Post-operative chest imaging is important following lung resection surgery to identify normal postoperative changes and detect any complications. Common procedures discussed include lobectomy, pneumonectomy, and segmentectomy. Expected findings include fluid filling the post-pneumonectomy space and the remaining lung expanding. Potential early complications discussed are pulmonary edema, pneumonia, hemorrhage, bronchopleural fistula, and empyema. Late complications can include disease recurrence, bronchial stricture, and post-pneumonectomy syndrome. Accurate diagnosis of complications is important to minimize morbidity and mortality.

1. Post Operative Chest
Imaging
Dr Basant Regmi
Resident ;Radiodiagnosis
NAMS, Bir Hospital

2. Overview
• THORACOTOMY
PNEUMONECTOMY
LOBECTOMY
SEGMENTECTOMY
• COMPLICATIONS OF THORACOTOMY
EARLY
LATE
• CARDIAC SURGERY
• THORACIC COMPLICATIONS OF GENERAL
SURGERY

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.

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

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

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

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.

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.

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.

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

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.

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.

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.

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

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

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.

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.

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.

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.

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.

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).

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.

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 .

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.

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 .

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 .

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.

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.

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.

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 .

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 .

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 .

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.

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 .

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.

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)

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.

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: pneumopericardium
Fig : hemopneumopericardium

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.

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

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.

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).

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.

44. Thoracic complications of
General surgery
• Atelectasis
• Pleural effusions
• Pneumothorax
• Aspiration pneumonitis
• Pulmonary edema
• Pneumonia
• Subphrenic abscess
• Pulmonary embolism

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

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

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.

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.

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

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

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.

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.

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

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.

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.

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.

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.

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.

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.

60. Lines, Tubes and Devices

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

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

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

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

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 )

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

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

68. Nasogastric tubes/Feeding tubes
Figure b: Incorrect position of feeding tubes.Figure a: Correct position of feeding
tube.

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.

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

71. THANK YOU!