Multidetector computed tomography angiography prior to bronchial artery embolization helps detect culprit ectopic bronchial arteries and non-bronchial systemic arteries originating from subclavian and internal mammary arteries and improve hemoptysis-free early survival rate in patients with hemoptysis.

OBJECTIVES: To compare the average number of culprit arteries per patient, clinical success rate, and hemoptysis-free survival rate between hemoptysis patients with multidetector computed tomography (MDCT) angiography prior to bronchial artery embolization (BAE) and those without preprocedural MDCT angiography METHODS: This retrospective study was approved by the institutional review board with waiver of patient informed consent. From September 2012 to March 2017, 157 consecutive hemoptysis patients had been undergoing BAE. Among them, 106 patients received preprocedural MDCT angiography (MDCT group), while 51 patients did not receive preprocedural MDCT angiography (control group). The average number of culprit arteries per patient, clinical success rate, and hemoptysis-free survival rate were compared between the two groups. RESULTS: The average number of culprit ectopic bronchial arteries and that of non-bronchial systemic arteries originating from the subclavian and internal mammary arteries per patient in the MDCT group were both significantly higher than those in the control group (0.15 ± 0.51 vs 0.04 ± 0.20, p = 0.022, and 0.17 ± 0.56 vs 0.08 ± 0.39, p = 0.040, respectively). The clinical success rate of BAE with preprocedural MDCT angiography tended to be higher than that without MDCT angiography (97.2 vs 88.2%, p = 0.057). Importantly, patients in the MDCT group had a significantly higher hemoptysis-free early survival rate compared to those in the control group (96.1 vs 86.7%, p = 0.031). CONCLUSIONS: Preprocedural MDCT angiography helps detect culprit ectopic bronchial arteries and non-bronchial systemic arteries originating from subclavian and internal mammary arteries during BAE, and can improve the hemoptysis-free early survival rate, which could be recommended as a regular examination prior to BAE in patients with hemoptysis. KEY POINTS: • Preprocedural MDCT angiography helps detect culprit ectopic bronchial arteries and NBSAs originating from subclavian and internal mammary arteries during BAE. • Conducting MDCT angiography prior to BAE can improve hemoptysis-free early survival rate in hemoptysis patients.

Giant Chest Wall Arteriovenous Malformation: A Case Report and Literature Review.

BACKGROUND: We present an interesting case of a 55-year-old male with a large left chest mass after significant cutaneous bleeding. Computed tomography angiogram of the chest revealed arteriovenous malformation with blood supply from sub-branches of the left subclavian artery, left internal mammary artery, and left external carotid artery. Measuring 5.0 × 14.0 × 10.8 cm, the mass extended superior to the clavicle and inferior to the third rib with medial and lateral borders at the level of the clavicular head and coracoid, respectively. METHODS: Arteriovenous malformations (AVMs) are characterized by abnormal connections between arteries and veins which bypass the capillary system. Often small and asymptomatic, large AVMs can be painful, prone to bleeding and, if large enough, interfere with activities of daily living. While described involving various parts of the body, most notably in the central nervous system, there is a paucity of literature involving chest wall AVMs. RESULTS: Using a staged, multidisciplinary approach, treatment began with an endovascular exclusion of the arterial blood supply, which involved a combination of coil embolization and stent exclusion of feeder vessels. Two days postembolization, the patient underwent an en bloc resection of affected portion of his chest wall. Reconstruction was completed with a combination rotational flap and split-thickness skin graft. Following the procedures, the patient had an uncomplicated recovery. Three years following procedure, he has no signs of recurrence of his AV malformation. CONCLUSION: Surgical planning and indications for giant arteriovenous malformations remains a unique and difficult problem. The complex anatomy and extreme rarity of a chest wall AVM requires a multidisciplinary staged approach but can be treated with a multistage, multidisciplinary surgical approach with satisfactory and long-lasting results.

Internal mammary artery-to-pulmonary vasculature fistula: Systematic review of case reports.

The formation of a fistula between the internal mammary artery and the pulmonary vasculature (IMA-to-PV) is a rare anomaly. The etiology can be congenital; however, most recent cases have been associated with coronary artery bypass grafting, trauma, inflammatory conditions, chronic infections, or neoplasia. The knowledge base on the formation of these fistulas is derived primarily from case reports. To our knowledge, no systematic reviews or guidelines are available that provide information on how to manage these cases, and the treatment of an IMA-to-PV fistula is controversial. To our knowledge, this report is the first to review 80 cases of IMA-to-PV fistulas reported in the literature. We describe the etiologies, clinical presentation, and management of these fistulas.

Synovial Sarcoma-AV Malformation Collision in the Anterior Mediastinum.

Arteriovenous malformation (AVM) and synovial sarcomas are both rare lesions in the mediastinum. Rarer still is a collision tumor in that region. Herein we present a case of a collision tumor comprised of AVM and synovial sarcoma in a 76-year-old man, presenting with pneumonia. Imaging showed a vascular lesion that spontaneously ruptured, causing enlargement of the mass and hemothorax. The resected specimen revealed the malignant second component. This report is a discussion of the never-before reported lesion.

Minimally invasive fetal therapy for hydropic lung masses: three different approaches and review of the literature.

OBJECTIVE: To report three different antenatal therapeutic approaches for fetal lung masses associated with hydrops. METHODS: Three prospectively followed cases are described, and all 30 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed. RESULTS: Three hydropic fetuses with large intrathoracic lung masses presented at 17, 25 and 21 weeks of gestation, respectively. An aortic feeding vessel was identified in each case and thus a bronchopulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with interstitial laser (Case 1), radiofrequency ablation (RFA) (Case 2) and thrombogenic coil embolization (Case 3). Complete (Cases 1 and 2) or partial (Case 3) resolution of the lung mass and hydrops was observed. A healthy infant was born at term after laser therapy (Case 1), and the involved lung lobe was resected on day 2 of postnatal life. In Case 2, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labor at 33 weeks. In Case 3, despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolization. CONCLUSIONS: The prognosis of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolization led to procedure-related complications and need further evaluation.

The anatomy and variations of the internal thoracic (internal mammary) artery and implications in autologous breast reconstruction: clinical anatomical study and literature review.

BACKGROUND: The internal thoracic (IT) vessels (otherwise known as the thoracica interna or internal mammary vessels) are widely used as recipient vessels in autologous breast reconstruction. Despite this, normal and pathological variations in IT artery architecture have been described, and these have the potential to complicate dissection and the selection of suitable vessels. METHODS: A clinical anatomical study of 240 IT arteries (120 patients) and review of the literature was undertaken. Participants comprised 120 female patients undergoing preoperative imaging of the IT artery prior to autologous breast reconstruction, 42 with computed tomographic angiography (CTA) and 78 with ultrasound. RESULTS: There was complete concordance between surgical and radiological findings. An IT artery was present in 100% of cases, with a duplicate IT artery in two cases (1% overall). The position of the IT artery was between two IT veins most frequently (71.5% of cases), and was lateral to the vein(s) least frequently (6%). There were large IT perforators from the first and second intercostal spaces in 87 and 91% of cases, respectively, with the incidence of such perforators reducing in the lower spaces. The literature highlighted a range of cadaveric and clinical cases in which there was absence of a patent IT artery, variant course or size, and variant relationship to the IT vein. CONCLUSION: A range of congenital, pathological and iatrogenic variants in IT artery anatomy have the potential to limit the use of the IT artery in autologous breast reconstruction. Preoperative imaging with ultrasound or CTA may provide a clear and accurate method of identifying these anatomical variations pre-operatively.

[Fistula between the left internal mammary artery and pulmonary artery: a rare cause of recurrent angina after coronary bypass grafting]. / Koroner baypas sonrasi tekrarlayan anginal yakinmalarin nadir bir nedeni: Sol internal mamaryan arter grefti ile pulmoner arter arasinda fistül olusumu.

Left internal mammary artery (LIMA) to pulmonary vasculature fistula is a rare complication after coronary artery bypass surgery. In most cases, the duration between bypass grafting and fistula formation ranges from 2 to 5 years. We present a 62-year-old man who presented with anginal symptoms five years after bypass surgery. On coronary angiography, selective catheterization of the LIMA showed fistula formation to the pulmonary artery, which probably led to coronary steal syndrome and myocardial ischemia. He underwent surgery and the connection between the LIMA and pulmonary artery was terminated. After surgery, his anginal complaints improved and echocardiography showed improvement in the wall motion abnormality detected before surgery.

A patient with massive hemoptysis treated by videothoracoscopic clipping of the causative aberrant artery.

Massive hemoptysis is a life-threatening situation and can have a variety of underlying causes. Bronchial arteries are mostly the source of bleeding but in rare cases an aberrant systemic artery may be present, causing hemoptysis. Here, we present a patient in whom an aberrant systemic artery was defined to be the cause of hemoptysis. Obstruction of this artery by videothoracoscopic clipping was curative for the patient's hemoptysis.

A case of congenital agenesis of the right pulmonary artery presenting with hemoptysis and mimicking pulmonary hemosiderosis.

Congenital unilateral absence of a pulmonary artery is a rare anomaly most frequently accompanied by other cardiovascular anomalies. We report a 10-year-old girl presenting with fatigue and recurrent hemoptysis who was initially misdiagnosed with idiopathic pulmonary hemosiderosis. Her symptoms did not resolve despite treatment so she was referred to our center for further evaluation. We carried out an angiography which revealed the absence of the right pulmonary artery and multiple collaterals originating from the right subclavian and right internal mammary arteries supplying the right lung. During the follow-up the patient developed a severe episode of pulmonary infection and pulmonary hypertension which responded well to medical treatment. Physicians should be aware of the congenital absence of the right pulmonary artery especially in patients presenting with recurrent respiratory symptoms. Although this condition is generally considered to have a good prognosis, close observation is mandatory in order to prevent further complications and comorbidities.

Plexus network between internal mammary graft and pulmonary vasculature after coronary bypass grafting.

Left internal mammary artery to pulmonary vasculature fistulas are rare complications following coronary artery bypass grafting surgery. In symptomatic cases, management may either be conservative, or involve coil embolisation or surgical ligation of the fistula. We describe a 52-year-old male patient who suffered from an acute coronary syndrome due to significant stenosis of the right coronary artery 12 years after coronary artery bypass grafting surgery. Coronary angiography accidentally revealed a fistulous connection between the left internal mammary artery and the left pulmonary vasculature. The patient underwent percutaneous coronary intervention for his right coronary artery and was managed conservatively for his fistula.

Bilateral Lateral Costal Branches of the Internal Thoracic Arteries: A Case Report.

We report a case of bilateral lateral costal branches (LCB) of the internal thoracic artery (ITA). On the left side, the ITA branched from the subclavian artery as a common trunk with the thyrocervical trunk. The left LCB flew into the collateral branch of the fifth intercostal artery after reaching the upper end of the sixth rib and after exiting the left ITA at the upper part of the first rib. The left ITA was disconnected near the second rib because it had been used for coronary artery bypass surgery. The right ITA arose from the anterior surface of the right subclavian artery just after the right ITA diverged from the brachiocephalic artery. The right LCB reached the upper end of the fifth rib and flew into the collateral branch of the fourth intercostal artery. The right ITA descended along the back of the costal cartilages as usual. The mechanism of the development of the LCB is thought to be due to a lateral longitudinal anastomosis connecting the inter-node arteries arising from the dorsal aorta during the embryonic phase. More anatomical and embryological studies are necessary to further elucidate this variant arterial branch.

Embolization of a congenital arteriovenous malformation arising off the internal mammary artery.

Congenital arteriovenous malformations (AVM) of the internal mammary artery (IMA) are exceptionally rare. Patients with AVMs arising off the left IMA may present with continuous precordial murmurs and/or a pulsatile chest mass. AVMs in this location pose a risk of enlargement, rupture, infection, or high-output cardiac failure. The potential risks associated with AVMs warrant early therapeutic intervention. We describe a case of a congenital AVM originating from the left IMA, which was successfully embolized with n­butyl cyanoacrylate (NBCA) using a transcatheter arterial approach.

Incidental discovery of a new and clinically important anatomic variant of the internal thoracic artery in a young male trauma patient.

The internal thoracic artery (ITA) is the largest thoracic wall artery and is clinically important primarily for use in coronary artery bypass grafting. A number of anatomic variants of the ITA have been reported; however, bilateral, aberrant lateral branches of the ITA never have. The importance of this finding lies in the positioning of the artery at a potential chest tube insertion site. Here, we report the identification, on CT scan, of this rare variation in a young male trauma patient.

Extrapulmonary sequestration with a left internal thoracic arterial feeding vessel in an infant treated with video-assisted Thoracoscopic resection: a case report.

BACKGROUND: Congenital lung malformations exist along a spectrum of pathogenesis and disease severity. Extrapulmonary sequestration (EPS), in which nonfunctional lung tissue develops without connection to the tracheobronchial tree, is one rare manifestation of this disease. Atypical vascular anatomy with a systemic feeding vessel characterizes these lesions. CASE PRESENTATION: A 3 day old, 37 week gestation infant underwent chest X-ray for confirmation of umbilical catheter placement and was found to have an elevated left hemidiaphragm consistent with eventration versus congenital diaphragmatic hernia. He remained asymptomatic and was evaluated as an outpatient at the age of 9 months, where CT angiogram demonstrated extrapulmonary versus intrapulmonary sequestration with a systemic feeding vessel from the left internal mammary artery. CONCLUSIONS: It is exceedingly rare for the feeding artery to arise from the internal mammary; two such cases have been reported to date, both in adult patients. Here we present a third case of EPS with arterial supply from the internal mammary successfully treated with video-assisted thoracoscopic resection in a 9 month old infant.

Fistula of right internal thoracic artery as a rare cause of chest pain.

Variation in the origin of the internal thoracic arteries has been previously described and reported in the literature; however, there has been no report of an anomalous termination of the right internal thoracic artery into the pulmonary vein persisting and presenting in adult life. We report the case of the right internal thoracic artery originating from the first part of subclavian artery but terminating into the right superior pulmonary vein that presented during the third decade of life.

In-situ left-sided bilateral internal thoracic artery: elevated hemidiaphragm.

Background Procurement of the internal thoracic artery risks ipsilateral phrenic nerve injury and elevated hemidiaphragm. Anatomical variations increase the risk on the right side. Patients receiving left-sided in-situ right internal thoracic artery configurations appear to be at greatest risk. Methods From 2014 to 2016, 432 patients undergoing left-sided in-situ bilateral internal thoracic artery grafting were grouped according to right internal thoracic artery configuration: retroaortic via transverse sinus (77%) or ante-aortic (23%); targets were the circumflex and left anterior descending artery territories, respectively. Elevated hemidiaphragm was assessed by serial chest radiographs and categorized by side, complete (≥2 intercostal spaces) versus partial, and permanent versus transient. Results Right elevated hemidiaphragm occurred in 4.2% of patients. The incidence of radiological complete right elevated hemidiaphragm was 2.8% (12/432); 8 cases were transient with recovery in 3.5 ± 0.3 weeks. Permanent right elevated hemidiaphragm occurred in 0.9% (retroaortic group only). Permanent left elevated hemidiaphragm occurred in 0.9% and was significantly higher in the ante-aortic group (3/99 vs. 1/333, p = 0.039). No bilateral hemidiaphragm elevation was documented. Partial right elevated hemidiaphragm occurred in 1.4% and was not associated with adverse early or late respiratory outcomes. Conclusions Despite susceptible right phrenic nerve-internal thoracic artery anatomy, the incidence of permanent right elevated hemidiaphragm is low and no higher than left-sided in prone bilateral internal thoracic artery subsets. This reflects skeletonized internal thoracic artery procurement. Although statistical significance was not achieved, a retroaortic right internal thoracic artery configuration may constitute a higher risk of right phrenic nerve injury.

Anomalous Right Internal Thoracic Artery Terminating in the Right Superior Pulmonary Vein.

Variation in the origin of the internal thoracic arteries has been previously described and reported in the literature; however, there has been no report of an anomalous termination of the right internal thoracic artery (RITA) in the pulmonary vein persisting and presenting in adult life. We report the case of a right internal thoracic artery originating from the first part of the subclavian artery but terminating in the right superior pulmonary vein that presented during the third decade of life.

Bilateral accessory thoracodorsal artery.

The subscapular artery arises from the third part of the axillary artery and gives off the circumflex scapular and the thoracodorsal arteries. Although anatomical variations of the axillary artery are very common, the existence of a unilateral accessory thoracodorsal artery has been described in the literature only once. There are no reports of bilateral accessory thoracodorsal artery, in the literature. In the present study, a bilateral accessory thoracodorsal artery, originating on either side of the third part of the axillary artery, is described in a 68-year-old female cadaver. All the other branches of the axillary artery had a typical origin, course, distribution and termination. This extremely rare anatomical variation apart from the anatomical importance also has clinical significance for surgeons in this area. Especially, during the dissection or mobilization of the latissimus dorsi that is partly used for coverage problems in many regions of the body and also in dynamic cardiomyoplasty, any iatrogenic injury of this accessory artery may result in ischemia and functional loss of the graft.