Early and late outcomes of coil embolization of pulmonary sequestration in children

Endovascular embolization for massive hemoptysis in intralobar pulmonary sequestration with celiac artery supply: A comprehensive case report

Pulmonary sequestration (PS) is a rare congenital anomaly characterized by noncommunicative lung tissue supplied by an abnormal systemic vessel. We present a case of a 30-year-old male with intralobar PS, receiving arterial supply from the celiac artery, manifesting as massive hemoptysis. After urgent stabilization, endovascular embolization using polyvinyl alcohol particles was successfully employed. The patient's symptoms resolved, and follow-up confirmed satisfactory recovery. Our case underscores the diverse arterial origins of PS and the efficacy of endovascular embolization as a minimally invasive treatment. The complexity of PS, its diagnostic imaging, and alternative therapeutic options are discussed, emphasizing tailored approaches for optimal outcomes in managing this uncommon congenital anomaly.

Transcatheter Management of Pulmonary Sequestrations in Children-A Single-Center Experience

BACKGROUND

A pulmonary sequestration (PS) is an area of bronchopulmonary tissue with aberrant arterial supply. Transcatheter occlusion of PSs is an appealing treatment option, but data on outcomes remain scarce. We aim to describe our experience with transcatheter management of PS in infants and children.

METHODS

Retrospective review of clinical data of all patients with suspected PS sent for diagnostic and/or interventional cardiac catheterization at our institution between January 1999 and May 2021. Procedural considerations, techniques, standard safety, and outcomes were assessed.

RESULTS

We identified 71 patients (52.1% males), with median age and weight of 4.9 months (IQR, 2.1-26.6) and 4.2 kg (IQR, 3.9-12.1), respectively. Sixty-one (86%) patients had associated congenital heart defects (CHDs). Forty-two (59%) patients had pulmonary arterial hypertension (PAH) at the time of diagnosis. Fifty-three (74.7%) patients underwent embolization of the PS feeding vessel using microcoils and/or vascular plugs, and eight (15.1%) of these were neonates who presented with severe PAH and cardiac failure. Two patients had large feeding vessels and were treated surgically. Sixteen (22.5%) patients with small feeding vessels received conservative management. At median follow-up of 36.4 months (IQR, 2.1-89.9), seven patients had died, 24 patients had CHD corrective surgeries, 26 patients had redo catheterizations, and five patients had persistent PAH. No PS surgical resection was needed, and no infection of the remaining lung tissue occurred.

CONCLUSIONS

Transcatheter assessment and treatment of PSs is a safe and effective procedure. Neonates with large PSs are severely symptomatic and improve remarkably after PS closure. PS embolization and surgical repair of associated CHDs generally leads to the normalization of pulmonary pressures.

Aberrant artery embolization prior to pulmonary sequestration surgery: A case series report

Objectives

Pulmonary sequestration is a rare congenital malformation, and part of its treatment requires the removal of the aberrant artery by surgical means.

Materials and methods

Five patients treated at Military Hospital 103 - Department of Thoracic Disease were diagnosed with PS via CT scan, MS-CT, and DSA, and histopathological data were evaluated retrospectively between January and December 2019.

Results

In all patients, surgery is the preferred option, with two cases of video-assisted thoracoscopic surgery (one lobectomy and one wedge resection), and three cases of hybrid video-assisted thoracoscopic surgery (adhesive inflammation was observed, the bronchus is challenging to reveal, to resect, and tend to bleed when resecting).

The average length of stay following surgery is 11.6 ± 8.1 days. The mean duration of postoperative follow-up is 13.8 ± 3.3 months, all patients had a good quality of life, and no respiratory problems such as hemoptysis or pneumonia were detected.

Conclusion

The excellent outcomes obtained in all patients in our study during the follow-up period (13.8 ± 3.3 months) established the appropriate indication and treatment. However, these are preliminary findings; a longer study period with a larger sample size is required to draw more valid conclusions.

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Pulmonary sequestration is a rare congenital malformation.

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Aberrant artery embolization prior to pulmonary sequestration surgery is potential for excellent outcomes.

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The excellent outcomes obtained in all patients established the appropriate indication and treatment

Intralobar pulmonary sequestration associated with left main coronary artery obstruction and mitral regurgitation

A 4-year-old boy with left intralobar pulmonary sequestration associated with left main coronary artery obstruction (LMCAO) and severe mitral regurgitation (MR) was admitted to our hospital. Since the patient presented with dyskinesia of the cardiac apex and increased left ventricular end-diastolic volume (LVEDV), left main coronary artery reconstruction and mitral annuloplasty were performed. The enlargement of the left ventricle was improved after sequential surgeries. There was a risk of deterioration of MR and regrowth of LVEDV due to shunt blood flow; therefore, left lower lobectomy and aberrant artery division were performed. This is a very rare case of a patient with pulmonary sequestration associated with LMCAO and severe MR.

Pulmonary sequestration: What the radiologist should know

Pulmonary sequestration consists of a nonfunctioning mass of lung tissue, either sharing the pleural envelope of the normal lung (intralobar) or with its own pleura (extralobar), lacking normal communication with the tracheobronchial tree and receiving its arterial supply by one or more systemic vessels. It is the second most common congenital lung anomaly according to pediatric case series, but its real prevalence is likely to be underestimated, and imaging plays a key role in the diagnosis and treatment management of the condition and its potential complications. We will give a brief overview of the pathophysiology, clinical presentation and imaging findings of intra- and extralobar pulmonary sequestration, with particular reference to multidetector computed tomography as part of a powerful and streamlined diagnostic approach.

Coil embolization of intralobar pulmonary sequestration - an alternative to surgery: a case report

BACKGROUND

Pulmonary sequestration is a congenital lung disease characterized by nonfunctioning pulmonary tissue that lacks normal communication with the bronchial tree and is supplied by a nonpulmonary systemic artery. Symptomatic bronchopulmonary sequestration is uncommon, seen more frequently in the pediatric population than in adults. It has traditionally been treated with surgical resection; however, a limited but growing number of cases have been treated with angiographic embolization. Given the inherent risks of cardiothoracic surgery, embolization of the anomalous vessel is an enticing alternative treatment. We present a case of a 56-year-old woman with known, symptomatic, intralobar pulmonary sequestration that was successfully treated with coil embolization.

CASE PRESENTATION

A 56-year-old Pacific Islander woman with a history of chronic myeloid leukemia was admitted to the hospital with an episode of hemoptysis. Computed tomography of the chest demonstrated left lower lobe intralobar pulmonary sequestration fed by a large tortuous vessel branching off of the descending thoracic aorta. Surgical resection of the sequestration is the current standard treatment strategy of symptomatic intralobar pulmonary sequestration. The cardiothoracic surgeon noted that given the size and location of arterial blood supply, intervention would involve thoracotomy and lobectomy. The interventional radiologist offered embolization of the lesion as an alternative to surgery. Multiple coils, 6-13 mm in size, were used to embolize the sequestration. No considerable flow distal to the coils was noted postembolization.

CONCLUSIONS

Intralobar pulmonary sequestration is a rare condition that typically requires surgical management. This case demonstrates the efficacy of coil embolization as an alternative management strategy. To date, limited case reports of adults treated with endovascular embolization exist. Treatment of symptomatic pulmonary sequestration with embolization can be considered as an alternative to surgical resection.

Intralobar pulmonary sequestration originating from the intercostal arteries treated with surgical resection

Intralobar pulmonary sequestration originating from the intercostal arteries is rarely reported. Herein, we report an unusual case of a 56‐year‐old male patient with intralobar pulmonary sequestration supplied from the intercostal arteries on the left lower lobe who presented after a month of a repeated cough and massive hemoptysis. Although transcatheter arterial embolization was performed three times, the patient's symptoms were not relieved. A left lower lobectomy was performed with video‐assisted thoracic surgery. At the six‐month follow‐up after surgery, the patient had recovered well without any hemoptysis. Therefore, surgical resection with lobectomy may be a better alternative to transcatheter arterial embolization for the treatment of intralobar pulmonary sequestrations arising from the intercostal arteries. To our knowledge, this is the second reported case of intralobar pulmonary sequestration arising from the intercostal arteries.

Retrospective review of the diagnosis and treatment of pulmonary sequestration in 28 patients: surgery or endovascular techniques?

Background

Pulmonary sequestration (PS) is a rare congenital pulmonary malformation. In this study, we aimed to retrospect and evaluate the diagnosis, treatment, and outcomes of PS in 28 patients at our institute.

Methods

The files of 28 patients with PS who were treated with surgery (21 cases) or endovascular intervention (7 cases) between May 2005 and June 2016 from a single institute were retrospectively reviewed. The following data of all patients were analyzed: age, sex, clinical symptoms, diagnostic methods, operative techniques, and treatment outcomes.

Results

Twenty-eight patients, 15 male and 13 female, with a median age of 42.5 underwent operative intervention for PS. Twenty-one patients showed preoperative symptoms including cough, expectoration, hemoptysis, chest and/or back pain, and fever. General chest computed tomography (CT) scanning; percutaneous needle biopsy, bronchoscopy, enhanced CT scanning, and CT angiography (CTA) were used as diagnostic methods. Twenty-one patients were diagnosed preoperatively by enhanced CT scanning and CTA; seven patients were confirmed by surgery. Twenty-one patients underwent surgery (15 cases via thoracotomy and 6 cases via video-assisted thoracic surgery), seven patients underwent interventional therapy (three cases via endovascular embolization and four cases via thoracic aortic endovascular stent-graft exclusion). Three patients had a complication in surgery group (intraoperative hemorrhage in two patients and postoperative hydropneumothorax in one patient) and two patients had post-embolization syndrome in interventional group (fever and pain at embolism site). During the follow-up period ranging from 6 to 84 months, no recurrences or further complications were observed in two groups.

Conclusions

Enhanced CT or CTA may be a potential approach for the diagnosis of PS. Surgical resection for PS is the major treatment approach. Endovascular embolization of PS could be considered when pulmonary lesion is small-sized. Endovascular exclusion could be used to treat combined arterial aneurysm and dissection of PS.

Successful endovascular embolization of an intralobar pulmonary sequestration

Pulmonary sequestration is a congenital malformation characterized by dysplastic pulmonary tissue which receives blood supply by arterial systemic system, not in communication with tracheobronchial tree. Although it could be asymptomatic, it can also cause recurrent infections and hemoptysis, rarely massive and fatal.

The conventional treatment consists in surgical resection of the pulmonary sequestration, but in the last few years endovascular embolization has been proposed as a valid therapeutic alternative. In this paper, we report the case of a 43–year-old woman affected by recurrent hemoptysis. Computed tomography angiography of the chest, abdomen, and pelvis was performed in emergency setting. Intralobar pulmonary sequestration in the lower lobe of the right lung was found. A bulky aberrant artery originating from the thoracic aorta supplied the pulmonary sequestration. The interventional radiologist performed an endovascular embolization with coils of the vascular malformation.

The technical success of the procedure was confirmed by computed tomography angiography of the chest performed on the fourth day after procedure. Further examination performed 6 months later showed no complications.

The patient was completely asymptomatic during follow-up. This procedure can demonstrate that arterial embolization is a valid and effective therapeutic alternative to surgical resection in the treatment of pulmonary sequestration.

Transarterial embolization of intralobar pulmonary sequestration in a young adult with hemoptysis

Intralobar pulmonary sequestration is a rare congenital malformation characterized by the presence of dysplastic lung that does not communicate with the tracheobronchial tree, and has aberrant systemic arterial supply. While most are asymptomatic, they rarely can present with hemoptysis, which has been traditionally managed with surgical resection of the sequestration. We report a case of an 18-year-old male who presented with acute large-volume hemoptysis on a background of recurrent minor episodes of hemoptysis, due to intralobar sequestration. He was successfully treated with transarterial embolization with a combination of polyvinyl alcohol (PVA) particles, gelfoam and coils. Transarterial embolization can be effective in managing emergent hemoptysis from pulmonary sequestration.

Coil occlusion of aberrant arteries to pulmonary sequestration in a case with pulmonary atresia with intact ventricular septum: successful treatment of repetitive myocardial ischaemic attacks

In this study, we describe an infant case of pulmonary atresia with intact ventricular septum associated with ventriculo-coronary arterial communication for which a modified Blalock-Taussig shunt operation was performed. He experienced repeated myocardial ischaemic attacks. Further examination revealed pulmonary sequestration in the right lower lobe. He therefore underwent a bidirectional Glenn operation and coil occlusion of the feeding arteries. His myocardial ischaemic attacks subsequently improved.

Use of Amplatzer Vascular Plugs for the treatment of combined extralobar and intralobar pulmonary sequestration in a 5-year-old child

Pulmonary sequestration is a rare congenital anomaly that can be asymptomatic or present with recurrent infections, respiratory symptoms, or rarely heart failure. Sequestration is classified as intralobar or extralobar on the basis of whether there is separation from normal lung tissue by its own visceral pleura. Classically, patients are treated with surgical resection. We present a case of multivessel, combined intralobar and extralobar pulmonary sequestration treated with transcatheter embolisation.

Evaluation of pulmonary sequestration with multidetector computed tomography angiography in a select cohort of patients: A retrospective study

OBJECTIVES

This study aimed to evaluate the role of multidetector computed tomography angiography in diagnosing patients with pulmonary sequestration.

METHODS

We retrospectively analyzed the computed tomography studies and clinical materials of 43 patients who had undergone preoperative multidetector computed tomography angiography in our hospital and had pathologically proven pulmonary sequestration. Each examination of pulmonary sequestration was reviewed for type, location, parenchymal changes, arterial supply and venous drainage on two-dimensional and three-dimensional computed tomography images.

RESULTS

Multidetector computed tomography successfully detected all pulmonary sequestrations in the 43 patients (100%). This included 40 patients (93.0%) with intralobar sequestration and 3 patients (7.0%) with extralobar sequestration. The locations of pulmonary sequestration were left lower lobe (28 cases, 70% of intralobar sequestrations), right lower lobe (12 cases, 30% of intralobar sequestrations) and costodiaphragmatic sulcus (3 cases). Cases of sequestered lung presented as mass lesions (37.2%), cystic lesions (32.6%), pneumonic lesions (16.3%), cavitary lesions (9.3%) and bronchiectasis (4.6%). The angioarchitecture of pulmonary sequestration, including feeding arteries from the thoracic aorta (86.1%), celiac truck (9.3%), abdominal aorta (2.3%) and left gastric artery (2.3%) and venous drainage into inferior pulmonary veins (86.0%) and the azygos vein system (14.0%), was visualized on multidetector computed tomography. Finally, the multidetector computed tomography angiography results of the sequestered lungs and angioarchitectures were surgically confirmed in all the patients.

CONCLUSIONS

As a noninvasive modality, multidetector computed tomography angiography is helpful for making diagnostic decisions regarding pulmonary sequestration with high confidence and for visualizing the related parenchymal characteristics, arterial supply, and venous drainage features to help plan surgical strategies.

Successful endovascular treatment of bilateral intralobar pulmonary sequestration with a bridging isthmus in a child

Pulmonary sequestration refers to aberrant formation of segmental lung tissue that has no connection with the bronchial tree and receives a blood supply from a systemic artery. Bilateral pulmonary sequestration, especially with a bridging isthmus is extremely rare. Although endovascular treatment is regarded as the less invasive alternative for the treatment of pulmonary sequestration, all previously reported bilateral pulmonary sequestrations have been treated surgically. We report the case of a 13-year-old girl who underwent successful endovascular treatment for bilateral pulmonary sequestration with a bridging isthmus. Thoracic CT angiography showed a heterogeneous mass-like consolidation in the both lower lobes connected each other via a bridging isthmus behind the heart. CT also demonstrated an aberrant artery, which originated from the celiac trunk, supplied the sequestration of the left lower lobe, and that a branch from the aberrant artery traversed to the sequestration in the right lower lobe. After percutaneous endovascular embolization using microcoils and gelfoam, the patient had no complications and the bilateral sequestration showed markedly decrease in the size.

Pulmonary atresia with ventricular septal defect and pulmonary sequestration

A 5-day-old girl who had pulmonary atresia with ventricular septal defect, patent ductus arteriosus, intralobar pulmonary sequestration of the right lower lobe, and retroesophageal innominate vein, was referred to our institution. We successfully performed a systemic-to-pulmonary shunt. During cardiopulmonary bypass, the arteries supplying the sequestrated lung were ligated above the diaphragm through the median sternotomy, without a thoracotomy. The postoperative course was uneventful, and we avoided the potential complications of lung infection and ventricular overload.

Massive hemoptysis in a case of intralobar pulmonary sequestration associated with pulmonary hypoplasia and meandering right pulmonary vein: diagnosis and management

Pulmonary sequestration is a congenital malformation characterized by focal area of dysplastic lung tissue that lacks normal communication with tracheobronchial tree and receives blood supply from systemic arteries. Surgical resection has been the conventional method of treatment of pulmonary sequestration. In recent years transarterial embolization of the anomalous systemic arteries has emerged as a suitable alternative to surgery. In this paper, we describe transarterial coil embolization for control of massive life-threatening hemoptysis in a rare case of intralobar sequestration in right lung associated with ipsilateral pulmonary hypoplasia and meandering right inferior pulmonary vein. A 3-year follow-up computed tomographic (CT) angiography revealed complete regression of the sequestration along with altered pulmonary arterial contour. To the best of our knowledge, transarterial coil embolization for control of massive life-threatening hemoptysis in such a complex pulmonary anomaly has not yet been reported.

The clinical value of computer tomographic angiography for the diagnosis and therapeutic planning of patients with pulmonary sequestration

OBJECTIVES

This study was conducted to evaluate the clinical value of computed tomographic (CT) angiography for diagnosis and therapeutic planning in patients with pulmonary sequestration.

METHODS

Forty-three patients with suspected pulmonary sequestration underwent CT angiography before undergoing digital subtraction angiography or surgery. For each patient, CT angiography was used to determine whether the pulmonary sequestration was suitable for coil embolization, surgical resection or conservative treatment. The treatments planned using CT angiography were compared with actual treatment decisions made or treatments administered using digital subtraction angiography or surgery.

RESULTS

Digital subtraction angiography and/or surgery confirmed pulmonary sequestration in 37 patients; six patients had no pulmonary sequestration. The diagnostic performance of CT angiography for pulmonary sequestration in the patient-based evaluation yielded an accuracy of 97.7%, sensitivity of 97.3%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 85.7%. The aberrant systemic artery-based evaluation yielded an accuracy of 98.0%, sensitivity of 97.8%, specificity of 100%, PPV of 100% and NPV of 85.7%. Treatments could be correctly planned using CT angiography with 100% accuracy, sensitivity, specificity, PPV and NPV according to the aneurysm-based evaluation.

CONCLUSIONS

We have obtained promising results with a CT angiography-based protocol, rather than a digital subtraction angiography-based protocol, as the only diagnostic and pretreatment planning tool in patients with pulmonary sequestration. The CT angiography-based selection of treatment strategies seems to be safe and effective in the majority of patients with pulmonary sequestration.

[Congenital malformations of the lung, the radiologist's point of view]

Congenital lung malformations include a complex range of developmental abnormalities. Currently, most are diagnosed prenatally or during early childhood. They may, however, be discovered later, incidentally or in connection with non-specific symptoms, sometimes severe. Knowledge of their radiological appearances is necessary for their detection. Proper technique and analysis of cross-sectional imaging, computed tomography and magnetic resonance imaging, allow a definitive diagnosis in most patients and pre-treatment evaluation of surgical cases. This review will describe the radiological aspects of congenital pulmonary malformations, especially those which may occur in late childhood or adult life. When present, alternative diagnoses will be discussed. A distinction will be made between anomalies originating from bronchopulmonary structures, such as bronchial atresia, bronchogenic cyst, congenital lobar overinflation, cystic adenomatoid malformation, and forms related to vascular anomalies (vascular rings, anomalous left pulmonary artery, pulmonary underdevelopment, proximal interruption of the pulmonary artery, pulmonary sequestration, scimitar syndrome).

[Endovascular treatment of pulmonary sequestration with Amplatzer® vascular plugs]

Pulmonary sequestration is a rare malformation characterised by non-functioning lung tissue, separated from the tracheobronchial tree and with arterial supply from the systemic circulation. The classical therapeutic approach is surgical resection. In recent years, the endovascular embolisation technique is increasingly being used for the treatment of this disease. The embolisation materials used are coils and vascular plugs. The Amplatzer® vascular plug is a self-expandable cylindrical mesh device, particularly useful for the embolisation of large vessels with high flow. Three cases of pulmonary sequestration were treated by embolisation with Amplatzer® vascular plugs. In all cases the procedure was performed without complications, and the aortopulmonary collateral vessels were completely occluded. Our study provides new data on the safety and efficacy of pulmonary embolisation with Amplatzer® vascular plugs, and its preference over coils in the embolisation of large vessels.

Transcatheter coil embolisation: a novel definitive treatment option for intralobar pulmonary sequestration

Pulmonary sequestrations have been conventionally treated surgically with removal of the tissue mass and ligation of its feeding vessels. There is established evidence to support the use of transcatheter arterial coil embolisation as an effective definitive treatment option for extralobar sequestration especially in the paediatric literature describing good long-term clinical outcomes. We present a case of an adult with intralobar sequestration in whom the diagnosis was established with multi-detector computed tomography (MDCT) and in whom transcatheter arterial coil embolisation was successfully performed as a definitive treatment option to support the growing body of evidence of transcatheter arterial coil embolisation as a safe and effective treatment option for both form of pulmonary sequestrations.