Anomalous Bronchial Artery Research Articles

Anomalous bronchial artery origin - canary in the coal mine - for diagnosing chronic thromboembolic pulmonary hypertension

Anomalous bronchial artery origins may have clinical implications beyond their anatomical curiosity. In this case, the identification of such an anomaly led to the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH). A 49-year-old male with a history of recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE) on anticoagulation presented with chest pain and shortness of breath. Laboratory analysis was remarkable for a troponin peak of 14.74 ng/ml, a brain natriuretic peptide level of 602 pg/ml and a D-dimer level of 0.62 µg/ml. Electrocardiogram showed non-specific ST elevation in the anterolateral and inferior leads. Computed tomography angiography (CTA) of the chest was positive for PE involving the right lower lobe pulmonary arterial tree. Echocardiogram showed reduced left ventricular function (ejection fraction 38%) and akinesis of the antero-apical and infero-apical segments. Cardiac catheterization revealed non-obstructive coronary arteries, and an anomalous origin of a right bronchial artery from the right coronary artery. The right bronchial hypertrophied as it supplied collateral flow to the occluded right pulmonary artery. This anomaly and the patient’s history of multiple DVT/PEs while on therapeutic levels of warfarin with near normal D-dimer levels raised suspicion for a false positive PE. Pulmonary angiogram revealed chronic occlusion in branches of the right pulmonary artery, mean pulmonary artery pressure of 36 mmHg and no acute thrombus. Ventilation-perfusion scan confirmed the diagnosis of CTEPH. The patient underwent successful pulmonary thromboendarterectomy and subsequently had normalization of mean pulmonary artery pressure. This case underscores the importance of a comprehensive diagnostic approach, and consideration of alternative explanations for imaging findings, that unveiled the diagnosis of a complex and life-threatening condition such as CTEPH.

Abstract 15837: Anomalous Bronchial Artery Origin- The Canary in the Coal Mine- For the Diagnosis of Chronic Thromboembolic Pulmonary Hypertension

Introduction- Anomalous bronchial artery origin is seen in 8.3% to 35% of cases with most originating from the aortic arch, internal mammary artery, and subclavian artery. Origin of this vessel from a coronary artery is extremely rare. Case presentation- A 49-year-old male with history of unprovoked pulmonary embolisms (PE) in the setting of triple antibody positive Antiphospholipid antibody syndrome on lifelong anticoagulation presented with left sided chest pain and dyspnea. Initial lab work showed a troponin of 5.46 ng/mL, BNP of 602 pg/mL and D-dimer of 0.62 ug/mL. EKG showed normal sinus rhythm with non-specific ST segment changes in anterior leads. Computed Tomography Angiography (CTA) was positive for a PE. There was concern for a false positive result due to previous history of multiple PEs while on therapeutic levels of warfarin and near normal D-dimer. Echocardiogram showed ejection fraction of 38% with akinesis of anteroapical and inferoapical segments and no evidence of shunt on bubble study. Cardiac catheterization showed non-obstructive coronaries. From the ostium of the right coronary artery there appeared a fistula like structure extending into the pulmonary vasculature. Pulmonary angiogram was performed and showed chronic occlusion in branches of right pulmonary artery (RPA), pulmonary hypertension (PH) with mean pulmonary artery pressure of 36 mmHg and no evidence of acute thrombus. There was aberrant origin of the right bronchial artery from the right coronary artery that was hypertrophied as it supplied collateral flow to the area of the occluded RPA. The patient was started on guideline directed medical therapy for heart failure and follow up was arranged for further outpatient management of PH. Discussion- A rare congenital anomaly was used to guide the diagnosis of a potentially devastating and treatable medical condition. It shows the limitations of a CTA in the setting of chronic PE.

Hemothorax From an Anomalous Bronchial Artery Bleed in an Infected Intralobar Pulmonary Sequestration

Pulmonary sequestration is a rare congenital malformation. It represents 0.15-6.4% of all congenital pulmonary malformations. It is characterized by non-functional, dysplastic mass of lung tissue that is not in communication with the normal tracheobronchial tree and is associated with a systemic arterial supply. We report a young gentleman in his mid-thirties who presented with community-acquired pneumonia from an infected intralobar pulmonary sequestration which subsequently developed a hemothorax from an anomalous bronchial artery bleed.

Repeat Episodes of Massive Hemoptysis Due to an Anomalous Origin of the Right Bronchial Artery in a Patient with a History of Coccidioidomycosis

Anomalous bronchial arteries originate outside the space bound by the T5 and T6 vertebrae at the major bronchi. Here, we highlight a case of a 37-year-old man with a past medical history of coccidioidomycosis and who presented with massive hemoptysis. A bronchial angiogram showed the patient had a right bronchial artery originating anomalously from the left subclavian artery. The patient ultimately underwent a bronchial artery embolization, after which he achieved symptomatic remission.

Potential Factors Affected Safety and Efficacy of Transcatheter Plug Closure for Pediatric Hemoptysis with Anomalous Bronchial Arteries.

Objective To evaluate the safety and efficacy of interventional care in pediatric hemoptysis for anomalous bronchial arteries (BAs) and to identify the potential factors resulting in hemoptysis recurrence. Methods 20 children complained of hemoptysis were diagnosed with anomalous BAs. All patients received transcatheter plug occlusion in Department of Cardiology, Children's Hospital of Chongqing Medical University. The safety and efficacy were evaluated according to clinical symptoms and images monitoring of enrolled subjects grouped as recurrence group and nonrecurrence group. The potential factors causing hemoptysis recurrence were reviewed and summarized. Results No deaths were recorded in a follow-up. Otherwise, hemoptysis recurrence was found in 8 subjects for 14 times, accounting for about 40%. Compared with nonrecurrence group, it indicated a statistical significance in hemoglobin levels (P=0.049), mycoplasma pneumonia particle assays (MP-PA) titers (P=0.030), and number of anomalous BAs (P=0.020). Meanwhile, 50% recurrent scenarios were associated with a respiratory infection by microbiological assessment before transcatheter plug occlusion. The repeat occlusion was applied for unclosed BAs leading to visual recurrent hemoptysis, the average interval time of which was 5.4 ± 3.6 mon. Conclusion The data from this retrospective study have shown that transcatheter plug occlusion is a relatively safe procedure with a low mortality. The number of abnormal BAs has been identified as a highly significant predictor of recurrence, and the role of MP and other potential factors should be verified in a multicenter, larger sample size, and randomized controlled trial.

Anomalous Bronchial Arteries Originating from a Common Bronchial Arterial Trunk Detected by Trans-Esophageal Echocardiography: A Multi-Faceted Imaging Approach

A 56-year-old male presented to the hospital with fever, chills and malaise. His past medical history included; coronary artery disease status post coronary artery bypass graft surgery, chronic severe mitral regurgitation, monoclonal gammopathy of undetermined significance and chronic portal vein thrombosis. Vital signs demonstrated a blood pressure of 130/70 mmHg, heart rate of 110 bpm and normal temperature. The physical examination was unremarkable except for an apical pan-systolic murmur. Two sets of blood culture revealed Group B streptococci. A transesophageal echocardiogram (TEE) showed mobile vegetation attached to the mitral valve anterior leaflet with severe mitral regurgitation. Additionally, an abnormal continuous turbulent flow with systolic augmentation was noted posterior to the main pulmonary artery trunk. The Peak systolic velocity of this jet was 1.8-2.0 m/s. The high aliasing velocity, the spectral Doppler profile and flow proximity to pulmonary trunk were consistent with an aortic origin of the flow. A cardiac CT angiogram revealed a completely occluded venous graft to the right coronary artery and a patent graft to the obtuse marginal branch. An incidental finding was an anomalous common bronchial artery (BA) trunk arising from the proximal descending thoracic aorta. It gave rise to a large, tortuous right and small left BA. To the best of our knowledge this is the first case report of an anomalous BA detected by TEE. In our patient, two mechanisms may explain the extensive dilatation and tortuosity of the BA system: increased left atrial pressure from chronic severe mitral regurgitation and chronic pulmonary hypertension

Reply to N. Eid et al.

1. Kajiyama Y, Iwanuma Y, Tomita N, Amano T, Isayama F, Saita M, Ozaki A, Shibamoto M, Kitano H, Uchida T. Relational topographical anatomy between right bronchial artery and thoracic duct. Esophagus. 2014. doi:10.1007/s10388-014-0450-8. 2. Eid N, Otsuki Y. Anomalous bronchial arteries with surgically important relationships to abnormal recurrent laryngeal nerve and thoracic duct. Clin Anat. 2010;23:897–8. 3. Eid N, Ito Y, Otsuki Y. Thoracic duct relationships to abnormal neurovascular structures in cervicothoracic regions: case study and clinical relevance. Surg Radiol Anat. 2013;35:969–72. It is our pleasure to respond to the letter written with regard to our recently published article [1]. First, Eid asked Figure 1 in our article. In this figure, we wanted to present normal relational anatomy between right bronchial artery and 3rd intercostal artery, and did not present thoracic duct clearly. Eid referred to their two case reports published in 2010 and 2013 [2, 3]. In those reports, Eid also mentioned relationship between anomalous common bronchial artery trunk and thoracic duct. However, “anomalous common bronchial artery trunk” in Eid’s papers is quite different from “anomalous right bronchial artery” in our article. In Eid’s articles, “anomalous common bronchial artery trunk” arose from higher level of descending aorta than usual and ran anterior side of right main bronchus. On the contrary, “anomalous right bronchial artery” in our article originated from usual level of descending aorta and ran posterior side of right main bronchus. We just used the word “anomalous” as a meaning that “without connection to 3rd intercostal artery”.

Relational topographical anatomy between right bronchial artery and thoracic duct

Thoracic duct injury leads to “chylothorax”. We found a close relationship of topographical anatomy between right bronchial artery and thoracic duct from esophageal cancer operations. We retrospectively analyzed topographical anatomy of right bronchial artery and location of thoracic duct in 124 cases operated in 2012. Of 124 cases, we recognized 8 cases of anomalous right bronchial artery. In these cases, the right bronchial artery originated directly from descending aorta without connections with third intercostal artery. When the right bronchial artery has a connection with third intercostal artery, the thoracic duct was located within the loop of the right bronchial artery. However, in these 8 anomalous cases, thoracic duct was located dorsally outside the loop of the right bronchial artery without exceptions. We have to be very careful in exploring the thoracic duct when we notice the anomalous right bronchial artery during esophageal cancer operation.

Anomalous Vascular Supply of Bronchial Circulation in Cystic Fibrosis Patients with Massive Hemoptysis

Background: Hemoptysis occurs commonly in patients with Cystic Fibrosis, and massive bleeding requiring emergent intervention occurs in a subset. Bronchial artery embolization (BAE) is recommended in clinically unstable CF patients with massive hemoptysis (MH); however, no consensus exists regarding selective versus extensive embolization, and recommendations of targets are scant. Objective: We sought to characterize the frequency of abnormal bronchial circulation in MH in CF in order to suggest interventional approach for BAE. Methods: A retrospective chart review of BAE for MH was performed. Characterization of angiography was described, and CF and non-CF patients were compared. Results: 10 CF and 7 non-CF patients with MH were identified. Dilated, tortuous bronchial vessels were ubiquitous in CF, and 70% had non-bronchial collaterals. CF patients required more extensive BAE and 50% had >1 collateral. Anomalous supplies were described, and a correlation between the volume of hemoptysis and number of collaterals was determined. Conclusion: Anomalous bronchial arteries origin and supply should be suspected in CF. Angiographic approach in CF should include arch aortograms to demonstrate entire supply of the bronchial arterial field. Keywords: Bronchial artery embolization, cystic fibrosis, hemoptysis.

Bronchial Artery Arising from the Left Vertebral Artery: Case Report and Review of the Literature

Knowledge of bronchial artery anatomy, including the possible locations of anomalous origin, is essential for complete catheter directed embolization for massive hemoptysis. Undetected anomalous bronchial arteries can be a source of failed bronchial artery embolization. We report a case of a common trunk bronchial artery arising from the left vertebral artery and review standard and variant bronchial artery anatomy.

Abstract No. 310: Potential pitfalls of bronchial artery embolization

Review a multitude of potential complications specific to the bronchial artery embolization procedure. Bronchial artery embolization is an important therapeutic method used to control acute and chronic hemoptysis. Bronchial artery embolization has been proven to be a safe and effective nonsurgical treatment for patients with hemoptysis. This pictorial review will emphasize complications and potential complications associated with bronchial artery embolization. Technical complications related to the procedure including: bronchial artery aneurysm, spasm, dissection, pseudoaneyrusm, and rupture will be depicted. Digitial subtraction images will depict bronchial-artery to pulmonary artery shunts and subsequent pulmonary infarction via computed tomography images. Digital subtraction images will also depict a bronchial artery to pulmonary vein shunt. One of the most disastrous complication of bronchial artery embolization, non-target embolization of the anterior medullary artery, will also be addressed. The review will be highlighted by a case that occured at our institution that resulted in posterior circulation infarction and death as a consequence of the procedure likley due to nonvisable bronchial artery to vertebral artery collaterals. Anomalous bronchial arteries will also be depicted as potential pitfall in clinically unsuccessful bronchial artery embolization. Images will demonstrate the more common origin of the anomalous bronchial arteries: subclavian artery, aorta, internal mammary artery, thyrocervical trunk, and inferior phrenic artery. 1) Identify potential pitfalls of the bronchial artery embolization procedure. 2) Identify potential technical procedural complications. 3) Recognize potential visible sources of non-target embolization. 4) Describe potential nonvisible sources of non-target embolization. 5) Identify possible sources of anomalous bronchial arteries as a potential cause of clinically unsuccessful bronchial artery embolization.

A case of anomalous bronchial artery ramified from coronary artery

There have been no anatomical reports on the origin of the bronchial artery derived from the coronary artery. In a 2006 cadaveric dissection course, an anomalous bronchial artery that reached the middle lobe of the right lung from the left coronary artery was observed in an 88-year-old Japanese man. In this specimen, the circumflex branch of the left coronary artery passed under the left auricle in the coronary sulcus and bifurcated to three branches (left marginal branch, posterior left ventricular branch, atrial branch), which were 3.2-3.4mm in diameter. The atrial branch intersected on the surface of the great cardiac vein, ran along the oblique vein of the left atrium, and reached the atrial side of the transverse pericardial sinus, and then divided into two branches. One of them led to the right atrium. The other branch passed between two right superior pulmonary veins, which derived from superior and middle lobes of the right lung, respectively, through the hilum of the lung along the right superior pulmonary vein derived from the middle lobe, and finally became the bronchial artery in the middle lobe of the right lung. In the middle lobe, the bronchial artery divided into a thin branch along the pulmonary vein for the lateral segment, ran along the surface of the right middle bronchus, and then reached the medial segment, being wedged between the segmental bronchus and vein.

Anomalous bronchial arteries with surgically important relationships to abnormal recurrent laryngeal nerve and thoracic duct

Department of Anatomy and Cell Biology, Osaka Medical College, Takatsuki, Osaka, JapanStudies investigating the relationships between thebronchial arteries and left recurrent laryngeal nerve(LRLN) or the thoracic duct (TD) and more impor-tantly, the clinical relevance of such relationships areseemingly very rare. Based on text books of anat-omy (Standring et al., 2008; Moore et al., 2010),there are usually two left bronchial arteries arisingfrom the thoracic aorta passing to the dorsal surfaceof left main bronchus and one right bronchial artery,which arises from the third posterior intercostalartery to the right main bronchus. However, thebronchial arteries that originate outside the areabetween the T5 and T6 vertebrae are anomalous orectopic (Yoon et al., 2002; Hartmann et al., 2007).In anatomy text books, it is always mentioned thatLRLN loops around the aortic arch during its upwardcourse toward the larynx.During the dissection of 25 cadavers, anomalouscommon bronchial artery trunk (ACBAT) arising fromthe distal aortic arch was detected in an 80-year-oldman who was suffering pneumonia shortly beforedeath (Fig. 1A and 1B). This artery was tortuous anddilated with a diameter of 2.7 mm. The LRLN loopedaround the ACBAT passing deep to it during itsupward course. The artery soon gave rise to terminalbranches which traveled along the walls of the leftmain bronchus, crossed the later ventrally towardthe carina where it terminated at the right mainbronchus. A right bronchial artery with diameter of1.1 mm originating from the third posterior intercos-tal artery and coursing toward the deep surface ofright main bronchus was observed (Fig. 1C and 1D).The TD crossed the posterior intercostal arterymedial and close to the origin of the right bronchialartery.Our report is a rare case of LRLN looping arounda tortuous dilated ACBAT with abnormal branchingpattern to the ventral aspect of the main bronchi,which is different from the literature (Hartmannet al., 2007; Standring et al., 2008). Understand-ing the clinical relevance of the variable anatomyin our case is essential for cardiothoracic surgeons,interventional radiologists and otolaryngologists. Abronchial artery with a diameter greater than 2mm is considered to be enlarged and may rupture(Chung et al., 2006; Hartmann et al., 2007).Therefore, the dilated tortuous ACBAT may ruptureresulting in severe hemoptysis (Yoon et al., 2002,Hartmann et al., 2007). Moreover, the ACBAT maybe injured during mediastinoscopy as a result of itsintimate contact with the carina (Shields et al.,2009). Ortner or cardiovocal syndrome is vocalcord paralysis due to compression of the LRLN byenlargement of heart and great vessels (Lee et al.,2006; Khaki et al., 2007). Accordingly, there is apossibility that the enlarged ACBAT may compressthe LRLN resulting in cord palsy and consequentaspiration pneumonia (Lee et al., 2006). In addi-tion, the LRLN may be damaged during emboliza-tion or ligation of ACBAT for hemoptysis treatmentor during other invasive procedures dealing withthe anomalous artery (Yoon et al., 2002; Shieldset al., 2009). In our case, the coursing of TD closeto the intercostal and right bronchial arteries maydamage it during the exposing of the intercostalartery for treatment of aortic aneurysm (Minamiet al., 2006) or during surgical procedures relatedto the right bronchial artery.

Anomalous bronchial artery originating from the right coronary artery in a patient with angina (2009: 4b)

Bronchial artery origins are subject to a wide range of anatomic variations, of which interventional radiologists should be aware. The authors report a patient with angina in whom an anomalous bronchial artery originated from the sinus node branch of the right coronary artery, causing a coronary steal phenomenon. The patient's symptom was successfully treated by transcatheter embolisation of the anomalous bronchial artery, which seems to be an effective alternative to surgery.

Anomalous origin of bronchial arteries in patients with cystic fibrosis: therapeutic implications for embolisation

Bronchial artery embolisation (BAE) is an accepted method of controlling haemoptysis in patients with cystic fibrosis. However, anomalous origin of the bronchial arteries, documented in anatomical and angiographic studies, makes the procedure more difficult and increases the number of recurrences. Clinical records and films from three patients affected by cystic fibrosis with haemoptysis, in which the origin of the bleeding vessels was considered anomalous, out of a total of seven patients who underwent BAE, were reviewed. In two patients the source of bleeding was identified from, respectively, the left and the right internal mammary artery and in one from the left thyrocervical trunk. All the vessels considered to be the possible source of haemoptysis were embolised; immediate control of haemoptysis after embolisation was achieved in all patients, but minor haemoptysis recurred in two patients who were conservatively treated. In haemoptysis in patients with cystic fibrosis the possibility of anomalous origin of the bronchial arteries should be considered. This frequency may be higher than in other pulmonary diseases that cause haemoptysis, so a search for anomalous bronchial arteries is mandatory to achieve accurate embolisation and reduce the rate of recurrence.

Embolization of an Anomalous Bronchial Artery Aneurysm in a Patient with Agenesis of the Left Pulmonary Artery

Embolization of an Anomalous Bronchial Artery Aneurysm in a Patient with Agenesis of the Left Pulmonary Artery

Anomalous Origin of Bronchial Arteries: Potential Pitfall of Embolotherapy for Hemoptysis

Bronchial artery embolization was performed in two patients with anomalous origins of the bronchial artery. In one patient, the anomalous bronchial artery originated from the convex surface of the aortic arch between the origins of the brachiocephalic and left carotid arteries, while in the other, it originated from the internal mammary artery. Anomalous bronchial arteries represent a potential pitfall during bronchial artery embolization. Radiologists involved in embolotherapy for hemoptysis should therefore be alerted to the possible presence of anomalous bronchial arteries, especially when significant bronchial artery supply to areas of abnormal pulmonary parenchyma is not demonstrated at a catheter search or aortography of the descending aorta. In these instances, arch aortography should be performed to identify anomalous origins of the bronchial arteries or other nonbronchial systemic collateral vessels.