Left Main Pulmonary Artery Research Articles

The first rib hypoplasia and the aberrant pulmonary artery branch detected by three-dimensional computed tomography in a surgical case with apical lung cancer, a case report

BackgroundThe complete resection is one of the most crucial requirements to achieve favorable outcomes in oncologic surgery. The apex of the lung is surrounded complicatedly by the clavicle, the first rib, the subclavian artery and vein, and the brachial plexus. Therefore, the image information especially about the infiltration of adjacent anatomic structures, facilitates the surgery in the apical lung cancer.Case presentationA 70-year-old man presented at our hospital with a computed tomography (CT) scan showing a tumor at the left lung apex that infiltrated the chest wall. Two anatomical anomalies were found, which were the first rib hypoplasia and the aberrant pulmonary artery branch. The three-dimensional (3D) CT enhanced with using bolus tracking method, simultaneously revealed that the subclavian vessels existed between the clavicle and the second rib, and the left lingual pulmonary artery and the ventrobasal pulmonary artery diverged from the left main pulmonary artery as the first branch. We diagnosed the tumor as a primary lung squamous cell carcinoma that infiltrated the second rib, because sputum cytology suggested squamous cell carcinoma. Left lung upper lobectomy with lymph node dissection and chest wall resection (the second and third ribs) were performed with caution for the anatomical anomalies. The pathological diagnosis was pleomorphic carcinoma (5.0 × 3.0 × 1.9 cm) that invaded the second costal bone, and the pathological stage was confirmed to be pT3N0M0. Pathologically curative resection was accomplished. The patient was discharged from the hospital on 10 days after surgery.ConclusionThe 3D-CT precisely detected the anomalous structure consisted with the clavicle, the second rib, the subclavian artery and vein, the aberrant pulmonary artery branch. In the present case with the apical lung cancer, the evaluation of the anatomical structure via 3D-CT facilitated to achieve a pathological complete resection.

Lung injury pathways: Adenosine receptor 2B signaling limits development of ischemic bronchiolitis obliterans organizing pneumonia

ABSTRACTPurpose/Aim of the Study: Adenosine signaling was studied in bronchiolitis obliterans organizing pneumonia (BOOP) resulting from unilateral lung ischemia. Materials and Methods: Ischemia was achieved by either left main pulmonary artery or complete hilar ligation. Sprague–Dawley (SD) rats, Dahl salt sensitive (SS) rats and SS mutant rat strains containing a mutation in the A2B adenosine receptor gene (Adora2b) were studied. Adenosine concentrations were measured in bronchoalveolar lavage (BAL) by HPLC. A2A (A2AAR) and A2B adenosine receptor (A2BAR) mRNA and protein were quantified. Results: Twenty-four hours after unilateral PA ligation, BAL adenosine concentrations from ischemic lungs were increased relative to contralateral lungs in SD rats. A2BAR mRNA and protein concentrations were increased after PA ligation while miR27a, a negatively regulating microRNA, was decreased in ischemic lungs. A2AAR mRNA and protein concentrations remained unchanged following ischemia. A2BAR protein was increased in PA ligated lungs of SS rats after 7 days, and 4 h after complete hilar ligation in SD rats. SS-Adora2b mutants showed a greater extent of BOOP relative to SS rats, and greater inflammatory changes. Conclusion: Increased A2BAR and adenosine following unilateral lung ischemia as well as more BOOP in A2BAR mutant rats implicate a protective role for A2BAR signaling in countering ischemic lung injury.

P1.08-064 Surgery for Malignant Pulmonary Tumor Invading Proximal Left Main Pulmonary Artery

Surgery for tumor invading proximal left main pulmonary artery (PA) may be technical challenge, and the current study conducted to assess its feasibility. Patients who received surgery for malignant pulmonary tumor invading left main PA, PA proximal to the first branch (usually A3), from 2011 through 2015 in our institute were retrospectively reviewed. Among 32 eligible patients (Table 1), 31 (97%) patients received complete resection with pneumonectomy (n=4) or lobectomy with PA-reconstruction (n=27). Pericardiotomy was necessary for proximal control of main PA in 12 patients, and combined bronchial sleeve resection and reconstruction were performed in 11 patients. Postoperative complications occurred in 7 patients, but a > grade 3 complication (ARDS) occurred in only one patient who received pneumonectomy. There was no operative or in-hospital death.Tabled 1Characteristics of Patients (n=32)No. of Patients%Age, median (range)70 years (47-85)Sex, Female / Male6 / 2619% / 81%Histology Primary lung cancer3094% Lung metastasis26%Mode of lung resection Upper lobectomy2784% Pneumonectomy413% Exploratory thoracotomy13%Pericardiotomy1238%PA-resection3197% Circumferential resection18 Partial resection13PA-reconstruction2784% Direct closure25 Patch closure (with pericardium)1 Vascular conduit (pulmonary vein)1Bronchial sleeve resection1134%Morbidity722% Arrythmia5 Prolonged air leak2 ARDS1Mortality00% Open table in a new tab Lobectomy with PA-resection and reconstruction was feasible to avoid pneumonectomy for tumor invading proximal left PA.

Video-Assisted Thoracic Surgery in Patients With Previous Sternotomy and Cardiac Surgery.

Although video-assisted thoracic surgery (VATS) lobectomy has become a standard approach for early-stage 1 lung cancer, concerns exist regarding potential damage to the heart or bypass grafts when VATS is performed after cardiac surgery via median sternotomy. We could find only case reports regarding VATS lobectomy after sternotomy for cardiac surgery. Therefore, we reviewed our series of patients who underwent VATS anatomic resections after sternotomy for cardiac surgery. Between 1996 and 2010, there were 87 patients who underwent 88 pulmonary resections after sternotomy for coronary artery bypass grafting (64), valve replacement or repair (12), coronary artery bypass graft and valve replacement (6), and transplant (5). There were 10 women (11.5%) and 77 men (88.5%) with a mean age of 76.2 years. Diagnoses included lung cancer (83), pulmonary metastases (4), and benign disease (1). Dense adhesions between the lung and the mediastinum sometimes occur after cardiac surgery. Compared with the total series of 2684 VATS lobectomies, operations after sternotomy are associated with greater mortality (12, 0.4% vs 5, 5.7%), myocardial infarction (13, 0.5% vs 2, 2.3%), transfusion (45, 1.7% vs 12, 13.6), conversion to thoracotomy (188, 7% vs 14, 15.9%). Injury occurred to the left main pulmonary artery (1, 1%) and internal mammary artery graft (1, 1%). There were no intraoperative deaths. Previous sternotomy for cardiac surgery does increase the risk for VATS lobectomy. Conversion to thoracotomy should be considered if dense adhesions are found. Techniques to reduce the risk for the heart are discussed.

Successful conservative repair of the traumatic left main pulmonary artery pseudoaneurysm.

Successful conservative repair of the traumatic left main pulmonary artery pseudoaneurysm.

PUB113 Organs at Risk Contouring in Lung Cancer Radiation Therapy: An Anatomo-Radiological Atlas

The accuracy of organ at risks (OARs) delineation may impact on dosimetric parameters and influence the treatment planning. In thoracic radiation therapy, the normal tissues are often dose limiting. Aim of this study are to provide anatomical boundaries for the correct identification and contouring of OARs in thoracic district. A dedicated thoracic Radiologist, a Neuro-radiologist and three Radiation Oncologists were gathered to generate a 3D radiologic description of the thoracic OARs on axial CT scans. This interdisciplinary team provides anatomical boundaries detectable on planning-CT for each thoracic OAR (“Delineating Organs at risk in Radiation Therapy,” Ausili Cefaro G. et al. 2012). Three-dimensional descriptions of lung, esophagus, proximal bronchial tree, spinal cord, heart and brachial plexus were performed. A CT atlas was developed with definition of cranial, caudal, anterior, posterior, medial and lateral limit for each OARs (table 1).Tabled 1OARsCranialCaudalLateralMedialAnteriorPosteriorProximal Bronchial Tree2 cm above carenaLine through inferior pulmonaryAortic arch. Left: left main pulmonary artery, descending aorta, lung parenchyma. Right: lung parenchyma, azygos arch./Aortic arch, ascending aorta, righ e left main pulmonary artery, left atrium.Esophagus, azygos vein. Left: descending aorta, pulmonary vein. Right: lung parenchyma.LungLine through posterior arch of the first ribDiaphragmChest wallLarge mediastinal vessels. Cardiac chambers.Chest wallChest wallHeartLine through inferior edge of left main pulmonary arteryLine through superior edge of the left hepatic lobeMediastinal pleura. Lung parenchyma./Adipose tissue of the anterior mediastinum.Esophagus. Descending aorta.EsophagusLine through inferior edge of the cricoid.Esophago-gastric junction.Spinal CordLine through inferior edge of the cricoid.Esophago-gastric junction.Vertebral canal.Vertebral canalBrachial PlexusNeuronal foramen C4-C5.First half of clavicular head.Subclavian and neurovascular bundel. Clavicle. Open table in a new tab The contouring atlas for thoracic OARs represents a considerable tool in our clinical practice. We believe that the development of interdisciplinary atlas is a formative tool to optimize both 3D-CRT and IMRT-VMAT planning.

Endovascular Stent Graft Placement in the Left Main Pulmonary Artery for Management of a Giant Pulmonary Artery Pseudoaneurysm

Endovascular Stent Graft Placement in the Left Main Pulmonary Artery for Management of a Giant Pulmonary Artery Pseudoaneurysm

Catheter ablation for atrial fibrillation in a patient with unilateral left pulmonary artery agenesis: an enlarged right pulmonary vein caused arrhythmogenicity of atrial fibrillation

A 55-year-old male with persistent atrial fibrillation (AF) was admitted to our hospital for catheter ablation (CA). Enhanced computerized tomography before CA demonstrated a left shrunken lung and absence of the left main pulmonary artery ( Panel A ). Collateral flow via the coronary and bronchial …

Visualization of bronchial circulation at bronchial anastomotic site using bronchial fluorescein angiography technique.

Successful bronchial healing after a bronchoplastic procedure mainly depends on bronchial circulation at the anastomostic site. We developed a bronchial fluorescein angiography (B-FAG) technique for visualizing circulation on the bronchial surface. The technique was evaluated in animals. Fluorescein was used as a contrast agent and an autofluorescence imaging (AFI) bronchoscope as a detector. The left main pulmonary artery (PA) and main bronchus of 10 pigs were isolated. After transection of the left main bronchus and bronchial arteries and re-anastomosis of the bronchus, the pigs were randomly divided into two groups: the PA- group (n = 5), in which the pulmonary artery was transected; and the PA+ group (n = 5), in which the pulmonary artery was preserved. Following intravenous injection of fluorescein, the distal anastomotic site was observed for 30 min with autofluorescence imaging bronchoscopy. Bronchial specimens sampled 2 days after the surgical intervention were histologically evaluated. In the PA- group, there was no fluorescein enhancement in the distal bronchus throughout the observation time. However, enhancement, which turned the bronchial surface from magenta to bright green, was clearly observed in less than 207 ± 102.5 s in the PA+ group. The enhancement status detected by bronchial fluorescein angiography was related to the extent of tissue damage, as was proven histologically in the acute healing stage. Bronchial fluorescein angiography clearly visualized the circulatory status promptly after the anastomosis procedure at the central bronchus. This technique is a potentially practical approach to predict ischaemic airway complications following bronchial anastomosis.

Invasive pericardial hydatid cyst: Excision of multiple huge cysts

Cardiac hydatid cyst is rare even in endemic countries, and poses a therapeutic challenge due to varying presentation and unpredictable pre-, peri-, and postoperative complications. We herein present a case of multiple, multifocal, huge pericardial hydatid cyst, with invasion into the left ventricle and main pulmonary artery in a young male patient, presented with atypical chest pain.

Precontrol of the pulmonary artery during thoracoscopic left upper lobectomy and systemic lymph node dissection.

The main reasons of emergent conversion during thoracoscopic lobectomy included tumor invasion, hilar lymph node (LN) metastasis, and lymphoid tuberculosis. We presented a video which depicted a three-portal thoracoscopic left upper lobectomy with dissection of large LNs. Severe adhesions between a large LN and the first branch of the left pulmonary artery (PA) were found during surgery. For safety reasons, the left main pulmonary artery (LMPA) was clamped with an endoscopic bulldog clamp prior to lymph nodal dissection. The strategy of precontrolling the LMPA during thoracoscopic lobectomy is useful for these patients with complicated hilum, and may assure the safety of the operation.

A rare intravascular tumour diagnosed by endobronchial ultrasound

A 24-year-old man was referred to the haematologists for investigation of unexplained anaemia on the background of a 6-month history of exertional breathlessness, mild cough and night sweats. Investigations revealed...

CT-defined phenotype of pulmonary artery stenoses in Alagille syndrome.

Alagille syndrome is a rare disorder commonly associated with pulmonary artery stenosis. Studies exist discussing the cardiovascular sequela but no consistent phenotype, or pattern of pulmonary artery stenosis, has been described. The objective of this study was to characterize the distribution and severity of pulmonary artery stenosis in patients with Alagille syndrome based on computed tomography angiography. A retrospective chart review identified patients with Alagille syndrome who had undergone CT angiography. Pulmonary trunk (MPA), left main pulmonary artery (LPA) and right main pulmonary artery (RPA) diameters in Alagille patients were compared with those from matched control subjects. Stenoses at lobar and segmental pulmonary arteries were categorized as: Grade 1 (<33% stenosis), Grade 2 (33-66% stenosis) or Grade 3 (>66% stenosis). Involvement among the different lung regions was then compared. Fifteen patients ages 6months to 17years were identified; one had surgical augmentation of the central pulmonary arteries and was excluded from the central (main, right and left) pulmonary artery analysis. The proximal LPA and RPA, but not the MPA, were significantly smaller than those of the control subjects (P<0.01). The proximal LPA was significantly smaller than the proximal RPA (P<0.01) in the Alagille group (0.55 LPA:RPA ratio). Within the Alagille group, 75% of the lobar and segmental branches showed mild or no stenoses (Grade 1), 17% showed moderate stenosis (Grade 2) and 8% showed severe stenosis (Grade 3). While not statistically significant, the right lung demonstrated a greater percentage of Grades 2 and 3 stenoses (28%, right vs. 20% left, P=0.1). The right middle and lingula lobes of both lungs showed more Grade 2 and 3 stenoses (33% upper/middle vs. 18% lower, P<0.01). We describe a common pattern pulmonary artery stenosis in Alagille patients consisting of severe proximal LPA stenosis, heavy involvement of the lobar and segmental branches (more often right than left), and a greater involvement of the upper lobes. Knowledge of this phenotypic pattern can help in the diagnosis of Alagille syndrome in patients presenting with pulmonary artery stenosis.

Pulmonary 64-MDCT angiography with 50 mL of iodinated contrast material in an unselected patient population: a feasible protocol.

ObjectiveTo propose a protocol for pulmonary angiography using 64-slice multidetector computed tomography (64-MDCT) with 50 mL of iodinated contrast material, in an unselected patient population, as well as to evaluate vascular enhancement and image quality.Materials and MethodsWe evaluated 29 patients (22-86 years of age). The body mass index ranged from 19.0 kg/m2 to 41.8 kg/m2. Patients underwent pulmonary CT angiography in a 64-MDCT scanner, receiving 50 mL of iodinated contrast material via venous access at a rate of 4.5 mL/s. Bolus tracking was applied in the superior vena cava. Two experienced radiologists assessed image quality and vascular enhancement.ResultsThe mean density was 382 Hounsfield units (HU) for the pulmonary trunk; 379 and 377 HU for the right and left main pulmonary arteries, respectively; and 346 and 364 HU for the right and left inferior pulmonary arteries, respectively. In all patients, subsegmental arteries were analyzed. There were streak artifacts from contrast material in the superior vena cava in all patients. However, those artifacts did not impair the image analysis.ConclusionOur findings suggest that pulmonary angiography using 64-MDCT with 50 mL of iodinated contrast can produce high quality images in unselected patient populations.

Arterial input function placement effect on computed tomography lung perfusion maps.

A critical source of variability in dynamic perfusion computed tomography (DPCT) is the arterial input function (AIF). However, the impact of the AIF location in lung DPCT has not been investigated yet. The purpose of this study is to determine whether the location of the AIF within the central pulmonary arteries influences the accuracy of lung DPCT maps. A total of 54 lung DPCT scans were performed in three pigs using different rates and volumes of iodinated contrast media. Pulmonary blood flow (PBF) perfusion maps were generated using first-pass kinetics in three different AIF locations: the main pulmonary trunk (PT), the right main (RM) and the left main (LM) pulmonary arteries. A total of 162 time density curves (TDCs) and corresponding PBF perfusion maps were generated. Linear regression and Spearman's rank correlation coefficient were used to compare the TDCs. PBF perfusion maps were compared quantitatively by taking twenty six regions of interest throughout the lung parenchyma. Analysis of variance (ANOVA) was used to compare the mean PBF values among the three AIF locations. Two chest radiologists performed qualitative assessment of the perfusion maps using a 3-point scale to determine regions of perfusion mismatch. The linear regression of the TDCs from the RM and LM compared to the PT had a median (range) of 1.01 (0.98-1.03). The Spearman rank correlation between the TDCs was 0.88 (P<0.05). ANOVA analysis of the perfusion maps demonstrated no statistical difference (P>0.05). Qualitative comparison of the perfusion maps resulted in scores of 1 and 2, demonstrating either identical or comparable maps with no significant difference in perfusion defects between the different AIF locations. Accurate PBF perfusion maps can be generated with the AIF located either at the PT, RM or LM pulmonary arteries.

Diagnostic Evaluation of Pulmonary Embolism: A Computerized Tomography Based Study

Pulmonary embolism (PE) is potentially life threatening condition which requires adequate diagnosis. Since computerized tomography pulmonary angiography (CTPA) described the presence of a clot subjectively, an objective and quantification method to characterize plural parenchymal abnormality, pulmonary vessels and heart is needed (in order to diagnose PE). This study was directed to investigate whether the presence of plural parenchymal findings correlates with the PE and as well, it was designed to answer two basic questions based on CTPA findings done for clinical suspicion of PE: firstly, what are the plural parenchymal abnormalities associated with PE; secondly, correlation of PE with the presence of heart changes and pulmonary vessels measurements. CTPA scans were acquired for 55 patients suspected of having PE and another 50 subjects who were considered as control. The clinical signs and pleuroparenchymal abnormalities, pulmonary artery tree measurements, right ventricle and atrium diameters, Inter ventricular septum width as well as the myocardium thickening were characterized and correlated with PE. The results showed that the PE patients group has more dilated measurements than the normal control subjects. The right ventricle diameter changes were found to be significantly related to the presence of PE at p ≤ 0.001. Significant changes at p ≤ 0.005 were also noticed in the pulmonary trunk diameter as well as the right and left main pulmonary arteries with no significant changes detected in the distal portion of both pulmonary arteries diameters. The common complaints from PE patients were chest pain, shortness of breathing, lower limb swelling, tachycardia and syncope. Consolidation, ground glass opacifications, mosaic, right ventricle morphological changes and pleural effusion were present in the majority of patients undergoing CTPA for the clinical suspicion of PE. CTPA is considered as the diagnostic modality of choice in characterization of pulmonary vessels, atrium and ventricle changes as well as pleura parenchymal abnormalities in patients with or without PE.

Uniportal complete video-assisted thoracoscopic surgery lobectomy with partial pulmonary arterioplasty for lung cancer with calcified lymph node.

Now, more and more complete video-assisted thoracoscopic surgery (cVATS) surgeons are capable of performing lobectomy by uniportal approach. However, concerns regarding the safety of uniportal procedures for complex cases such as neoadjuvant chemotherapy, bronchial sleeves or vascular reconstructions still remains. As experience with uniportal VATS has increased, its application toward more technically demanding operations has also expanded. This article describes a uniportal cVATS left upper lobectomy with partial pulmonary arterioplasty for lung cancer with calcified lymph nodes. In order to reduce the risk of bleeding, we looped the left main pulmonary artery and applied two-stage maneuvering for left upper lobe (LUL) bronchus, cut the bronchus at the distal end and close the stump using a stapler at the end, which are conducive to maximal safety.

Successful pneumonectomia of a patient with squamous cell carcinoma of lung operated by median sternotomy and anterior approach due to suspicion of left main pulmonary artery invasion and possible need for cardiopulmonary bypass

Peripheral invasion of cancers may require multidisciplinary approach for increasing safety and efficacy of curative surgical interventions.

Pleuropneumonectomy for a large thymoma with multiple pleural dissemination using median sternotomy followed by posterolateral thoracotomy.

We present 2 cases of a large thymoma with invasion to the hilum of the lung and pleural dissemination. Case 1: a 47-year-old woman was diagnosed with a type B3 thymoma with abundant left pleural effusion and multiple pleural masses, Masaoka stage IVa. A radical resection was planned after chemical pleurodesis and systemic chemotherapy. The left main pulmonary artery and left upper and inferior veins were dissected and resected in the pericardium, while the left main bronchus was cut behind the pericardium through a median sternotomy. Next, the median incision was closed and a left posterolateral thoracotomy was made, thus allowing the pleuropneumonectomy to be safely performed. Case 2: a 47-year-old woman was diagnosed with a type B3 thymoma with lymph node swelling and multiple pleural masses, indicating Masaoka stage IVb. Following induction chemotherapy, a thymothymectomy combined with a right pleuropneumonectomy was performed under a median sternotomy followed by a right posterolateral thoracotomy. The left brachiocephalic vein (BCV) was reconstructed with a ringed polytetrafluoroethylene (PTFE) graft, followed by resection of the right BCV. Next, the right main pulmonary artery and right upper and inferior veins were resected in the pericardium, and the right main bronchus was cut behind the pericardium, followed by reconstruction of the right BCV. Finally, the median incision was closed and a right posterolateral thoracotomy was made, thus allowing performance of a safe pleuropneumonectomy. The median sternotomy allowed safe dissection of pulmonary vessels surrounding the hilum of the lung and, in combination with a posterolateral thoracotomy, was required for performing a pleuropneumonectomy in patients with a huge thymoma with pleural dissemination.Electronic supplementary materialThe online version of this article (doi:10.1186/s40792-015-0071-z) contains supplementary material, which is available to authorized users.

Pulmonary fixation sleeve embolism and its acute management

A 65-year-old male with ischemic cardiomyopathy underwent primary prophylaxis implantable cardioverter-defibrillator (ICD) implantation. During lead manipulations for appropriate implantation site in the right ventricle using a passive lead inadvertent migration of the fixation sleeve on the lead to subclavian vein occurred. In a few seconds the sleeve embolized to the left pulmonary arterial tree (Fig. 1A). Acute percutaneous retrieval was considered to eliminate potential risks of infection and thrombosis. Through the right femoral vein access a 8.5 French steerable introducer (AgilisTM, St. Jude Medical, Inc., MN, USA) was advanced to the left main pulmonary artery, and then a 6 French diagnostic catheter (AlvisionTM Multi-Purpose A, Alvimedica, Inc., IST, Turkey) used for right heart catheterization procedureswas advanced through the steerable catheter more distally next to embolized fixation sleeve. A 15 mm loop diameter snare catheter (AndraSnare, Andramed GmbH, Germany) was introduced through the diagnostic catheter, and then the sleeve was caught (Fig. 1B) and retrieved by removal of the entire systemwithout any complications (Fig. 1C–F). Lastly an ICD generator with an active fixation lead was implanted (Movie). Transvenous retrieval of embolized pacemaker/ICD system fragments using various endovascular tools has been successfully performed at both acute and chronic periods [1–3]. Due to inherent risks of infection and thrombosis related to embolized foreign objects such as fixation sleeve, lead fragments, peel-away sheath fragments the retrieval procedure should be attempted.