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J Thorac Cardiovasc Surg 2007;133:1384-1385
© 2007 The American Association for Thoracic Surgery

Brief Communication

Necessary resection of the left lower lobe due to systemic arterial supply

^a Department of General Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
^b Department of Pulmonology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.

Received for publication December 16, 2006; accepted for publication January 8, 2007.

^_* Address for reprints: Rogier Jaspers, MD, Department of Surgery, Canisius Wilhelmina Ziekenhuis, Weg dour Jonkerbosch 100, Nijmegen, Gelderland, 6532 SZ, The Netherlands. (Email: rogier.jaspers{at}gmail.com).

Symptomatic lung sequesters are usually treated with resection.¹ Most often the aberrant arterial supply is ligated or reimplanted onto the pulmonary artery. Baek and colleagues² recently described a patient with anomalous arterial supply of a left basal segment of the lung in which mere ligation of the anomalous artery produced a satisfactory result.² We present a similar case in which resection had to be performed despite our initial goal to preserve the entire lung.

Clinical Summary

A 34-year-old man was referred with recurrent episodes of hemoptysis. Chest radiography showed enhanced vascularization in the lower left quadrant. Computed tomographic scan revealed a solid lesion in the posterobasal segment of the left lower lobe with an anomalous artery originating from the descending aorta (Figure 1). An aortogram confirmed the presence of a single accessory artery from the descending aorta and normal venous drainage to the left atrium. There was a matched defect in the ventilation-perfusion scan of the lung.

View larger version (87K): [in this window] [in a new window]   Figure 1. Computed tomographic scan reconstruction showing the normal pulmonary artery and solitary accessorial anomalous artery arising from the descending aorta.

Initially the patient recovered well from the operation, but fever developed on postoperative day 5. Chest radiography showed an infiltrate in the left lower lobe. Antibiotics were started for the presumed diagnosis of postoperative pneumonia. The patient recovered and was discharged without symptoms on postoperative day 8. Two weeks after discharge the patient was readmitted with fever, the same dense infiltrate on chest radiography, and left-sided pleural effusion. Computed tomographic scan confirmed pleural effusion and showed a collapsed left lower lobe with vital lung tissue ventrally and hypodense tissue dorsally and caudally, indicative of necrosis. A rethoracotomy was performed, and the left lower lobe was resected in a standard manner. After the second operation, the patient recovered without episodes of fever and was discharged uneventfully on postoperative day 10.

Histologic examination of the resected left lower lobe showed hemorrhagic infarction with substantial necrosis and an abnormal connection of the affected lung tissue with the tracheobronchial tree, consistent with an intralobar sequester.

Discussion

Although normal pulmonary vascular supply was seen during the first operation, the affected left lower lobe became necrotic after ligation of the anomalous artery from the descending aorta. As stated by Baek and colleagues,² it is difficult to diagnose the presence of a normal pulmonary artery in the diseased segments of the lung, probably because of flow from the anomalous artery. Even during operation, visualization of the pulmonary arterial supply to the affected lung segment and unchanged shape, color, or arterial oxygenation after ligation of the anomalous artery do not guarantee vital lung tissue after operation. In this case the preoperatively matched defect in the ventilation-perfusion scan and angiographically confirmed venous drainage in the left atrium were highly suggestive of an intralobar lung sequester, as was confirmed with histologic examination of the resected left lower lobe. In retrospect, the benefit of preserving a small diseased segment of the lung seemed minor compared with the risk of infection and reoperation in case of necrosis. Therefore, we believe that resection of the affected lung segment remains the safest treatment option for symptomatic intralobar lung sequester.

References

1. Yamanaka A, Hirai T, Fujimoto T, Hase M, Noguchi M, Konishi F. Anomalous systemic arterial supply to normal basal segments of the left lower lobe. Ann Thorac Surg 1999;68:332-338.[Abstract/Free Full Text]
   
2. Baek WK, Cho J, Kim JT, Yoon YH, Kim KH, Lim HK, et al. Systemic arterial supply to normal basal segments of the left lower lobe along with the pulmonary artery: is lung resection warranted?. J Thorac Cardiovasc Surg 2006;131:742-743.[Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Jaspers, R. Articles by Visser, F. Search for Related Content PubMed PubMed Citation Articles by Jaspers, R. Articles by Visser, F. Related Collections Lung - other