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Figure 4. Sagittal chest CT image shows a normal-appearing collapsed esophagus (arrow).
be a treatment option, especially in patients unfit for surgery.
REFERENCES 1. van Till JW, van Sandick JW, Cardozo ML, Obertop H. Symptomatic mucocele of a surgically excluded esophagus. Dis Esophagus 2002; 15: 96–98. 2. Haddad R, Teixeira Lima R, Henrique Boasquevisque C, Antonio Marsico G. Symptomatic mucocele after esophageal exclusion. Interact Cardiovasc Thorac Surg 2008; 7:742–744. 3. Collins KC, Odell DD, Sheiman RG, Gangadharan SP. Critically compromised airway secondary to expanding esophageal mucocele. Ann Thorac Surg 2012; 94:635–636, http://dx.doi.org/10.1016.
Bronchial and Systemic Artery Embolization of Hemorrhagic Adenocarcinoma Arising from a Pulmonary Sequestration From: M. Cody O’Dell, MD, MPH Joseph Limback, MD Francisco J. Contreras, MD Nicholas Feranec, MD Andrew R. Lewis, MD Department of Radiology Florida Hospital, University of Central Florida College of Medicine 601 E. Rollins Street Orlando, FL 32803
Editor: A pulmonary sequestration is a bronchopulmonary foregut malformation, a mass of nonfunctioning lung tissue characterized by lack of a connection to the bronchial tree and receiving systemic arterial circulation. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.09.003
O’Dell et al
’
JVIR
Pulmonary sequestrations are divided into extralobar and intralobar types based on the venous drainage and pleural covering. Extralobar sequestrations drain systemically into the inferior vena cava, portal vein, or azygos system and are invested in their own visceral and parietal pleural layers. Intralobar sequestrations are characterized by venous drainage into the pulmonary veins, and are separated from the adjacent lung by visceral pleura only (1–3). We report a case of a hemorrhagic adenocarcinoma arising from a pulmonary sequestration that was refractory to bronchoscopic intervention, which we treated through embolization of the systemic and bronchial arterial supplies. Institutional review board approval was not required for this case report. A 68-year-old white man with recently diagnosed right lower lobe adenocarcinoma presented to the emergency department with shortness of breath and hemoptysis for the preceding 2 days. His hemoglobin at that time was 6.7 g/dL (normal range, 13.8–17.2 g/dL). A computed tomography (CT) scan of the chest was ordered. CT scan demonstrated diffuse ground-glass opacities throughout the right lung, a cavitary mass in the right lower lobe, and mediastinal adenopathy (Fig 1a). Incidental note was made of an atherosclerotic ectopic vessel arising from the aorta and coursing into the right lower lobe mass, consistent with a pulmonary sequestration (Fig 1b). Bronchoscopy was performed and demonstrated copious blood products within the bronchi. The operator was unable to pass the flexible bronchoscope into the right lower lobe bronchus or to identify a bleeding endobronchial mass, so the procedure was aborted. Because the patient was not a surgical candidate and was at high risk for asphyxiation, he was referred to the interventional radiology service for possible bronchial artery embolization to control his hemoptysis. A right bronchial artery branch arising from the thoracic aorta was selected with a 5-F Mickelson catheter (Cook, Inc, Bloomington, Indiana) (Fig 2a). Embolization of this branch was performed using 500– 700 μm Embosphere microspheres (Merit Medical Systems, Inc, South Jordan, Utah). The right intercostal bronchial trunk artery was then selected with the 5-F Mickelson catheter. Using a Progreat microcatheter (Terumo Medical Corporation, Somerset, New Jersey), the right bronchial artery was selected. Embolization of this branch was also performed using 500–700 μm Embosphere microspheres until stasis of flow was achieved. The sequestration branch arising from the abdominal aorta was selected with a Mickelson catheter, and a Progreat microcatheter was advanced into the branch artery (Fig 2b). This branch artery was coiled with a 4 mm 30 cm Penumbra Occlusion Device (POD) microcoil (Penumbra Inc, Alameda, California). A completion angiogram demonstrated stasis of flow (Fig 2c).
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Figure 1. Initial CT scan of right lower lobe necrotic mass with adjacent pulmonary alveolar hemorrhage. (a) Coronal contrastenhanced CT image demonstrates a necrotic right lower lobe mass (arrows) with diffuse ground-glass opacities in the adjacent lung parenchyma. (b) Reconstructed CT image demonstrates a calcified artery (arrows) originating from the abdominal aorta and extending into the right lower lobe mass.
Figure 2. Embolization of bronchial arteries and systemic artery supplying hemorrhagic right lower lobe sequestration. (a) Arteriogram of a right bronchial artery arising directly from the thoracic aorta. (b) Arteriogram of the systemic branch (arrow) supplying the sequestration (arrowheads). (c) Arteriogram obtained after embolization demonstrates a coil within the systemic branch supplying the sequestration.
The patient improved symptomatically in the days after the procedure. He was discharged to hospice care on day 10 after the procedure because he chose not to undergo further chemotherapy or radiation therapy. At the 5-week follow-up examination, the patient continued to complain of shortness of breath, although the hemoptysis had resolved. The gold standard for treatment of a pulmonary sequestration is surgical resection. However, in this patient with unresectable adenocarcinoma, this was not an option (1). Furthermore, surgical resection is associated with increased morbidity compared with endovascular treatment and would have likely decreased the quality of life in this terminally ill patient. In adult patients, treatment of pulmonary sequestration is usually reserved for symptomatic patients (4). The literature regarding the endovascular technique in adults is limited to case reports, necessitating further research.
Adenocarcinoma is an exceedingly rare complication of a pulmonary sequestration, with only one case reported in our review of the literature (1). Our case was further complicated by acute hemorrhage. Clinically, this case demonstrates the importance of determining the arterial supply to a hemorrhagic mass before embolization. Embolization of the bronchial arteries would not have treated the hemoptysis in this case. Fortuitously, a calcified systemic artery was noted to supply the hemorrhagic mass on the CT scan performed before embolization.
REFERENCES 1. Belchis D, Cowan M, Mortman K, Rezvani B. Adenocarcinoma arising in an extralobar sequestration: a case report and review of the literature. Lung Cancer 2014; 84:92–95. 2. Ganeshan A, Freedman J, Hoey ET, Steyn R, Henderson J, Crowe PM. Transcatheter coil embolisation: a novel definitive treatment option for intralobar pulmonary sequestration. Heart Lung Circ 2010; 19:561–565.
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3. Kim TE, Kwon JH, Kim JS. Transcatheter embolization for massive hemoptysis from an intralobar pulmonary sequestration: a case report. Clin Imaging 2014; 38:326–329. 4. Madhusudhan KS, Das CJ, Dutta R, Kumar A, Bhalla AS. Endovascular embolization of pulmonary sequestration in an adult. J Vasc Interv Radiol 2009; 20:1640–1642.
CT-Guided Transosseous Alcohol Block of the Inferior Alveolar Nerve in the Mandibular Canal for Unrelenting Pain: Technical Note From: Daniel Crawford, MS II Eric vanSonnenberg, MD Tung Trang, MD Amrit Hansra, MD University of Arizona College of Medicine, Phoenix (D.C.) Department of Radiology (E.v.) 550 East Van Buren Street, Office 550 Phoenix, AZ 85004 Departments of Medicine and Radiology (E.v.) David Geffen School of Medicine at UCLA (E.v.S.) Los Angeles, California Departments of Radiology (E.v., A.H.) and Surgery (T.T.) Kern Medical Center Bakersfield, California Department of Radiology (A.H.) University of Arizona Tucson, Arizona
Editor: Mandibular nerve block can be an effective treatment for orofacial pain resulting from trigeminal neuralgia, trauma, and malignant tumors (1). Nerve blocks can target different locations along the mandibular nerve, depending on the location of the pain and the desired area for anesthesia. Several percutaneous techniques for treatment of trigeminal neuralgia anesthetize the Gasserian ganglion in the middle cranial fossa and can provide pain relief to multiple branches of the trigeminal nerve (1). Nerve blocks isolated to the third branch of the trigeminal nerve (the mandibular nerve) often can be achieved with extraoral and intraoral approaches (2), but these blocks may anesthetize a larger area than desired based on the clinical problem. Inferior alveolar nerve blocks typically are direct, visually-guided, intraoral injections that anesthetize primarily the inferior alveolar nerve by targeting its entrance into the mandibular foramen. These procedures are performed regularly by oral and maxillofacial surgeons and otolaryngologists for operations that require anesthesia for the mandible. Success rates for this type of nerve block are high, but failure can occur because of suboptimal needle placement and diffusion of the anesthetic away from the target site (3).The fifth cranial nerve None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.10.006
Crawford et al
’
JVIR
(CN V) exits the pons and gives rise to the trigeminal (Gasserian) ganglion which is situated in the middle cranial fossa. The ganglion trifurcates into the ophthalmic (CN V1), maxillary (CN V2), and mandibular (CN V3) nerves. These nerves collectively provide sensory innervation of the face. The mandibular nerve (CN V3) exits the skull through the foramen ovale and branches into the auriculotemporal, buccal, lingual, pterygoid, masseteric, mylohyoid, and inferior alveolar nerves. The inferior alveolar nerve enters the mandible through the mandibular foramen and travels through the mandibular canal where it innervates the mandibular teeth (Fig 1). The institutional review board at Kern Medical Center approved this study. A 76-year-old man with a history of metastatic prostate cancer presented with persistent and severe right jaw pain that severely limited his eating. A computed tomography (CT) scan of the neck performed 9 months previously revealed a mixed lytic and blastic expansile lesion that extended from the right mandibular condyle to the mandibular ramus. The lesion contained an incomplete pathologic fracture of the neck of the mandibular condyle. The patient declined surgical treatment. To alleviate the pain, a visually-guided intraoral inferior alveolar nerve block was attempted three times by the patient’s otolaryngologist. The patient experienced temporary pain relief that lasted a few months, after which the pain returned. Two CT-guided nerve blocks via the conventional transoral route were attempted. There was no confirmation by clinical response or imaging that the needles were optimally positioned near the origin of the mandibular canal, and the patient’s severe jaw pain persisted. Given the lack of success of the five attempts at nerve block, the patient’s unrelenting severe pain, and the lack of optimal needle placement, we attempted a novel approach. We postulated that a transosseous, transmandibular approach might allow more precise access through pathologic bone to target the inferior alveolar nerve in the mandibular canal. This route presumably
Figure 1. Human skull illustrating the mandibular foramen (arrow) where a branch of CN V3, the inferior alveolar nerve, enters the mandible.
’
Letters to the Editor
Figure 4. Sagittal chest CT image shows a normal-appearing collapsed esophagus (arrow).
be a treatment option, especially in patients unfit for surgery.
REFERENCES 1. van Till JW, van Sandick JW, Cardozo ML, Obertop H. Symptomatic mucocele of a surgically excluded esophagus. Dis Esophagus 2002; 15: 96–98. 2. Haddad R, Teixeira Lima R, Henrique Boasquevisque C, Antonio Marsico G. Symptomatic mucocele after esophageal exclusion. Interact Cardiovasc Thorac Surg 2008; 7:742–744. 3. Collins KC, Odell DD, Sheiman RG, Gangadharan SP. Critically compromised airway secondary to expanding esophageal mucocele. Ann Thorac Surg 2012; 94:635–636, http://dx.doi.org/10.1016.
Bronchial and Systemic Artery Embolization of Hemorrhagic Adenocarcinoma Arising from a Pulmonary Sequestration From: M. Cody O’Dell, MD, MPH Joseph Limback, MD Francisco J. Contreras, MD Nicholas Feranec, MD Andrew R. Lewis, MD Department of Radiology Florida Hospital, University of Central Florida College of Medicine 601 E. Rollins Street Orlando, FL 32803
Editor: A pulmonary sequestration is a bronchopulmonary foregut malformation, a mass of nonfunctioning lung tissue characterized by lack of a connection to the bronchial tree and receiving systemic arterial circulation. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.09.003
O’Dell et al
’
JVIR
Pulmonary sequestrations are divided into extralobar and intralobar types based on the venous drainage and pleural covering. Extralobar sequestrations drain systemically into the inferior vena cava, portal vein, or azygos system and are invested in their own visceral and parietal pleural layers. Intralobar sequestrations are characterized by venous drainage into the pulmonary veins, and are separated from the adjacent lung by visceral pleura only (1–3). We report a case of a hemorrhagic adenocarcinoma arising from a pulmonary sequestration that was refractory to bronchoscopic intervention, which we treated through embolization of the systemic and bronchial arterial supplies. Institutional review board approval was not required for this case report. A 68-year-old white man with recently diagnosed right lower lobe adenocarcinoma presented to the emergency department with shortness of breath and hemoptysis for the preceding 2 days. His hemoglobin at that time was 6.7 g/dL (normal range, 13.8–17.2 g/dL). A computed tomography (CT) scan of the chest was ordered. CT scan demonstrated diffuse ground-glass opacities throughout the right lung, a cavitary mass in the right lower lobe, and mediastinal adenopathy (Fig 1a). Incidental note was made of an atherosclerotic ectopic vessel arising from the aorta and coursing into the right lower lobe mass, consistent with a pulmonary sequestration (Fig 1b). Bronchoscopy was performed and demonstrated copious blood products within the bronchi. The operator was unable to pass the flexible bronchoscope into the right lower lobe bronchus or to identify a bleeding endobronchial mass, so the procedure was aborted. Because the patient was not a surgical candidate and was at high risk for asphyxiation, he was referred to the interventional radiology service for possible bronchial artery embolization to control his hemoptysis. A right bronchial artery branch arising from the thoracic aorta was selected with a 5-F Mickelson catheter (Cook, Inc, Bloomington, Indiana) (Fig 2a). Embolization of this branch was performed using 500– 700 μm Embosphere microspheres (Merit Medical Systems, Inc, South Jordan, Utah). The right intercostal bronchial trunk artery was then selected with the 5-F Mickelson catheter. Using a Progreat microcatheter (Terumo Medical Corporation, Somerset, New Jersey), the right bronchial artery was selected. Embolization of this branch was also performed using 500–700 μm Embosphere microspheres until stasis of flow was achieved. The sequestration branch arising from the abdominal aorta was selected with a Mickelson catheter, and a Progreat microcatheter was advanced into the branch artery (Fig 2b). This branch artery was coiled with a 4 mm 30 cm Penumbra Occlusion Device (POD) microcoil (Penumbra Inc, Alameda, California). A completion angiogram demonstrated stasis of flow (Fig 2c).
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Figure 1. Initial CT scan of right lower lobe necrotic mass with adjacent pulmonary alveolar hemorrhage. (a) Coronal contrastenhanced CT image demonstrates a necrotic right lower lobe mass (arrows) with diffuse ground-glass opacities in the adjacent lung parenchyma. (b) Reconstructed CT image demonstrates a calcified artery (arrows) originating from the abdominal aorta and extending into the right lower lobe mass.
Figure 2. Embolization of bronchial arteries and systemic artery supplying hemorrhagic right lower lobe sequestration. (a) Arteriogram of a right bronchial artery arising directly from the thoracic aorta. (b) Arteriogram of the systemic branch (arrow) supplying the sequestration (arrowheads). (c) Arteriogram obtained after embolization demonstrates a coil within the systemic branch supplying the sequestration.
The patient improved symptomatically in the days after the procedure. He was discharged to hospice care on day 10 after the procedure because he chose not to undergo further chemotherapy or radiation therapy. At the 5-week follow-up examination, the patient continued to complain of shortness of breath, although the hemoptysis had resolved. The gold standard for treatment of a pulmonary sequestration is surgical resection. However, in this patient with unresectable adenocarcinoma, this was not an option (1). Furthermore, surgical resection is associated with increased morbidity compared with endovascular treatment and would have likely decreased the quality of life in this terminally ill patient. In adult patients, treatment of pulmonary sequestration is usually reserved for symptomatic patients (4). The literature regarding the endovascular technique in adults is limited to case reports, necessitating further research.
Adenocarcinoma is an exceedingly rare complication of a pulmonary sequestration, with only one case reported in our review of the literature (1). Our case was further complicated by acute hemorrhage. Clinically, this case demonstrates the importance of determining the arterial supply to a hemorrhagic mass before embolization. Embolization of the bronchial arteries would not have treated the hemoptysis in this case. Fortuitously, a calcified systemic artery was noted to supply the hemorrhagic mass on the CT scan performed before embolization.
REFERENCES 1. Belchis D, Cowan M, Mortman K, Rezvani B. Adenocarcinoma arising in an extralobar sequestration: a case report and review of the literature. Lung Cancer 2014; 84:92–95. 2. Ganeshan A, Freedman J, Hoey ET, Steyn R, Henderson J, Crowe PM. Transcatheter coil embolisation: a novel definitive treatment option for intralobar pulmonary sequestration. Heart Lung Circ 2010; 19:561–565.
156
’
Letters to the Editor
3. Kim TE, Kwon JH, Kim JS. Transcatheter embolization for massive hemoptysis from an intralobar pulmonary sequestration: a case report. Clin Imaging 2014; 38:326–329. 4. Madhusudhan KS, Das CJ, Dutta R, Kumar A, Bhalla AS. Endovascular embolization of pulmonary sequestration in an adult. J Vasc Interv Radiol 2009; 20:1640–1642.
CT-Guided Transosseous Alcohol Block of the Inferior Alveolar Nerve in the Mandibular Canal for Unrelenting Pain: Technical Note From: Daniel Crawford, MS II Eric vanSonnenberg, MD Tung Trang, MD Amrit Hansra, MD University of Arizona College of Medicine, Phoenix (D.C.) Department of Radiology (E.v.) 550 East Van Buren Street, Office 550 Phoenix, AZ 85004 Departments of Medicine and Radiology (E.v.) David Geffen School of Medicine at UCLA (E.v.S.) Los Angeles, California Departments of Radiology (E.v., A.H.) and Surgery (T.T.) Kern Medical Center Bakersfield, California Department of Radiology (A.H.) University of Arizona Tucson, Arizona
Editor: Mandibular nerve block can be an effective treatment for orofacial pain resulting from trigeminal neuralgia, trauma, and malignant tumors (1). Nerve blocks can target different locations along the mandibular nerve, depending on the location of the pain and the desired area for anesthesia. Several percutaneous techniques for treatment of trigeminal neuralgia anesthetize the Gasserian ganglion in the middle cranial fossa and can provide pain relief to multiple branches of the trigeminal nerve (1). Nerve blocks isolated to the third branch of the trigeminal nerve (the mandibular nerve) often can be achieved with extraoral and intraoral approaches (2), but these blocks may anesthetize a larger area than desired based on the clinical problem. Inferior alveolar nerve blocks typically are direct, visually-guided, intraoral injections that anesthetize primarily the inferior alveolar nerve by targeting its entrance into the mandibular foramen. These procedures are performed regularly by oral and maxillofacial surgeons and otolaryngologists for operations that require anesthesia for the mandible. Success rates for this type of nerve block are high, but failure can occur because of suboptimal needle placement and diffusion of the anesthetic away from the target site (3).The fifth cranial nerve None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.10.006
Crawford et al
’
JVIR
(CN V) exits the pons and gives rise to the trigeminal (Gasserian) ganglion which is situated in the middle cranial fossa. The ganglion trifurcates into the ophthalmic (CN V1), maxillary (CN V2), and mandibular (CN V3) nerves. These nerves collectively provide sensory innervation of the face. The mandibular nerve (CN V3) exits the skull through the foramen ovale and branches into the auriculotemporal, buccal, lingual, pterygoid, masseteric, mylohyoid, and inferior alveolar nerves. The inferior alveolar nerve enters the mandible through the mandibular foramen and travels through the mandibular canal where it innervates the mandibular teeth (Fig 1). The institutional review board at Kern Medical Center approved this study. A 76-year-old man with a history of metastatic prostate cancer presented with persistent and severe right jaw pain that severely limited his eating. A computed tomography (CT) scan of the neck performed 9 months previously revealed a mixed lytic and blastic expansile lesion that extended from the right mandibular condyle to the mandibular ramus. The lesion contained an incomplete pathologic fracture of the neck of the mandibular condyle. The patient declined surgical treatment. To alleviate the pain, a visually-guided intraoral inferior alveolar nerve block was attempted three times by the patient’s otolaryngologist. The patient experienced temporary pain relief that lasted a few months, after which the pain returned. Two CT-guided nerve blocks via the conventional transoral route were attempted. There was no confirmation by clinical response or imaging that the needles were optimally positioned near the origin of the mandibular canal, and the patient’s severe jaw pain persisted. Given the lack of success of the five attempts at nerve block, the patient’s unrelenting severe pain, and the lack of optimal needle placement, we attempted a novel approach. We postulated that a transosseous, transmandibular approach might allow more precise access through pathologic bone to target the inferior alveolar nerve in the mandibular canal. This route presumably
Figure 1. Human skull illustrating the mandibular foramen (arrow) where a branch of CN V3, the inferior alveolar nerve, enters the mandible.
