Congenital bronchopulmonary vascular malformations, "sequestration" and beyond

Right lung hypoplasia associated with polysplenia: A case report and literature review

Pulmonary agenesis is a very rare congenital abnormality that can be missed in a routine radiographic examination, which delays diagnosis until adulthood. It can be associated with other congenital malformations, such as valvular heart disease and gastrointestinal organ abnormalities. Computed tomography (CT) is a useful modality for its better delineation of pulmonary and vascular structures. The reported case here is for an adult male who presented with dextroposition of the heart and was found to have a unilobed right lung associated with polysplenia. This has not been previously reported in the literature.

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.

A 33-Year-Old Man With Acute Hemoptysis

CASE PRESENTATION

A 33-year-old man with a medical history of childhood exercise-induced asthma presented to the ED with 2 days of hemoptysis. He described the hemoptysis as bright red blood with clots, approximately 100 cm³ in total. He denied prior hemoptysis, pulmonary infections, or exposure to TB. Years ago he had an episode of gross hematuria, but a urologic workup was unrevealing.

Can Prenatal Diagnosis of Total Anomalous Pulmonary Venous Return (TAPVR) Using Routine Fetal Ultrasound be Improved? A Case-Control Study

Objectives

To determine the most common fetal ultrasound markers of total anomalous pulmonary venous return (TAPVR) during mid-trimester ultrasound using standardly obtained images and evaluate the performance of diagnostic algorithms for improving prenatal diagnosis.

Methods

This was a matched case-control study at a regional referral centre (2005 to 2019). Cases of TAPVR were matched to controls 1 : 4 by date of birth and biologic sex. Postprocessing review of stored fetal ultrasound images was performed by two blinded and independent observers in a standardized fashion using nine sonographic markers: (i) left/right heart disproportion; (ii) abnormal distribution of great vessels; (iii) pulmonary vein entry into the left atrium (LA); (iv) confluence behind the LA; (v) abnormal coronary sinus; (vi) absence of the Coumadin ridge; (vii) aortic diameter; (viii) distance between LA and aorta; and (ix) post-LA space index >1.27. Descriptive and inferential statistics were used to present results and compare cases and controls. Diagnostic algorithms were compared by sensitivity/specificity.

Results

21 cases of isolated TAPVR were matched to 84 controls (n = 105). The most common ultrasound marker of TAPVR was absence of pulmonary vein entry into the LA (42.9%), followed by abnormal Coumadin ridge (38.1%). Cases of TAPVR had significantly larger post-LA spaces than controls (p < 0.0001) and wider aortic diameters (p=0.006). A diagnostic algorithm stratifying on absence of pulmonary veins followed by an abnormal Coumadin ridge, can correctly identify cases of TAPVR with high specificity (90.5%) and moderate sensitivity (61.9%). Conversely, a diagnostic algorithm using the presence of any 3 abnormal markers had improved specificity (94.1%) but poorer sensitivity (23.8%).

Conclusions

Using standardly obtained images from routine fetal ultrasound, improved prenatal detection of isolated TAPVR is possible. A standardized diagnostic approach can be highly specific for fetal TAPVR, however, algorithms that are sufficiently sensitive for screening in the general population are still needed.

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.

A rare pediatric case of bilateral bronchopulmonary vascular malformations and right isomerism

We present an unusual case of an 18-day-old term neonate with coexistent bilateral bronchopulmonary vascular malformations and right isomerism. This case highlights the importance of computed tomography angiography in depicting such complex anomalies and classifying them according to components involved providing a systematic approach for evaluation of the disease process.

Imaging of the spectrum of abnormal systemic arterial supply to the lungs using dual-source CT

Abnormal systemic arterial supply to the lungs can be seen in various congenital and acquired diseases. Identification and characterisation of aberrant vascular supply is essential for further management and treatment. Multidetector computed tomography (CT) with its multiplanar capabilities and volume-rendering techniques provides precise information regarding the anatomy and spatial relationship of arterial vascular channels. The following concise review elucidates the characteristic imaging findings of conditions in which systemic arteries are seen supplying the lung parenchyma on dual-source CT.

Airway anomalies in cases of anomalous pulmonary venous connection - A single-center experience

Background

Patients with congenital heart defects may present with concomitant defects involving other organ systems. Roughly 4 percent of this nature are airway anomalies. Presence of anomalous airways summon major challenge before the anesthesiologist, surgeon, and intensivist in the perioperative management of such patients. There is paucity of literature in the study of airway anomalies in the subset of congenital anomalous pulmonary venous connections. We present the analysis of three cases of airway anomalies in patients operated for anomalous venous drainage at our center. We hope to explicate the clinical implications and management of such rare presentations.

Methods

The records of all patients who underwent surgical correction for anomalous venous return between January 2016 and January 2018 were reviewed retrospectively. The records were examined for presence of any airway issues, abnormal radiological findings, perioperative intubation or extubation issues and perioperative surgical findings.

Results

Amidst the 410 cases operated for congenital heart defects in this period, 92 were operated cases for anomalous pulmonary venous return, of which 3 patients presented with airway issues. One patient had an aberrant right tracheal bronchus with normal carina and bilateral main bronchial stenosis, the second patient had a hypoplastic left lung and the third patient had congenital lobar emphysema of the left lung.

Conclusion

Prudent perioperative management necessitates prior evaluation and preemptive planning for airway anomalies in patients with anomalous venous return, since they can belong to the "Malinosculation Syndrome" group, which involves anomalous communication by means of small openings between the different components of lung tissue, namely, the lung parenchyma, tracheobronchial tree, arteries, and veins.

Agreement between magnetic resonance imaging and computed tomography in the postnatal evaluation of congenital lung malformations: a pilot study

OBJECTIVES

To compare postnatal magnetic resonance imaging (MRI) with the reference standard computed tomography (CT) in the identification of the key features for diagnosing different types of congenital lung malformation (CLM).

METHODS

Respiratory-triggered T2-weighted single-shot turbo spin echo (ss-TSE), respiratory-triggered T1-weighted turbo field echo (TFE), balanced fast field echo (BFFE), and T2-weighted MultiVane sequences were performed at 1.5 T on 20 patients prospectively enrolled. Two independent radiologists examined the postnatal CT and MRI evaluating the presence of cysts, hyperinflation, solid component, abnormal arteries and/or venous drainage, and bronchocele. Diagnostic performance of MRI was calculated and the agreement between the findings was assessed using the McNemar-Bowker test. Interobserver agreement was measured with the kappa coefficient.

RESULTS

CT reported five congenital pulmonary airway malformations (CPAMs), eight segmental bronchial atresias, five bronchopulmonary sequestrations (BPS), one congenital lobar overinflation, one bronchogenic cyst, and three hybrid lesions. MRI reported the correct diagnosis in 19/20 (95%) patients and the malformation was correctly classified in 22/23 cases (96%). MRI correctly identified all the key findings described on the CT except for the abnormal vascularization (85.7% sensitivity, 100% specificity, 100% PPV, 94.1% NPV, 95% accuracy for arterial vessels; 57.1% sensitivity, 100% specificity, 100% PPV, 84.2% NPV, 87% accuracy for venous drainage).

CONCLUSIONS

MRI can represent an effective alternative to CT in the postnatal assessment of CLM. In order to further narrow the gap with CT, the use of contrast material and improvements in sequence design are needed to obtain detailed information on vascularization, which is essential for surgical planning.

KEY POINTS

• Congenital lung malformations (CLMs) can be effectively studied by MRI avoiding radiation exposure. • Crucial features of CLM have similar appearance when comparing CT with MRI. • MRI performs very well in CLM except for aberrant vessel detection and characterization.

A graph-cut approach for pulmonary artery-vein segmentation in noncontrast CT images

Lung vessel segmentation has been widely explored by the biomedical image processing community; however, the differentiation of arterial from venous irrigation is still a challenge. Pulmonary artery-vein (AV) segmentation using computed tomography (CT) is growing in importance owing to its undeniable utility in multiple cardiopulmonary pathological states, especially those implying vascular remodelling, allowing the study of both flow systems separately. We present a new framework to approach the separation of tree-like structures using local information and a specifically designed graph-cut methodology that ensures connectivity as well as the spatial and directional consistency of the derived subtrees. This framework has been applied to the pulmonary AV classification using a random forest (RF) pre-classifier to exploit the local anatomical differences of arteries and veins. The evaluation of the system was performed using 192 bronchopulmonary segment phantoms, 48 anthropomorphic pulmonary CT phantoms, and 26 lungs from noncontrast CT images with precise voxel-based reference standards obtained by manually labelling the vessel trees. The experiments reveal a relevant improvement in the accuracy ( ∼ 20%) of the vessel particle classification with the proposed framework with respect to using only the pre-classification based on local information applied to the whole area of the lung under study. The results demonstrated the accurate differentiation between arteries and veins in both clinical and synthetic cases, specifically when the image quality can guarantee a good airway segmentation, which opens a huge range of possibilities in the clinical study of cardiopulmonary diseases.

A rare case of intralobar pulmonary sequestration: combined endovascular and video-assisted thoracoscopic approach

Pulmonary sequestration is a congenital malformation characterized by cystic, non-functioning embryonic lung tissue supplied by an abnormal systemic artery. It's a rare disease widely variable in clinical presentation and severity, depending mostly on the degree of lung involvement and location in the thoracic cavity. Most patients have recurrent infections and inflammatory conditions in the affected lobe. Surgical resection continues to be the gold standard of therapy and in this context anatomical resection is the procedure of choice and yields excellent long-term results. There are few studies reporting the use of combined endovascular and thoracoscopic approaches for pulmonary sequestration. We describe a case of intralobar pulmonary sequestration located in the lower lobe of the right lung, which was treated with video-assisted thoracoscopic surgery (VATS) after endovascular embolization of systemic artery arising from celiac trunk.

Thoracoscopic treatment of left-to-right shunt in a child with scimitar syndrome

Scimitar syndrome represents a rare variant of partial anomalous pulmonary venous connection with right lung hypoplasia, dextrocardia, and concomitant airway-vessel abnormalities. Surgical correction is preferred in symptomatic patients or in patients with increased left-to-right shunt. In this report, the first case of scimitar syndrome with dual arterial supply and venous drainage to be treated with thoracoscopic approach is presented.

Not all right-sided hearts are the same-the importance of identifying the correct diagnosis

Scimitar syndrome is characterized by an anomalous venous return with the characteristic chest roentgenogram (CxR) appearance of the anomalous vein draining into the inferior vena cava (IVC). This appears as a curvilinear opacity paralleling the right border of the heart resembling a curved sword or Scimitar. A 27-year-old white woman with a reported history of dextrocardia was admitted after a drug overdose. Examination demonstrated an obtunded woman with tachycardia and right sided heart sounds. Her CxR revealed a right sided heart image with two curvilinear opacities in the retrocardiac area. Chest computed tomography (CT) demonstrated that these opacities join to represent an anomalous vein draining into IVC. Furthermore, an anomalous systemic artery arising from the abdominal aorta was seen to supply the right lower lobe. The patient was eventually diagnosed with Scimitar syndrome. This syndrome affects 1-3 in 100,000 live births while nearly half of the patients remain asymptomatic with some initially being misdiagnosed as dextrocardia, such as in our case. Correctly diagnosing these patients is of paramount importance as some can develop severe pulmonary hypertension and right ventricular failure. In turn, close ongoing echocardiographic monitoring can help identify those that may benefit from surgical interventions to prevent them from developing these complications.