Congenital fistula between an aberrant systemic artery and a pulmonary vein without sequestration. A report of three cases

Anomalous systemic arterial supply to the basal segment of the lung presenting with haemoptysis in the third trimester of pregnancy

Anomalous systemic arterial supply to the basal segment of the lung (ABLL) is a rare cause of haemoptysis. ABLL may be complicated by massive haemoptysis, heart failure due to left-to-right shunt and infection. We describe a case of this condition presenting in the third trimester of pregnancy. Computed tomography chest angiogram confirmed the diagnosis. A multidisciplinary approach was necessary to determine treatment, which ultimately consisted of elective caesarean section at 36 weeks and 4 days' gestation, followed by transarterial embolisation 9 days postpartum.

Rare Condition of Aberrant Arterial Supply to a Normal Lung: A Cases Series and Literature Review

Herein, we describe an aberrant artery to a normal lung, focusing on its classification, embryological hypotheses, diagnostic methods, and treatment modalities. We present three cases of aberrant arterial supply to a normal lung in various age groups (51 years, 5 months, and 29 years). The cases presented symptoms ranging from hemoptysis to respiratory distress. Successful transarterial embolization was performed in the 5-month-old infant. In addition, we collected case reports published from 1962 to the present from the literature to compare the trends in management and variations in manifestations.

Isolated arterial pulmonary malinosculation without sequestration in an adult: A case report and literature review

Abnormal connections between systemic and pulmonary vascular systems are rare conditions and have been mostly documented in the pediatric population. We report a case of type B isolated arterial pulmonary malinosculation in an adult. The patient's chief complaint was intermittent hemoptysis during physical exertion. He had a dual arterial supply from the anomalous systemic artery and the pulmonary artery to the left lower lobe and the venous drainage was through the pulmonary vein. The bronchial connection appeared normal. The fistula was identified on chest computed tomography and was treated endovascularly. The patient remains asymptomatic at 1-year follow-up.

Successful percutaneous intervention in a rare case of aberrant systemic artery to a normal lung presented with hemoptysis

Aberrant systemic artery to the lung without evidence of sequestration is a rare congenital anomaly. Treatment of choice for this anomaly is controversial. A 27-year-old man with bicuspid aortic valve (AV) and a history of AV replacement was admitted to our center with hemoptysis. Aberrant systemic artery to the lung without sequestration was diagnosed. Endovascular closure of aberrant vessel with septal occluder was performed. After 2 years the previous device was embolized to the distal part and he came back with hemoptysis. The second endovascular procedure was performed with a larger device with a successful result. There are surgical and interventional treatment options for systemic arterialization to a normal lung without sequestration. In this case we used Amplatzer septal occluder (St. Jude Medical, Minneapolis, MN, USA) for occlusion of the aberrant vessel. <Learning objective: Systemic arterialization of the lung is a rare congenital anomaly, the treatment of choice for this anomaly is controversial, using septal occluder may be a useful method for management of this anomaly. Here we report a patient with this rare anomaly who had an educational clinical course. The type of management performed is not reported in other articles with similar cases.>.

Surgical management of the scimitar syndrome

BACKGROUND AND AIM

We sought to address the varied anatomical details, the diagnostic challenges, associated cardiopulmonary anomalies, the techniques, and outcomes of management, including re-interventions of scimitar syndrome.

METHODS

A total of 92 published investigations of scimitar syndrome were reviewed. Diagnostic information was provided by clinical presentations, radiographic findings, transthoracic and transesophageal echocardiography, computed-tomographic angiography, magnetic resonance imaging, angiocardiography, and ventilation/perfusion scans. These investigations served to elucidate the origin, course, and termination of the scimitar vein, the intracardiac anatomy, the presence of associated defects, and the patterns of any accompanying pulmonary lesions prior to surgical intervention.

RESULTS

Of the patients described, up to four-fifths presented during infancy, with cardiac failure, increased pulmonary flow, and pulmonary hypertension. Associated cardiac and extracardiac defects, particularly hypoplasia of the right lung, are present in up to three-quarters of cases. Overall operative mortality has been cited between 4.8% and 5.9%. Mortality was highest in patients with preoperative pulmonary hypertension, and those undergoing surgery in infancy. Despite timely surgical intervention, post-repair obstruction of the scimitar vein, intra-atrial baffle obstruction, or stenosis of the inferior caval vein were reported in up to two-thirds of cases. The venous obstruction could not be related to any particular surgical technique. On long term follow-up, one sixth of patients reported persistent dyspnoea and recurrent respiratory infections.

CONCLUSIONS

Any infants presenting with heart failure, right-sided heart, and hypoplastic right lung should be evaluated to exclude the syndrome. An increased appreciation of variables will contribute to improved surgical management.

Percutaneous treatment of anomalous systemic artery to pulmonary venous fistulas in children: Description of three cases and review of the literature

In the normal lung, the only communications between the systemic and pulmonary arterial systems are the connections between the bronchial and pulmonary arteries that occur at the respiratory bronchioles, where pulmonary and bronchial capillaries freely anastomose. Rarely, anomalous connections can occur between normal or aberrant systemic arteries and pulmonary vessels. We performed a comprehensive literature review of all available manuscripts on PubMed and Google Scholar that included a case report or case series with diagnosis of systemic artery to pulmonary venous fistulas who underwent percutaneous treatment. Furthermore, we report three cases of children diagnosed and treated in our Pediatric Cardiology Center.

Congenital Descending Aorta to Pulmonary Vein Fistula: Imaging Findings and Differential Diagnosis

Congenital descending aorta to pulmonary vein fistula (cDAPVF) is an extremely rare vascular abnormality that is usually diagnosed in infancy. Patients can become symptomatic, presenting with heart failure and hemoptysis. It is important to differentiate cDAPVF from its potential mimickers due to differences in treatment implications. In this pictorial essay, we will highlight the pathophysiology and key imaging findings of cDAPVF and how to separate it from its more common mimickers using cases that presented at our institution.

Congenital anomalous/aberrant systemic artery to pulmonary venous fistula: closure with vascular plugs & coil embolization

A 7-month-old girl with failure to thrive, who, on clinical and diagnostic evaluation [echocardiography & CT angiography] to rule out congenital heart disease, revealed a rare vascular anomaly called systemic artery to pulmonary venous fistula. In our case, there was dual abnormal supply to the entire left lung as¹ anomalous supply by normal systemic artery [internal mammary artery]² and an aberrant feeder vessel from the abdominal aorta. Left Lung had normal bronchial connections and normal pulmonary vasculature. The fistula drained through the pulmonary veins to the left atrium leading to ‘left–left shunt’. Percutaneous intervention in two stages was performed using Amplatzer vascular plugs and coil embolization to close them successfully. The patient gained significant weight in follow up with other normal developmental and mental milestones.

Diagnosis and management of congenital coronary arteriovenous fistula in the pediatric patients presenting congestive heart failure and myocardial ischemia

PURPOSE

Four pediatric patients with congenital coronary arteriovenous fistula (CAVF) were reported to remind pediatric practitioners and cardiologists of its diagnosis and management.

MATERIALS AND METHODS

Four pediatric patients with congenital CAVF from June 1999 to November 2007 were included in this retrospective study. Study modalities included reviews of patients' profiles of clinical features, chest radiograph, Doppler echocardiography, cardiac catheterization with angiography, myocardial perfusion scan, and computed tomography.

RESULTS

All 4 patients were symptomatic. The clinical symptoms and signs were feeding problem, continuous murmur, tachycardia, tachypnea, cardiomegaly, and exertional chest pain. Myocardial enzyme was elevated in 1 patient. Echocardiography showed dilatation of the coronary artery in all 4 patients, and traced down its origin in 3 and drainage in 4. The fistulas originated from the right coronary artery in 2 patients and left coronary artery in 2, and were drained into the right ventricle in 2, right atrium in 1, and pulmonary artery in 1. Single left coronary artery was found in 1 patient. The pulmonary-to-systemic blood flow ratios ranged from 1.2 to 2.5. Transcatheter coil occlusion was successfully performed in 4 patients through a coaxial delivery system. The symptoms and signs of congestive heart failure and myocardial ischemia disappeared after the procedure.

CONCLUSION

Diagnosis of congenital CAVF could be achieved by appreciation of continuous murmur over area unusual for the ductus, and by scrupulous examination of echocardiography as well as angiography of the coronary artery through which coaxial transcatheter coil occlusion could be performed successfully.

A systematic classification of the congenital bronchopulmonary vascular malformations: dysmorphogeneses of the primitive foregut system and the primitive aortic arch system

PURPOSE

We reviewed the cases of 33 patients from our clinic and 142 patients from the literature with congenital bronchopulmonary vascular malformations (BPVM), systematically analyzed the bronchopulmonary airways, pulmonary arterial supplies, and pulmonary venous drainages, and classified these patients by pulmonary malinosculation (PM).

MATERIALS AND METHODS

From January 1990 to January 2007, a total of 33 patients (17 men or boys and 16 women or girls), aged 1 day to 24 years (median, 2.5 months), with congenital BPVM were included in this study. Profiles of clinical manifestations, chest radiographs, echocardiographs, esophagographs, computer tomography (CT), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), cardiac catheterizations with angiography, contrast bronchographs, bronchoscopies, chromosomal studies, surgeries, and autopsies of these patients were analyzed to confirm the diagnosis of congenital BPVM. A total of 142 cases from the literature were also reviewed and classified similarly.

RESULTS

The malformations of our 33 patients can be classified as type A isolated bronchial PM in 13 patients, type B isolated arterial PM in three, type C isolated venous PM in two, type D mixed bronchoarterial PM in five, type F mixed arteriovenous PM in one, and type G mixed bronchoarteriovenous PM in nine.

CONCLUSION

Dysmorphogeneses of the primitive foregut system and the primitive aortic arch system may lead to haphazard malinosculations of the airways, arteries, and veins of the lung. A systematic classification of patients with congenital BPVM is clinically feasible by assessing the three basic bronchovascular systems of the lung independently.

Upper Lung Lobe Systemic Artery–Pulmonary Vein Fistula with Signs and Symptoms of Congestive Heart Failure: Successful Treatment with Coil Embolization

Systemic artery-pulmonary vein fistula with a pulmonary left-left shunt is extremely rare. In this report, we present the case of a 3-month-old infant with enlarged right upper lobe systemic artery-pulmonary vein fistula and signs and symptoms of vascular tracheal compression and congestive heart failure. Two major aberrant arteries with separate origins came from the descending thoracic aorta and entered the right upper pulmonary lobe where they branched into many vascular channels and promptly drained into the enlarged right upper pulmonary vein. One of the two aberrant arteries was successfully coil embolized, and the other aberrant artery spontaneously closed after cardiac catheterization.

Usefulness of selective contrast echocardiography and selective scintigraphy for the evaluation of pulmonary arteriovenous fistula in a patient with systemic arterial supply to a normal lung

To determine a surgical procedure for the correction of a systemic arterial supply to a normal lung, it is important to evaluate whether the patient has a pulmonary arteriovenous fistula. In this article, the authors report for the first time a patient in which selective contrast echocardiography and selective perfusion scintigraphy from an abnormal artery clearly demonstrated and quantified the pulmonary arteriovenous fistula. The authors believe that these methods are useful in determining the appropriate operative procedure for this condition.

Anomalous systemic arterial supply to normal basal segments of left lower lobe: characteristic imaging findings

PURPOSE

The purpose of this study was to describe the characteristic findings in each imaging modality of anomalous systemic arterial supply to normal basal segments of the left lower lobe of the lung.

METHOD

Five patients with anomalous systemic arterial supply to normal basal segments of the left lower lobe were retrospectively reviewed. Chest radiography, contrast-enhanced CT scan, angiography, and other imaging modalities were analyzed.

RESULTS

The imaging findings of this anomaly were characterized by three issues as follows: an anomalous systemic artery arising from the thoracic aorta, absence of pulmonary arterial supply, and normal bronchial system as well as normal pulmonary parenchyma in the affected segments. The anomalous systemic artery was demonstrated on chest radiography, contrast-enhanced CT scan, MRI, and thoracic aortography. Absence of pulmonary arterial supply was revealed by pulmonary angiography, radiolabeled perfusion scan, and CT scan. Normal bronchial system was confirmed by radiolabeled ventilation scan, bronchography, and CT scan.

CONCLUSION

CT is useful in making the correct diagnosis of this anomaly because it is the only diagnostic method that can demonstrate the anomalous systemic artery, absence of pulmonary arterial supply, and normal bronchial system in the affected segments.

Radionuclide angiography and ventilation/perfusion studies in two patients with systemic arterial supply to the basal segment of the left lung

The findings of radionuclide studies in two adult men with systemic arterial supply to the basal segment of the left lung without sequestration are reported. Radionuclide angiography with Tc-99m human serum albumin-diethylenetriamine showed that the lung was perfused by the systemic circulation rather than by the pulmonary artery. Ventilation and perfusion scans with Xe-133 and Tc-99m MAA showed a V/Q mismatch in this area, suggesting the presence of normal bronchial communication without a pulmonary arterial supply. These results also suggest the presence of a left-to-left shunt in the well-ventilated lung in this area. MRI and conventional angiography showed an aberrant artery arising from the descending thoracic aorta, supplying the basal segment of the left lung without a pulmonary artery. In both patients, left lower lobectomy showed normal alveobronchial structures without sequestration. Radionuclide angiography and ventilation/perfusion imaging appear to be reliable noninvasive methods for diagnosing this rare anomaly with a left-to-left shunt.

Anomalous systemic arterial supply to normal basal segments of the left lower lobe. A report of two cases

Two cases of anomalous systemic arterial supply to the basal segments of the lower lobe of the left lung without sequestration are presented. In the first case, the final diagnosis was made during a surgical operation, and lobectomy of the lower lobe of the left lung was performed. In the second case, the preoperative diagnosis made by CT was confirmed by angiography. An anastomosis was performed between the anomalous artery and the pulmonary artery without resection of the basal segments. Six months after surgery, pulmonary angiography showed improved flow of the anastomosed vessel, but little improvement was evidenced in the perfusion scan.

Scimitar syndrome in infancy

OBJECTIVES

The objectives of this study were to determine the anatomic and physiological factors most responsible for the severe symptoms and poor prognosis of infants with scimitar syndrome.

BACKGROUND

Whereas the diagnosis of scimitar syndrome is often made incidentally in older children and adults who undergo chest radiography for diverse reasons, infants in whom the diagnosis is made typically present with severe symptoms and have a poor prognosis.

METHODS

The clinical, catheterization and imaging data of 13 consecutive infants with scimitar syndrome who underwent cardiac catheterization in the 1st 6 months of life were reviewed, with emphasis on the pulmonary artery pressure, pulmonary and cardiovascular anatomy, therapeutic interventions and outcome.

RESULTS

Twelve of the 13 infants had pulmonary hypertension at the time of diagnosis. Six patients died despite specific treatment. Eleven of 13 infants had associated cardiac malformations and 9 had large systemic arterial collateral channels to the right lung. Seven patients had anomalies involving the left side of the heart, especially varying degrees of hypoplasia of the left heart or aorta, and six of these patients died. Ten patients underwent surgical or transcatheter therapy in the 1st year of life. Systemic arteries to the right lung were ligated in three patients and occluded by transcatheter embolization in four. Balloon angioplasty was carried out in two patients, one with stenosis of the left-sided pulmonary veins and one with stenosis of the anomalous right pulmonary vein. The latter had placement of a balloon-expandable stent. In both patients, pulmonary vein stenosis progressed. Six patients had surgical repair of associated cardiovascular anomalies, and two required repair of extracardiac congenital anomalies. Occlusion of the anomalous systemic arteries was generally associated with clinical improvement, but congestive heart failure and pulmonary hypertension recurred in those patients with associated cardiovascular anomalies, whose condition subsequently responded after correction of the shunt lesions.

CONCLUSIONS

The severe symptoms and pulmonary hypertension found in infants with scimitar syndrome have many causes. Anomalous systemic arterial supply, pulmonary vein stenosis and associated cardiovascular anomalies play a significant role, and the ultimate outcome of individual infants depends on the feasibility of treating these anomalies in early infancy.

Aberrant systemic artery-pulmonary venous fistula: diagnosis with Doppler imaging

A 6-year-old asymptomatic girl presented with a continuous murmur at two different locations. Using Doppler imaging modalities, a small patent arterial duct and an aberrant systemic artery arising near the coeliac axis, piercing the right hemidiaphragm, and connecting to the right lower pulmonary vein were identified. Angiography confirmed the diagnosis and revealed additional pulmonary abnormalities. Doppler examination helped in planning appropriate angiographic projections and sites of the contrast medium injection.

Systemic artery-pulmonary vein fistula without sequestration

Fistulae between an artery arising from the aorta and a pulmonary vein associated with absence of a branch of the pulmonary artery, but without anomalies of the bronchial tree, are exceedingly rare. We report a case in a child who presented with a continuous vascular murmur and developed heart failure due to the left-left shunt. Left lobectomy was performed and showed that the entire left lower lobe was occupied by a huge arteriovenous fistula between an artery stemming from the aorta and the pulmonary veins.

Thoracic surgical problems in infancy and childhood

Thoracic surgical problems in infants and children range from congenital anomalies to acquired inflammatory problems. This article reviews the most common parenchymal, pleural, and mediastinal problems encountered in infants and children and presents recommendations for prompt and accurate diagnosis and therapy.

Spectrum of pulmonary sequestration: association with anomalous pulmonary venous drainage in infants

Pulmonary sequestration is a spectrum of related lesions, each of which may be absent or present: (1) bronchial sequestration of pulmonary parenchyma; (2) arterial supply from systemic circulation; (3) anomalous pulmonary venous drainage to the right atrium; (4) communications between bronchus and esophagus; (5) defects of diaphragm; (6) gross lung anomalies, such as horseshoe lungs or hypoplasia. Any combination of these primary lesions can occur in an individual patient. Diagnosis should be directed towards each component of the spectrum. Of special importance is the venous connection, as anomalous pulmonary venous drainage can involve not only the sequestered segment but the entire ipsilateral lung, making surgical therapy far more complex. Treatment of choice is surgical resection, associated, if needed, with rerouting of the pulmonary venous return. Classification of sequestration of the lung as intra- and extralobar is of secondary importance: these 2 groups do not represent lesions of different embryological significance.

Aberrant systemic arterial supply to the left lung with congestive heart failure

A six-month-old girl with an aberrant systemic arterial supply from the descending thoracic aorta to the left lower lobe had congestive heart failure. Although the pulmonary parenchyma was normal, there was an absence of normal pulmonary arterial supply to the left lower lobe. Main pulmonary arterial and aortic cineangiograms led to the correct diagnosis. Left lower lobectomy was performed and resulted in clinical and hemodynamic improvement.

Anomalous systemic arterial supply to the basal segments of the lung presenting with a murmur

A murmur was discovered on routine preschool physical examination of a 5 year and 7 month-old boy. A lower lobe lesion was detected by chest X-ray. Aortography demonstrated that a large systemic artery from the descending thoracic aorta supplied the basilar segments of the left lower lobe, which had no normal pulmonary arterial supply. A clinical diagnosis of intralobar sequestration of the lung was made, and left lower lobectomy was performed.

Unusual vascular anomalies causing persistent pulmonary hypertension in a newborn

A unique case of pulmonary vascular anomalies causing persistent pulmonary hypertension in a newborn is described. The child died 3 days after birth. Necropsy revealed marked hypoplasia of the right and left pulmonary arteries with a normal main pulmonary artery, patent ductus arteriosus, bilateral systemic arteries to the lungs from the abdominal aorta, and partial anomalous pulmonary venous connection. Quantitative morphometric techniques demonstrated slight abnormalities of alveolar development and severe arterial medial hypertrophy with abnormal extension of muscle into small peripheral arteries. Bronchopulmonary development appeared relatively normal in spite of the vascular abnormalities.