PMC8441071_01
A plain chest radiograph reveals a homogenous, tubular retrocardiac/left lower lung opacity (black arrow). The normal left lower lobar pulmonary artery is still visible in the left infrahilar region (white arrow). Note increased interstitial markings in the peripheral left lower lung zone (arrowhead) compared to the normal right side.
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A chest X-ray revealed a homogeneous tubular opacity at the left lower lobe, otherwise unremarkable (Fig. 1).
Coronal contrast-enhanced CT chest on mediastinal window (A) and 3D reconstruction (B) images demonstrate a tortuous, dilated anomalous artery (long arrow) originating from left antero-lateral descending thoracic aorta and entering the basal segments of the left lower lobe. Venous return (short arrow) is through the left lower pulmonary vein, indicating a left-to-left shunt. The left lower pulmonary vein is enlarged compared to its contralateral counterpart suggesting a high-flow fistula. Axial contrast-enhanced CT chest on mediastinal window (C) clearly depicts the aortic origin of the anomalous artery (black arrowhead) with wall calcification (thick arrow). Axial image on lung window (D) reveals a normal bronchial tree and accompanying pulmonary arteries (arrowhead). Note also a slight decrease in lung volume and subtle ground-glass opacity of the left lower lobe.
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Contrast-enhanced computed tomography demonstrated a high flow fistula between the descending aorta and the left lower pulmonary vein (Fig. 2).
Selective serial digital subtraction angiographic images of the anomalous artery shows (A) a tortuous and dilated afferent artery (black arrow), (B) an abnormal parenchymal blush and prominent vascular staining (asterisk) in the region of the left lower lobe, and (C) a normal venous return to the left pulmonary vein (thick arrow). There is no direct communication between the abnormal systemic artery and the veins of the involved lung tissue. These findings are compatible with a high-flow isolated arterial pulmonary malinosculation. Completion angiogram (D) confirms a total occlusion of the afferent artery after embolizing with multiple detachable coils (white arrow). Note the regurgitation of contrast media into the aorta and opacification of intercostal arteries (arrowheads). Bilateral bronchial arteries and other intercostal arteries have normal angiographic appearances and have no supply to the affected lobe (not shown).
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The fistula was confirmed on digital subtraction angiography and was embolized with multiple detachable coils (Interlock, Boston Scientific, Natick, MA, USA) (Fig. 3).