Clinical Image
Transpleural Systemic Artery to Pulmonary Artery Fistulas: Doppler Ultrasound Findings
Luis Gorospe
, Miguel Ángel Gómez-Bermejo, Ana Palomera-Rico
Corresponding author
Department of Radiology, Ramón y Cajal University Hospital, Madrid, Spain
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Axial CT contrast-enhanced image (C) demonstrated slight enhancement of the swollen lymph nodes. At six-month follow-up, chest CT (D and E) showed the shrinkage of lymph nodes and the relief of main bronchus compression. H&E staining (F) demonstrated numerous spherical yeast cells of variable size surrounded by a clear halo (400×), suggesting the diagnosis of cryptococcosis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jia He, Xian-Zheng Tan, Peng Liu" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jia" "apellidos" => "He" ] 1 => array:2 [ "nombre" => "Xian-Zheng" "apellidos" => "Tan" ] 2 => array:2 [ "nombre" => "Peng" "apellidos" => "Liu" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623003629?idApp=UINPBA00003Z" "url" => "/03002896/0000006000000001/v3_202406051404/S0300289623003629/v3_202406051404/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0300289623003186" "issn" => "03002896" "doi" => "10.1016/j.arbres.2023.10.003" "estado" => "S300" "fechaPublicacion" => "2024-01-01" "aid" => "3418" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Arch Bronconeumol. 2024;60:50-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Primary Tracheal Adenoid Cystic Carcinoma: Therapeutic Challenges Posed by Unresectable" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "50" "paginaFinal" => "52" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2827 "Ancho" => 1874 "Tamanyo" => 575417 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A and B) A huge pedunculated round mass in the inferior third of the trachea (20/3/2015). (C and D) Right lung tumor before and after receiving argon-helium cryoablation targeted therapy (30/10/2020; 4/11/2020). (E and F) Esophageal stenosis, and then esophageal covered metal mesh stent (MTN-SE-S-20/100-A-8/650) implantation under DSA (5/1/2021; 6/1/2021). (G and H) Tracheal space occupying, esophageal space occupying after esophageal covered metal mesh stent implantation (7/6/2023). (I and J) Rigid bronchoscopy combined with flexible bronchoscopy to remove the new organisms in the esophagus and then move the esophageal covered metal mesh stent up 1<span class="elsevierStyleHsp" style=""></span>cm(7/6/2023). (K and L) Rigid bronchoscopy combined with flexible bronchoscopy to remove tracheal new organisms and then Y-shaped covered metal mesh stent (size: 16<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>mm trachea/12<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>mm left principal bronchus/15<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>mm right principal bronchus) was implanted (7/6/2023; 9/6/2023). (M) Chest CT was used to evaluate the placement of double stents (10/6/2023). (N) Digestive-respiratory tract fistulas (8/7/2023).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jun Teng, Heng Zou, Hongwu Wang" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jun" "apellidos" => "Teng" ] 1 => array:2 [ "nombre" => "Heng" "apellidos" => "Zou" ] 2 => array:2 [ "nombre" => "Hongwu" "apellidos" => "Wang" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623003186?idApp=UINPBA00003Z" "url" => "/03002896/0000006000000001/v3_202406051404/S0300289623003186/v3_202406051404/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical Image</span>" "titulo" => "Transpleural Systemic Artery to Pulmonary Artery Fistulas: Doppler Ultrasound Findings" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "53" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Luis Gorospe, Miguel Ángel Gómez-Bermejo, Ana Palomera-Rico" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Luis" "apellidos" => "Gorospe" "email" => array:1 [ 0 => "luisgorospe@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Miguel Ángel" "apellidos" => "Gómez-Bermejo" ] 2 => array:2 [ "nombre" => "Ana" "apellidos" => "Palomera-Rico" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Radiology, Ramón y Cajal University Hospital, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 821 "Ancho" => 1136 "Tamanyo" => 179705 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Doppler ultrasound of the right thoracic wall identifies prominent right-sided intercostal arteries showing spectral broadening (increased peak systolic velocity [134 cm/s] and decreased resistance index [0.53]), suggesting an arterial fistula with an increased and turbulent blood flow. (B) Doppler ultrasound of the left thoracic wall shows a normal doppler waveform of the intercostal arteries (low peak systolic velocity [27 cm/s] and high resistance index [0.84]). (C) Coronal thoracic maximum intensity projection (MIP) CT image shows hypertrophy of the right superior intercostal arteries (arrows) compared to the left hemithorax. (D) Coronal thoracic MIP CT image shows an unexpected early and prominent contrast enhancement of the right upper lobe vessels (asterisks) due to retrograde filling through the hypertrophied intercostal arteries. (E) Volumetric reconstruction CT image shows the hypertrophy of the posterior right intercostal arteries. (F) Digital subtraction angiogram shows the right intercostal arteries embolization procedure using polyvinyl alcohol particles (300–500 μm in size).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 69-year-old lung cancer survivor (the patient was treated 6 years earlier with chemoradiation therapy) who presented to our hospital with hemoptysis. Chest radiograph showed a right upper lobe atelectasis. A thoracic ultrasound was first performed and identified right-sided prominent intercostal arteries with a low resistance spectral waveform on Doppler interrogation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1A,B</a>), suggesting the presence of transpleural systemic artery to pulmonary artery fistulas (TPSAPAFs). These TPSAPAFs were later confirmed on CT as the cause for the hemoptysis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1C–E</a>), and the patient underwent a successful embolization of several non-bronchial systemic arteries (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1F</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">TPSAPAFs are abnormal anastomoses between systemic arteries and peripheral pulmonary arteries and can be congenital or, more frequently, acquired. Acquired TPSAPAFs may occur due to long-standing inflammation/infection, trauma, surgery, and cancer. In these conditions, TPSAPAFs mostly occur between systemic nonbronchial arteries (intercostal, internal mammary, costocervical trunk, and inferior phrenic arteries) and peripheral branches of the pulmonary artery.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">1,2</span></a> In our patient, chronic radiation changes in the lung most likely facilitated the hypertrophy and recruitment of systemic nonbronchial arteries. To our knowledge, Doppler ultrasound findings of TPSAPAFs have not been previously described. Understanding the pathophysiology, complex anatomy, and treatment for these rare vascular anastomoses is crucial prior to angiographic intervention in order to improve outcomes, avoid misdiagnosis, and prevent inappropriate intervention.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">This study received no funding.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 821 "Ancho" => 1136 "Tamanyo" => 179705 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Doppler ultrasound of the right thoracic wall identifies prominent right-sided intercostal arteries showing spectral broadening (increased peak systolic velocity [134 cm/s] and decreased resistance index [0.53]), suggesting an arterial fistula with an increased and turbulent blood flow. (B) Doppler ultrasound of the left thoracic wall shows a normal doppler waveform of the intercostal arteries (low peak systolic velocity [27 cm/s] and high resistance index [0.84]). (C) Coronal thoracic maximum intensity projection (MIP) CT image shows hypertrophy of the right superior intercostal arteries (arrows) compared to the left hemithorax. (D) Coronal thoracic MIP CT image shows an unexpected early and prominent contrast enhancement of the right upper lobe vessels (asterisks) due to retrograde filling through the hypertrophied intercostal arteries. (E) Volumetric reconstruction CT image shows the hypertrophy of the posterior right intercostal arteries. (F) Digital subtraction angiogram shows the right intercostal arteries embolization procedure using polyvinyl alcohol particles (300–500 μm in size).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:2 [ 0 => array:3 [ "identificador" => "bib0015" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Computed tomography angiography for presence of systemic-to-pulmonary artery shunt in transpleural systemic arterial supply" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Y.F. Zhang" 1 => "Q. Zhao" 2 => "R. Huang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejrad.2020.109060" "Revista" => array:5 [ "tituloSerie" => "Eur J Radiol" "fecha" => "2020" "volumen" => "129" "paginaInicial" => "109060" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32446128" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0020" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "CT for evaluation of hemoptysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.M. Marquis" 1 => "C.A. Raptis" 2 => "M.Z. Rajput" 3 => "K.L. Steinbrecher" 4 => "T.S. Henry" 5 => "S.E. Rossi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/rg.2021200150" "Revista" => array:6 [ "tituloSerie" => "Radiographics" "fecha" => "2021" "volumen" => "41" "paginaInicial" => "742" "paginaFinal" => "761" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33939537" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000006000000001/v3_202406051404/S0300289623003575/v3_202406051404/en/main.assets" "Apartado" => array:4 [ "identificador" => "94561" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Clinical Images" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000006000000001/v3_202406051404/S0300289623003575/v3_202406051404/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623003575?idApp=UINPBA00003Z" ]
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