Combined surgical therapy for pulmonary sequestration and aberrant artery from the abdominal aorta

Unexpected pulmonary sequestration in a pregnant patient

A pregnant woman in her early 30s, at 20 weeks of gestational age, presented with recurrent haemoptysis, pleuritic chest pain and a productive cough of 6 months duration. She underwent CT pulmonary angiogram which demonstrated right pulmonary sequestration and right-sided consolidation. Pre-existing pulmonary comorbidities such as chronic inflammation, structural abnormalities or weakened blood vessels within the lungs can encourage the growth of abnormal blood vessels. During pregnancy, these dynamics can be further aggravated by increasing cardiac output to promote blood flow to the placenta and increasing oxygen delivery to the developing foetus. These changes likely cause increased blood flow to the pulmonary sequestration, resulting in haemoptysis. The patient was treated conservatively for community-acquired pneumonia with a course of oral amoxicillin 500 mg three times a day for 5 days, and she is doing well on follow-up.

Sublobar resection utilizing near-infrared thoracoscopy with intravenous indocyanine green for intralobar pulmonary sequestration: a case report and literature review

BACKGROUND

Pulmonary sequestration is a rare pulmonary malformation, with intralobar pulmonary sequestration being the most common subtype. Lobectomy has generally been performed for its treatment, owing to unclear boundaries of the lesion. However, recent reports have introduced lung resection using intravenous indocyanine green (ICG) as a treatment for pulmonary sequestrations.

CASE DESCRIPTION

A 34-year-old woman presented with chest pain, and enhanced chest computed tomography (CT) displayed a solid mass of 4.5 × 3.1 cm in the right S10 area. An aberrant artery was found running from the celiac artery through the diaphragm to the thoracic cavity. The patient was diagnosed as having pulmonary sequestration Pryce type III, and surgical resection was performed. Intrathoracic findings demonstrated that the precise area of the pulmonary sequestration could not be clearly identified, and a 5-mm aberrant artery was present in the pulmonary ligament. Following the separation of the aberrant artery, intravenous injection of ICG clearly delineated the border between the normal lung tissue and the pulmonary sequestration. Wedge resection was then performed without any postoperative events, and the pathological diagnosis was also pulmonary sequestration.

CONCLUSIONS

We herein reported a case of a patient who underwent sublobar resection for intrapulmonary sequestration using intravenous ICG injection, together with a literature review. Our case suggests that a comprehensive understanding of abnormal vessels and pulmonary vasculature in pulmonary resection for intrapulmonary sequestrations, complemented with the use of ICG, might potentially avoid unnecessary pulmonary resection and enable sublobar surgical resection.

A strange case of pleuritic pain in the third trimester of pregnancy

Pulmonary sequestration is an uncommon congenital malformation of the lung, generally diagnosed in childhood or adolescence, corresponding to dysplastic lung tissue not communicating with the rest of vascular or bronchial lung system but receiving an arterial blood supply from systemic arteries. Currently, surgical resection is usually indicated in order to prevent or treat related symptoms or complications, although controversy exists regarding its use in asymptomatic patients and adults. We present the case of a 32-year-old pregnant woman with acute chest pain and vomiting diagnosed with intralobar sequestration at 32+2 weeks of gestation and treated with pulmonary lobectomy after giving birth by cesarean section at 33+0 weeks of gestation.

Indocyanine Green to Visualize and Resect Pulmonary Sequestration in Adults

Pulmonary sequestration (PS) is a rare congenital pulmonary dysplasia which presents with recurrent chest infections and haemoptysis. Its diagnosis is difficult and suspected on contrast-enhanced chest CT. The definitive treatment of pulmonary sequestration is surgical resection or endoluminal occlusion of the abnormal feeding vessel. Here, we report an innovative technique in which per-operative indocyanine green guided excision of intra-lobar sequestrated lung parenchyma and ligation of abnormal feeding vessel. The first patient was a 44-year-old gentleman with recurrent bouts of cough for 2 years. Courses of antibiotics failed to resolve it. Fibreoptic bronchoscopy and routine blood tests did not show any abnormality. CECT chest showed multiloculated cystic solid and low density mass in the right lower lung. The area of the lesion received its blood supply from anomalous systemic artery originating from coeliac trunk. Intraoperative, indocyanine green was injected into the atypical vessel, and pulmonary sequestration turned green. A sequential atypical lung resection could be completely removed with parenchyma preservation. The second patient was a 53-year-old lady presenting with chest pain, cough and expectoration for 2 years not responding to general management and antibiotics. CECT showed a low-density mass in the right lower lung lobe, with a feeding arterial vessel arising from the abdominal aorta. This was diagnosed as PS and resected using per-operative indocyanine green with parenchymal preservation and ligation of feeding vessel. Both patients have been followed up for at least 1 year and are symptom free. The intraoperative use of indocyanine green could greatly facilitate the presentation of the extent of a lung sequestration and safe resection.

Lessons learned from hybrid surgery with preoperative coil embolization for an aberrant artery in pulmonary sequestration

Background

The optimal management of an aberrant artery in pulmonary sequestration (PS) is controversial. Several studies have shown that hybrid surgery with preoperative coil embolization for an aberrant artery and surgical resection of the sequestrated lung is effective. However, there are no clear indications for the procedure.

Case presentation

A 68-year-old woman without any complaints was diagnosed with right intralobar PS, which was supplied by an aberrant artery from the thoracic aorta, via computed tomography performed during a medical examination. In addition, lung adenocarcinoma was detected over the border between the right upper and middle lobes. Preoperative coil embolization was performed by an interventional radiologist the day before surgery to decrease the risk of severe intraoperative hemorrhage. On the following day, bi-lobectomy of the right upper and middle lobes for lung adenocarcinoma with systemic lymph node dissection and segmentectomy of the sequestrated lung with thoracotomy was performed. Although no active hemorrhage was observed during surgery, the aberrant artery was challenging to dissect using an energy device due to the presence of an intravascular coil. Eventually, the coil stump was exposed, and it was cut with scissors. The postoperative course was uneventful.

Conclusions

We reported the pitfall of the hybrid surgery for intralobar PS. Preoperative coil embolization can prevent fatal intraoperative hemorrhage. If embolization is performed using a coil for an aberrant artery supplied from the thoracic aorta, where and how to dissect the aberrant artery should be cautiously determined based on preoperative images, with consideration of the presence of an intravascular coil.