Chest Wall Vascular Malformations

Abstract

To the Editor:A 32-year-old woman's gynecologist auscultated a “murmur” in her chest. The patient's past history was positive for a spontaneous right pneumothorax 14 years previously. This resolved without treatment. A second spontaneous pneumothorax on the right occurred four years after the first, and was treated with an anterior thoracostomy tube. The results of the current physical examination were unremarkable except for a two-component vascular sound in the posterior right side of the chest medial to the scapula. A harsh systolic bruit was followed by a soft venous hum that continued through cardiac diastole. Both sounds diminished with the Valsalva maneuver. A two-view chest x-ray examination was normal. Selective intercostal arteriography showed a congenital arteriovenous malformation arising from the seventh right intercostal artery and feeding into an anomalous tangle of venous structures in the chest wall (Fig 1). Right heart catheterization showed no pulmonary vascular communication.While the natural history of this condition is conjectural, it is postulated that periods of rapid enlargement of the malformation may disrupt normal continuity between the parietal and visceral pleura of the lung, causing pneumothorax. Other possible complications include rupture of the malformation and precipitous bleeding. Magnetic resonance imaging studies of this region obtained periodically during a two-year period disclosed no enlargement in the vascular structure.Vascular malformations in the chest wall are extremely uncommon. Their presence should be sought by careful auscultation if repeated pneumothoraces are documented in a young patient without detectable lung or pleural abnormalities. To the Editor: A 32-year-old woman's gynecologist auscultated a “murmur” in her chest. The patient's past history was positive for a spontaneous right pneumothorax 14 years previously. This resolved without treatment. A second spontaneous pneumothorax on the right occurred four years after the first, and was treated with an anterior thoracostomy tube. The results of the current physical examination were unremarkable except for a two-component vascular sound in the posterior right side of the chest medial to the scapula. A harsh systolic bruit was followed by a soft venous hum that continued through cardiac diastole. Both sounds diminished with the Valsalva maneuver. A two-view chest x-ray examination was normal. Selective intercostal arteriography showed a congenital arteriovenous malformation arising from the seventh right intercostal artery and feeding into an anomalous tangle of venous structures in the chest wall (Fig 1). Right heart catheterization showed no pulmonary vascular communication. While the natural history of this condition is conjectural, it is postulated that periods of rapid enlargement of the malformation may disrupt normal continuity between the parietal and visceral pleura of the lung, causing pneumothorax. Other possible complications include rupture of the malformation and precipitous bleeding. Magnetic resonance imaging studies of this region obtained periodically during a two-year period disclosed no enlargement in the vascular structure. Vascular malformations in the chest wall are extremely uncommon. Their presence should be sought by careful auscultation if repeated pneumothoraces are documented in a young patient without detectable lung or pleural abnormalities.