Ann Thorac Surg 2012;93:1318. doi:10.1016/j.athoracsur.2011.09.033
© 2012 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Multivessel Intralobar Pulmonary Sequestration
Patrick Georgoff, BSa,*,
Sunil Singhal, MDb
a University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
b Department of Surgery, Division of Thoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
* Address correspondence to Mr Georgoff, 315 S 45th St, Apt 3J, Philadelphia, PA 19104 (Email: georgoff{at}mail.med.upenn.edu).
A 50-year-old woman presented with an incidental lung mass. She was asymptomatic, had no significant past medical history, and was a lifelong nonsmoker. Enhanced chest computed tomography (CT) revealed a 3.5 cm mass in the left lower lobe (Fig 1, CT scan). Positron emission tomography showed no evidence of fluorodeoxyglucose accumulation, and we recommended continued surveillance. On repeated chest CT 6 months later, the mass was unchanged; however, the patient chose to undergo elective resection via left lateral thoracotomy. Intraoperatively during dissection of the pulmonary ligament, two large caliber vessels were visualized branching off the distal thoracic aorta and coursing to the left lower lobe (Fig 2, intraoperative photograph). The aberrant vessels were divided by an endovascular stapler, and the mass was removed by wedge resection. On examining the specimen, multiple dysplastic bronchial segments were visualized and a diagnosis of pulmonary sequestration was confirmed by histopathology (Fig 3, gross pathology). The patient had an uneventful postoperative course and was discharged home 2 days later.
Pulmonary sequestration is an embryonic mass of lung tissue that has no identifiable bronchial communication and that receives its blood supply from one or more anomalous systemic arteries. There are two types: intralobar (75%) and extralobar (25%). The most common location is the left lower lobe. Intralobar sequestration is typically diagnosed in the first or second decade of life and is rarely found in patients older than 50 years. Some patients remain asymptomatic for life, but most present with chronic cough, hemoptysis, or recurrent pneumonia. Treatment consists of resection with ligation of the aberrant blood supply. Important surgical considerations include the number and location of aberrant vessels. Multiple arteries are found in 15% of sequestrations, and 74% receive blood supply from the thoracic aorta [1]. This case highlights the presence of large-bore vessels in the pulmonary ligament and the need for careful dissection because of the possible presence of multiple branches from the aorta.
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References
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- Savic B, Birtel FJ, Tholen W, et al. Lung sequestration: report of seven cases and review of 540 published cases Thorax 1979;34:96-101.[Abstract/Free Full Text]
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