Anterior Chest Research Articles

Feasibility of tele-guided patient-administered lung ultrasound in heart failure

BackgroundReadmission rates for heart failure remain high, and affordable technology for early detection of heart failure decompensation in the home environment is needed. Lung ultrasound has been shown to be a sensitive tool to detect pulmonary congestion due to heart failure, and monitoring patients in their home environment with lung ultrasound could help to prevent hospital admissions. The aim of this project was to investigate whether patient-performed tele-guided ultrasound in the home environment using an ultraportable device is feasible.Affiliations: Journal instruction requires a country for affiliations; however, these are missing in affiliations [1, 2]. Please verify if the provided country are correct and amend if necessary.CorrectMethodsStable ambulatory patients with heart failure received a handheld ultrasound probe connected to a smart phone or tablet. Instructions for setup were given in person during a clinic visit or over the phone. During each ultrasound session, patients obtained six ultrasound clips from the anterior and lateral chest with verbal and visual tele-guidance from an ultrasound trained clinician. Patients also reported their weight and degree of dyspnea, graded on a 5-point scale. Two independent reviewers graded the ultrasound clips based on the visibility of the pleural line and A or B lines.ResultsEight stable heart failure patients each performed 10–12 lung ultrasound examinations at home under remote guidance within a 1-month period. There were no major technical difficulties. A total of 89 ultrasound sessions resulted in 534 clips of which 88% (reviewer 1) and 84% (reviewer 2) were interpretable. 91% of ultrasound sessions produced interpretable clips bilaterally from the lateral chest area, which is most sensitive for the detection of pulmonary congestion. The average time to complete an ultrasound session was 5 min with even shorter recording times for the last session. All patients were clinically stable during the study period and no false positive B-lines were observed.ConclusionsIn this feasibility study, patients were able to produce interpretable lung ultrasound exams in more than 90% of remotely supervised sessions in their home environment. Larger studies are needed to determine whether remotely guided lung ultrasound could be useful to detect heart failure decompensation early in the home environment.

A Bull’s Head Sign in SAPHO

A syndrome of synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) is a rare autoimmune disease. It occurs in genetically predisposed individuals by immune activation triggered by possible infectious agents. A 60-year-old man was presented with musculoskeletal and cutaneous manifestations. After exclusion of differential diagnoses, he was diagnosed with SAPHO and successfully treated with adalimumab. He had a typical image defined as a bull’s head sign in bone scintigraphy with 99mTcmethylene diphosphonate. Positron emission tomography also revealed increased inflammatory activity in related anterior chest joints and soft tissue. We want to emphasize diagnostic radiological images in patients with SAPHO to increase the awareness of clinicians.

脂漏性角化症が侵入門戸と考えられた破傷風の1例(A case of tetanus in which the portal of entry was presumed to be seborrheic keratosis)

要旨87歳の男性が開口障害，嚥下困難のため経口摂取不能となり，他院に入院した。入院後から徐々に刺激による下肢の痙攣，筋緊張が出現し，気道閉塞による一過性の呼吸停止があり，当院へ転院搬送された。破傷風と診断し，破傷風トキソイド，破傷風免疫グロブリン，ペニシリンGを投与し，人工呼吸器管理および筋弛緩薬，鎮静薬，鎮痛薬，マグネシウム製剤などで全身管理を行った。明らかな外傷はなかったが，右前胸部の脂漏性角化症に浸出液を認めたため培養に提出したところ，Clostridium tetaniが検出され，腫瘤を切除した。経過は良好であり，気管切開孔を閉鎖し，リハビリ継続目的に転院した。脂漏性角化症が侵入門戸となって破傷風を発症した症例は，過去に報告されていない。破傷風は本邦では高齢者に多い疾患であり，高齢者には脂漏性角化症がほぼ必発である。また破傷風の治療においては，侵入門戸を検索し，必要があれば処置を行わなければならない。したがって，高齢者にごくありふれた疾患である脂漏性角化症が，Clostridium tetaniの侵入門戸となりうるということを，救急医が認識することは極めて重要と考える。

Three Zone Scanning Protocol For Lung Ultrasound: An Anatomical Basis.

Lung ultrasound is rapidly gaining popularity based on point of care ease of use, diagnostic fidelity and lack of ionizing radiation. This was particularly notable at the beginning of the COVID-19 pandemic, where concerns of contamination of the x-ray department led to a reluctance to order frequent chest x-rays. Early COVID-19 lung involvement is of a bronchopneumonia, and patches of consolidation adjacent to the chest wall were easily detectable by ultrasound. A large number of proposed scanning protocols were advocated and are often complex and largely based on traditional stethoscope examination or access points on the chest wall rather than the underlying lung anatomy. A surgical understanding of lung anatomy and related surface anatomy has led us to develop a simplified three zone scanning protocol in 2013. The anterior zone corresponds to the upper lobe, and the posterior zone is divided between upper lobe and lower lobe. The relationship between lung lobes and the surface of the chest wall provides the anatomical basis for a simple three scanning zone lung ultrasound protocol.

The management of pectus excavatum in pediatric patients: a narrative review.

Pectus excavatum is the most common congenital chest wall anomaly, the hallmark of which is the caved-in appearance of the anterior chest. A growing body of literature exists surrounding methods of surgical correction, though considerable variability in management remains. The primary objectives of this review are to outline the current practices surrounding the care of pediatric patients with pectus excavatum and present emerging trends in the field that continue to impact the care of these patients. Published material in English was identified utilizing the PubMed database using multiple combinations of the keywords: pectus excavatum, pediatric, management, complications, minimally invasive repair of pectus excavatum, MIRPE, surgery, repair, and vacuum bell. Articles from 2000-2022 were emphasized, though older literature was included when historically relevant. This review highlights contemporary management principles of pectus excavatum in the pediatric population, comprising preoperative evaluation, surgical and non-surgical treatment, postoperative considerations including pain control, and monitoring strategies. In addition to providing an overview of pectus excavatum management, this review highlights areas that remain controversial including the physiologic effects of the deformity and the optimal surgical approach, which invite future research efforts. This review also features updated content on non-invasive monitoring and treatment approaches such as three-dimensional (3D) scanning and vacuum bell therapy, which may alter the treatment landscape for pectus excavatum in order to reduce radiation exposure and invasive procedures when able.

Metastatic Breast Carcinoma with Cutaneous Metastasis and Right Pleural Effusion

Cutaneous metastasis is when cancerous cells spread from a primary tumour to the skin. This is a case of a 75-year-old patient who developed skin metastasis with underlying primary breast. A 75-year-old lady presented with a 3-week history of the progressive appearance of multiple asymptomatic nodular lesions on the chest. Eight months earlier, she was diagnosed with right breast carcinoma and underwent neoadjuvant chemotherapy followed by a right modified radical mastectomy. She presented with progressive skin lesion over the right upper limb and anterior chest wall. She denied any fever, pain or pruritus and any preceding burn or trauma. She also completed a course of antibiotic for the lesion. Physical examinations revealed an erythematous lesion with multiple exophytic nodules. It was painless and extended from the anterior chest wall to the right upper limb. Lung auscultation revealed reduced air entry over the right upper zone. She was then referred to the Oncology Department and diagnosed with metastatic breast carcinoma with right pleural effusion and cutaneous metastases. As she was unfit for further systemic therapy, she was discharged home and continuation of supportive care. Chest radiograph revealed right upper lobe opacity and bedside ultrasound confirmed right upper lobe pleural effusion. Other investigations were unremarkable. Cutaneous metastasis accounts for 24% of breast carcinoma and may manifest as the presenting lesion or after the tumour diagnosis. The commonest manifestation is the presence of nodules in the ipsilateral chest wall to the primary tumour, their size varies, is painless and are commonly spread via lymphatic drainage. Skin biopsy helps in diagnosis confirmation. Definitive treatment depends on the management of the primary malignancy. As it may mimic benign lesions, one should be highly suspicious of skin metastasis as he might be the first person to identify the primary tumour. International Journal of Human and Health Sciences Supplementary Issue: 2023 Page: S22

Tracheal injury from dog bite in a child

BackgroundDog bites associated with the head and neck area in children are a common problem. Most of the lacerations are found in the upper lip and the nose region, and tracheal injury is rare [1]. Tracheal injury requires prompt and accurate diagnosis and treatment to rescue the patient. Especially in children, securing the airway is often more difficult than in adults because of their short neck and narrow trachea. In this report, we experienced a pediatric case of multiple dog bites with tracheal injuries in the neck.Case presentationWe report the case of a 3-year-old girl who presented with multiple dog bites. There were multiple wounds on the head, face, neck, and anterior chest, and air leakage was observed from the cervical wound at the time of transfer. It was difficult to perform oral endotracheal intubation, therefore, we extended the neck wound, probed the trachea with finger, and inserted a tracheal tube directly from the cervical wound in the emergency room. Tracheoplasty and another wound cleansing were performed in the operating room. The patient was discharged on the 18th day after surgery, without further complications.ConclusionTracheal injury from a dog bite is rare. It is important to prompt and accurate diagnosis and treatment. Children should be especially careful because of their short necks and narrow tracheas.

Systematic Review of Penetrating Cardiac Injury by a Firearm: Forensic Implications.

Penetrating injuries of the heart, named penetrating cardiac injury (PCI), may cause hemorrhagic shock as well as cardiac tamponade, leading to death if not treated immediately. This systematic review aims to highlight the main aspects of penetrating cardiac injuries after firearm wounds. The cases of 39 subjects (age 37.05 + 15.4) were selected (6 fatal cases). Specifically, 4/39 cases involved subjects under 18 y.o.; analyzing the entrance wound, in 30/39 cases it was located in the anterior chest, 4/39 in the posterior chest, 3/39 in the shoulder/axilla area, 1/39 in the neck, and 1/39 in the pelvis (gluteus). The exit wound was found in only 3/39 cases. Several factors may influence the prognosis: firstly, prompt intervention represents a crucial point, then considering the complications related to PCI, the most important are myocardial infarction, and projectile migration with embolization. The mortality rate is related to: (1) area and severity of the heart injury; (2) duration of transport and intervention; (3) contemporary lesion to other organ/s; (4) the quantity of blood lost; (5) and presence/absence of cardiac tamponade. Based on these findings, a correct approach in the management of PCI may be considered important from a forensic point of view, both as regards to medical liability and from the trial perspective.

Multiple pulmonary masses with diffuse cystic lesions

A 50-year-old female patient, presenting with a past history of Reynaud's syndrome, xerostomia and xerophthalmia, was admitted to Fujian Provincial Hospital because of coughing for 10 days and left anterior chest pain for 1 day. Chest imaging showed multiple nodules and masses, and diffuse cystic lesions in both lungs. Based on the differential diagnosis of multiple pulmonary masses and diffuse cystic lesions respectively, autoantibodies, radionuclide dynamic imaging of the parotid, positron emission tomography-CT, CT-guided percutaneous transthoracic needle biopsy, and other examinations were performed. The diagnosis of diffuse large B-cell lymphoma stage ⅣA (lung, parotid gland) and Sjögren's syndrome was confirmed. By analyzing the imaging features and pathogenesis in detail, the diffuse cystic lesions of both lungs were considered to be related to lymphocytic interstitial pneumonia caused by Sjögren's syndrome. The pulmonary space-occupying lesions in the lungs were significantly absorbed after RCHOP regimen for lymphoma.

Fracture of the Costal Cartilage A Misdiagnosed Pathology: about A Case and Literature Review

Costal cartilage fracture is a rare traumatic injury but the frequency is probably underestimated. This lesion, not visible on X-rays, is nevertheless simple diagnosis in ultrasound, computed tomography and MRI. We report here a case of low anterior anterior post-traumatic chest pain following a brawl in a young patient in general condition.

Combined Serratus Intercostal Fascial Block (SIFB) and Rectus Sheath Block (RSB) for Chest Wall Fracture

Purpose: Rib fractures are common in patients presenting chest trauma and are associated with significant morbidity and mortality. Traditional pain management options for rib fractures include thoracic epidural and/or paravertebral blocks. However, novel regional anesthesia techniques have been demonstrated to improve pain scores and aid patient recovery. We describe the application of a combined Serratus-Intercostal Fascial (SIFB) and Rectus Sheath (RS) nerve blocks to provide analgesia for a patient with lower anterior and lateral rib fractures. Clinical Features: To perform the combined block, an 18-gauge Tuohy needle was inserted deep to the rectus sheath muscle above the transversus muscle with obvious spread of local anesthetic superficial to the posterior rectus sheath where 10mls of 0.375% bupivacaine was injected. The needle continued laterally under the external oblique until it was positioned deep to the left serratus anterior muscle where an additional 15ml was injected. In both blocks, CPNB catheters were inserted beyond the end of the Tuohy needles. On postoperative day 2, the patient reported no pain in his anterior chest and abdomen with improved inspiratory capacity and was able to ambulate. After postoperative day 7 the patient no longer required his oral scheduled opioids and continued to report no chest pain. Conclusion: A combined SIFB and RS block using a single-incision was effective in providing analgesia while being less invasive and providing more control over potential infection sites. The technique also allows for lower dosage of anesthetics which can be relevant in other clinical settings.

Dermoscopy of Cylindroma in Fitzpatrick Type IV Skin: A Case Report and Review of Literature.

Dermoscopy of Cylindroma in Fitzpatrick Type IV Skin: A Case Report and Review of Literature.

Usefulness of supplemental parasternal block for sternal keloid excision under general anesthesia in a child status post multiple cardiac surgeries

Sir A 12-year-old boy weighing 60 kg, with history of tricuspid atresia, had undergone right modified Blalock–Thomas–Taussig shunt, and patent ductus arteriosus ligation on day 1 of life. One year later he underwent bidirectional Glenn shunt, and extra cardiac Fontan surgery was done at 6 years. He presented now with a thick keloid in the midline sternotomy scar for keloid excision. Current screening echo showed tricuspid atresia, normally related great arteries with normal ventricular flow and unobstructed Glenn and Fontan flow profiles. Intravenous midazolam 1 mg, fentanyl 100 mcg and ketamin 60 mg were given and incremental bolus of propofol 10 mg (total 20 mg) was given till loss of response to verbal commands and relaxation of jaw. Airway was then secured with size 3 proseal laryngeal mask airway (PLMA) and correct placement was ensured with regular endtidal carbon dioxide (ETCO2) waveforms. Parasternal block was then given under ultrasound guidance at third and fifth intercostal spaces 2 cm lateral to midline bilaterally. Spread of injected solution causing separation of pectoralis major muscle from the rib and external intercostal muscle confirmed deposition of drug in the correct plane (Fig. 1). Ten milliliter of 0.25% bupivacaine was injected at each site.Figure 1: Superficial parasternal-intercostal plane block.Anesthesia was maintained with sevoflurane (1.5–2%) in air oxygen mixture under spontaneous ventilation. Intraoperatively patient remained stable with heart rate 86-98/min, systolic blood pressure 90–100 mmHg, oxygen saturation 96–98% and ETCO2 32-40 mmHg and had received 500 ml of Ringer lactate. At the end of surgery, which lasted for 2 h, PLMA was removed when patient was awake. He had good postoperative analgesia. Anesthetic goals in a child post-Fontan surgery include adequate hydration, avoidance of hypoxia, hypercabia, and acidosis and preservation of spontaneous ventilation whenever possible. If general anesthesia is mandated, low inspiratory pressures and minimal positive end expiratory pressures are to be used [1,2]. Sternotomy produces considerable pain which increases with chest wall movement and reduces pulmonary function with higher risk of development of postoperative hypoxia, atelectasis, and pneumonia [3]. Parasternal block is commonly advocated to provide supplemental anaesthesia intraoperatively and for postoperative analgesia following median sternotomy, breast surgery and cardioverter-defibrillator implantation [4,5]. The nerve targeted is the anterior branches of intercostal nerves which enters intercostal and pectoralis major muscles and innervates the antero-medial region of chest wall. Local anesthetic is injected deep to pectoralis major muscle and superficial to intercostal muscles or between internal thoracic muscle and transverses thoracis muscle. Therefore, these blocks are essentially described as superficial or deep parasternal-intercostal plane blocks, depending on where the target nerves are blocked. The anatomical injection site differentiates these techniques though both techniques provide analgesia to the antero-medial chest wall [5]. Supplemental regional block helps to reduce dose requirement of anesthetic agents intraoperatively. Use of supplemental parasternal block enabled us to keep the child spontaneously breathing under general anaesthesia using PLMA with use of lesser doses of anesthetic agents, thereby minimising drug adverse effects which could be deleterious in the presence of cardiac diseases. It is concluded that supplemental parasternal block provides good intraoperative and postoperative analgesia following anterior midline chest wall surgeries.

Effect of Local Hyperthermia on Respiratory Indices of Patients with Chronic Obstructive Pulmonary Disease.

Change in respiratory indices is the most common problem in Chronic Obstructive Pulmonary Disease (COPD) patients. This problem is managed through pharmaceutical and non-pharmaceutical methods. This study aimed to determine local hyperthermia effect on respiratory parameters of COPD patients. This randomized controlled trial study was conducted on 46 patients with COPD referred to Allameh Bohlool Hospital in Gonabad, Iran in 2019. The participants were randomly assigned into two groups using quadrupled blocks. In both groups, a local pack was placed on the anterior chest for 23 min twice daily for 5 days. In the intervention group, the temperature of the hot pack was 50° and in the placebo group was the same as the body temperature. Respiratory indices including force vital capacity (FVC), forced expiratory volume in first second (FEV1), etc., were measured and compared before and after the last intervention in both groups. To gather data, demographic information form and respiratory indices record form were used. Compared to before the intervention, all respiratory indices such as vital capacity (VC) (z = -4.25, p < 0.001), FEV1 (t22 = -114.18, p < 0.001), PEF (t22 = 5.91, p < 0.001) in the experimental group were increased significantly. Moreover, the difference in the mean respiratory indicators such as Pick Expiratory Flow rate (PEF) (t44 = 94.63, p < 0.001) and SPO2 (z = -3.27, p < 0.05) was also statistically significant in the two groups before and after the intervention. Local hyperthermia is effective in the improvement of respiratory indices among COPD patients, but it is recommended to conduct further studies before the implementation of this approach.

Some biochemical tips in the etiopathogenesis of Pectus Excavatum

Pectus excavatum (PE) is the most common deformity among anterior chest wall abnormalities. Although many theories on the pathogenesis of PE have been described, the uncertainty is still going on whether it is a result of developmental, biochemical, or biomechanical reasons or their combination. The aim of this study was to evaluate the biochemical parameters that may cause or be associated with the development of PE between children with PE and their healthy peers. A total of 33 patients' medical records were retrospectively analyzed who followed up because of pectus excavatum between 2019 and 2021. A control group was formed from 32 healthy children from the hospital records with similar age and gender profiles as the patient group. The data from both groups were collected and statistically analyzed in terms of gender, age, and laboratory tests, including hemogram, Vit B12, Parathormone (PTH), Vit.D, Alkaline phosphatase (ALP), and serum Calcium (Ca) and Phosphor (P) levels. Compared to the control group, statistically, significantly higher serum ALP, P, and PTH levels with low Vit.B12 levels were detected. The significant difference in the levels of ALP, PTH, P, and Vit B12, which have an important place in the construction and development of osteochondral structures, may impair the remodeling capacity of the costosternal structure with the contribution of thoracic biomechanics. When PE deformity is noticed, if appropriate medical treatment such as vitamin and mineral supplements and diet regulation is applied to children in the follow-up process, the process can be slowed down, and the deformity can be alleviated.

A modified method for measuring the length of peripherally inserted central catheters to reduce the risk of malposition during catheter insertion.

Malposition may occur during peripherally inserted central catheter insertion. Accurately measuring the length of a peripherally inserted central catheter is crucial to preventing malposition, including "long peripherally inserted central catheter placement," in which the tip of a peripherally inserted central catheter is deeper than the target position. The traditional method of measuring peripherally inserted central catheter length involves measuring from the insertion site to the parasternal notch and down to the third or fourth intercostal space, which may result in overestimation because of the thickness of the pectoralis major and anterior chest wall. To avoid this overestimation, the authors developed and tested a modified method for reducing long peripherally inserted central catheter placement. This study employed a retrospective design. Chest X-rays were used to examine the peripherally inserted central catheter tip positions in 48 patients in the medical intensive care unit who had undergone peripherally inserted central catheter insertion. The traditional and modified measurement methods were used to measure the peripherally inserted central catheter length in 17 and 31 patients, respectively. Fisher's exact test was used to examine between-group differences in the incidence of different types of peripherally inserted central catheter malposition. The peripherally inserted central catheter tip position was near the target position in five patients (29.41%) in the traditional measurement group and 17 patients (54.84%) in the modified measurement group (p = 0.132), whereas long peripherally inserted central catheter placement occurred in six patients (35.29%) in the traditional measurement group and one patient (3.23%) in the modified measurement group (p = 0.006). However, the incidence of other types of peripherally inserted central catheter malposition did not differ significantly between the groups. The results of this study that the proposed modified measurement method may be able to reduce the incidence of long peripherally inserted central catheter placement among medical intensive care unit patients. The method must be further evaluated in prospective studies and studies with larger sample sizes in the future.

Autologous Cell Collection and Noncultured Cell Suspension Preparation for Pediatric Application to Anterior Chest and Abdominal Burns

Autologous Cell Collection and Noncultured Cell Suspension Preparation for Pediatric Application to Anterior Chest and Abdominal Burns

Occurrence of Extensive Scrofuloderma in an Immunocompromised Child: A Rare Case Report

Scrofuloderma also called Tuberculosis colliquativa cutis is one of the variants of cutaneous tuberculosis. It can be a skin manifestation of concealed tuberculosis infection. It is most common in countries under development, such as India. It is possible that the individual suffering from Scrofuloderma may not have underlying tuberculosis however, the patient may have come in contact with a tuberculosis patient in the past and due to his/her immunocompromised state the disease manifests. Here, we describe the case of a four-year-old boy presented to the Outpatient Department (OPD) with all the classical sign and symptoms of tuberculosis as low-grade fever, multiple ulcerated nodules at the site of lymph nodes over the neck, axillae, anterior chest wall and inguinal region with history of rupture and extensive crusting. On the basis of presentation and examination the differential diagnosis was made in which Scrofuloderma was first listed. To confirm the diagnosis all the relevant investigations were advised in which Mantoux test, Erthrocyte Sedimentation Rate (ESR) came positive and chest X-ray revealed old resolved tuberculosis. After correlating, clinical findings and laboratory investigations a confirmed diagnosis of scrofuloderma was made and the patient was treated with standard Anti-Tubecular Treatment (ATT). After the completion of standard prescribed period of treatment and specific puckered healing of the ulcerated lesions again confirmed the diagnosis. The aim of reporting is presentation of lesions as superficial bacterial infection and healed old tuberculosis.

Investigation of intrathoracic morphology in computed tomography images of individuals with anterior chest wall deformity

Investigation of intrathoracic morphology in computed tomography images of individuals with anterior chest wall deformity

PS-BPR02-5: A CASE OF JUVENILE-ONSET HYPERTENSION WITH A GIANT LEFT ANTERIOR THORACIC ARTERIOVENOUS FISTULA

(Case) 3X years old male: (Current medical history) In school days he had been aware of a subcutaneous mass in the left anterior chest and from the same period he often had severe headache but left it unattended. He was diagnosed with hypertension at the age of 20 years old and with giant left anterior thoracic arteriovenous fistula. He was operated but could not completely remove it. Then he has performed vascular embolization at five times. He was hospitalized for the sixth embolization in 202x due to increased arteriovenous fistula. A high blood pressure (178/97 mmHg) was observed at admission and the sixth embolization of the left thoracic shoulder lateral thoracic and internal thoracic artery was performed the day after hospitalization. After embolization he was discharged one week later. However the high blood pressure continued even after discharge and the headache did not improve so he was referred to our department. His father and mother and grandparents and brothers had high blood pressure. It may be suggesting familial and juvenile hypertension. Blood pressure of upper limb left 171/108 mmHg / right 178/112 mmHg (not significantly difference) ABI left 1.13 / right 1.10 and PWV left 2069 / right 1804 cm/s and arteriosclerosis was remarkable. CT imaging showed no adrenal enlargement but multiple kidney stones. Serum Ca and Mg levels were in the normal range and no high ARR84 (renin/aldosterone ratio) was observed. Ask-Mark syndrome was negative. He started taking amlodipine 5 mg for hypertension and then increased the dose and exchanged NifedipineCR 40 mg. After that carvedilol 10 mg was added and the blood pressure decreased to 120–130 / 70–80 mmHg and the control became good. Blood pressure showed a tendency to increase in eight months after the sixth embolization again and at the same time CT showed a slight increase in arteriovenous fistula. Conclusion: We experienced a case of juvenile-onset hypertension in which blood pressure could be controlled using three antihypertensive drugs in addition to the treatment of giant thoracic arteriovenous fistula embolization. The cause of juvenile onset and increased blood pressure was thought to be related to the effects of congenital battlement and longitudinal arteriovenous fistula which do not exhibit pulmonary circulation or circulatory system. Conventionally congenital battlement / longitudinal arteriovenous fistula has a mild left ventricular load and almost no increase in blood pressure has been reported. However it may be possible the left ventricular load became larger and caused hypertension because of the huge thoracic arteriovenous fistula.