EBUS‐Guided Incidental Finding of Pulmonary Vein Thrombosis: A Case Report and Literature Review

ABSTRACT

Pulmonary vein thrombosis (PVT) is an uncommon but potentially fatal condition that is often underdiagnosed due to nonspecific clinical presentation. We report a case of a 47‐year‐old woman with a thrombus in the right inferior pulmonary vein incidentally found during a robotic‐assisted bronchoscopy biopsy (RAB) and endobronchial ultrasound (EBUS) performed for mediastinal evaluation and lymph node sampling. PVT was confirmed with computed tomography pulmonary angiography, and the patient was successfully treated with anticoagulation therapy. A review of the literature revealed that reports of PVT detected via EBUS are exceedingly rare and usually malignant in nature. To our knowledge, this is the first peer‐reviewed case report describing PVT identified incidentally during EBUS, underscoring the potential of this technique to reveal clinically significant vascular abnormalities.

Pulmonary vein thrombosis (PVT) is an uncommon but potentially fatal condition that is often underdiagnosed due to nonspecific clinical presentation. We report a case of PVT identified incidentally during EBUS, underscoring the potential of this technique to reveal clinically significant vascular abnormalities.

1. Introduction

Pulmonary vein thrombosis (PVT) is a rare and often underrecognised thrombotic entity whose true incidence remains unknown. It is most frequently associated with lung transplantation, lobectomy, malignancy and radiofrequency catheter ablation for atrial fibrillation [1], while a small number of cases occur without an identifiable precipitating factor [1, 2]. Clinical manifestations for PVT are usually nonspecific and vary widely, including cough, dyspnea and hemoptysis or may be absent, often resulting in delayed or missed diagnosis [1, 3, 4].

Consequently, a high index of suspicion is essential, and identifying PVT requires a comprehensive approach involving conventional imaging modalities. While transthoracic echocardiography is often part of the initial assessment, a combination of more advanced techniques, including transesophageal echocardiography, computed tomography (CT) and magnetic resonance imaging, is typically used to characterise the thrombus and adjacent anatomy definitively [3, 5]. Potential complications can significantly alter patients' hemodynamic stability and may comprise hypoxic respiratory failure, stroke, systemic embolisation or death [4]. Treatment plans typically involve anticoagulation therapy and may also involve thrombectomy or resection in some cases [1, 3].

Endobronchial ultrasound (EBUS), primarily used for transbronchial needle aspiration (TBNA) in mediastinal and hilar lymph node evaluation, has demonstrated diagnostic capabilities beyond its conventional role and can incidentally identify pulmonary vascular abnormalities such as pulmonary embolism (PE). Literature reports describe incidental PE detection during EBUS in up to 0.7% of procedures, with approximately 96% diagnostic concordance with CT angiography [6, 7]. However, reports of PVT detected via EBUS are exceedingly rare and mostly describe malignant thrombi. We present a case report of a 47‐year‐old female with a bland thrombus found incidentally during robotic‐assisted bronchoscopy (RAB) biopsy and EBUS for diagnostic evaluation of lung nodules and lymph node sampling. This finding is discussed within the context of current literature, emphasising its significance and clinical implications. A review of the relevant literature is also presented.

2. Case Report

A 47‐year‐old female nonsmoker with a history of a right lower lobe (RLL) mass and cutaneous mycobacterial infection underwent RAB biopsy of a RLL nodule, EBUS‐TBNA and bronchoalveolar lavage. During EBUS assessment, an unexpected intraluminal filling defect was visualised within a distal branch of the right inferior pulmonary vein, raising concern for PVT (Figure 1 and Video 1). The procedure was completed without complications, and the patient was directly admitted for further examination of a PVT on postprocedure imaging.

FIGURE 1.

Endobronchial ultrasound view of intraluminal filling defect within a distal branch of the right inferior pulmonary vein (yellow arrow).

VIDEO 1.

Download video file ^{(9.3MB, mp4)}

Endobronchial ultrasound (EBUS) imaging demonstrating a pulmonary vein containing intraluminal echogenic material consistent with thrombus. The EBUS probe provides real‐time visualisation of the vascular lumen, vessel wall and surrounding mediastinal structures, enabling evaluation of vascular involvement. Video content can be viewed at https://onlinelibrary.wiley.com/doi/10.1002/rcr2.70612.

A postbronchoscopy CT angiogram performed on the same day revealed a persistent thin linear filling defect within the right inferior pulmonary vein, suggestive of a pedunculated thrombus at the pulmonary venous ostium (Figure 2). No pulmonary emboli were identified in the pulmonary arteries (Figure 3).

FIGURE 2.

Computed tomography angiogram view of linear filling defect within the right inferior pulmonary vein (yellow arrows), suggestive of pedunculated thrombus at pulmonary venous ostium.

FIGURE 3.

Computed tomography angiogram view of pulmonary artery showing no evidence of pulmonary emboli (yellow arrow).

The patient remained hemodynamically stable throughout hospitalisation and did not require supplemental oxygen, maintaining adequate oxygenation in room air. She reported mild wheezing and shortness of breath, without associated chest pain, hemoptysis or extremity swelling. Anticoagulation therapy was initiated prior to discharge with apixaban 10 mg twice daily for 7 days, followed by a planned transition to 5 mg twice daily for a minimum duration of 3 months, based on established PE and venous thromboembolism (PE/VTE) treatment guidelines [8, 9]. She was discharged home in stable condition the following day, with outpatient follow‐up arranged for ongoing management of her underlying conditions. No complications related to the PVT were observed during hospitalisation or early follow‐up.

Results from the biopsy of the RLL mass yielded suspicious but nondiagnostic findings, describing lung tissue with areas of organisation and several fragments containing lymphoid infiltrates concerning for involvement by low‐grade extranodal marginal zone lymphoma. Two weeks after the initial procedure, a positron emission tomography (PET) scan was performed, which demonstrated scattered hypermetabolic pulmonary lesions, findings suspicious for low‐grade marginal zone lymphoma. No additional abnormalities or associated vascular involvement were identified.

The patient remains under active evaluation and follow‐up for her underlying diagnosis suspicious of extranodal lymphoma. No follow‐up imaging specific to PVT was performed.

3. Discussion

The clinical manifestations of PVT vary from asymptomatic presentations to life‐threatening embolic events [1, 3, 10], and the known etiologies of PVT typically involve important disruption to the anatomy or physiology of pulmonary veins such as surgery, active malignancy, direct extension of malignant processes or extrinsic vein compression, which can produce tumour thrombi within the pulmonary veins [1, 2, 3]. Hypercoagulable states and mechanical compression of veins, leading to stasis and endothelial damage, are major contributors to the development of this condition [11, 12]. In this case, the RLL mass likely exerted mechanical compression on a pulmonary vein branch, resulting in impaired blood flow and subsequent PVT.

Due to the nonspecific or absent nature of symptoms, diagnosis is often delayed or overlooked, highlighting the importance of maintaining a high index of clinical suspicion, particularly in patients with risk factors. Accurate identification relies on comprehensive imaging, as clinical findings alone are rarely diagnostic [2]. Conventional modalities such as pulmonary angiography, transthoracic echocardiography and transesophageal echocardiography are commonly used and can help differentiate between a benign or bland thrombus and a malignant thrombus or tumour invasion [1, 3]. To reduce flow‐related artefacts, late‐phase CT with intravenous contrast material is often employed, and magnetic resonance imaging has also emerged as a valuable diagnostic tool [3].

In the present case, the initial suspicion was not raised by any of these conventional modalities, but rather incidentally by EBUS and subsequently confirmed with CT angiography. Although EBUS is not a primary tool for identifying venous thrombosis, it may serve as a valuable adjunctive technique for specialists, enabling visualisation of vascular abnormalities during intrathoracic ultrasound procedures [5, 7, 13]. Prompt recognition can allow earlier confirmation with cross‐sectional imaging and initiation of appropriate management.

A review of the literature indicates that sonographic identification of pulmonary vein pathology with EBUS is rare. Of note, four cases involved malignant thrombi, in which EBUS enabled direct visualisation and diagnostic sampling of tumour thrombus within the pulmonary vein via EBUS‐TBNA, allowing confirmation of malignancy on histology [14, 15, 16, 17], while only one previous EBUS‐guided evidence of a benign thrombus within the pulmonary vein documented after detection by CT [18] (Table 1). Although the thrombus did not appear to represent direct tumour invasion, it was classified as a bland thrombus. To our knowledge, this case provides the first comprehensive account of a bland thrombus PVT incidentally identified by EBUS in the absence of prior imaging or clinical suspicion.

TABLE 1.

Published cases of pulmonary vein thrombosis or tumour visualised by EBUS.

References	Study design	No. of patients	Pulmonary vein location	Thrombus type	EBUS role	Key finding
MacEachern et al. [17]	Case report	1	Right pulmonary vein	Malignant (tumour invasion)	Diagnosis and sampling	Case report of a tumour invasion detected by EBUS
Braddy et al. [14]	Case report	1	Left superior PV	Malignant (NSCLC)	Diagnosis and sampling	Confirmed tumour thrombus extension of lung cancer via EBUS‐TBNA
Diotti et al. [15]	Case report (abstract)	1	Left superior PV	Malignant (NSCLC)	Diagnosis and sampling	Demonstrated trans‐vascular EBUS sampling of a tumour thrombus
Elmas et al. [16]	Case report	1	Left inferior PV	Malignant (intimal sarcoma)	Diagnosis and sampling	Diagnosed a rare primary pulmonary vein sarcoma via EBUS‐FNA
Kumar et al. [18]	Case report (abstract/conference)	1	Superior pulmonary vein	Benign (‘Clot’)	Incidental visualisation	Brief report of a benign clot seen on EBUS, after detection by CT
Our Case (2025)	Case report	1	Right inferior PV	Bland thrombus	Incidental visualisation	Full report of an incidental bland thrombus identified on EBUS.

Abbreviations: CT, computed tomography; EBUS, endobronchial ultrasound; FNA, fine needle aspiration; PV, pulmonary vein; TBNA, transbronchial needle aspiration.

To date, no specific guidelines have been established for the diagnosis of PE or PVT during EBUS, and the available literature remains limited to isolated case reports. CT pulmonary angiogram can be used to confirm suspected PVT, while EBUS should be used adjunctively when CT pulmonary angiogram is contraindicated or not immediately available. This case report underscores the potential for EBUS to detect clinically significant vascular findings that extend beyond its conventional role in mediastinal lymph node staging. It serves to expand the awareness of the spectrum of pulmonary venous pathology that may be encountered during routine interventional pulmonology procedures and highlights the critical importance of distinguishing between benign and malignant intravascular findings to ensure appropriate and safe patient management.

This rare case of incidentally found PVT further illustrates the versatility of EBUS beyond nodal and parenchymal assessment and emphasises the value of thoroughly examining adjacent vascular structures during EBUS techniques, particularly in patients with a history of or high risk of malignancy and other prothrombotic risk factors.

Author Contributions

Mohammed A. Alqawasma, Yunus E. Yesilkaya and Tatiana A. Rojas‐Zapata were responsible for manuscript conception, writing and reviewing of the manuscript. Regina Murillo‐Torres, Alejandra Yu Lee‐Mateus, Linh H. Vu, Zachary J. Fleissner, Bryan C. Husta, David Abia‐Trujillo and Sebastian Fernandez‐Bussy contributed substantially to the writing and reviewing of the manuscript. All authors reviewed and approved the final draft of the manuscript.

Funding

The authors have nothing to report.

Ethics Statement

The authors acknowledge that this case report is original and has not been previously published, nor is it currently being considered for publication elsewhere. All sources used are properly disclosed, and all authors who have been involved are mentioned.

Consent

The authors declare that written informed consent was obtained for the publication of this manuscript and accompanying images and attest that the form used to obtain consent from the patient complies with the Journal requirements as outlined in the author guidelines.

Conflicts of Interest

The authors declare no conflicts of interest.

Alqawasma M. A., Yesilkaya Y. E., Rojas‐Zapata T. A., et al., “ EBUS‐Guided Incidental Finding of Pulmonary Vein Thrombosis: A Case Report and Literature Review,” Respirology Case Reports 14, no. 6 (2026): e70612, 10.1002/rcr2.70612.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.