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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Axial abdominal CT image showing a mass in the anterior mediastinum &#40;asterisk&#41;&#46; Note the presence of inflammatory changes in the right costophrenic sinus &#40;arrow&#41;&#46; &#40;B&#41; Maximum intensity projection &#40;MIP&#41; coronal reconstruction of the CT angiogram of the chest and upper abdomen showing a communication between a hypertrophic right inferior phrenic artery &#40;black arrow&#41; and a subsegmental pulmonary artery in the right lower lobe &#40;white arrow&#41;&#46; &#40;C&#41; Volume rendering of CT angiogram of the systemic-pulmonary fistula &#40;short arrows indicate right inferior phrenic artery&#44; while long arrows indicate the pulmonary artery&#41;&#46; &#40;D&#41; Angiogram showing retrograde filling of pulmonary arteries &#40;long arrows&#41; from a tortuous&#44; hypertrophic right inferior phrenic artery &#40;short arrows&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Anastomosis between the systemic and pulmonary circulation can be congenital or acquired&#46; Approximately 15&#37; of systemic-pulmonary fistulas &#40;SPF&#41; are congenital&#44; and associated with heart disease or hypoplasia of the pulmonary artery&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Acquired SPF&#44; the most common kind&#44; may be due to inflammation&#44; infection&#44; trauma&#44; surgery&#44; or cancer&#44; among others&#46; SPF mostly occur between a bronchial artery and subsegmental branches of the pulmonary artery&#46; Exceptionally&#44; arterio-arterial anastomosis can occur between abdominal systemic arteries &#40;hepatic artery or inferior phrenic artery&#41; and pulmonary arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> We report the case of SPF between an abdominal systemic artery &#40;right inferior phrenic artery&#41; and a pulmonary artery as a late complication of a biliary surgery&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a 79-year-old man who consulted due to repeated&#44; self-limiting episodes of hemoptysis&#46; Significant history included laparoscopic cholecystectomy compounded with a right subphrenic abscess &#40;resolved with drainage and antibiotics&#41; 2 years previously &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Hemoptysis originating in the upper airway and digestive tract was ruled out by fiberoptic bronchoscopy and gastrointestinal endoscopy&#44; but in a computed tomography &#40;CT&#41; scan of the chest with contrast medium&#44; an opacity was identified in the right postero-basal segment in contact with the diaphragmatic surface that was surrounded by characteristically tortuous vessels&#46; Given these findings&#44; suggestive of a vascular malformation&#44; we decided to perform an CT angiogram of the chest&#44; which confirmed the existence of an SPF between a hypertrophic right inferior phrenic artery and a subsegmental branch of the pulmonary artery of the right lower lobe &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B and <span class="elsevierStyleSmallCaps">C</span>&#41;&#46; This SPF was treated by selective embolization with Onyx<span class="elsevierStyleSup">&#174;</span> &#40;an ethylene vinyl alcohol copolymer&#41; of the systemic feeding artery of the right inferior phrenic artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; There have been no subsequent complications nor have any new episodes of hemoptysis occurred to date&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">SPF are abnormal anastomosis between systemic arteries and pulmonary vessels&#59; they may be congenital or&#44; more frequently&#44; acquired&#46; The latter usually occur in the presence of pleural adhesions as a result of various long-standing inflammatory processes of the chest&#44; such as bronchiectasis &#40;particularly in patients with cystic fibrosis&#41;&#44; tuberculosis&#44; or chronic empyema&#46; These processes are often associated with pleural fibrosis and the resulting decrease in pulmonary blood flow&#44; which cause hypertrophy of the systemic arteries&#46; Although several cases of SPF due to surgical interventions have been described &#40;aortocoronary bypass surgery&#44; thoracotomies&#44; and video-assisted thoracoscopic surgery&#41;&#44; very few cases have been reported in association with abdominal surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1&#44;3</span></a> In most cases&#44; SPF are asymptomatic&#44; although one of the most common presenting symptoms is hemoptysis&#46; Other less common symptoms have been described&#44; such as dyspnea or chronic chest pain&#44; and complicated cases with pulmonary hypertension or endocarditis have also been documented&#46; This disease can be diagnosed with CT angiogram or arteriography&#44; and several treatment options are available&#58; surgery&#44; endovascular treatment &#40;embolization&#41;&#44; or observation&#46; In patients like ours&#44; with repeated episodes of moderate hemoptysis&#44; embolization is often the first-choice treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; the SPF secondary to biliary surgery are exceptional&#46; For this reason&#44; when a fistula in an inferior phrenic artery is observed in a patient with hemoptysis&#44; the index of suspicion should be high&#44; and the patient&#39;s history and previous tests should be reviewed to correctly identify its cause&#46;</p></span>"
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Scientific Letter
Systemic-to-Pulmonary Artery Fistula as a Late Complication of Biliary Surgery
Fístula arterio-arterial sistémico-pulmonar como complicación tardía de cirugía biliar
Sara Fra Fernándeza,
Corresponding author
sarafrafernandez@gmail.com

Corresponding author.
, Luis Gorospe Sarasúab, Andreina Olavarría Delgadob, Diurbis Velasco Álvarezc
a Servicio de Cirugía Torácica, Hospital Universitario Ramón y Cajal, Madrid, Spain
b Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, Spain
c Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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and a pulmonary artery as a late complication of a biliary surgery&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a 79-year-old man who consulted due to repeated&#44; self-limiting episodes of hemoptysis&#46; Significant history included laparoscopic cholecystectomy compounded with a right subphrenic abscess &#40;resolved with drainage and antibiotics&#41; 2 years previously &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Hemoptysis originating in the upper airway and digestive tract was ruled out by fiberoptic bronchoscopy and gastrointestinal endoscopy&#44; but in a computed tomography &#40;CT&#41; scan of the chest with contrast medium&#44; an opacity was identified in the right postero-basal segment in contact with the diaphragmatic surface that was surrounded by characteristically tortuous vessels&#46; Given these findings&#44; suggestive of a vascular malformation&#44; we decided to perform an CT angiogram of the chest&#44; which confirmed the existence of an SPF between a hypertrophic right inferior phrenic artery and a subsegmental branch of the pulmonary artery of the right lower lobe &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B and <span class="elsevierStyleSmallCaps">C</span>&#41;&#46; This SPF was treated by selective embolization with Onyx<span class="elsevierStyleSup">&#174;</span> &#40;an ethylene vinyl alcohol copolymer&#41; of the systemic feeding artery of the right inferior phrenic artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; There have been no subsequent complications nor have any new episodes of hemoptysis occurred to date&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">SPF are abnormal anastomosis between systemic arteries and pulmonary vessels&#59; they may be congenital or&#44; more frequently&#44; acquired&#46; The latter usually occur in the presence of pleural adhesions as a result of various long-standing inflammatory processes of the chest&#44; such as bronchiectasis &#40;particularly in patients with cystic fibrosis&#41;&#44; tuberculosis&#44; or chronic empyema&#46; These processes are often associated with pleural fibrosis and the resulting decrease in pulmonary blood flow&#44; which cause hypertrophy of the systemic arteries&#46; Although several cases of SPF due to surgical interventions have been described &#40;aortocoronary bypass surgery&#44; thoracotomies&#44; and video-assisted thoracoscopic surgery&#41;&#44; very few cases have been reported in association with abdominal surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1&#44;3</span></a> In most cases&#44; SPF are asymptomatic&#44; although one of the most common presenting symptoms is hemoptysis&#46; Other less common symptoms have been described&#44; such as dyspnea or chronic chest pain&#44; and complicated cases with pulmonary hypertension or endocarditis have also been documented&#46; This disease can be diagnosed with CT angiogram or arteriography&#44; and several treatment options are available&#58; surgery&#44; endovascular treatment &#40;embolization&#41;&#44; or observation&#46; In patients like ours&#44; with repeated episodes of moderate hemoptysis&#44; embolization is often the first-choice treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; the SPF secondary to biliary surgery are exceptional&#46; For this reason&#44; when a fistula in an inferior phrenic artery is observed in a patient with hemoptysis&#44; the index of suspicion should be high&#44; and the patient&#39;s history and previous tests should be reviewed to correctly identify its cause&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fra Fern&#225;ndez S&#44; Gorospe Saras&#250;a L&#44; Olavarr&#237;a Delgado A&#44; Velasco &#193;lvarez D&#46; F&#237;stula arterio-arterial sist&#233;mico-pulmonar como complicaci&#243;n tard&#237;a de cirug&#237;a biliar&#46; Arch Bronconeumol&#46; 2019&#59;55&#58;227&#8211;228&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Axial abdominal CT image showing a mass in the anterior mediastinum &#40;asterisk&#41;&#46; Note the presence of inflammatory changes in the right costophrenic sinus &#40;arrow&#41;&#46; &#40;B&#41; Maximum intensity projection &#40;MIP&#41; coronal reconstruction of the CT angiogram of the chest and upper abdomen showing a communication between a hypertrophic right inferior phrenic artery &#40;black arrow&#41; and a subsegmental pulmonary artery in the right lower lobe &#40;white arrow&#41;&#46; &#40;C&#41; Volume rendering of CT angiogram of the systemic-pulmonary fistula &#40;short arrows indicate right inferior phrenic artery&#44; while long arrows indicate the pulmonary artery&#41;&#46; &#40;D&#41; Angiogram showing retrograde filling of pulmonary arteries &#40;long arrows&#41; from a tortuous&#44; hypertrophic right inferior phrenic artery &#40;short arrows&#41;&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
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