the time of surgery In the late postoperative period, a recurrent tumor or chronic inflammation with origins in the esophagus, the bronchial stump, or the surrounding tissues may be the causal mechanism .
Slide 35-

The diagnosis of an esophagopleural fistula may be confirmed with various investigations, including chest radiography, esophagoscopy, and bronchoscopy . The features of an esophagopleural fistula at chest radiography are similar to those of a bronchopleural fistula and include a decrease in the air-fluid level during the postoperative period and the reappearance of an air-fluid level in a previously opacified postpneumonectomy space. CT can directly depict the fistula and any additional abnormalities, such as a recurrent tumor mass, inflammatory lymph nodes, empyema in the postpneumonectomy space.
Slide 36-

Figure 8a. Esophagopleural fistula in a 53-year-old man after right pneumonectomy for squamous cell carcinoma. (a) Chest radiograph 2 years after pneumonectomy shows a recurrent air-fluid level (arrow) in the postpneumonectomy space Figure 8b. Esophagopleural fistula in a 53-year-old man after right pneumonectomy for squamous cell carcinoma. (b) Axial CT image demonstrates a fistula between the esophagus and the postpneumonectomy space (arrowhead). Figure 8c. Esophagopleural fistula in a 53-year-old man after right pneumonectomy for squamous cell carcinoma. (c) Esophagogram shows leakage of oral contrast material through the esophagopleural fistula (arrow)
Slide 37-

Cardiac Surgery Most of them are performed through a sternotomy incision and wire sternal sutures are often seen on postoperative films. Following cardiac surgery, some widening of the cadiovascular silhouette is usual, and represents bleeding and oedema. Marked mediastinal widening suggests significant haemorrhage.
Slide 38-

Some air remains in pericardium following cardiac surgery. So that the signs of pneumopericardium may be present. Pulmonary opacities are very common following open heart surgery, and left basal shadowing is almost invariable, indicating atelectasis. Small pleural effusions are also common in immediate post op period. Fig : hemopneumopericardium Fig: pneumopericardium
Slide 39-

Pneumoperitoneum is sometimes seen due to involvement of peritoneum by sternotomy incision. Violation of left or right pleural space may lead to pneumothorax. Damage of major lymphatic vessel may lead to chylothorax or more localised collection, a chyloma. Phrenic nerve damage cause paresis or paralysis of hemidiaphragm and elevation of hemidiaphragm. Prosthetic heart valves are usually visible on CXR.
Slide 40-

Heart Valves Fig: showing normal location of heart valves Fig : Aortic and mitral valves are metallic valves. And pulmonary and tricuspid Valves are tissue valves
Slide 41-

Sternal dehiscence appears radiographically as a linear lucency appearing in sternum and alteration in position of the sternal sutures. It may be associated with osteomyelitis. Fractures of 1st or 2nd rib occur when the sternum is spread apart, and they explain the chest pain in postoperative period.
Slide 42-

Acute mediastinitis can occur as complication of surgery. It is more commonly associated with esophageal perforation or surgery. Radiographically there will be mediastinal widening or pneumomediastinum. Fig: CT scan obtained on postoperative day 9 of aortic valve replacement demonstrates a large retrosternal fluid collection (straight arrows) adjacent to the ascending aorta that extends posteriorly into the aortopulmonary window. Note the bilateral air-space disease due to pneumonia and the left pleural effusion. Lymphadenopathy is present in the precarinal region and anterior to the left pulmonary artery (curved arrows).
Slide 43-

The postpericardotomy syndrome is an autoimmune phenomenon, usually occuring in the month after surgery. It presents with fever, pleurisy, and pericarditis. Pleural effusions and cardiomegaly may be present on CXR. Ultrasound demonstrate pericardial fluid. Patchy Consolidation may occur in lung bases.
Slide 44-

Thoracic complications of General surgery Atelectasis Pleural effusions Pneumothorax Aspiration pneumonitis Pulmonary edema Pneumonia Subphrenic abscess Pulmonary embolism
Slide 45-

Atelectasis Commonest after thoracic or abdominal surgery Predisposing factors: long anaesthetics, obesity, chr. Lung disease and smoking. It results form retained secretions and poor ventilation. Postoperatively it is painful to breathe deeply or cough. CXR findings: Elevation of diaphragm due to poor inspiration. Lower zone opacities representing subsegmental volume loss and consolidation (appear at 24hrs- resolve by 2-3days). Fig: Homogenous opacity in right hemithorax .Mediastinal shift to right ,Trachea shift to right .Right ht and diaphragamatic silhoute are not identifiable
Slide 46-

Pleural effusion Occur immediately following Thoracic and abdominal surgery and resolve in 2 weeks. May be associated with pulmonary infarction. Effusions due to sub phrenic infection usually occur later. Figure :Bilateral pleural effusion
Slide 47-

Pneumothorax When it complicates extrathoracic surgery, it is a complication of positive pressure ventilation or central venous line insertion. It may be complication even after nephrectomy.
Slide 48-

Aspiration pneumonitis It is common due to anaesthetics . When significant, patchy consolidation appears within a few hours, usually basally or around the hila. Clearing occurs within few days, unless there is super added infection.
Slide 49-

Pulmonary edema It be may due to cardiogenic or noncardiogenic. Non-cardiogenic includes fluid overload and the adult respiratory distress syndrome.
Slide 50-

Pneumonia Post-op Atelectasis and Aspiration pneumonitis may be complicated by pneumonia. They tend to be associated with bilateral basal shadowing.
Slide 51-

Subphrenic Abscess It produces elevation of hemidiaphragm, pleural effusion and basal atelectasis. Loculated gas may be seen below diaphragm and fluoroscopy may show splinting of diaphragm. It can be demonstrated by CT or ultrasound.
Slide 52-

Pulmonary Embolism It produces pulmonary shadowing, pleural effusion or elevation of diaphragm. Normal chest radiograph does not exclude pulmonary embolism. So initial investigation is perfusion lung scan.
Slide 53-

Transplantations Cardio pulmonary transplantations are uncommon procedures, with only a few thousand cases undertaken worldwide each year. Heart transplant remains most frequent procedure.
Slide 54-

Following Heart transplantation Basal atelectasis especially in left lower lobe. Small effusions. Haematoma within pleura or mediastinum. Chest drains are places during surgery, pneumothorax and pneumomediastinum are frequent. Pneumoperitoneum is seen in immediate postop period.
Slide 55-

Pulmonary edema is seen if cardiac function depresses in post op period. Complications related to rejection are usually manifest by cardiac failure. Rejection may be acute , within 3 months, or chronic in subsequent months or years. Specific complication of heart transplantation is accelerated coronary artery disease. Long term immune suppression to prevent rejection- increased risk of lymphoma. Fig. Post-transplantation lymphoma following heart and lung transplantation. The chest radiograph demonstrate widespread pulmonary nodules 2-3 cm in size which developed within 2 months of surgery. There was also mediastinal and hilar lymph node enlargement. Needle biopsy confirmed B-cell lymphoma which proved rapidly fatal.
Slide 56-

Following Lung Transplantation Low success rate. Single lung transplantation is preferred over double lung transplantation. Radiology plays role in multidisciplinary approach of donor selection, particularly in excluding occult contraindications like lung tumours / infections in opposite lung and assessment of degree and extent of pleural abnormality.
Slide 57-

Complications Acute phase: Reperfusion edema due to prolonged ischemia resulting in increased capillary permeability. lymphatic or autonomic interruption as a result of surgery. Usually apparent by day 3 and clears by day 10. Duration and severity of reimplantation response is reduced by minimising ischaemic time and careful restriction of post-op fluid replacement.
Slide 58-

Acute rejection: occur after 5th post op day. CXR may be normal or may demonstrate diffuse interstitial edema with pleural effusion, usually without increase in heart size. Infections may complicate postoperative period. Anastomotic failures, occasionally vascular but more frequently bronchial, may result in dehiscence or stenosis. Bronchial dehiscence may cause mediastinal emphysema, confirmed by CT, by identifying bronchial wall defect and mediastinal air collections.
Slide 59-

No of late complications includes: chronic rejection, oppertunistic and other infections and complications with anastomosis. Late rejections commonly manifest as bronchiolitis obliterans, confirmed by HRCT, demonstrates variation in attenuation of parenchyma (air trapping). Fig. Bronchiolitis obliterans following transplantation. There is marked bronchial dilatation in the lower lobes bilaterally, although the lung parenchyma appears unremarkable.
Slide 60-

Lines, Tubes and Devices
Slide 61-

Central venous catheters Fiigure a :Norrmal position of CVP catheters. Catheters entering from right IJV with tip in the distal right brachiocephalic vein and catheter entering from left subclavian vein with tip in the superior venacava illustrates location of venous anatomy Placed into large veins In neck (IJV ,SCV, Axillary vein) and in groin femoral vein To admister medicines and fluids and to measure central venous pressure
Slide 62-

Complications Secondary to Central Venous Catheters Malposition Pneumothorax Vascular laceration (hemothorax, chest wall/neck/mediastinal hematoma) Infection (possible source of septic emboli) Catheter fragmentation and embolization Venous thrombosis Venous stenosis Malpositioned central venous catheters. Posteroanterior radiograph demonstrate a central venous catheter in the azygos vein (arrowheads)
Slide 63-

Neck hematoma (asterisk) after right internal jugular line placement attempt. Note the endotracheal tube tip is in the right main bronchus. Fatal right hemothorax after right internal jugular line placement attempt in a patient with undiagnosed idiopathic thrombocytopenic purpura
Slide 64-

Pulmonary Artery Catheter Figure a: Normal position of pulmonary artery catheter placed through the right internal jugular vein with the tip in proximal right pulmonary artery. Note the chest wall port in rt chest wall. Figure b: Frontal chest radiograph shows malposition of a Swan-Ganz catheter (arrows) in the inferior vena cava
Slide 65-

Cardiac Pacemaker Biventricular pacemaker in a patient with ischemic cardiomyopathy. Device was placed for syncope and bradycardia 14 years earlier. Dual-chamber pacemaker as demonstrated on posteroanterior and radiograph Generator is in the left anterior chest wall with lead tips in the right atrium (arrowheads) and right ventricle (arrows )
Slide 66-

Endotracheal tubes Figure (A, B): Frontal chest radiographs show an endotracheal tube in the right main bronchus (arrowhead in A), causing hyperinflation of the ipsilateral lung and partial collapse of the left lung (curved arrow in A). After withdrawal of the tube into the trachea (arrow in B), the left lung has inflated
Slide 67-

Tracheostomy Tubes Figure b: Frontal chest radiograph shows complications of tracheostomy: pneumothorax (straight arrow), pneumomediastinum (curved arrow), and surgical emphysema (notched arrow) Figure a: Correct position tracheostomy tube
Slide 68-

Nasogastric tubes/Feeding tubes Figure b: Incorrect position of feeding tubes. Figure a: Correct position of feeding tube.
Slide 69-

CONCLUSION Thoracic surgery can produce challenging imaging appearances. • Surgical complications can present in the early or late postoperative period, with morbidity and mortality ranging from benign to catastrophic. • In many instances, postoperative complications require urgent intervention. • Understanding the imaging appearances of both anticipated postsurgical changes and unexpected complications will improve the timeliness and accuracy of diagnosis.
Slide 70-

References Textbook of radiology and imaging David Sutton 7th edition Radiographic and CT Findings of Thoracic Complications after Pneumonectomy Eun Jin Chae, Joon Beom Seo, So Yeon Kim, Kyung-Hyun Do, Jeong- Nam Heo, Jin Seong Lee, Koun Sik Song, Jae Woo Song, Tae-Hwan Lim Published Online:Sep 1,2006 – https://doi.org/10.1148/rg.265055156 http//www.radiopedia.org
Slide 71-

THANK YOU!