A Rare Case Of Paradoxical Pulmonary Embolism: Something To Consider
Neelam Mulji, Kurt Fichtner, Joann Lohr.
Prisma Health Midlands, Columbia, SC, USA.
OBJECTIVES: We report an unusual case of paradoxical pulmonary embolism confirmed on CTA from a congenital pulmonary artery fistula in a 62 year old African American male patient.
METHODS: This is a retrospective case review where the patient presented with dyspnea and hemoptysis. CTA revealed a pulmonary embolism but incidentally identified a systemic artery to pulmonary artery fistula.
RESULTS: Systemic artery to pulmonary artery fistulas are rare direct pathologic connections that may be due to congenital or acquired etiologies. The resulting sequela are alterations in the pulmonary circulation and hemodynamics which may include pulmonary hypertension, hemoptysis, pulmonary emboli, and /or shunts. This patient had no prior thoracic pathologies, thoracic trauma, or prior thoracic surgeries. Additionally, he had no prior episodes of pneumothorax or chest tubes. Echocardiogram and EKG were unremarkable. CTA imaging illustrated a connection between the right inferior phrenic artery to the right lower lobe pulmonary artery. The thrombophilic evaluation was negative but he was reported to have alpha-1-antitrypsin deficiency. Treatment was achieved with robotic surgical interruption of the fistula and endovascular embolization.
CONCLUSIONS: As in this case, diagnosis of systemic artery to pulmonary artery fistulas typically occurs as an incidental finding on CT angiography. This is the first reported case of robotic thoracic treatment of a pulmonary artery to systemic artery fistula. Systemic-pulmonary artery fistulas should be considered in the differential diagnosis for those with unprovoked pulmonary emboli, especially in patients with pre-existing lung pathophysiology.
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