Left pulmonary artery sling--anatomy and imaging

Bronchoscopy findings in children with congenital lung and lower airway abnormalities

Congenital lung and lower airway abnormalities are rare, but they are an important differential diagnosis in children with respiratory diseases, especially if the disease is recurrent or does not resolve. The factors determining the time of presentation of congenital airway pathologies include the severity of narrowing, association with other lesions and the presence or absence of congenital heart disease (CHD). Bronchoscopy is required in these cases to assess the airway early after birth or when intubation and ventilation are difficult or not possible. Many of these conditions have associated abnormalities that must be diagnosed early, as this determines surgical interventions. It may be necessary to combine imaging and bronchoscopy findings in these children to determine the correct diagnosis as well as in operative management. Endoscopic interventional procedures may be needed in many of these conditions, ranging from intubation to balloon dilatations and aortopexy. This review will describe the bronchoscopic findings in children with congenital lung and lower airway abnormalities, illustrate how bronchoscopy can be used for diagnosis and highlight the role of interventional bronchoscopy in the management of these conditions.

Pulmonary Artery Sling Blurs the Distal Trachea on Frontal Chest Radiography

Teaching Point: The pulmonary artery sling can be suspected on frontal chest radiography, not only by ancillary findings like lobe/lung emphysema or persisting atelectasis, but also blurring of the distal trachea or carina.

Airway abnormalities associated with congenital heart disease

Airway abnormalities are important but sometimes overlooked problems in children with congenital heart disease. It is often difficult to separate symptoms related to cardiac disease from those associated with airway or lung disease. Some of the lesions are incidental while others cause significant symptoms and are important in overall functional outcome. Congenital and acquired as well as intrinsic and extrinsic lesions occur and can overlap. We review and illustrate these lesions here. Imaging plays a crucial role in diagnosing and assessing the severity of airway abnormalities and guiding medical and surgical management decisions.

Fetal Diagnosis of Dextroposition, Left Pulmonary Artery Sling, Partial Anomalous Left Pulmonary Artery, and Aortic Coarctation

•LPA sling is a rare anomaly definable by fetal echocardiography. •LPA sling is frequently associated with significant respiratory morbidity and mortality. •Fetal diagnosis should prompt planning for postnatal management at a pediatric center. •We present a fetal case of dextroposition, partial LPA sling, and aortic coarctation. •Progressive dextroposition was an indicator for the presence of an LPA sling.

Lung Cancer in a Patient With Pulmonary Artery Sling: A Case Report

INTRODUCTION

Pulmonary artery sling (PAS) is a rare congenital vascular anomaly that results when the left pulmonary artery arises from the right pulmonary artery. There is little relevant literature on lobectomy for the treatment of lung cancer in patients with PAS, and the prognosis is unknown.

CASE DESCRIPTION

A 54-year-old asymptomatic man was found to have a nodule on the left lower lobe of the lung, which measured 2.5 cm. The patient also had PAS. Three-dimensional computed tomography angiography confirmed that the left pulmonary artery arose from the right pulmonary artery and passed between the main trachea and the esophagus toward the left thorax. No obvious contraindication was found in the preoperative examination, and the patient successfully underwent lobectomy of the left lower lobe by video-assisted thoracoscopic surgery. Histological examination of the lesion revealed invasive adenocarcinoma. The postoperative course was uneventful, and no complications occurred in the subsequent 3 years of follow-up.

CONCLUSIONS

Lobectomy in a lung cancer patient with PAS did not increase perioperative risk and had no significant effect on prognosis.

Left Pulmonary Artery Sling: Postoperative Outcomes for Patients at a Single Center

BACKGROUND

Left pulmonary artery (LPA) sling is a rare anomaly characterized by the origin of the LPA from the right pulmonary artery with a course between the trachea and esophagus. It is often associated with airway and cardiac anomalies.

METHODS

This is a retrospective case series of consecutive patients who underwent LPA sling repair (LPASR) at a tertiary care center over a 35-year period with a focus on tracheal and/or LPA reinterventions and survival.

RESULTS

Between June 1983 and July 2018, 42 patients were identified: isolated LPASR was performed in 16 (38%), LPASR/intracardiac repair in 10 (24%), and LPASR/tracheal repair in 16 (38%). There were 5 (12%) in-hospital and 4 (10%) late deaths. Survival rates (15 years) were as follows: 100% (isolated LPASR), 65% (concomitant intracardiac repair), and 52% (concomitant tracheal surgery). Preoperative intensive care unit (ICU) hospitalization was associated with future intervention on the LPA/trachea (61%, 11/18). The median distribution of blood flow to the left lung post-index surgery was 38%. Freedom from isolated LPA intervention was 100% after isolated LPASR, 93% after LPASR/tracheal surgery, and 69% after LPASR/intracardiac repair. Freedom from isolated tracheal intervention was 92% after isolated LPASR, 73% after LPASR/tracheal surgery, and 78% after LPASR/intracardiac repair.

CONCLUSIONS

ICU hospitalization prior to index surgery may indicate the severity of associated cardiac/tracheal abnormalities as this is associated with increased morbidity and mortality. Patients who underwent LPASR/intracardiac surgery were more likely to undergo isolated LPA intervention and those who underwent LPASR/tracheal surgery were more likely to undergo isolated tracheal intervention.

A Delayed Anatomic Diagnosis and Management Challenge in an Initially Asymptomatic Infant With Type II Pulmonary Artery Sling: A Case Report

Pulmonary artery sling (PAS) is a rare but fatal malformation. Patients with PAS tend to develop obstructive symptoms in few weeks of life. Conversely, some patients may be otherwise mild or asymptomatic in their early life. Currently, no consensus on the intervention timing and treatment strategy for asymptomatic and mild cases has been reached. Moreover, the extent of tracheal stenosis is another determining factor for the choice of intervention timing since clinical symptoms might not correspond well with the degree of stenosis. Lack of comprehensive assessment of entire airways confer underestimation of disease severity and in turn improper choice of treatment regimens and poor outcomes. Herein, we described an infantile case of PAS, who was scheduled initially for periodic outpatient follow-up on account of the absence of symptoms and inadequate imaging assessment at diagnosis. The patient developed recurrent wheezing and progressive respiratory distress at 7 months of age. After left pulmonary artery (LPA) reimplantation without tracheal intervention, bronchoscopy was performed due to failure to wean from mechanical ventilation, which demonstrated complete tracheal cartilage rings, a long segment tracheal stenosis, a low tracheal bifurcation at T6, and the absence of a separate right middle lobe bronchus. The patient was finally diagnosed with type IIb PAS and extubated successfully following conservative treatment. Miserably, neurological sequelae were devastating, leading to poor outcomes. Comprehensive airway evaluation using bronchoscopy is substantial to early identification of all components responsible for airway compromise in PAS anatomic subtypes. Considering severe concomitant maldevelopment of the bronchial tree in children with type IIb PAS, early and complete correction by surgery might decrease perioperative morbidities and mortalities of these patients.

A case report of pulmonary artery sling and situs inversus incompletes

RATIONALE

Pulmonary artery sling (PAS) is a rare congenital anomaly. Associated airway anomalies and/or those of the cardiovascular system are present in about half the patients. Situs inversus is a rare disease in which organs of the chest and/or abdomen are arranged in a mirror image reversal of their normal position. Herein, we report a rare case of pulmonary artery sling and situs inversus incompletus, which has not yet been reported.

PATIENT CONCERNS

A 10-year-old girl was admitted because of heart murmur for more than 9 years. On physical examination, the second heart sound was prominent, and a grade 2/6 systolic murmur was heard at the left mid-sternal border. Echocardiography revealed PAS and atrial septal defect (8.6 mm). A chest computer tomography angiograph demonstrated that she had lung inversus, right aortic arch, and right lung hypoplasia in addition to PAS, with a normal positioning of the heart. The PAS intersected and twisted across the bronchus, which was obviously narrowed. The PAS was type II B, since the carina was at the T6 level without a separate right upper lobe bronchus.

DIAGNOSES

Her final diagnosis was that of PAS, tracheal stenosis, situs inversus incompletus, right lung hypoplasia, right aortic arch, ASD and PDA.

INTERVENTIONS

She underwent one-stage total correction for her initial cardiovascular defects through median sternotomy under cardiopulmonary bypass support.

OUTCOMES

She had an uneventful recovery and completely healthy following the procedure.

LESSONS

A thorough examination before PAS surgery was essential in discovering and carefully evaluating complicated heart and lung anomalies.

Congenital central pulmonary artery anomalies: Part 2

There is a broad spectrum of congenital anomalies of the central pulmonary arteries including abnormalities of development, origin, course and caliber. These anomalies incorporate simple lesions such as isolated pulmonary valve stenosis to very complex anomalies with many associated abnormalities. Part 1 and Part 2 of this review describe the range of anatomical variations that are encountered as well as important aspects of anatomy, physiology and surgical correction. The authors summarize and illustrate both well-recognized and more complex anomalies to provide a broad and comprehensive understanding of these lesions and their appearances on CT and MR imaging. In Part 2 the authors review abnormalities in development, origin and course of the central branch pulmonary arteries as well as abnormal pulmonary artery caliber.

Complex Lobectomy in a Patient With Lung Cancer and Pulmonary Artery Sling

Pulmonary artery sling is a rare congenital anomaly of the origin and course of the left pulmonary artery. Patients with this condition typically present with respiratory failure in young infancy, and asymptomatic cases are uncommon. We describe the case of an adult patient with a lung adenocarcinoma of the right upper lobe, extending into the hilum and superior mediastinum, and with a previously unknown pulmonary artery sling anomaly. The local invasiveness of the tumor and the peculiar vascular anatomy contributed to a unique surgical scenario, wherein multiple reconstructive procedures were required.

Congenital Pulmonary Artery Anomalies: A Review and Approach to Classification

Congenital pulmonary artery anomalies are infrequent but given improved prenatal diagnosis and care, and neonatal surgical advances, over the past two decades are not uncommonly encountered by cardiothoracic imagers. An understanding of their etiology, classifications, associated anomalies, and surgical management can be helpful to avoid under or overdiagnosis. Timely diagnosis assisted by familiarity with imaging findings across modalities and recognition of surgical findings allows for medical management and surgical planning for these patients, with more patients reaching adulthood than ever before.

Clinical and imaging features of pulmonary artery sling: The experience in one major medical center

This case series describes echocardiographic and computed tomography angiographic (CTA) characteristics, clinical features, diagnosis, and treatment in 15 patients of Pulmonary artery sling (PAS). Echocardiography is effective in diagnosing PAS, when the main pulmonary artery extends to the right pulmonary artery directly with the left pulmonary artery arising from the right pulmonary artery. CTA, clearly demonstrating the position and extent of trachea compression, the anatomy of PAS and the spatial relationships among the PAS, trachea and the esophagus, is necessary for the final diagnosis. Clinical presentations are caused by the compression of the tracheobronchial tree rather than the PAS itself. Left pulmonary artery reimplantation is the treatment of choice.

A Rare Case of Pulmonary Artery Sling and Complete Atrioventricular Canal Defect in an Infant With Trisomy 21

Pulmonary artery sling is a very rare congenital vascular anomaly. Patients usually present in infancy with symptoms of airway compression. Patients with trisomy 21 often have upper airway obstruction, most commonly related to pharyngeal causes or subglottic stenosis. Although the incidence of congenital heart defects in patients with trisomy 21 is very high, a review of the literature showed only one previously reported case of pulmonary artery sling in an infant with trisomy 21. We report a case of pulmonary artery sling and complete atrioventricular canal defect in a one-month-old female with trisomy 21. Echocardiography is an important diagnostic method for pulmonary artery sling, but this anomaly may be easily overlooked in the presence of more commonly anticipated defects in this population.

Prevalence of non-cardiovascular findings on CT angiography in children with congenital heart disease

BACKGROUND

CT angiography is gaining broader acceptance in the evaluation of children with known or suspected congenital heart disease. These studies include non-cardiovascular structures such as the mediastinum, lung parenchyma and upper abdominal organs. It is important to inspect all these structures for potential abnormalities that might be clinically important and, in some cases, may impact care plans.

OBJECTIVE

To determine the prevalence of non-cardiovascular findings in CT angiography of children with congenital heart disease.

MATERIALS AND METHODS

During 28 months, 300 consecutive children (170 males; mean age: 7.1 years, age range: 6 h-26 years), referred from a tertiary pediatric cardiology center, underwent clinically indicated CT angiography to evaluate known or suspected congenital heart disease. Slightly more than half (n = 169) of the patients were postoperative or post-intervention. Examinations were retrospectively reviewed, and non-cardiovascular findings were recorded and tabulated by organ system, congenital heart disease and operative procedure in conjunction with outcomes from medical charts.

RESULTS

Non-cardiovascular findings were identified in 83% (n = 250 / 300) of the studies for a total of 857 findings. In 221 patients (n = 73.7% of 300) a total of 813 non-cardiovascular findings were clinically significant, while in 9.7% (n = 29 / 300) of patients, 5.1% (n = 44 / 857) of the findings were nonsignificant. In 38.3% (n = 115 / 300) of patients with significant non-cardiovascular pathology, the findings were unexpected and directly impacted patient care plans. Commonly involved organs with non-cardiovascular findings were the lungs with 280 non-cardiovascular findings in 176 / 300 (58.7%) of patients, the airway with 139 non-cardiovascular findings in 103 / 300 (34.3%) of patients and the liver with 108 non-cardiovascular findings in 72 / 300 (24.0%) of patients. Syndromic associations were noted in 22% (n = 66 / 300) of the patients.

CONCLUSION

Non-cardiovascular findings are common in children with congenital heart disease who undergo CT angiography. Based upon our study population, if a child with congenital heart disease has a CT angiography, five out of six will have non-cardiovascular findings, while nearly three out of four (73.7%; 221 / 300) will have significant non-cardiovascular findings. Close attention to the non-cardiovascular structures in children with congenital heart disease presenting for a CT angiography is recommended as in nearly 40% of these children, findings were unexpected and directly altered patient care.

Bridging bronchus: Importance of recognition on airway endoscopy

Bridging bronchus is an anomalous bronchus, which crosses the mediastinum from the contralateral mainstem bronchus and it is commonly associated with congenital great vessel abnormalities. This is a case report of an infant that underwent airway endoscopy and attempt at cannulation of a mainstem bronchus with supposed bronchial cast after cardiac surgery in the intensive care unit. After multiple failed attempts, further workup was completed which revealed a bridging bronchus. A bridging bronchus must be suspected in a patient with abnormal appearing endoscopy in presence of great vessel anomalies to prevent accidental injury to the tracheobronchial tree.

Newborn respiratory distress: airway abnormalities

Respiratory distress is a common symptom in the newborn. Surfactant deficiency in the preterm infant and meconium aspiration and transient tachypnea in the term newborn are among the most common causes of respiratory distress, but primary airway abnormalities can also present with respiratory distress in the newborn. Delay in diagnosis of airway abnormality can be life threatening. Radiologists are among the first to be consulted in the evaluation of a neonate with respiratory distress, and knowledge of the spectrum of airway anomalies is essential for making the correct diagnosis. This article describes airway abnormalities that can present as respiratory distress in a neonate.

Successful surgical repair of complex Christmas-tree pattern tracheo-bronchial anatomy with stenosis

Congenital anomalies of bronchial division are extremely rare. Presence of complete cartilaginous rings in bronchial tree with co-existent bronchial division anomalies make surgical correction more challenging, and needs a well-structured surgical pathway. We report a case of complex airway pattern similar to Christmas-tree appearance with associated stenosis due to complete rings, treated by modified sliding tracheoplasty with a successful outcome.

Imaging of congenital and acquired disorders of the pulmonary artery

The pulmonary artery is affected by a multitude of conditions that can be congenital or acquired. These disorders may be detected incidentally, or the clinical features of the different conditions may overlap. This pictorial review illustrates the imaging findings of some of the main conditions that affect the pulmonary artery by considering them in 3 main categories: congenital disorders; enlargement of the pulmonary arteries, most commonly seen in pulmonary hypertension; obstruction or occlusion of the pulmonary arteries, as seen in thromboembolic disease or large vessel vasculitis. It is important for the radiologist to understand the radiological manifestations of these disorders, as early recognition would be of significant benefit in their diagnosis and treatment.

The triad of bridging bronchus malformation associated with left pulmonary artery sling and narrowing of the airway: the legacy of Wells and Landing

Although noted in the 19th century, it was not until 1938 that Scheid published the combination of left pulmonary artery sling and narrowing of the airway due to annular tracheal cartilages. Unaware of these prior descriptions, and without a precise preoperative diagnosis, Willis Potts in Chicago performed the first successful sling repair in 1953. In 1976, Cohen and Landing described Scheid's combination of left pulmonary artery sling and stenosis caused by complete tracheal rings, and the term "ring-sling complex" was introduced by Berdon in 1984. Four years later, Wells and Landing noted characteristic tracheobronchial malformations associated with these lesions and proposed a classification that has been confirmed to be clinically relevant in recent cross-sectional imaging studies.

Imperforate anus, diaphragmatic hernia, horseshoe kidney, and pulmonary sling complex: case description

This report describes an infant with imperforate anus, delayed presentation of congenital diaphragmatic hernia, horseshoe kidney, and pulmonary sling complex, a unique combination of anomalies that we recently treated at our facility.