Pulmonary tumour thrombotic microangiopathy or chronic thromboembolic pulmonary hypertension? - diagnosed by pulmonary wedge aspiration cytology using a Swan–Ganz catheter - a case report

Sep 29, 2026

Pulmonary tumour thrombotic microangiopathy (PTTM) is a malignancy-associated disorder causing rapidly fatal pulmonary hypertension (PH) and is rarely diagnosed before death. Because PTTM can mimic chronic thromboembolic pulmonary hypertension (CTEPH) in clinical and imaging features, differentiation is often difficult. This case report documents a 64-year-old woman with pancreatic cancer presenting with progressive dyspnoea, cough, and oedema, initially suspected as CTEPH, but confirmed as PTTM by pulmonary wedge aspiration cytology via a Swan–Ganz catheter.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

Case report

Case summary

Discussion

Learning points

European Heart Journal-Case Reports (2026) 10, ytaf648 [https://doi.org/10.1093/ehjcr/ytaf648](https://doi.org/10.1093/ehjcr/ytaf648) CASE REPORT Heart failure Pulmonary tumour thrombotic microangiopathy or chronic thromboembolic pulmonary hypertension?—diagnosed by pulmonary wedge aspiration cytology using a Swan–Ganz catheter: a case report Taku Shimojo 1*, Tomohisa Tada1, Haruyasu Ito1, Hideyuki Kinoshita2, and Fujio Hayashi1 1Department of Cardiology, Japanese Red Cross Osaka Hospital, 5-30, Fudegasaki-cho, Tennouji-ku, Osaka 543-8555, Japan; and 2Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Konoe-cho, Yoshida, Sakyo-ku, Kyoto 606-8501, Japan Received 21 December 2024; revised 10 November 2025; accepted 2 December 2025; online publish-ahead-of-print 12 December 2025 Background Pulmonary tumour thrombotic microangiopathy (PTTM) is a malignancy-associated disease that causes fatal pulmonary hypertension (PH). Due to its rapidly progressive clinical course, antemortem diagnosis is often difficult. Pulmonary tumour thrombotic microangiopathy shares several clinical and imaging characteristics with chronic thromboembolic pulmonary hypertension (CTEPH), making differentiation between these two diseases challenging. Case summary A 64-year-old woman with pancreatic cancer treated with chemotherapy presented with shortness of breath and cough over the past 5 months and was admitted due to a 2-week history of worsening dyspnoea and peripheral oedema. Transthoracic echocardiography found dilated right ventricle, interventricular septal flattening, and severe tricuspid regurgitation. Although contrast-enhanced computed tomography showed no evidence of pulmonary thromboembolism, pulmonary perfusion scintigraphy demonstrated multiple wedge-shaped defects in the peripheral regions of both lungs. Right heart catheterization confirmed pre-capillary PH, and pulmonary angiography revealed vascular narrowing of the peripheral pulmonary arteries. Based on the radiological findings and the relatively slow clinical course, CTEPH was initially suspected. However, pulmonary wedge aspiration cytology—performed by aspirating a blood sample via a Swan–Ganz catheter from the wedged position during right heart catheterization—revealed tumour cells, confirming the diagnosis of PTTM rather than CTEPH. Because of the poor prognosis, the patient received palliative care and died 2 months later. Discussion Pulmonary tumour thrombotic microangiopathy is a rare but fatal cause of PH and is rarely diagnosed antemortem. Pulmonary wedge aspiration cytology is a minimally invasive and valuable tool that helps differentiate PTTM from CTEPH and plays a crucial role in guiding both diagnosis and management. Keywords Pulmonary tumour thrombotic microangiopathy • Chronic thromboembolic pulmonary hypertension • Pulmonary hypertension • Pulmonary wedge aspiration cytology • Swan–Ganz catheter • Malignancy • Case report - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ESC curriculum 9.6 Pulmonary hypertension • 9.5 Pulmonary thromboembolism • 4.5 Tricuspid regurgitation • 6.7 Right heart dysfunction * Corresponding author. Tel: +81 6 6774 5111, Email: [shimotakua15ma036@outlook.jp](shimotakua15ma036@outlook.jp)[ ](shimotakua15ma036@outlook.jp)Handling Editor: Giacomo Tini Melato Peer-reviewers: Monica Salvi; Emiliano Fiori Compliance Editor: Deepti Ranganathan © The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ([https://creativecommons.org/licenses/by-nc/4.

FAQs

Why is PTTM difficult to diagnose before death?

PTTM has a rapidly progressive course and is rarely identified antemortem. Its clinical and imaging findings overlap with chronic thromboembolic pulmonary hypertension, making early recognition challenging.

What initially suggested chronic thromboembolic pulmonary hypertension in this case?

CT findings showed no pulmonary thromboembolism, but imaging and clinical course led clinicians to initially suspect CTEPH based on radiological features and a relatively slower progression.

How was the final diagnosis of PTTM confirmed?

Pulmonary wedge aspiration cytology performed during right heart catheterization, using a Swan–Ganz catheter to aspirate a wedged blood sample, revealed tumour cells, confirming PTTM rather than CTEPH.

Sep 29, 2026

Uploaded by Rainbow Cat