A case of anomalous systemic arterial supply to the left basal lung with lateral chest pain and palpitation followed by left basal segmentectomy

A 38-year-old man was admitted because of left lateral chest pain and palpitation. A further examination revealed anomalous systemic arterial supply to the left basal lung. As pulmonary arteriography showed a complete lack of pulmonary arterial supply to these segments, we performed a ligation of the aberrant artery and left basal segmentectomy. Eight months after surgery, a lung perfusion scan showed improved uptake in the apical segment of the lower lobe.     

A case of systemic origin of an aberrant artery to the basal segments of the left lung

A thirteen-year-old asymptomatic boy was referred to our hospital because of a cardiac murmur detected on a routine physical examination at school. A plane chest radiography showed increased vascular markings in the left lower field. An Aortogram revealed a large artery arising from the descending aorta and suppling the left posterior basal segment which had no pulmonary arteries. A bronchogram showed no abnormal findings in the bronchial tree. A clinical diagnosis of systemic origin of an aberrant artery to the basal segments of the left lung was made, and left lower lobectomy was performed successfully. We discussed the difference of this anomaly from pulmonary sequestration as well as the surgical procedure.     

Abnormal systemic artery originating from descending aorta to normal basal segments of left lung. Report 2 cases

Two patients with a large abnormal systemic artery originating from the descending aorta several centimeters above the diaphragm to the four basal segments of normal left lower lobe (without cystic change like that found in the bronchopulmonary sequestration) were treated. No pulmonary artery was found to supply the basal segments. The patients suffered from repeated hemoptysis. In one patient the abnormal artery was incidentally found during bronchial arteriography. Lower lobectomy was performed in the two patients. Microscopic examination of specimens revealed some dilated small blood vessels with extremely thin walls and their rupture may be the cause of hemoptysis. Abnormal systemic artery must be suspected if hemoptysis or local murmur during chest examination cannot be explained by other conditions, and care must be taken not to injure the artery in isolating pleural adhesion and pulmonary ligament.     

Anomalous systemic arterial supply to normal basal segment of the left lower lobe; report of a case

A 28-year-old male was referred to our hospital because of hemoptysis. A chest X-ray revealed an increase of vascular marking in the left lower field and a partial defect in the lateral line of the descending thoracic aorta. An aortogram and pulmonary arteriogram showed a large artery arising from the descending thoracic aorta and supplying the left basal segment, which had no normal pulmonary arteries. A bronchoscopy showed no abnormal findings in the bronchial tree. A clinical diagnosis of systemic arterial supply to the basal segment of the left lower lung was made, and a left lower lobectomy and closure of the anomalous systemic artery by video-assisted thoracic surgery (VATS) were successfully performed. Vascular marking of the visceral pleura of left lower basal segment was observed and the anomalous arterial pressure was 84 mmHg, as high as systemic arterial pressure, during the procedure. The histopathological examination revealed normal alveolar structure, and sclerosis and hypertrophy of pulmonary arteries of the lesion (Heath-Edwards V, which means irreversible vascular changes due to pulmonary hypertension). The patient had an uneventful postoperative course and was discharged on postoperative day 8. The VATS procedure is a more useful and less invasive method for cases of systemic arterial supply to the basal segment of the left lower lung than an open thoracotomy.     

Anomalous systemic arterial supply to normal basal segments of the left lower lobe.

BACKGROUND: Anomalous arterial supply to the normal basal segments of the lower lobe without sequestration is a rare congenital abnormality, and whether it belongs to the broad spectrum of sequestration disorders remains controversial. METHODS: The cases of all 4 patients who were treated surgically by us were reviewed together with 8 previously reported cases. RESULTS: The anomalous artery originated from the descending thoracic aorta, distributed to the basal segments of the left lower lobe, and drained to a normal inferior pulmonary vein in each case. The anomalous artery was thick and elastic walled. From the review of all 12 cases, male gender, left side, descending thoracic aorta as the aberrant arterial origin, absence of pulmonary blood flow to the basal segments, and normal pulmonary venous drainage were predominant. Despite some differences, the findings seemed closely related to intralobar sequestration. Surgical treatments were lung resection, anastomosis, and ligation of the anomalous artery. CONCLUSIONS: This anomaly is probably one type of sequestration complex. Both aortic and pulmonary arterial angiographic studies are needed to plan the definitive surgical procedure.     

Video-assisted thoracoscopic lobectomy in the treatment of intralobar pulmonary sequestration

Pulmonary sequestration is a congenital malformation characterised by cystic, non-functioning embryonic lung tissue with vascularisation of an abnormal systemic artery. They are classified as intralobar (75%) and extralobar (25%) and are more common in the left lung and lower lobes (60-90%). We report two cases of intralobar pulmonary sequestration located in the lower lobe of the left lung which were subjected to video-assisted thoracoscopic surgery (VATS). Both patients had recurrent infections for which, after performing imaging tests, they were diagnosed with intralobar pulmonary sequestration in the left lower lobe, with an afferent arterial branch to the malformation from the aorta. A lower lobectomy was performed by video-assisted surgery, dividing the aberrant aortic artery with an endostapler. A single thoracic chest tube was placed and removed on postoperative day 2 and the patients were discharged on the same day. In both cases, the pathology examination revealed intralobar pulmonary sequestration. Pulmonary sequestrations are uncommon malformations that can be operated on using minimally invasive techniques, thereby permitting early discharge and a low rate of complications.     

Anomalous systemic arterial supply to the basal segments of the left lung with two aberrant arteries

A 30-year-old man was admitted to our hospital because of hemoptysis. Digital subtraction aortography revealed an anomalous systemic artery (10 mm diameter) from the descending thoracic aorta to the basal segments of the left lung. The presence of another smaller aberrant artery from the abdominal aorta was strongly suspected on the basis of aortography. We confirmed the presence of a smaller aberrant artery (3 mm diameter) traversing the pulmonary ligament after thoracotomy. We performed left lower lobectomy with resection of the two aberrant arteries via posterolateral thoracotomy with a favorable postoperative outcome. Although it is rare, the possibility of the presence of several aberrant arteries should be considered in anomalous systemic arterial supply to the basal segment of the left lung. Preoperative identification of aberrant arteries was useful for a safe operative procedure.     

Anomalous systemic arterial supply to the basal segments of the left lung with two aberrant arteries.

A 30-year-old man was admitted to our hospital because of hemoptysis. Digital subtraction aortography revealed an anomalous systemic artery (10 mm diameter) from the descending thoracic aorta to the basal segments of the left lung. The presence of another smaller aberrant artery from the abdominal aorta was strongly suspected on the basis of aortography. We confirmed the presence of a smaller aberrant artery (3 mm diameter) traversing the pulmonary ligament after thoracotomy. We performed left lower lobectomy with resection of the two aberrant arteries via posterolateral thoracotomy with a favorable postoperative outcome. Although it is rare, the possibility of the presence of several aberrant arteries should be considered in anomalous systemic arterial supply to the basal segment of the left lung. Preoperative identification of aberrant arteries was useful for a safe operative procedure.     

A case report of pulmonary sequestration (Pryce I) associated with infective endocarditis

We experienced a case of pulmonary sequestration of Pryce type I associated with infective endocarditis (IE). A 19-old-man had prolonged high fever of 39 degrees C against antibiotic therapy. He was referred to our hospital because of the positive blood culture and abnormal echocardiographic findings, which were severe aortic regurgitation with vegetations clinging the aortic cusps. In addition, his chest X-ray film showed mass lesion behind the cardiac shadow, and continuous murmur was auscultated on this portion. The left pulmonary arteriography revealed no arterial distribution to the left lower lobe, while aortography showed an aberrant artery arising from the descending aorta entering into this lobe. One month after aortic valve replacement for IE, left lower lobectomy and amputation of the aberrant artery were performed successfully. Pathologically, inflammatory changes of the aortic valve and proliferations of intimal and medial wall of the aberrant artery were shown. However, alveo-bronchial structure of the resected lobe was normal. Diagnosis, complications and surgical management of pulmonary sequestration were discussed.     

A case of aberrant left pulmonary basal aneurysm arising from the descending aorta]

A 65-year-old man was referred to our hospital because of fever and abnormal shadow in the left lung. An aortogram revealed a large artery arising from the descending aorta supplying the left basal segment and, which then flowed into the pulmonary vein. This artery had an aneurysm and 30 mm in diameter. Bronchography showed compression of the left basal branch. A clinical diagnosis of an aberrant left pulmonary basal aneurysm arising from descending aorta was made, and left lower lobectomy was performed, because of the danger apprehension of the aneurysmal rupture. The procedure was successful. There are only 15 case reports of a systemic artery supplying the lung with normal bronchial branch in Japan. Differences of this anomaly from pulmonary sequestration were discussed.     

Anomalous systemic arterial supply to the basal segments of the lung with three aberrant arteries

We report a case of anomalous systemic arterial supply with three aberrant arteries supplying the basal segments of the right lung. There is no published report of a patient of anomalous systemic arterial supply to the basal segments with three aberrant arteries. Transverse computed tomography (CT) showed one aberrant artery in the right lower lobe, and preoperative three-dimensional CT showed three aberrant arteries, which provided detailed information and assisted in the thoracoscopic surgery. The patient underwent a complete thoracoscopic right lower lobectomy.     

Large anomalous systemic arterial supply to basal segments of the left lung

A 29-year-old man with a large anomalous systemic arterial supply to basal segments of the lower lobe was reported here. Pulmonary arteriography showed the absence of blood flow to basal segments. Aortography verified the anomalous artery from the descending thoracic aorta. Lobectomy was performed because the anastomosis between the anomalous and pulmonary arteries was anatomically difficult and segment 6 was small. The resected specimen showed that the anomalous artery had findings of pulmonary hypertension equivalent to grade V in the classification of Heath and Edwards. If the anastomosis between the anomalous and pulmonary arteries is anatomically feasible, pathological examination of open lung biopsy specimen is necessary to determine the operative procedures in this disease and two-staged operation is desirable.     

Anomalous systemic arterial supply to normal Basal segments of the left lower lobe of the lung: therapeutic implication

We describe a 5-month old infant who presented with a continuous murmur and enlargement of the left heart. The patient's diagnosis was an anomalous systemic arterial supply to basal segments of the left lower lobe characterized by a lack of a pulmonary arterial supply. This condition was treated without lobectomy. To our knowledge, this report is the first to describe an anomalous systemic arterial supply to basal segments of the lower lobe of the left lung with a single arterial supply that was treated in childhood without lung resection. Our case offers an alternative treatment to surgical lobectomy for this abnormality.     

Extended bronchoplasty and angioplasty with a right upper-middle bilobectomy and S6 segmentectomy for lung cancer: a novel technique for anastomosis

In the lung cancer case described here, we resected the right upper lobe, right middle lobe, and superior segment of the right lower lobe with concomitant resection of the pulmonary artery and bronchoplastic and pulmonary arterial reconstruction. The basal segmental bronchus was anastomosed to the right main stem bronchus using a novel, specific technique: The tumor was extirpated with division of the upper and middle lobe bronchus and the superior segmental bronchus. Parts of the middle bronchus and superior segmental bronchus on the distal side were used to expand their orifice. The cut end of the pulmonary artery was sutured, reversing the long and short axes, to shorten and adjust the pulmonary artery.     

Surgical treatment of infected intralobar pulmonary sequestration: a collective review of patients older than 50 years reported in the literature.

We report on the rare and surgical treatment of a senile patient of infected intralobar pulmonary sequestration. A 56-year-old male who had complained of headache, vomiting, cough, sputum production, and high fever was admitted to our hospital. Chest computed tomography (CT) showed an infected intralobar pulmonary sequestration as an 8x6 cm cystic mass with multiple air-fluid cavities in the left lower basal segment and severe pneumonia in the left upper and lower lobes around the mass. A 3-D CT showed an aberrant artery entering the consolidation from the descending aorta. A standard lower lobectomy was performed with a ligation of the aberrant artery with a diameter of 1 cm supplying the posterior segment of the left lower lobe. A histological examination of the lung revealed acute and chronic broncho-bronchiolitis with cystic dilatation consistent with intralobar pulmonary sequestration. We discuss the characters of senile patients compared with juvenile patients, with reference to a collective review of patients older than 50 reported in the literature.     

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.     

Pulmonary sequestration with high levels of tumor markers tending to be misdiagnosed as lung cancer

A 62-year-old man with hemoptysis and an abnormal shadow on chest roentgenogram was diagnosed as having anomalous systemic arterial supply to the normal basal segment of the left lower lobe. The preoperative serum carbohydrate antigen 19–9 and carcinoembryonic antigen levels were 73.8 units/ml and 10.8 ng/ml, respectively. Histopathological examination confirmed that the lesion was an intralobar pulmonary sequestration without air connection. There was no malignant finding in the resected specimen. The serum values of tumor markers returned to their approximate normal ranges after lower lobectomy.     

Endovascular stent-graft implantation for a cecum of an aberrant artery from a systemic arterial supply to the basal segment of the left pulmonary lobe

A 64-year-old man with a history of repeated pneumonia underwent left lower lobectomy with a diagnosis of a systemic arterial supply to the basal segment of the left pulmonary lobe. Three months after the operation, follow-up computed tomography revealed a large cecum of the stump of the feeding artery. We performed endovascular aortic repair for the cecum.     

Pulmonary artery reconstruction using a great saphenous vein autograft in the treatment of bronchogenic cancer

Sleeve resection of the pulmonary artery, followed by reconstruction with or without bronchoplasty, for bronchogenic carcinoma located at a major lobar orifice has been reported as an alternative to pneumonectomy in patients with poor respiratory functional reserve. We describe herein what is, to our knowledge, the first, report of a successful pulmonary arterial reconstruction using a saphenous vein autograft. This operation was performed in a 63-year-old man with poor pulmonary functional reserve who was diagnosed as having a large bronchogenic cancer in the left lower lobe of the lung, located close to the pulmonary hilum. First, a left lower lobectomy was performed with segmental resection of the pulmonary artery, from the basal artery to the lingular artery, after which pulmonary arterial continuity was reconstructed using a saphenous vein autograft. The patient had an uneventful recovery and remains well without any sign of recurrence 4 months after his operation.Presented at the Ninth Meeting of Ibaraki Prefectural Vascular Surgical Society, Hitachi, Ibaraki January 23, 1993.     

Coil embolization to treat pulmonary sequestration in the right upper lobe

Although there have been a few case reports of pulmonary sequestration, it is primarily located in the lower lobe and left lung, rarely in the right upper lobe. Here, we report a case presented with haemoptysis. Computed tomography images revealed flake ground-glass shadows in the right upper lobe. Computed tomography angiography demonstrated an artery supplied the affected lesions stemmed from the aortic arch. We diagnosed and treated her with bronchial artery angiography with coil embolization. No complications were found after operation until now. Thus, CTA could help identify the abnormal blood vessels, and interventional therapy may be an effective alternative to surgery of pulmonary sequestration.