ABSTRACT. We report a rare case of dual arterial supply to an otherwise normal left lower lobe. In addition to normal pulmonary arterial supply, the lower lobe of the left lung also received systemic arterial supply from the coeliac axis. The relevant anatomy and literature are reviewed. To the best of our knowledge, there are no other reported cases of anomalous systemic arterial supply from the coeliac axis to the basal segments of the left lower lobe with normal bronchial branching and pulmonary arterial supply. Systemic arterial supply to the lungs can be congenital or acquired. In the commonly reported congenital form of systemic arterial supply to the basal segments of the left lower lobe, there is abrupt tapering of the left lower lobar pulmonary artery distal to the origin of the superior segmental artery and the aberrant systemic artery originates from the descending thoracic aorta [1,2]. We report a rare case of dual arterial supply from the pulmonary and systemic arteries to the basal segments of the left lower lobe with a normal bronchial tree.
Case reportA 47-year-old woman presented with history of occasional blood-streaked sputum for the past 9 years. There was no history of excessive sputum production or past history of tuberculosis. Clinical examination was unremarkable, as were routine laboratory investigations.The chest radiograph showed a few linear opacities in the left retrocardiac region (Figure 1). Bronchoscopy was normal. High-resolution computed tomography (HRCT) of the thorax was carried out to look for underlying bronchiectasis as the cause of haemoptysis. HRCT revealed a few asymmetrical dilated vessels in the left lower lobe; there was minimal adjacent ground-glass opacity and few linear opacities, suggesting postinflammatory changes (Figure 2). In view of the presence of dilated vessels, a vascular malformation was suspected and CT angiography was performed. The CT angiogram showed aberrant systemic arterial supply to the basal segments of the left lower lobe; this arterial supply arose from the coeliac axis. This anomalous artery entered the thorax via the oesophageal hiatus, traversed parallel and to the left of the oesophagus and entered the left lower lobe via the pulmonary ligament, supplying the basal segments. There was no arteriovenous malformation. Pulmonary arterial supply to the left lower lobe was also present with normal arborisation. Although the descending pulmonary artery appeared slightly smaller than on the right side, all the basal segmental branches were identified. The normal pattern of venous drainage into the inferior pulmonary vein was seen. The lung parenchyma showed mild linear and ground-glass opacity with normal branching of the bronchial tree (Figures 3, 4, 5, 6, 7 and 8). The patient was not keen on surgery or endovascular treatment and is on follow-up.
The high frequency of this finding re-emphasizes the need for caution in attributing abdominal symptoms to such compression based on imaging findings alone.
Congenital slow-flow vascular malformations of the orbital region are rare lesions that should be treated using a multidisciplinary approach. Monitoring of the intraorbital pressure is required both during and after the procedure to decide about the need for lateral canthotomy to reduce the transiently increased intraorbital pressure.
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