Multislice Computed Tomography Assessment of Tracheobronchial Patterns in Partial Anomalous Left Pulmonary Artery.

OBJECTIVE: The aim of this study was to present relationship between partial anomalous left pulmonary artery (PALPA) and the tracheobronchial tree and patterns of the tracheobronchial tree assessed by multislice computed tomography (MSCT). METHODS: Nine patients were assessed by MSCT. The relationships between the tracheobronchial tree and PALPA and different tracheobronchial patterns, location of tracheobronchial stenosis, severity of stenosis, and associated cardiac defects were evaluated. The results of MSCT for these patients were compared with the operative findings. RESULTS: The anatomy of PALPA was clearly identified by MSCT in all 9 patients. Three relationships between PALPA and the tracheobronchial tree were noted. In addition, 3 patterns of tracheobronchial tree anatomy were also demonstrated. The PALPA arose from the right pulmonary artery, forming a pulmonary sling (n = 2). The PALPA, which arose from the proximal right pulmonary artery, went below the tracheal bifurcation and passed anterior (n = 1) or inferior-anterior (n = 6) to the proximal left main bronchus. Three patterns of the tracheobronchial tree were presented with normal (n = 5), normal pattern with right tracheal bronchus (n = 3), and bridging bronchus (n = 1). The rate of tracheobronchial stenosis was 56% (5/9).Five patients underwent operation, and at that time, the relationship between PALPA and the tracheobronchial tree defined on MSCT was confirmed. CONCLUSIONS: The PALPA can be associated with tracheobronchial anomalies and airway compression depending on its orientation to the airway. Noninvasive imaging modalities such as MSCT will be helpful for making further management decisions.

Multi-slice computed tomography assessment of bronchial compression with absent pulmonary valve.

BACKGROUND: Absent pulmonary valve is a rare cardiovascular anomaly that can result in profound tracheobronchial compression. OBJECTIVE: To demonstrate the advantage of multi-slice CT in diagnosing tracheobronchial compression, its severity as related to the adjacent dilated pulmonary arteries, and associated lung and cardiac lesions. MATERIALS AND METHODS: We included children with absent pulmonary valve who were reviewed by multi-slice CT during a 17-year period. The number and locations of stenoses and lung lesions were noted and the severity of stenosis was categorized. The diameter of the pulmonary artery was measured and associated cardiac defects were demonstrated. RESULTS: Thirty-one children (14 girls and 17 boys) were included. Of these, 29 had ventricular septal defect and 2 had an intact ventricular septum. Twenty-nine children (94%) had tracheobronchial compression, judged to be mild in nine children (31%), moderate in 10 (34%) and severe in 10 (34%). The different locations of the stenosis (carina, main bronchi, lobar and segmental bronchi) were observed. And the number and location of lung lesions demonstrated that the right middle and left upper and lower lobes were often affected. The diameter of the pulmonary artery in these children was well above normal published values, and Spearman rank correlation analysis showed a correlation between the size of the pulmonary artery and the severity of the tracheobronchial stenosis. Nineteen children (61%) underwent surgery and 4 of these children had a multi-slice CT post-operative follow-up study. CONCLUSION: Absent pulmonary valve can cause significant morbidity and mortality in children. Multi-slice CT can accurately depict areas of tracheobronchial compression, associated lung lesions and cardiac defects, helping to direct the surgeon.

CT assessment of tracheobronchial anomaly in left pulmonary artery sling.

BACKGROUND: The left pulmonary artery sling (LPAS) is a rare vascular anomaly where the left pulmonary artery arises from the right pulmonary artery, passes over the right bronchus, and goes posteriorly between the trachea and esophagus. The LPAS is frequently associated with cardiac and non-cardiac defects including tracheobronchial abnormalities. OBJECTIVE: To evaluate the utility of multislice CT (MSCT) and helical CT (HCT) in diagnosing and defining the tracheobronchial anomaly and anatomic relationships between the trachea and aberrant left pulmonary artery. MATERIALS AND METHODS: MSCT or HCT was performed in 27 children to determine the tracheobronchial anatomy and identify tracheobronchial stenosis. Eighteen children underwent surgery. RESULTS: According to the Wells classification of LPAS, which includes two main types and two subtypes, there were eight cases of type 1A, five cases of type 1B, six cases of type 2A and eight cases of type 2B in this group. Twenty-four of the 27 children had substantial tracheobronchial stenosis. Four died before surgery; the 18 had reanastomosis of the left pulmonary artery. Five children also had tracheoplasty; three died after surgery. CONCLUSION: CT, especially MSCT, is an ideal modality for simultaneously identifying aberrant left pulmonary artery and any associated tracheobronchial anomaly. The Wells classification is useful for operative planning.

Contrast-enhanced magnetic resonance angiography of persistent fifth aortic arch in children.

BACKGROUND: Cine angiography and echocardiography have been utilized to diagnose congenital aortic arch anomalies. However, the visualization of great vessels by echocardiography is limited, while cine angiography requires cardiac catheterization with ionizing radiation. Contrast-enhanced magnetic resonance angiography (MRA) is a noninvasive modality suitable for visualization of congenital aortic arch anomalies. OBJECTIVE: To evaluate the utility of contrast-enhanced MRA in the diagnosis of persistent fifth aortic arch, a rare congenital aortic arch anomaly, and to compare the diagnostic accuracy of MRA with that of echocardiography and cine angiography. MATERIALS AND METHODS: In four pediatric patients, contrast-enhanced MRA studies were performed for diagnosing persistent fifth aortic arch. The findings of MRA were compared with echocardiographic findings and confirmed by cine angiography and operation. RESULTS: Transthoracic surface echocardiography noted an aberrant vessel arising from the ascending aorta in two of four patients; the etiology of this vessel was uncertain. In the other two patients a diagnosis of coarctation was made. Of the four patients, only one was diagnosed with interruption of the aortic arch. Contrast-enhanced MRA clarified uncertain echocardiographic findings, enabling the correct diagnosis of persistent fifth aortic arch with fourth aortic arch interruption in all four patients. CONCLUSION: Contrast-enhanced MRA is a safe, accurate, and fast imaging technique for the evaluation of persistent fifth aortic arch and may obviate the need for conventional cine angiography. Cardiac catheterization may be reserved for some types of complicated congenital heart disease and for obtaining hemodynamic information.

Percutaneous cholecysto-cholangiography in the diagnosis of obstructive jaundice in infants.

BACKGROUND: Once it is established that a jaundiced infant has an elevated direct bilirubin level, the principal diagnostic concern is the differentiation of hepatocellular from obstructive cholestasis, of disorders of physiology from disorders of anatomy, and of disease that is managed medically from disease that is managed surgically. Traditional tests such as ultrasonography, liver biopsy, and technotium 99m HIDA scan are often not sufficiently discriminating. General anesthesia is required for invasive imaging with endoscopic retrograde cholangio pancreatography (ERCP) or operative cholangiogram. The authors describe a facile alternative using percutaneous cholecystocholangiography (PCC) with intravenous sedation. METHODS: Nine cholestatic infants underwent PCC (age, 27 to 73 days; mean, 44 days) after ultrasoundscan, liver biopsy, and (99mTc)HIDA scan failed to provide a definitive diagnosis. RESULTS: In the 4 infants without complete biliary filling, we found biliary atresia (3) and biliary hypoplasia (1). The biliary tree was completely opacified in 5 infants with the following diagnosis: neonatal hepatitis (2), duplication of the gallbladder (1), choledochocele (1), total parenteral nutrition (TPN) cholestasis (1). There were no complications. CONCLUSIONS: When the etiology of cholestasis remains elusive after traditional firstline tests, PCC has proven to be an accurate simple alternative in differentiating obstructive from hepatocellular causes of infantile cholestatic jaundice.