The American Journal of Medicine
Volume 120, Issue 1 , Pages 23-25, January 2007

An Alternate Route: 64-Slice CT Diagnosis of Pulmonary Pseudosequestration

  • Jeffrey M. Schussler, MD

      Affiliations

    • Division of Cardiology, Baylor University Medical Center, Dallas, Tex
    • Corresponding Author InformationRequests for reprints should be addressed to Jeffrey M. Schussler, MD, 621 N. Hall Street, Suite 500, Dallas, TX 75226.
    • ,
  • William D. Dockery, MD

      Affiliations

    • Division of Radiology, Baylor University Medical Center, Dallas, Tex
    • ,
  • Jack G. Gilbey, MD

      Affiliations

    • Division of Pulmonary Medicine, Arlington Memorial Hospital, Arlington, Tex.
    • ,
  • Vinit R. Lal, MD

      Affiliations

    • Division of Cardiology, Arlington Memorial Hospital, Arlington, Tex.

Article Outline

 

Back to Article Outline

Presentation 

A 64-year-old man with a history of recurrent right–middle-lobe pneumonia, presented with worsening dyspnea on exertion. Pulmonary causes were ruled out, and cardiac stress testing was suggestive of ischemia.

Back to Article Outline

Assessment 

Cardiac catheterization revealed significant, flow-limiting disease in the left coronary system. Upon injection of the right coronary artery, a large anomalous branch was seen (Figures 1A and 1B). This branch appeared to have a fistulous connection with an extracardiac structure, but its exact route was unclear.

  • View full-size image.
  • Figure 1. 

    A, A portion of the patient’s lung received its blood supply from an anomalous branch (arrowhead in each panel) off the right coronary artery (arrow in each panel). A-C, The anomalous branch and the right coronary artery were visible with conventional angiography. D-F, They were also seen with computed tomography coronary angiography. C, Tangles of right pulmonary vessels became opaque after coronary injection, as indicated by asterisks. This confirmed the location of the sequestration. D, The course of the anomalous pulmonary supply was verified using several computed tomography modalities, including maximum intensity pixel; E, 3-dimensional- rendering; and F, axial imaging.

The patient underwent successful percutaneous coronary intervention of the left anterior descending and circumflex arteries and had an unremarkable postoperative course. His symptoms were significantly reduced after the procedure. However, the curious coronary anomaly remained a matter of speculation.

Back to Article Outline

Diagnosis 

Referral was made for 64-slice computed tomographic coronary angiography (GE Lightspeed VCT), which has been shown to be an excellent method of defining coronary anomalies.1 Imaging confirmed a large anomalous branch from the proximal right coronary artery, with a course posterior to the aorta (Figures 1D-1F). The artery then supplied a network of smaller vessels in the right middle lobe of the lung. Based on these findings and the patient’s history, a diagnosis of a pulmonary sequestration with arterial supply from the right coronary artery was made.

Pulmonary sequestration is an uncommon condition whereby the arterial supply of a portion of the lung originates from a separate anomalous arterial source, usually arising from the aorta. An increased incidence of infection has been noted with this condition, possibly due to compromised blood flow or to an inadequate or partial connection with the tracheobronchial tree.2, 3, 4 Confirmation of the diagnosis is frequently demonstrated by computed tomography of the chest, with or without invasive angiography.5, 6, 7 When this condition results in recurrent infection, treatment is ligation of the arterial supply with removal of the sequestered segment of the lung.

Rarely, arterial supply can be seen from one of the coronary arteries.8, 9 This is the first reported case in which computed tomography coronary angiography was used to diagnose pulmonary sequestration with coronary arterial supply by defining the course of the anomalous coronary artery.

Back to Article Outline

Management 

In this case, the patient’s main complaint of dyspnea seemed to be related to his coronary arterial stenoses, as it improved after percutaneous coronary intervention. While he did have a history of recurrent pneumonia in the sequestered lung, these infections were not recent, and it was felt to be most prudent to manage him expectantly. If pneumonia recurs, right-middle-lobe resection with ligation of the anomalous arterial supply could be performed.

Back to Article Outline

References 

  1. Berbarie RF, Dockery WD, Johnson KB, Rosenthal RL, Stoler RC, Schussler JM. Use of multislice computed tomographic coronary angiography for the diagnosis of anomalous coronary arteries. Am J Cardiol. 2006;98:402–406
  2. Lohani S, Varma R, Leahy B. A case of pulmonary sequestration with Aspergillus species infection presenting as an enlarged right paratracheal mass. J Thorac Cardiovasc Surg. 2005;129:1459–1460
  3. Miyazaki H, Gemma H, Koshimizu N, et al. [Two cases of intralobar pulmonary sequestration associated with nontuberculous mycobacterial infection in a young patient.]. Nihon Kokyuki Gakkai Zasshi. 2004;42:277–283
  4. Elia S, Alifano M, Gentile M, Somma P, D’Armiento FP, Ferrante G. Infection with Mycobacterium tuberculosis complicating a pulmonary sequestration. Ann Thorac Surg. 1998;66:566–567
  5. Di Maggio EM, Dore R, Preda L, Fianza AL, Solcia M, Campani R. Spiral CT findings in a case of pulmonary sequestration. Eur Radiol. 1997;7:718–720
  6. Ferretti GR, Jouvan FB, Coulomb M. MDCT demonstration of intralobar pulmonary sequestration of the right upper lobe in an adult. AJR Am J Roentgenol. 2005;185:1663–1664
  7. Wassia HL, Hussein H, Binyaheb S, Chedid F. CT scan diagnosis of extralobar pulmonary sequestration: angiography not required. Saudi Med J. 2003;24(5 Suppl):S35
  8. Hunninghake GM, Kanarek DJ. Pulmonary sequestration supplied by a coronary artery. Thorax. 2005;60(9):792
  9. Matsunaka T, Hara Y, Okayama H, et al. Pulmonary sequestration receiving arterial supply from the right coronary artery (A case report). Angiology. 1997;48:827–831

 Michael Bettmann, MD, Section Editor

PII: S0002-9343(06)01256-3

doi:10.1016/j.amjmed.2006.10.010

The American Journal of Medicine
Volume 120, Issue 1 , Pages 23-25, January 2007

Article Tools

* Image Usage & Resolution