An anomalous segmental vein of the left upper lobe of the lung: preoperative identification by three-dimensional computed tomography pulmonary angiography

A number of variations in the pulmonary arteries and veins have been documented, and the information is very important for performing a safe lung resection. This report describes a case of an anomalous segmental vein of the left upper lobe of the lung. The patient was a 75-year old male who was suspected to have lung cancer in the left upper lobe. A contrast-enhanced computed tomography showed a vessel behind the left lower bronchus. A three-dimensional computed tomography angiography demonstrated that it was an anomalous vein for the apicoposterior segment of the left upper lobe of the lung, draining into the left inferior pulmonary vein. The aberrant vein was readily identified during surgery and was divided without injury, and a left upper lobectomy was successfully performed. Aberrant pulmonary veins for the superior segment of the right upper lobe of the lung are rarely observed, and the same kind of anomaly on the left side has not been reported.     

Management of congenital abnormalities of the donor lung

Congenital abnormalities were encountered in three donor lungs. A donor tracheal bronchus was incorporated into the right bronchial anastomosis. Anomalous pulmonary venous return of the right upper lobe to the superior vena cava and the left upper lobe to the innominate vein were managed by bridging the anomalous veins to the left atrial cuff with autologous pericardium and donor iliac vein, respectively.     

Mixed type of total anomalous pulmonary venous return: a rare pattern of pulmonary venous drainage]

The occurrence of multiple drainage sites in total anomalous pulmonary venous return (TAPVR) has important implication in preoperative diagnosis and surgical treatment. We report a rare pattern of pulmonary venous drainage with the right upper pulmonary vein draining into the innominate vein and the other three pulmonary veins into the portal vein (Ib + III type). The preoperative diagnosis was made by echocardiography and confirmed by angiography. In operation, an anastomosis was made between the common pulmonary vein and the left atrium through posterior approach, but the right upper pulmonary vein was left uncorrected because the anomalously draining blood flow of a single pulmonary vein was about 20% of total pulmonary blood flow. The postoperative course was uneventful, however, the long-term follow-up is mandatory because of the right upper pulmonary vein being left uncorrected.     

Bilateral partial anomalous pulmonary venous connection; report of a case

We have experienced a case of bilateral partial anomalous pulmonary venous connection with a fossa ovalis type of atrial septal defect and pulmonary stenosis. The right upper pulmonary vein returned to the superior vena cava and the left upper pulmonary vein returned to the left innominate vein via the vertical vein. The atrial septal defect was enlarged and the right upper pulmonary vein was baffled into the left atrium with an equine pericardial patch. The left upper pulmonary vein was divided and anastomosed to the left atrial appendage. Pulmonary commissurotomy was also done for concomitant pulmonary stenosis. Postoperative course of the patient was excellent with constantly normal sinus rhythm. Angiography 2 weeks after operation showed no evidence of pulmonary venous obstructions on both sides.     

Surgical repair of scimitar syndrome by direct anastomosis between right pulmonary vein and left atrium

A surgical case of 8-year-old boy with scimitar syndrome is presented. The patient was admitted to the hospital because of exertional dyspnea and underdevelopment. Cardiac catheterization revealed a large amount of left to right shunt and O2 step up at the level of the inferior vena cava below the diaphragm. Angiography showed that the pulmonary vein draining the right lower lobe pierced the diaphragm and emptied into IVC. At operation the right pleural cavity was entered and a large anomalous pulmonary vein trunk was found which headed downward and medially and eventually entered in the diaphragm. A direct anastomosis between the scimitar vein and left atrium was made. To avoid kinking or stenosis of this vein, the parenchyma of the right lung (S7) was divided to create a passway of the vein. Anastomosis was performed without excessive tension or kinking on it. We conclude that the method applied in this case might be a procedure of choice for the repair of scimitar syndrome especially when there is no associating atrial septal defect or scimitar vein drains into IVC at the level lower than hepatic vein.     

Total anomalous pulmonary venous connection showing an unusual shape of the pulmonary vein successfully repaired in a neonate; report of a case

A 10-day-old neonate with Darling type Ia of total anomalous pulmonary venous connection is presented. The left pulmonary vein entered the right thoracic cavity behind the right atrium and drained into the innominate vein together with the right lower, middle and upper pulmonary veins. The patient was treated with right-sided approach. The postoperative course was uneventful. To our knowledge, this case is the first successful correction of this subtype of anomaly in Japan.     

Anomalous dual drainage of the right pulmonary veins in a patient with cor triatriatum: report of a case without scimitar sign

The majority of patients with partial anomalous drainage of pulmonary veins are asymptomatic during infancy and childhood. Patients with significant left-to-right shunt develop symptoms and benefit from early corrective surgery. Anomalous pulmonary veins draining into inferior vena cava is very rare and frequently encountered in association with scimitar syndrome. The purpose of this case report is to describe a non-scimitar patient with cor triatriatum who had anomalous dual drainage of right pulmonary veins into inferior vena cava/left atrium and anomalous connection of persistent left superior vena cava with a common pulmonary venous chamber. The patient underwent an operation with redirection of anomalous pulmonary venous drainage into left atrium and ligation of persistent left superior vena cava.     

Lung cancer which accompanies anomalous venous connections, pulmonary and systemic-partial anomalous pulmonary venous connection and persistent left superior vena cava: report of 2 cases

We report the cases of a left partial anomalous pulmonary venous connection (PAPVC) and a persistent left superior vena cava (PLSVC), combined with primary lung cancer. Our case of PAPVC, the anomalous pulmonary vein originated from the hilum of the left upper lobe flowed into the left brachiocephalic vein. A left lower lobectomy was performed uneventfully without correcting the anomalous vein. And a case of PLSVC, the left superior vena cava flowed into the right superior vena cava, running under the aortic arch. A left upper lobectomy and mediastinal lymph node dissection was performed in safety. Although PLSVC was detected by chest computed tomography (CT) before operation, PAPVC was noticed intraoperatively in our case. We should keep in mind the possibility of variations of pulmonary vessel distribution, especially PAPVC located in a different lobe for resection, when undertaking lung resection.     

Surgical repair of inferior sinus venosus atrial septal defect.

A 9-year-old girl presented for cardiac evaluation with symptoms of dyspena, fatigue, and cyanosis with exercise. Cardiac catheterization demonstrated an atrial septal defect; an anomalous right superior pulmonary vein was suspected but not confirmed. Operation disclosed anomalous drainage of the right superior and inferior pulmonary veins into the right atrium, an intact fossa ovalis, and an inferior sinus venosus defect. Repair was accomplished by detaching the posterior edge of the atrial septum and suturing it to the right of the pulmonary veins, so that the defect was closed and all the pulmonary venous blood was directed to the left atrium.     

A unique pulmonary venous abnormality: with associated pulmonary arterial anomaly and arteriovenous malformation.

A man aged 29 was first seen at the age of 11, when he was found to have a congenital anomaly of the pulmonary veins which follow an abnormal course to the hilum. On the left side, two large veins descend peripherally before turning medially towards the left atrium; on the right, several smaller veins follow a similar circuitous route from the periphery, before uniting into two main veins which enter the left atrium. The proximal pulmonary arteries are normal in their pattern of branching and distribution but are dilated and tortous and taper abruptly: the left lower lobe artery is abnormally large almost down to the diaphragm. There is also a systemic arterio/pulmonary venous fistula. There is no haemodynamic disturbance, but gas transfer is slightly impaired, and there is slight arterial desaturation. The congenital anomaly is unique. Reported cases described as having pulmonary venous varices are a heterogeneous group, but one patient described as such shows resemblances to our case.     

Total anomalous pulmonary venous connection to the portal and splenic vein associated with unilateral hypoplasia of pulmonary veins

Total anomalous pulmonary venous return (TAPVR) represents a rare congenital anomaly with wide anatomical and physiological variability. We report a case of a newborn with a challenging form of obstructed infracardiac TAPVR, in whom left and right pulmonary veins drained separately into the portal system. The right pulmonary venous sinus connected to the left branch of the portal vein, whereas the left venous sinus connected to the splenic vein. Surgical repair consisted of the creation of a common retrocardiac venous trunk which was anastomosed to the left atrium. The postoperative course was characterized by persisting congestion of the right lung. Two months later, right pulmonary vein hypoplasia was successfully enlarged with autologous pericardium.     

Partial anomalous pulmonary venous connection of singular form.

We have recently experienced a rare case of partial anomalous pulmonary venous connection, in a 3-year-old female. The case was diagnosed preoperatively as anomalous left superior pulmonary venous connection with atrial septal defect. Surgery, however, revealed that only the right superior pulmonary vein returned to the left atrium, while the other three pulmonary veins returned to the coronary sinus or innominate vein. No associated atrial septal defect was found. An enlarged coronary sinus was observed. In the present case, three of the four pulmonary veins were found to have anomalous connections, and were hemodynamically close to being total anomalous pulmonary venous connection. We performed unique radical surgery using autologous tissue for multiple anomalous pulmonary venous connections and here report the results, with a short discussion of the literature.     

Azygos Vein Agenesis and PAPVR: A Potential Surgical Hazard

A 15-year-old boy underwent surgical correction of partial anomalous pulmonary venous return (right upper and middle lobe veins) into the high superior vena cava with an intact atrial septum using entirely autologous tissue. The rare association of azygos vein agenesis and partial anomalous pulmonary venous return should be emphasized to prevent the inadvertent inclusion of the anomalous systemic vein (hemiazygos vein) into the pulmonary venous circuit during the surgical repair.     

Endograft repair of partially anomalous pulmonary venous connection with dual drainage

A 73-year-old woman with dyspnea and fatigue was found to have a partially anomalous pulmonary venous connection with communication between the right upper lobe pulmonary vein and the superior vena cava, as well as a normal pulmonary vein confluence with the left atrium. She was successfully treated with an endograft implanted in the superior vena cava, covering the defect. The unique dual drainage of the pulmonary vein allowed percutaneous treatment of a condition that ordinarily requires complex caval and intracardiac reconstruction. Except for several episodes of arrhythmias, she has been doing well, with exercise tolerance improving from New York Heart Association class III at baseline to class I after treatment. Follow-up imaging and clinical findings at 36 months showed no migration of the stents and significant improvement of quality of life.     

Anomalous pulmonary vein detected using three-dimensional computed tomography in a patient with lung cancer undergoing thoracoscopic lobectomy

Few clinicians are familiar with the anatomy of anomalous pulmonary veins, and studies reporting patients who required right lower lobectomy for lung cancer and who had anomalies of the middle and lower pulmonary veins are even rarer. This report describes the case of a lung cancer patient who had an anomalous lateral part of the middle lobe vein (V4) draining into the right inferior pulmonary vein, which was confirmed by three-dimensional 64-row multidetector computed axial tomography (3D-MDCT) angiography. She was then successfully treated with video-assisted thoracic surgery. The preoperative 3D imaging of the pulmonary vein and artery allowed us to comprehend fully the patient's vascular anatomy before the operation. Thus, we recommend preoperative 3D-MDCT angiography for patients with lung cancer undergoing thoracic surgery, especially video-assisted thoracic surgery.     

Anomalous right upper lobe venous drainage

Anomalous pulmonary venous return is a rare congenital anomaly mainly involving the right lung and is often associated with congenital intracardiac malformations as atrial septal defect. We report a case of anomalous right upper lobe venous drainage resulting in two right upper lobe veins draining into the azygous vein and into the confluence between superior vena cava and azygous vein, respectively. Preoperative identification of such an aberrant venous drainage is useful for avoiding unexpected intraoperative bleeding.     

Successful surgical treatment of total anomalous pulmonary venous connection (supracardiac Ib type) showing an unusual shape of the pulmonary veins in an infant

An experience of a 9-month-old infant with Darling's type Ib of total anomalous pulmonary venous connection is presented. In this case, the left pulmonary vein traveled horizontally behind the atrium, entered the right thoracic cavity and drained into the SVC together with the right lower, middle and upper pulmonary veins. The patient was treated with repair using Gersony-Malm's method and plasty of SVC because of the stenosis of the common pulmonary vein's entrance to the SVC. Her postoperative course was uneventful, and the result was satisfactory. To our knowledge, our case is the first successful correction not associated with other complex cardiac anomalies in the world.     

A case of isolated anomalous return of bilateral superior pulmonary veins

A 14-year-old girl was admitted for evaluation of heart murmur. Intravenous digital subtraction angiography (DSA) showed the right superior pulmonary vein drained into the superior vena cava and the left superior pulmonary vein drained into the innominate vein. At the operation, an anomalous bilateral superior pulmonary venous return with an intact atrial septum was confirmed. An atrial septal defect was created and the right superior pulmonary vein was baffled into the left atrium with a pericardial patch. The left superior pulmonary vein was divided and anastomosed to the left inferior pulmonary vein with a expanded polytetra-fluoro-ethylene graft. Post-operative DSA showed satisfactory long-term result of the operation.     

Metastatic renal cell carcinoma extending to the left atrium through the inferior pulmonary vein

Metastatic renal cell carcinoma with involvement through the pulmonary veins to the left atrium is very rare. We report the case of a 70-year-old male with metastatic renal cell carcinoma to the right lower lobe of the lung abutting the inferior pulmonary vein with extension to the left atrium without pre-operative evidence. Surgical resection was achieved through a posterolateral thoracotomy. Lung masses that abut the pulmonary veins should prompt further investigation with a pre-operative transoesophageal echocardiogram to minimize unexpected intraoperative findings.     

Correction of total anomalous pulmonary venous connection below the diaphragm

Six infants with total anomalous pulmonary venous connection below the diaphragm had correction by modification of conventional surgical technique. Catheterization revealed the confluence of the pulmonary veins draining into a descending vein below the diaphragm. Symptoms of pulmonary venous hypertension and low cardiac output were typical. All had repair with circulatory arrest (average time, 32 minutes). Mobilization of the pulmonary veins and the descending vein is important. The descending vein was transected at the diaphragm. Its anterior surface was incised through the confluence of the pulmonary veins, thus creating an open Y incision. This large Y-shaped vein was anastomosed to the left atrium and carried obliquely to the tip of the left atrial appendage. The anastomosis was fashioned so that the long limb of the Y rotated anteriorly and superiorly to substantially enlarge the left atrium, making the total diameter of the anastomosis larger than the mitral valve orifice. This simplified the surgical repair and allowed direct suture closure of the atrial septal defect in all patients, as the left atrial size was at least doubled. No postoperative complications occurred, and the patients were discharged an average of 4.2 days postoperatively. Restudy at an average of 3.5 years revealed normal pressures and normal architecture by angiography. Use of the descending vein as an integral part of the reconstruction and enlargement of the left atrium was the major technical factor leading to a successful outcome in these patients and eliminating a patch or transposition of the atrial septum.