Pulmonary resection and contralateral anomalous venous drainage: a lethal combination

A rare case of right upper lung cancer with azygos lobe and partial anomalous pulmonary venous return

BACKGROUND

The azygos lobe (AL) combined with partial anomalous pulmonary venous return (PAPVR) is comparatively uncommon as well as in radical surgery for right lung cancer.

CASE PRESENTATION

We herein present an extremely rare case of lung cancer coexisting with AL and asymptomatic PAPVR, which was diagnosed with preoperative contrast three-dimensional reconstruction and received radical surgery by thoracoscopy. During the surgery, we preserved azygos vein successfully and found a split type of PAPVR in right upper pulmonary vein.

CONCLUSIONS

AL combined with PAPVR may cause confusion on the vascular separation and disconnection of the right pulmonary hilar. However, preoperative 3D reconstruction is more conducive to the correct performing of this type of surgery.

The Evolving Landscape of Lung Cancer Surgical Resection: An Update for Radiologists With Focus on Key Chest CT Findings

Evolution of the multimodality management of early lung cancer, including progress in surgical techniques, has introduced the possibility of resection for lung cancer cases that historically were considered unresectable (e.g., select cases of T4 disease and oligometastatic disease). However, the TNM classification does not uniformly correlate with lung cancer operability and resectability. Radiologic evaluation is therefore critical in identifying patients' suitability to undergo lung cancer resection and in guiding the selection of a surgical approach from among a range of such approaches, including wedge resection, segmentectomy, lobectomy, bilobectomy, and pneumonectomy. The radiologist must understand the available surgical options, along with their advantages and disadvantages, and provide a report that includes critical information on tumor size, location, and extension and anatomic relations that may influence the surgical technique. Preoperative CT findings may also help predict expected postoperative lung function and the associated impact on the postoperative course of the patient. This article reviews the role of chest CT in the preoperative evaluation of lung cancer, focusing on the key CT findings that help direct surgical decision making in the context of an expanding range of patients who may be considered candidates for resection.

Lung cancer with partial anomalous pulmonary venous connection in a different lobe: a case report

Background

Anomalous pulmonary venous connection (APVC) is a congenital malformation in which the pulmonary veins connect to the systemic venous system but not to the left atrium. APVC can be classified as total or partial (PAPVC). PAPVC is rare among surgical patients with lung cancer, and most cases are detected incidentally during surgery. We herein report a patient with lung cancer in whom PAPVC was diagnosed before surgery, which made it difficult to determine the surgical procedure.

Case presentation

A 71-year-old man was followed-up as an outpatient after surgery for renal cell carcinoma. Chest computed tomography showed a 22-mm nodule in the right lower lobe and PAPVC in the right upper lobe. He was diagnosed with lung adenocarcinoma (cT1cN0M0 stage IA3) and scheduled for surgery. Preoperative catheterization showed a pulmonary to systemic flow ratio (Qp/Qs) of 1.64 and mean pulmonary artery pressure (MPAP) of 16 mmHg. Surgical repair of PAPVC is indicated when a patient is symptomatic and has a Qp/Qs ≥1.5–2.0. The patient was scheduled for right lower lobectomy, but postoperative worsening of right heart strain was considered. Concomitant PAPVC repair was therefore considered, but he had no atrial septal defect and was asymptomatic; therefore, PAPVC treatment was considered unnecessary. However, we planned to perform concomitant PAPVC repair if his circulatory dynamics worsened during surgery or if his MPAP exceeded 25 mmHg. His MPAP was 20 mmHg and his circulatory dynamics remained stable, and right lower lobectomy was therefore completed. His postoperative course was favorable. Follow-up catheterization at 6 months showed a Qp/Qs of 1.19 and MPAP of 18 mmHg, with no evidence of increased right heart strain. There was no evidence of right heart failure or recurrence of lung cancer at last follow-up at 18 months after surgery.

Conclusions

We present a case of right lower lung cancer complicated by PAPVC in the right upper lobe. This case suggests that concomitant repair of PAPVC in the right upper lobe may not be necessary when performing right lower lobectomy, although the patient’s Qp/Qs and MPAP should be considered.

Partial anomalous pulmonary venous connection and a tracheal bronchus associated with lung cancer in the same lobe: classification of partial anomalous pulmonary venous connection in lung resection

A 73-year-old man with primary lung adenocarcinoma (StageIA3), which was solid nodule in the posterior segment, was simultaneously diagnosed as having partial anomalous pulmonary venous connection (PAPVC) and a tracheal bronchus in the same lobe on preoperative chest computed tomography. Right upper lobectomy was performed as the definitive treatment for both the lung cancer and the PAPVC. The superior pulmonary vein connected to the proximal superior vena cava and the pulmonary artery to the apical segment diverged at the proximal portion of the right pulmonary artery trunk along with the tracheal bronchus. The patient's pulmonary arterial pressure improved after lobectomy. The patient is living well without recurrence of lung cancer 6 months after surgery. In conclusion, it is important to confirm the presence of anomalous pulmonary vein drainage to prevent the lethal change of pulmonary-systemic blood flow. Based on the classification of PAPVC proposed, surgical plan should be considered carefully.

Identifying partial anomalous pulmonary venous connection in the superior vena cava before pulmonary resection

OBJECTIVE

There are only limited reports on pulmonary resection complicated with partial anomalous pulmonary venous connection. Preoperative partial anomalous pulmonary venous connection was overlooked in approximately 50% of these reports, while most cases of were located on the same side as the pulmonary resection. We examined the prevalence of overlooked partial anomalous pulmonary venous connection and determined appropriate measures to avoid misdiagnosis.

METHODS

We retrospectively reviewed the records and computed tomography data of consecutive patients who underwent pulmonary resection at the University of Yamanashi Hospital between 2006 and 2019. We re-evaluated the computed tomography images in horizontal and coronal views, focusing on the four common sites of partial anomalous pulmonary venous connection. Further, we conducted a literature review of studies that reported partial anomalous pulmonary venous connection cases.

RESULTS

Among the 1389 patients who underwent pulmonary resection, 1205 were enrolled. There were five partial anomalous pulmonary venous connection cases (0.41%). Two were diagnosed through re-evaluation. The partial anomalous pulmonary venous connection was located between the right upper lobe and the superior vena cava in four patients (80%). All patients underwent left superior segmentectomy, and none experienced postoperative heart failure or hypoxia. In the literature, the incidence rates of partial anomalous pulmonary venous connection observed by computed tomography (0.1-0.25%) were lower than those observed by autopsy (0.62%) and angiography (0.82%).

CONCLUSION

There may be a considerable number of overlooked partial anomalous pulmonary venous connection cases. Therefore, particularly the superior vena cava should be carefully monitored in preoperative computed tomography examinations.

Lobectomy with bronchoplasty and pulmonary arterial angioplasty for lung cancer after correction of contralateral partial anomalous pulmonary venous connection

Background

There have been few reports on surgically treated primary lung cancer accompanied by contralateral partial anomalous pulmonary venous connection (PAPVC). In such cases, repair of the PAPVC might be necessary to avoid postoperative right-heart failure due to the increased flow of the left-to-right shunt.

Case presentation

We herein report a case of lung adenocarcinoma treated by left-upper lobectomy with bronchoplasty and pulmonary arterial angioplasty after induction chemoradiation therapy followed by surgical correction of the PAPVC in the right-upper lobe. The patient is alive without recurrence of lung cancer or any symptoms of heart failure 17 months after pulmonary resection.

Conclusion

When considering performing major pulmonary resection for lung tumor, thoracic surgeons should pay close attention to the presence of a PAPVC not only on the ipsilateral side of the lung tumor, but also the contralateral side, although it is a rare phenomenon.

Partial anomalous pulmonary venous return in a patient undergoing left upper lobectomy for adenocarcinoma of the lung: A case report

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Surgical management of left superior pulmonary venous return directly to the left innominate/brachiocephalic vein in patient with pulmonary adenocarcinoma.

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Left upper lobectomy in patient with adenocarcinoma of the lung in the presence of partial anomalous pulmonary venous return.

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Case report describing operative management of adenocarcinoma of the lung in a patient afflicted with partial anomalous pulmonary venous return of left superior pulmonary vein into the left brachiocephalic vein.

Introduction

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital heart disease that complicates surgical management of pulmonary pathology.

Case presentation

This case describes the successful management of a 73-year-old female with a left upper lobe adenocarcinoma and pre-operative discovery of left superior anomalous pulmonary venous return into the innominate vein. This patient presented to our clinic for evaluation regarding her newly discovered adenocarcinoma of the lung. Here, we also discuss findings in the literature for management of these patients regarding the importance of preoperative evaluation to determine the extent to which a lobectomy will alter pulmonary function with special emphasis on identifying patients at risk of increased shunting leading to cardiopulmonary failure.

Conclusion

Consideration should focus on the extent of the shunting, the presence of symptoms, and underlying right heart strain or pulmonary hypertension.

A simple and reliable method to preoperatively detect a common trunk of the left pulmonary vein

Background

It is difficult to detect a common trunk of the left pulmonary vein (PV) preoperatively, which may cause intraoperative accidental complications. The purpose of this study is to establish a simple and reliable method of detecting a common trunk in preoperative computed tomography (CT) images.

Methods

A total of 428 patients who underwent thin-section CT preoperatively for left lung cancer at 4 institutions were reviewed. The characteristic findings of a common trunk in the axial view were considered by confirming the preoperative CT findings of cases that had been verified to have a common trunk based on intraoperative findings. The CT images were reviewed independently by two evaluators.

Results

We found that the distance between the mediastinal side of the left lower bronchus and the junction of two left PVs was extremely short in the cases with a common trunk in the axial view. In a typical case, the axial section of the bronchus is close to the junction. Of the 416 patients that were evaluable among the 428 total patients, 26 (6.3%) were diagnosed as having a common trunk by both evaluators, and the diagnosis was coincident in 413 patients (99.2%). We were able to evaluate the surgical videos of 16 of the 26 patients, and a common trunk was confirmed in 15 patients (94%).

Conclusions

We established a simple and reliable method of detecting a common trunk of the left PV in the axial view on chest CT that was routinely performed prior to lung cancer surgery.

An extremely rare case with right superior pulmonary vein translocation

Background

There have been a number of reports on pulmonary venous anomalies. However, most of the reports focused on the anatomical branching pattern of the peripheral pulmonary veins.

Case presentation

We report a 75-year-old female whose right superior pulmonary vein V1 existed dorsal to the right main pulmonary artery and V2+3 existed dorsal to V4+5. Thus, we could not find V1 and V2+3 in the hilum just after a thoracotomy to perform right upper lobectomy for lung cancer. Thus, the right main pulmonary artery and the superior trunk (A1+3) were exposed without cutting the superior pulmonary vein.

Conclusion

There has been no report so far regarding this type of pulmonary vein translocation. Preoperative three-dimensional computed tomography images were helpful to identify this variant.

Partial anomalous pulmonary venous connection detected during right pneumonectomy

Partial anomalous pulmonary venous connection (PAPVC) is a rare congenital anomaly. Generally, it is seen on the right side and is associated with an atrial septal defect. Herein, we present a case of a 50-year-old male patient with a supracardiac type PAPVC detected during pneumonectomy for a right hilar mass. This is the second case report in the literature presenting surgical treatment of both lung cancer and PAPVC using pneumonectomy. Thoracic surgeons should be aware of this anomaly when they are planning to perform a major lung resection. If PAPVC and lung cancer are in the same lobe, anatomical lung resections including pneumonectomy can be safely performed.

Anesthetic Management of Right Single-lung Ventilation in a Patient with Anomalous Left Superior Pulmonary Venous Return for Left Pulmonary Lobectomy

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital anomaly in which one or more of the pulmonary veins are connected to the right atrium or to the systemic venous system. One lung ventilation (OLV) is required for a number of thoracic procedures. When switching to OLV, right-to-left shunt fraction increases, oxygenation is impaired, and hypoxemia may occur. Hypoxemia during OLV may affect the safety of the patient and is a challenge for the anesthesiologist and the surgeon. This case details the intraoperative anesthetic management of an elderly patient with a PAPVR who underwent single-lung ventilation for lung resection surgery.

Surgical Management of Concurrent Partial Anomalous Pulmonary Venous Return and Lung Cancer of the Same Lobe

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital left-to-right shunt where pulmonary veins drain into systemic circulation. This is a presentation of the case of a patient with concurrent PAPVR and adenocarcinoma of the same lobe. The pulmonary veins of right upper lobe drained into superior vena cava (SVC), whereas the middle and lower lobes veins drained into the left atrium as two distinct vessels. Surgeons should always perform a diligent search for anomalous vascular structure using computed tomographic (CT) angiography prior to surgery. In our case, surgical approach was "safe" because both pathologies developed in the same lobe.

Vena cava anomalies in thoracic surgery

BACKGROUND

Vena cava anomalies are a rare group of anatomical variations due to an incorrect development of the superior or inferior vena cava during fetal life. They generally show no clinical relevance and the diagnosis is done due to the association with congenital heart diseases in most of cases. However, preoperative identification of these anomalies is mandatory for surgeons to proper surgical planning. If not recognized, lethal complications may occur, as already reported in literature.

CASE PRESENTATION

We report a case series of three different unidentified vena cava anomalies in patients undergoing lung resection. These unrecognized anomalies led to minor complications in two cases and required an accurate intraoperative evaluation in another. A careful retrospective evaluation of preoperative radiological images showed the anomalies.

CONCLUSIONS

A careful evaluation of the vena cava anatomy at pre-operative imaging is mandatory for thoracic surgeons to properly plan the surgery and avoid complications.

Lung Cancer Surgery in Partial Anomalous Pulmonary Venous Connection Patients

We report pulmonary resections for lung cancers in 2 patients with partial anomalous pulmonary venous connection (PAPVC) identified preoperatively. In case 1, right upper lobectomy was performed as the definitive operation for both lung cancer and PAPVC in the same lobe. In case 2, because lung cancer and PAPVC existed in different lobes, cardiac catheterization was performed to evaluate the need for correction of the PAPVC. Then, left lower lobectomy was safely performed without correcting the PAPVC located in the left upper lobe. The treatment plan for patients with PAPVC who require pulmonary resection should be carefully considered.

Management of partial anomalous pulmonary venous connections in patients requiring pulmonary resection: a case report and systematic review

Partial anomalous pulmonary venous connections (PAPVCs) are rare congenital anomalies that are frequently asymptomatic in adults. When PAPVCs are encountered in the patient requiring pulmonary resection, improper management can result in fulminant right-heart failure and death. In this report, we note our management of a 70-year-old male who presented with a right upper lobe ground-glass opacity (GGO) and a PAPVC. We also provide a systematic review of all contemporary reports and provide an algorithm for PAPVC management in the adult patient requiring pulmonary resection.

Misdiagnosis of anomalous pulmonary venous connections in a patient with lung cancer and a review of the literature

A partial anomalous pulmonary venous connection (PAPVC) is a rare congenital defect in which at least one pulmonary vein doesn't drain into the left atrium but into a systemic vein or even into the right atrium, causing a left-to right shunt. PAPVC with a small amount of shunt are usually asymptomatic, and can not be detected during lifetime. Nevertheless, if those patients undergo a major lung resection, the surgical procedure could precipitate right heart failure if this anomalous shunt remains uncorrected. Therefore, it is considered to be very important preoperative diagnosis. In case report, we present a case of a 54-year-old woman with a right upper lobe non-small cell lung cancer and previous history of left lung resection for tuberculosis. During surgery, an anomalous pulmonary vein branch draining into the superior vena cava was incidentally detected. The abnormality was diagnosed as a PAPVC. A right upper open lobectomy was performed. The anomaly was corrected and the surgery was successful without postoperative complications. Surgeons should be aware of this rare anomaly and carefully evaluate preoperative images CT scans of the pulmonary veins.

Anomalous pulmonary venous connection: An underestimated entity

Anomalous pulmonary venous connection is an uncommon congenital anomaly in which all (total form) or some (partial form) pulmonary veins drain into a systemic vein or into the right atrium rather than into the left atrium. The authors present one case of total anomalous pulmonary venous connection and two cases of partial anomalous pulmonary venous connection, one of supracardiac drainage into the brachiocephalic vein, and the other of infracardiac anomalous venous drainage (scimitar syndrome). Through the presentation of these cases, this article aims to review the main pulmonary venous developmental defects, highlighting the role of imaging techniques in the assessment of these anomalies.

Thoracoscopic lobectomy for lung cancer in a patient with a partial anomalous pulmonary venous connection: a case report

Background

A partial anomalous pulmonary venous connection is a rare congenital defect in which blood from the pulmonary vein is returned to the right atrium. Asymptomatic patients with a partial anomalous pulmonary venous connection with a small left-to-right shunt do not require surgical treatment. If such patients require a major lung resection, the surgical procedure could precipitate fetal right heart failure if the anomalous venous connection remains uncorrected.

Case presentation

A 59-year-old man was found to have an abnormal shadow on chest roentgenogram. Chest computed tomography imaging showed a mass in the right upper lobe. At the same time, we incidentally found an anomalous vessel. We diagnosed the abnormality as a partial anomalous pulmonary venous connection. Because the mass may have been lung cancer, a right upper lobectomy was performed using video-assisted thoracoscopic surgery. The right upper lobe vein drained into the superior vena cava. The anomaly was not corrected and the surgery was successful. His postoperative course was uneventful without cardiac failure.

Conclusions

Before performing a major lung resection, surgeons should be aware of this rare anomaly and carefully interpret clinical images of all pulmonary veins.

Partial Anomalous Pulmonary Venous Connection Coexisting with Lung Cancer: A Case Report and Review of Relevant Cases from the Literature

A 45-year-old man had an abnormal shadow in the right lung field on an annual screening chest X-ray. He was diagnosed with Stage IA (cT1bN0M0) lung cancer. Initially, we did not notice an anomalous vein on non-contrast computed tomography. However, we found that the right upper lobe bronchus branched from the lateral wall of the right main bronchial orifice, above the level of the common right upper lobe bronchus. Therefore, the bronchus was thought to be a tracheal bronchus. We carefully reevaluated the patient using three-dimensional computed tomography angiography. This technique showed that the anomalous right superior pulmonary vein drained into the azygos vein along the superior vena cava. These findings confirmed a partial anomalous pulmonary venous connection of the right upper lobe. We performed video-assisted thoracoscopic right upper lobectomy and mediastinal lymph node dissection for definitive treatment for lung cancer and partial anomalous pulmonary venous connection. No hemodynamic problems occurred in the postoperative course.

A rare case of anomalous venous drainage of the right upper lobe

We present an unusual case of partial anomalous venous drainage in which the vein of the right upper lobe drains into the superior vena cava, together with the azygos vein. This was discovered during surgery for a lung tumor of the right upper lobe. We present the embryological background, functional consequences and literature on this rare anatomical anomaly.

Importance of carefully interpreting computed tomography images to detect partial anomalous pulmonary venous return

BACKGROUND

Partial anomalous pulmonary venous return (PAPVR) is characterized by an abnormal connection of the pulmonary vein (PV). The left-to-right shunt results in an increased pulmonary blood flow, which may be followed by developing pulmonary hypertension (PH). We found that computed tomography (CT) scans may be misinterpreted, potentially leaving anomalous PVs undetected when reviewing diagnostic findings of PAPVR patients. The purpose of this study was to delineate this risk and assess the usefulness of our interpretation methods.

METHODS

We retrospectively reviewed the records of 8 patients diagnosed with PAPVR, diagnosed with right heart catheterization (RHC) findings, at our department between 1991 and 2013. Our CT screening method for assessing anomalous PVs consisted of two points: 1) confirming that four PVs were connected to the left atrium (LA) and 2) checking that the vena cava was not connected with anomalous PVs. The accuracy of this method was analyzed in a blinded manner.

RESULTS

In 4 patients, anomalous PVs delineated on enhanced CT scan images obtained before RHC were undetected. The sensitivity and specificity of detecting PAPVRs using our protocol were 0.800 and 0.978, respectively. Four of 8 patients went on to develop PH. Age at the time of diagnosis was positively correlated with mean pulmonary arterial pressure (r=0.929, p=0.002).

CONCLUSION

There is a potential risk of CT scan misinterpretation when looking for anomalous PVs. Careful interpretation of CT findings that focus on PVs may be useful for detecting PAPVR and obtaining a PH differential diagnosis.

Right lung cancer with partial anomalous pulmonary venous return and absent right upper lobe

When a vascular shunt is present, major lung resection may cause acute right heart failure. We report a case of right lung cancer with ipsilateral partial anomalous pulmonary venous return (PAPVR) and absent right upper lobe managed by pneumonectomy. A 48-year-old former smoker was diagnosed as right lung cancer; chest computed tomography (CT) revealed an anomalous right pulmonary vein draining into inferior vena cava. Bronchus of right upper lobe was not found in fiberoptic bronchoscopy. Right pneumonectomy was performed. Pathological examination revealed a T2aN2M0 squamous lung cancer. The patient tolerated well without notable descending of arterial oxygen pressure.

Ipsilateral partial anomalous pulmonary venous connection in right lung cancer with absent right upper lobe

A partial anomalous pulmonary venous connection (PAPVC) is an uncommon congenital anomaly. This report documents the case of a 48-year-old man with PAPVC which was incidentally discovered with right lung cancer and absence of right upper lobe. Right pneumonectomy was successfully performed, and the patient had an uneventful postoperative course. Asymptomatic PAPVC without septal defect is extremely rare. If the PAPVC is located in a different lobe, a pulmonary resection for lung cancer would precipitate an adverse outcome without a correction of the PAPVC. Surgeons should therefore be cautious regarding the potential existence of a PAPVC when a patient undergoes surgical procedures.

Right upper lobe partial anomalous pulmonary venous connection

Partial anomalous pulmonary venous return (PAPVR) is a left-to-right shunt where one or more, but not all, pulmonary veins drain into a systemic vein or the right atrium. We report a case of a 45-year-old male with PAPVR to superior vena cava which was incidentally discovered during a right lower bilobectomy for lung cancer.

Left Pneumonectomy for Lung Cancer After Correction of Contralateral Partial Anomalous Pulmonary Venous Return

We report the successful treatment of a 48-year-old man with left lung cancer and contralateral partial anomalous pulmonary venous return (PAPVR). He was found to have an abnormal shadow on a regular checkup. Sputum cytology revealed squamous cell carcinoma. Chest computed tomography showed not only a left hilar mass but also showed that his right superior pulmonary vein was draining into the high portion of the superior vena cava. In the presence of the right partial anomalous pulmonary venous return, it was believed that left pneumonectomy would cause serious postoperative heart failure due to an increase in the left-to-right shunt. Therefore his partial anomalous pulmonary venous return was corrected first under cardiopulmonary bypass, and 3 weeks later he underwent successful radical left pneumonectomy.

Incidental partial anomalous pulmonary venous connection in left lung cancer

We present the case of a 79-year-old woman with partial anomalous pulmonary venous connection (PAPVC), discovered incidentally during upper left division segmentectomy for primary lung cancer. The left superior pulmonary vein originated from the hilum of the upper left lobe and flowed into the left brachiocephalic vein. The left inferior pulmonary vein was connected normally, and neither atrial septal defect nor other anomalous condition was present. Upper left lobectomy with ligation of the anomalous connected vein was performed, as the lingual segment was anatomically difficult to retain. Although this type of PAPVC is extremely rare, it is advisable to exercise caution when performing lung resection with the potential for PAPVC in mind.

Problem in diagnostic imaging: Mediastinal venous anomalies

This article presents as a diagnostic problem a rare mediastinal venous anomaly detected in a patient with a primary intrathoracic tumor. Its appearance on computed tomography (CT) is discussed and compared with that of other developmental mediastinal venous anomalies. The individual CT characteristics of these anomalies and their clinical significance with respect to the management of patients with cancer are also reviewed.

Spiral CT angiography of the pulmonary circulation

Spiral computed tomographic (CT) angiography of the pulmonary circulation has emerged recently as a potential useful diagnostic method for the evaluation of the pulmonary circulation. As a minimally invasive examination, this technique is becoming widely available and has progressively replaced conventional and digital pulmonary angiography as the standard diagnostic imaging modality of the pulmonary circulation. The purpose of this review is to capture the current state of the art of the technical aspects of spiral CT angiography, with special emphasis on the post-processing techniques currently available. As CT is responsible for a considerable part of the medical radiation dose applied to the population, the current trends for dose saving will also be emphasized. With regard to the clinical applications of spiral CT angiography, its introduction into the diagnostic work-up of pulmonary embolism has considerably modified the diagnostic algorithms. Our 8-year review of the literature presented herein is expected to provide the readers with a basis for formulating an informed opinion on this topic. In addition, a large number of congenital and acquired disorders of the pulmonary circulation are also relevant to this technique, and these indications are discussed in the context of the corresponding therapeutic options. Owing to the multiple possibilities inherent to this technique, spiral CT has the potential for cost savings without reduction in image quality or diagnostic accuracy.