PMC3056360_01
CT scan of the chest at two contiguous levels shows areas of bronchiectasis surrounded by air space opacities (arrow in A) representing hemorrhage within the consolidated right middle lobe, extending to the pleural surface (arrow in B)
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A contrast-enhanced CT scan of the chest revealed consolidation and bronchiectasis involving the lateral segment of the right middle lobe and a larger surrounding zone of hazy airspace opacities [Figure 1] probably representing hemorrhage.
(A, B): Contrast-enhanced CT scan of the chest (A) demonstrates hypervascularity involving the consolidated right middle lobe (arrow). Bone-subtracted, maximum-intensity projection (B) shows a complex right middle lobe vascular malformation (arrow) supplied by the right internal mammary artery (arrowhead) with drainage into the right pulmonary artery (curved arrow)
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A hypertrophied right internal mammary artery (IMA) was noted supplying a complex vascular malformation in the right middle lobe [Figure 2] via large pleural and phrenic collaterals draining into the right pulmonary artery.
(A-C): Selective right internal mammary artery injection (A) shows the presence of a high-flow right internal mammary artery (IMA) to pulmonary artery malformation (arrow). Selective right IMA arteriogram (B) following coil occlusion of the IMA distal to the lowest contributory branch and Onyx injection shows cessation of flow to the malformation (arrow). Radiograph of the chest (C) the day after embolization shows penetration of Onyx (arrows) into the first-order branches of the IMA
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More selective injection of the right IMA demonstrated a high-flow plexiform fistulous communication between the right internal mammary and the pulmonary arteries via a plexiform vascular malformation in the right middle lobe [Figure 3A]. Nevertheless, satisfactory occlusion of the IMA was achieved [Figure 3B, C] without opacification of any arterial feeders from the ipsilateral bronchial artery and contralateral intercostal artery, as demonstrated on the postembolization angiogram.