Robotic Resection of a Combined Capillary and Arteriovenous Malformation in the Mediastinum.

The adult presentation of a mediastinal arteriovenous malformation is rare. Resection of these lesions are commonly performed via open thoracotomy, with a risk of bleeding from multiple feeding vessels. This report describes a robotic resection of a mediastinal arteriovenous malformation in a 55-year-old man.

Fetal upper mediastinum - normal and abnormal findings in obstetric ultrasound screening.

Fetal cardiac assessment is an integral part of the obstetric ultrasound. The inclusion of the outflow tracts and the three-vessel and tracheal view into the ultrasound screening enhances the detection rate for cardiovascular anomalies. Both, international and Polish guidelines recommend routine evaluation of the upper mediastinum. The aim of the study was to present the principles for assessing the structures of the upper mediastinum in normal conditions and to draw attention to the pathologies which may be visible in this plane.

Right Lower Lobectomy for an Aberrant Mediastinal Inferior Lobar Artery.

A 74-year-old woman was referred for a right lower lobe consolidation (maximum diameter, 73 mm) pathologically diagnosed as invasive mucinous adenocarcinoma (c-T4 N0 M0, c-stage IIIA). Computed tomography revealed an aberrant mediastinal inferior lobar branch (A6 and common basal artery [A7 to A10]) from the right main pulmonary artery (PA). Right lower lobectomy and lymph node dissection were performed. A mediastinal inferior lobar branch is extremely rare, and this patient with lung cancer underwent right lower lobectomy for all inferior PA branches (A6 and A7 to A10) arising from the main PA into the lower lobe.

Therapeutic strategy of central vein perforation accompanied by a mediastinal lesion after catheterization.

Central vein perforation associated with a mediastinal lesion is a rare complication of catheterization. A 50-year-old woman was diagnosed with chronic kidney disease and required hemodialysis treatment. The patient developed central vein injury during attempted placement of a double-channel catheter. A computed tomographic scan and venography showed that the catheter had punctured the mediastinum from the central vein. After comprehensive assessment and multidisciplinary consultation, percutaneous catheter thrombin injection with follow-up balloon dilatation under fluoroscopy guidance successfully fixed the perforation. We summarize the therapeutic strategy of this complication and other treatment options, and discuss the related literature of central vein injury.

Automated quantification of reference levels in liver and mediastinal blood pool for the Deauville therapy response classification using FDG-PET/CT in Hodgkin and non-Hodgkin lymphomas.

BACKGROUND: 18F-FDG-PET/CT has become a standard for assessing treatment response in patients with lymphoma. A subjective interpretation of the scan based on the Deauville 5-point scale has been widely adopted. However, inter-observer variability due to the subjectivity of the interpretation is a limitation. Our main goal is to develop an objective and automated method for evaluating response. The first step is to develop and validate an artificial intelligence (AI)-based method, for the automated quantification of reference levels in the liver and mediastinal blood pool in patients with lymphoma. METHODS: The AI-based method was trained to segment the liver and the mediastinal blood pool in CT images from 80 lymphoma patients, who had undergone 18F-FDG-PET/CT, and apply this to a validation group of six lymphoma patients. CT segmentations were transferred to the PET images to obtain automatic standardized uptake values (SUV). The AI-based analysis was compared to corresponding manual segmentations performed by two radiologists. RESULTS: The mean difference for the comparison between the AI-based liver SUV quantifications and those of the two radiologists in the validation group was 0·02 and 0·02, respectively, and 0·02 and 0·02 for mediastinal blood pool respectively. CONCLUSIONS: An AI-based method for the automated quantification of reference levels in the liver and mediastinal blood pool shows good agreement with results obtained by experienced radiologists who had manually segmented the CT images. This is a first, promising step towards objective treatment response evaluation in patients with lymphoma based on 18F-FDG-PET/CT.

[Wedge Bronchoplastic Left Upper Lobectomy for Lung Cancer Patient with Abnormal Mediastinal Left Basal Pulmonary Artery].

A 65-year-old man with left lung squamous cell carcinoma was admitted to our hospital for operation. His tumor was located left upper lobe and invaded to the orifice of left upper bronchus. We diagnosed the tumor as cT2aN0M0 and intended to perform radical operation. Preoperative three-dimensional computed tomography (3D-CT) revealed that A9+10 which descended along lower bronchus was arisen from the left main pulmonary artery as a 1st branch of it. A wedge bronchoplastic left upper lobectomy was safely done with preserving the branch. Although this abnormal branching of left pulmonary artery is very rare, we should pay more attention this type of anomaly because unintended injury of the branch causes massive bleeding or ischemia of left lower lobe. Preoperative 3D-CT is useful for detecting the anomaly of pulmonary vessels.

Mediastinoscopic view of the bronchial arteries in a series of surgical cases evaluated with three-dimensional computed tomography.

BACKGROUND: We have routinely performed three-dimensional computed tomography (3-D CT) prior to video-assisted transmediastinal esophagectomy to evaluate the small arteries in the mediastinal operative field. This evaluation would be helpful in performing mediastinoscopic esophagectomy. METHODS: Thirty-one patients who underwent transmediastinal esophagectomy with preoperative evaluations by 3-D CT were the study subject. The bronchial arteries depicted by the 3-D CT were classified by their origin and laterality. In 18 of the 31 cases, the surgical video was available and the identification rate in the video was reviewed for each of the categorized bronchial arteries. RESULTS: The detection rates of each classified artery were as follows (abbreviations, detection rate); the intercostal-bronchial trunk (IBT, 22/31), the direct left bronchial artery (LBA, 17/31), the common trunk of bronchial arteries (CTB, 7/31), the direct right bronchial artery (RBA, 2/31), and the ectopic arteries (16/31). The ectopic arteries arose from the aortic arch (11 cases), the right subclavian artery (6 cases) or the left subclavian artery (1 case). The identification rates of IBT, LBA, CTB, RBA and any of the ectopic arteries in the video review were 12/13, 4/8, 3/4, 1/1 and 2/10, respectively. CONCLUSIONS: Preoperative 3-D CT was a highly sensitive evaluation for the bronchial arteries encountered during transmediastinal esophagectomy. Orthotopic arteries except for LBA were frequently identified at the predicted sites. Although RBA and CTB were present infrequently, they often flowed into regional nodes at the bilateral bronchi or the tracheal bifurcation and, therefore, should be preoperatively evaluated.

Anterior mediastinal Hodgkin lymphoma presenting as an extremely hypervascular tumor on computed tomography: A case report.

RATIONALE: In the thorax, Hodgkin lymphoma (HL) most frequently involves the anterior mediastinal and paratracheal regions and tends to spread to contiguous nodal groups. Enlarged lymph nodes typically have homogeneous soft tissue attenuation similar to that of muscle tissue on computed tomography (CT). PATIENT CONCERNS: A contrast-enhanced CT examination of a 19-year-old man with right-sided chest pain showed an intense, heterogeneously enhancing mass with organization of serpentine and dilated blood vessels in the right anterior mediastinum that had invaded the upper lobe of the right lung. DIAGNOSES: Following a wedge resection, histopathological examination showed Reed-Sternberg cells that were positive for CD-15 and CD-30, which is typical of HL. INTERVENTIONS: The patient was started treatment with 6 cycles of doxorubicin, bleomycin, vincristine, and dacarbazine (ABVD) regimen. OUTCOMES: After chemotherapy, the patient had shown a partial response to the treatment. LESSONS: This presentation of HL as an extremely hypervascular anterior mediastinal mass on CT imaging has not been previously reported in the literature. This case suggests that HL should be included in the differential diagnosis of a hypervascular anterior mediastinal mass, especially if the patient is a young adult.

[Mediastinal Bronchial Artery Aneurysm Associated with Bronchiectasis;Report of a Case].

The patient was a 66-year-old man who had treated with bronchiectasis. He was admitted to our hospital because of hemoptysis. A chest plain computed tomography (CT) showed bronchiectasis in the left lower lobe and nodular lesion in the mediastinum. Chest contrast CT revealed a left bronchial artery aneurysm, and hyperplastic left bronchial arteries dilating and winding toward the left lower lobe. We performed selective angiography of the bronchial artery, revealing an aneurysm, and we performed 3 times of bronchial arterial embolization( BAE). He was performed surgery at 7th day following BAE. After postoperative empyema treatment, he was discharged on the 124th postoperative day.

Extracranial Venous abnormalities: A true pathological finding in patients with multiple sclerosis or an anatomical variant?

OBJECTIVE: To evaluate the extracranial venous anatomy with contrast-enhanced MR venogram (CE-MRV) in patients without multiple sclerosis (MS), and assess the prevalence of various venous anomalies such as asymmetry and stenosis in this population. MATERIALS AND METHODS: We prospectively recruited 100 patients without MS, aged 18-60 years, referred for contrast-enhanced MRI. They underwent additional CE-MRV from skull base to mediastinum on a 3T scanner. Exclusion criteria included prior neck radiation, neck surgery, neck/mediastinal masses or significant cardiac or pulmonary disease. Two neuroradiologists independently evaluated the studies to document asymmetry and stenosis in the jugular veins and prominence of collateral veins. RESULTS: Asymmetry of internal jugular veins (IJVs) was found in 75 % of subjects. Both observers found stenosis in the IJVs with fair agreement. Most stenoses were located in the upper IJV segments. Asymmetrical vertebral veins and prominence of extracranial collateral veins, in particular the external jugular veins, was not uncommon. CONCLUSION: It is common to have stenoses and asymmetry of the IJVs as well as prominence of the collateral veins of the neck in patients without MS. These findings are in contrast to prior reports suggesting collateral venous drainage is rare except in MS patients. KEY POINTS: • The venous anatomy of the neck in patients without MS demonstrates multiple variants • Asymmetry and stenoses of the internal jugular veins are common • Collateral neck veins are not uncommon in patients without MS • These findings do not support the theory of chronic cerebrospinal venous insufficiency • MR venography is a useful imaging modality for assessing venous anatomy.

Lobectomy for a mediastinal basal pulmonary artery.

Anatomical variations of the pulmonary artery increase the risks for vessel injury and critical mistakes during pulmonary artery resection. The mediastinal basal pulmonary artery is a rare branch abnormality and is the first branch of the pulmonary artery to flow into the basal segment. We report a patient who underwent video-assisted thoracic surgery (VATS) right lower lobectomy for lung cancer with a mediastinal basal pulmonary artery. The mediastinal basal pulmonary artery was detected preoperatively by computed tomography. During VATS, this artery was found with careful dissection by dividing the lung parenchyma within the fissure, and right lower lobectomy was safely performed.

A rare variant between the left superior vena cava and the azygos vein.

During the educational dissection of a 68-year-old Chinese male cadaver, an azygos vein (AV) coursing on the left side with double superior vena cava was observed. The left superior vena cava (LSVC) began from the confluence of the left internal jugular and left subclavian veins, and extended downwards medially into the left edge of the dilated coronary sinus. The right superior vena cava was formed by the union of the right internal jugular and right subclavian veins, and drained into the right atrium from the above. The AV was formed by the union of the right and left ascending lumbar veins at the level of the tenth thoracic vertebra. It ascended along the left margin of the thoracic vertebra, receiving almost the bilateral posterior intercostal veins and then extended into the LSVC on the left wall via the azygos arch. Better understanding of these variations will reduce unnecessary and potential harmful testing, and unneeded patient anxiety.

[Association of sarcoidosis and Takayasu's disease: A case report]. / Association sarcoïdose et maladie de Takayasu : à propos d'une observation.

INTRODUCTION: Vascular lesion of sarcoidosis is rare, it may precede, follow or occur with the symptoms of a Takayasu's disease. Many pathogenic mechanisms (infectious, genetic and immunological) participate in associating those two diseases. OBSERVATION: We describe the case of a 24-year-old female patient, hospitalized for a check up for mediastinal and cervical adenopathies, nasal obstruction with intermittent claudication in the upper limbs evolving over eight months the clinic examination shows an abolition of radial pulses. The final diagnosis was sarcoidosis with mediastinal and peripheral lymphadenopathy and a nasal lesion associated to a Takayasu arteritis (4 ACR criteria for Takayasu disease). We noticed a good clinical and radiological evolution after one year of oral corticotherapy. CONCLUSION: The association between sarcoidosis and Takayasu's disease remains rare, thus a differential diagnosis.

Bicarotid Trunk in the Domestic Cat.

The origin of the pair of common carotid arteries in the cat is inadequately described, and there are conflicting accounts in English veterinary anatomy textbooks published in the USA. We found one-quarter of 40 adult domestic cats dissected had a bicarotid trunk (5 female, 5 male). When present, the bicarotid trunk arose from the brachiocephalic trunk approximately midway between the expected origins of the more frequently independently arising left and right common carotid arteries, and on average, it was 5.6 mm in length. Our findings make the incidence, topographical and measurement information available so that students and veterinarians can be aware of this not insignificant variation in branching of the major arteries, forming a bicarotid trunk, in the cranial mediastinum of domestic cats.

Mild tracheal compression by aberrant innominate artery and chronic dry cough in children.

BACKGROUND: In children with aberrant innominate artery (AIA) one of the most prevalent respiratory symptom is dry cough. How frequently this mediastinal vessels anomaly, that can induce tracheal compression (TC) of different degree, may be detected in children with chronic dry cough is not known. METHODS: In a 3-year retrospective study, the occurrence of mediastinal vessels abnormalities and the presence and degree of TC was evaluated in children with recurrent/chronic dry cough. RESULTS: Vascular anomalies were detected in 68 out of the 209 children evaluated. A significant TC was detected in 54 children with AIA, in eight with right aortic arch, in four with double aortic arch but not in two with aberrant right subclavian artery. In AIA patients, TC evaluated on computed tomography scans, was mild in 47, moderate in six and severe in one. During bronchoscopy TC increased in expiration or during cough, but this finding was more pronounced in children with right aortic arch and double aortic arch in which a concomitant tracheomalacia was more evident. Comorbidities were detected in 21 AIA patients, including atopy, reversible bronchial obstruction and gastroesophageal reflux. Aortopexy was performed in eight AIA patients, while the remaining AIA patients were managed medically and showed progressive improvement with time. CONCLUSION: Mild TC induced by AIA can be detected in a sizeable proportion of children with recurrent/chronic dry cough. The identification of this anomaly, that may at least partially explain the origin of their symptom, may avoid further unnecessary diagnostic examinations and ineffective chronic treatments.

A Life-Threatening Mediastinal Hematoma After Central Venous Port System Implantation.

BACKGROUND: We report a case of surgical central venous port system implantation using Seldinger's technique with a life-threatening mediastinal hematoma due to the perforation of the superior vena cava. CASE REPORT: A 68-year-old woman was admitted to our institution for port implantation. Open access to the cephalic vein and 2 punctures of the right subclavian vein were unsuccessful. Finally, the port catheter could be placed into the superior vena cava using Seldinger's technique. As blood aspiration via the port catheter was not possible, fluoroscopy was performed, revealing mediastinal contrast extravasation without contrasting the venous system. A new port system could be placed in the correct position without difficulties. After extubation, the patient presented with severe respiratory distress and required consecutive cardiopulmonary resuscitation and reintubation. The CT scan showed a significant hematoma in the lower neck and posterior mediastinum with tracheal compression. We assumed a perforation of the superior vena cava with the tip of the guidewire using Seldinger's technique. Long-term intensive treatment with prolonged ventilation and tracheotomy was necessary. The port system had to be subsequently explanted due to infection. CONCLUSIONS: Mediastinal hematoma is a rare but life-threatening complication associated with central venous catheterization using Seldinger's technique. Perforation occurs most often during central venous catheterization in critical care. Mediastinal hematoma is an example of a mechanical complication occurring after central venous catheterization, which has been described only a few times in the literature to date. This case highlights the importance of awareness of possible, rare, life-threatening complications during port implantation, mostly performed in multimorbid patients by surgeons in training.