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J Thorac Cardiovasc Surg 2007;134:535-536
© 2007 The American Association for Thoracic Surgery
Brief Communication |
Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo.
Received for publication March 20, 2007; accepted for publication April 12, 2007. * Reprint requests: Traves D. Crabtree, MD, Division of Cardiothoracic Surgery, Washington University School of Medicine, 3108 Queeny Tower, One Barnes-Jewish Hospital Plaza, Saint Louis, MO 63110-1013. (Email: crabtreet{at}wudosis.wustl.edu).
A 43-year-old woman, with no prior history of significant medical disease, presented with persistent vague chest discomfort and cough. A chest x-ray film showed a calcified mass in the left lower lobe, compatible with old granulomatous disease (Figure 1, A). However, a subsequent computed tomographic (CT) scan of the chest revealed a low-density lesion within the left lower lobe (Figure E1) with no evidence of surrounding parenchymal consolidation. A large feeding vessel, 2.5 cm in diameter, with a diffusely calcified wall was noted to arise from the lower thoracic aorta (Figure 1, B). Its course was better delineated on sagittal images and with a 3-dimensional reconstruction of a CT angiogram (Figures E2 and 2, A).
The lower lobe mass had venous drainage to the left atrium. This anatomic relationship was compatible with an intralobar pulmonary sequestration. The patient underwent a left thoracotomy. There was no surgical plane between the mass and the surrounding left lower lobe. The diagnosis of intralobar sequestration was confirmed by the intralobar position of the mass, a systemic arterial feeding vessel, and normal pulmonary venous drainage. After suture closure of the large feeding vessel (Figure 2, B), a standard resection of the left lower lobe containing the sequestration completed the procedure. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day.
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Pulmonary sequestration is a congenital abnormality characterized by a bronchopulmonary segment with an anomalous systemic arterial blood supply. There are two variants: intralobar and extralobar. The former is a lung segment contained within the normal visceral pleura and pulmonary parenchyma. In extralobar sequestration, the bronchopulmonary tissue is outside the visceral pleura and may be contained in its own pleural envelope.
Intralobar sequestration is most frequently diagnosed in the pediatric population and shows equal gender prevalence. It is rarely found in patients aged above 40 years.1,2 In the adult population, this lesion must be distinguished from the far more common neoplastic lesions, especially bronchogenic carcinoma. Up to 15% of patients, particularly in the adult population, do not have symptoms when the sequestration is discovered.3 Presentation varies from the incidental finding of a mass in an asymptomatic patient to symptoms of recurrent bronchitis or pneumonia. The diagnosis is usually obtained by CT scan, and the anatomy may be better defined using CT angiography or magnetic resonance angiography.
The pathogenesis of sequestration is the result of an accessory lung bud that develops from the ventral primitive foregut as it migrates caudally and receives systemic arterial supply instead of the normal pulmonary arterial supply. Some authors maintain that intralobar sequestration in older adults represents an acquired lesion related to bronchial obstruction, pneumonia, pulmonary artery occlusion, pleuritis, pulmonary ligament thickening, and parasitization of pulmonary ligament arteries.4
In approximately 95% of cases, the location is in the medial or posterior basal segments of the left lower lobe. Typically, there is no communication between the tracheobronchial tree and the sequestered lung. However, cases have been described in which there is a fistulous connection between the native tracheobronchial tree and the sequestered lung segment.
The systemic arterial supply derives predominantly from the descending thoracic aorta and less frequently from the abdominal aorta. Other derivations have been reported, including superior mesenteric artery and coronary circulation. Venous outflow is predominantly through the pulmonary venous system.
Resection by lobectomy (for intralobar) or sequestrectomy (for extralobar) should be performed at the time of diagnosis. These procedures can be conducted by open or video-assisted technique.5 Delaying surgery until infection or symptoms or signs of consolidation develop increases the morbidity of the operation. Preoperative delineation of the anomalous vasculature is fundamental in that it minimizes fatal outcomes from hemorrhage caused by accidental division of the systemic artery.
References
This article has been cited by other articles:
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  P. Berna, A. Cazes, P. Bagan, and M. Riquet Intralobar sequestration in adult patients Interact CardioVasc Thorac Surg, June 1, 2011; 12(6): 970 - 972. [Abstract] [Full Text] [PDF]
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 M. Ragusa, J. Vannucci, M. Lenti, E. Cieri, P. Cao, and F. Puma Pulmonary Sequestration Supplied by Giant Aneurysmal Aortic Branch Ann. Thorac. Surg., February 1, 2010; 89(2): e7 - e8. [Abstract] [Full Text] [PDF]
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 D. Fabre, A. Rohnean, E. Fadel, and P. G. Dartevelle Giant aneurysmal dilation of an intralobar pulmonary sequestration artery Eur J Cardiothorac Surg, August 1, 2009; 36(2): 413 - 414. [Abstract] [Full Text] [PDF]
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