Complications of Lung Transplantation: Update on Imaging Manifestations and Management

Abstract

As lung transplantation has become the most effective definitive treatment option for end-stage chronic respiratory diseases, yearly rates of this surgery have been steadily increasing. Despite improvement in surgical techniques and medical management of transplant recipients, complications from lung transplantation are a major cause of morbidity and mortality. Some of these complications can be classified on the basis of the time they typically occur after lung transplantation, while others may occur at any time. Imaging studies, in conjunction with clinical and laboratory evaluation, are key components in diagnosing and monitoring these conditions. Therefore, radiologists play a critical role in recognizing and communicating findings suggestive of lung transplantation complications. A description of imaging features of the most common lung transplantation complications, including surgical, medical, immunologic, and infectious complications, as well as an update on their management, will be reviewed here. Keywords: Pulmonary, Thorax, Surgery, Transplantation Supplemental material is available for this article. © RSNA, 2021.

Keywords: Pulmonary; Surgery; Thorax; Transplantation.

Figure 1:

Images in a 49-year-old man with left pulmonary vein stenosis identified 1 week after bilateral lung transplantation for cystic fibrosis. (A) Coronal chest CT bone window image shows stenosis of the left upper lobe pulmonary vein (arrow), and (B) axial chest CT image shows left upper lobe consolidation and ground-glass opacities due to pulmonary venous congestion and likely venous infarction.

Figure 2:

Image in a 58-year-old man with pulmonary artery stenosis identified at the first postoperative CT performed after bilateral lung transplantation for interstitial lung disease. Three-dimensional reconstructed axial chest CT image shows stenosis of the right main pulmonary artery (arrow) with relative lucency and hypovascularity of the right lung in the setting of right main pulmonary artery stenosis.

Figure 3:

Images in a 48-year-old woman with left lower lobe 90° (partial) torsion in the postoperative period after bilateral lung transplantation for sarcoidosis. (A) Axial chest CT image in lung window shows consolidative opacities in the left lower lobe. (B) Sagittal CT image in maximum intensity projection shows horizontal rather than vertical fissure (white arrows), swirling of the left lower lobe pulmonary artery (black arrow), and heterogeneous opacities in the left lower lobe. (C) Coronal CT image better demonstrates the horizontal left main fissure (arrow) with consolidations in the left lower lobe. (D) Nuclear perfusion scan shows substantially less radiotracer (technetium-99 macroaggregated albumin) uptake in the left lower lobe, correlating with the CT finding of lobar torsion. Patient was taken to the operating room, and the left lower lobe was repositioned, which improved her clinical status quickly and resulted in her discharge. Ll = left lower, Lm = left middle, Lu = left upper, Rl = right lower, Rm = right middle, Ru = right upper.

Figure 4:

Images in a 48-year-old man with bronchial dehiscence 1 month after bilateral lung transplantation for idiopathic pulmonary fibrosis. (A) Coronal chest CT three-dimensional reconstructed minimum intensity projection image and (B) volume-rendered reformat image show outpouching (orange arrow) arising from inferior aspect of the bronchus intermedius adjacent to the surgical clips, compatible with bronchial dehiscence. Bronchial dehiscence was managed with endobronchial stent placement.

Figure 5:

Image in a 52-year-old man with left bronchial stenosis after bilateral lung transplantation for end-stage chronic obstructive pulmonary disease. Axial chest CT lung window image shows focal narrowing of the left mainstem bronchus (arrow) 2 months after lung transplantation.

Figure 6:

Image in a 62-year-old woman with chest wall hematoma 2 weeks after bilateral lung transplantation for interstitial lung disease. Axial chest CT image shows fluid collection in the soft tissues of the left chest wall, measuring 45 HU on average, consistent with chest wall hematoma. Hematoma resolved in 2 weeks after surgical drain placement.

Figure 7:

Images in a 65-year-old woman with tracheobronchomalacia after right lung transplantation for interstitial lung disease. Bronchoscopic images show (A) a normal caliber right mainstem bronchus during inspiration and (B) a collapsed and narrowed right mainstem bronchus during expiration. These findings are compatible with bronchomalacia.

Figure 8:

Images in a 24-year-old man with posttransplant lymphoproliferative disease identified 18 months after bilateral lung transplantation for cystic fibrosis. (A) Axial chest CT and (B, C) axial fluorodeoxyglucose PET/CT images show spiculated bilateral pulmonary nodules with intense fluorodeoxyglucose avidity.

Figure 9:

Images in a 32-year-old woman with lymphangioleiomyomatosis recurrence. (A) Axial CT image shows multiple small thin-walled cysts and larger subpleural bulla in a pretransplant patient with lymphangioleiomyomatosis. There is a small right pneumothorax (arrow). (B) Axial CT image obtained 7 years after bilateral lung transplantation shows multiple small bilateral thin-walled cysts and trace right pneumothorax (arrow) compatible with lymphangioleiomyomatosis recurrence. There is also small pneumomediastinum.

Figure 10:

Images in a 55-year-old woman with pulmonary alveolar proteinosis recurrence. Axial CT lung window images at (A) 2 months, (B) 1 year, and (C) 2 years after lung transplantation show increasing patchy ground-glass opacities and septal thickening (crazy paving) compatible with recurrence of pulmonary alveolar proteinosis.

Figure 11:

Images in a 57-year-old man with adenocarcinoma of the lung allograft 16 years after bilateral lung transplantation for idiopathic pulmonary fibrosis. (A) Axial CT image shows a left lower lobe spiculated nodule with central cavitation, and (B) axial fluorodeoxyglucose PET/CT image shows intense fluorodeoxyglucose uptake of the nodule. Biopsy proved primary adenocarcinoma of the lung.

Figure 12:

Images in a 35-year-old man with acute cellular rejection after bilateral lung transplantation for cystic fibrosis. (A) Axial chest CT lung window image 2 years and 7 months after transplantation shows bilateral ground-glass opacities. (B) Axial chest CT lung window image 2 years and 8 months after transplantation shows increased mixed-attenuation nodular opacities.