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Solitary Intercostal Arterial Trunk: Second Case Report
1758
’
Letters to the Editor
Postprocedural CT showed no complications. The patient was admitted to the hospital for observation and was discharged the following day, as her pain completely subsided and her full range of motion was restored. She no longer required a back brace or walker. At 3-month and 1-year clinic follow-up, the patient reported no pain or other symptoms, and was pursuing her career in physical fitness. This successful RF ablation of a vertebral body osteoid osteoma suggests that this may be a safe treatment option in this atypical site for an osteoid osteoma. In addition, despite the contiguity of the osteoid osteoma with an intervertebral disc, RF ablation still was performed safely. These two aspects make this case highly unusual, if not unique. Thermal ablation (including RF and laser ablation) to treat vertebral body osteoid osteomas has been performed to a much lesser extent than in the posterior elements—a total of nine patients has been reported (3). The lower number of ablations to all spinal osteoid osteomas compared with those in the appendicular skeleton relates to the perceived risk of thermal damage to neural elements (4). The present case is another example to illustrate that RF ablation (and biopsy) can safely be performed in a vertebral body osteoid osteoma. To date, the recommendation has been to perform thermal ablation to an osteoid osteoma only if there is a 1-cm margin from vital structures in view of the risk of unwanted thermal injury (4). Dupuy et al (5) performed in vivo and ex vivo thermal ablation experiments in pigs and found that preserved cancellous or cortical bone between the lesion and the osseous spine provided an insulative effect and thus a margin of safety. In the patient described here, there was more than a 1-cm margin between the lesion and the spinal canal and neural foramina; however, there was no preserved bone surrounding the superior aspect of the lesion—
Solitary Intercostal Arterial Trunk: Second Case Report From: Jamie Edwards, DO Greg Bowers, MD William Bates III, MD Scott Forseen, MD Georgia Regents University Medical College of Georgia Augusta, Georgia
Editor: The solitary intercostal arterial trunk was described by Chang and Rubin (1) as an anomalous branch arising dorsally from the descending thoracic aorta at the level
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.05.061
Edwards et al
’
JVIR
there was open communication with the T12–L1 intervertebral disc. There are two documented cases of surgical treatment for vertebral body osteoid osteomas spanning across the intervertebral discs and into the contiguous vertebral body (2,6). Our patient had a theoretical risk of injury to the adjacent intervertebral disc by RF ablation; however, the immediate and long-term pain relief suggests that no damage occurred or that it was clinically insignificant. Although immediate postprocedural CT revealed no complications, no postprocedural MR imaging was done to evaluate the intervertebral disc because the patient became asymptomatic the day after the RF ablation and has continued so. After RF ablation, the patient’s condition improved rapidly and remarkably, despite the combined unusual location of an osteoid osteoma in the vertebral body and the contiguity with an intervertebral disc. Although this is only a single case, it provides encouragement for future therapy in similar patients.
REFERENCES 1. Motamedi D, Learch TJ, Ishimitsu DN, et al. Thermal ablation of osteoid osteoma: overview and step-by-step guide. Radiographics 2009; 29: 2127–2141. 2. Heiman ML, Cooley CJ, Bradford DS. Osteoid osteoma of a vertebral body: report of a case with extension across the intervertebral disk. Clin Orthop Relat Res 1976:159–163. 3. Woertler K, Vestring T, Boettner F, Winkelmann W, Heindel W, Lindner N. Osteoid osteoma: CT-guided percutaneous radiofrequency ablation and follow-up in 47 patients. J Vasc Interv Radiol 2001; 12:717–722. 4. Rosenthal DI, Hornicek FJ, Torriani M, Gebhardt MC, Mankin HJ. Osteoid osteoma: percutaneous treatment with radiofrequency energy. Radiology 2003; 229:171–175. 5. Dupuy DE, Hong R, Oliver B, Goldberg SN. Radiofrequency ablation of spinal tumors: temperature distribution in the spinal canal. AJR Am J Roentgenol 2000; 175:1263–1266. 6. Hurtgen KL, Buehler M, Santolin SM. Osteoid osteoma of the vertebral body with extension across the intervertebral disc. J Manipulative Physiol Ther 1996; 19:118–123.
of the T12 vertebral level and ascending between the aorta and vertebral column to the T3 vertebral level, giving off the intercostal arterial branches between T3 and T12. Additional anomalous branches arose dorsally from the aorta to supply the first and second intercostal arteries and the L2/L3 lumbar arteries. These authors also described an isolated splenic artery arising from the aorta at T11 and a replaced common hepatic artery. Our case is from a computed tomographic (CT) angiogram of the abdomen and pelvis with bilateral lowerextremity runoff. This case demonstrates an anomalous artery arising dorsally from the thoracic aorta at the T12 level that coursed rostrally between the descending thoracic aorta and thoracic spine with aberrant ventral displacement of the aorta. The anomalous artery supplied the T7– T11 intercostal arteries (Figures 1, 2). This patient was born without a vagina and also had a low-lying right kidney with a single right renal artery that originated from the proximal right common iliac
Volume 24
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Number 11
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November
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2013
1759
Figure 2. Axial CT angiogram shows the posterior location of the solitary intercostal artery, indicated by the arrow, in relation to the aorta. (Available in color online at www.jvir.org.)
Figure 1. Sagittal maximum intensity projection CT angiogram of the solitary intercostal arterial trunk, as indicated by the arrow. (Available in color online at www.jvir.org.)
lumbar artery (70% of cases) between T8 and L1 (approximately 90% of cases) (2). In our case, the characteristic hairpin loop of the artery of Adamkiewicz was observed at the T10 level. The solitary intercostal arterial trunk appears to be associated with other congenital anomalies.
artery. The single right renal vein inserted low upon the inferior vena cava. Bony dorsal dysraphic defects were present at L5, S1, S2, and S3. The anterior radicular artery of Adamkiewicz is the major supply to the thoracolumbar spinal cord and most commonly originates from a left-sided intercostal or
REFERENCES
Internal Mammary Artery–to–pulmonary Artery and Vein Fistula Acquired after Video-assisted Thoracoscopic Surgery and Pleurodesis
mostly congenital but may arise after trauma, inflammation, neoplasia, or surgery (1–3). Usually asymptomatic (1), SAPVFs can present with hemoptysis, hemothorax, myocardial ischemia, or heart failure. Treatment options include medical management (1,3), percutaneous embolization (2), surgical ligation, or adhesiolysis (1,2). Reported here is a case of SAPVF acquired from video-assisted thoracoscopic surgery (VATS) with pleurodesis. A 43-year-old woman with recurrent right-sided pneumothorax secondary to suspected right thoracic and diaphragmatic endometriosis was referred to the interventional radiology unit regarding a right chest arteriovenous malformation (AVM). Related to the AVM, she reported only minor positional discomfort in the anterior chest wall. She had undergone right-sided VATS with mechanical pleurodesis 7 years before presentation and talc pleurodesis 7 months later. She denied any relevant trauma history. She also denied any history of transient ischemic attack, stroke, brain abscess, hemoptysis, or hemothorax. She reported normal exercise tolerance. Physical examination revealed a continuous bruit along the right parasternal border. No heart
From: Yan Yan, BS Brian A. Tweddale, MD Scott O. Trerotola, MD Division of Interventional Radiology Department of Radiology Hospital of the University of Pennsylvania 1 Silverstein, 3400 Spruce St. Philadelphia, PA 19104
Editor: Systemic artery–to–pulmonary vessel fistula (SAPVF) is a rare abnormal communication between a nonbronchial systemic artery and a pulmonary vessel. SAPVFs are
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.05.063
1. Chang J, Rubin GD. Solitary intercostal arterial trunk: a previously unreported anatomical variant. Circ Cardiovasc Imaging 2009; 2: e49–e50. 2. Koshino T, Murakami G, Morishita K, Mawatari T, Abe T. Does the Adamkiewicz artery originate from the larger segmental arteries? J Thorac Cardiovasc Surg 1999; 117:898–905.
’
Letters to the Editor
Postprocedural CT showed no complications. The patient was admitted to the hospital for observation and was discharged the following day, as her pain completely subsided and her full range of motion was restored. She no longer required a back brace or walker. At 3-month and 1-year clinic follow-up, the patient reported no pain or other symptoms, and was pursuing her career in physical fitness. This successful RF ablation of a vertebral body osteoid osteoma suggests that this may be a safe treatment option in this atypical site for an osteoid osteoma. In addition, despite the contiguity of the osteoid osteoma with an intervertebral disc, RF ablation still was performed safely. These two aspects make this case highly unusual, if not unique. Thermal ablation (including RF and laser ablation) to treat vertebral body osteoid osteomas has been performed to a much lesser extent than in the posterior elements—a total of nine patients has been reported (3). The lower number of ablations to all spinal osteoid osteomas compared with those in the appendicular skeleton relates to the perceived risk of thermal damage to neural elements (4). The present case is another example to illustrate that RF ablation (and biopsy) can safely be performed in a vertebral body osteoid osteoma. To date, the recommendation has been to perform thermal ablation to an osteoid osteoma only if there is a 1-cm margin from vital structures in view of the risk of unwanted thermal injury (4). Dupuy et al (5) performed in vivo and ex vivo thermal ablation experiments in pigs and found that preserved cancellous or cortical bone between the lesion and the osseous spine provided an insulative effect and thus a margin of safety. In the patient described here, there was more than a 1-cm margin between the lesion and the spinal canal and neural foramina; however, there was no preserved bone surrounding the superior aspect of the lesion—
Solitary Intercostal Arterial Trunk: Second Case Report From: Jamie Edwards, DO Greg Bowers, MD William Bates III, MD Scott Forseen, MD Georgia Regents University Medical College of Georgia Augusta, Georgia
Editor: The solitary intercostal arterial trunk was described by Chang and Rubin (1) as an anomalous branch arising dorsally from the descending thoracic aorta at the level
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.05.061
Edwards et al
’
JVIR
there was open communication with the T12–L1 intervertebral disc. There are two documented cases of surgical treatment for vertebral body osteoid osteomas spanning across the intervertebral discs and into the contiguous vertebral body (2,6). Our patient had a theoretical risk of injury to the adjacent intervertebral disc by RF ablation; however, the immediate and long-term pain relief suggests that no damage occurred or that it was clinically insignificant. Although immediate postprocedural CT revealed no complications, no postprocedural MR imaging was done to evaluate the intervertebral disc because the patient became asymptomatic the day after the RF ablation and has continued so. After RF ablation, the patient’s condition improved rapidly and remarkably, despite the combined unusual location of an osteoid osteoma in the vertebral body and the contiguity with an intervertebral disc. Although this is only a single case, it provides encouragement for future therapy in similar patients.
REFERENCES 1. Motamedi D, Learch TJ, Ishimitsu DN, et al. Thermal ablation of osteoid osteoma: overview and step-by-step guide. Radiographics 2009; 29: 2127–2141. 2. Heiman ML, Cooley CJ, Bradford DS. Osteoid osteoma of a vertebral body: report of a case with extension across the intervertebral disk. Clin Orthop Relat Res 1976:159–163. 3. Woertler K, Vestring T, Boettner F, Winkelmann W, Heindel W, Lindner N. Osteoid osteoma: CT-guided percutaneous radiofrequency ablation and follow-up in 47 patients. J Vasc Interv Radiol 2001; 12:717–722. 4. Rosenthal DI, Hornicek FJ, Torriani M, Gebhardt MC, Mankin HJ. Osteoid osteoma: percutaneous treatment with radiofrequency energy. Radiology 2003; 229:171–175. 5. Dupuy DE, Hong R, Oliver B, Goldberg SN. Radiofrequency ablation of spinal tumors: temperature distribution in the spinal canal. AJR Am J Roentgenol 2000; 175:1263–1266. 6. Hurtgen KL, Buehler M, Santolin SM. Osteoid osteoma of the vertebral body with extension across the intervertebral disc. J Manipulative Physiol Ther 1996; 19:118–123.
of the T12 vertebral level and ascending between the aorta and vertebral column to the T3 vertebral level, giving off the intercostal arterial branches between T3 and T12. Additional anomalous branches arose dorsally from the aorta to supply the first and second intercostal arteries and the L2/L3 lumbar arteries. These authors also described an isolated splenic artery arising from the aorta at T11 and a replaced common hepatic artery. Our case is from a computed tomographic (CT) angiogram of the abdomen and pelvis with bilateral lowerextremity runoff. This case demonstrates an anomalous artery arising dorsally from the thoracic aorta at the T12 level that coursed rostrally between the descending thoracic aorta and thoracic spine with aberrant ventral displacement of the aorta. The anomalous artery supplied the T7– T11 intercostal arteries (Figures 1, 2). This patient was born without a vagina and also had a low-lying right kidney with a single right renal artery that originated from the proximal right common iliac
Volume 24
’
Number 11
’
November
’
2013
1759
Figure 2. Axial CT angiogram shows the posterior location of the solitary intercostal artery, indicated by the arrow, in relation to the aorta. (Available in color online at www.jvir.org.)
Figure 1. Sagittal maximum intensity projection CT angiogram of the solitary intercostal arterial trunk, as indicated by the arrow. (Available in color online at www.jvir.org.)
lumbar artery (70% of cases) between T8 and L1 (approximately 90% of cases) (2). In our case, the characteristic hairpin loop of the artery of Adamkiewicz was observed at the T10 level. The solitary intercostal arterial trunk appears to be associated with other congenital anomalies.
artery. The single right renal vein inserted low upon the inferior vena cava. Bony dorsal dysraphic defects were present at L5, S1, S2, and S3. The anterior radicular artery of Adamkiewicz is the major supply to the thoracolumbar spinal cord and most commonly originates from a left-sided intercostal or
REFERENCES
Internal Mammary Artery–to–pulmonary Artery and Vein Fistula Acquired after Video-assisted Thoracoscopic Surgery and Pleurodesis
mostly congenital but may arise after trauma, inflammation, neoplasia, or surgery (1–3). Usually asymptomatic (1), SAPVFs can present with hemoptysis, hemothorax, myocardial ischemia, or heart failure. Treatment options include medical management (1,3), percutaneous embolization (2), surgical ligation, or adhesiolysis (1,2). Reported here is a case of SAPVF acquired from video-assisted thoracoscopic surgery (VATS) with pleurodesis. A 43-year-old woman with recurrent right-sided pneumothorax secondary to suspected right thoracic and diaphragmatic endometriosis was referred to the interventional radiology unit regarding a right chest arteriovenous malformation (AVM). Related to the AVM, she reported only minor positional discomfort in the anterior chest wall. She had undergone right-sided VATS with mechanical pleurodesis 7 years before presentation and talc pleurodesis 7 months later. She denied any relevant trauma history. She also denied any history of transient ischemic attack, stroke, brain abscess, hemoptysis, or hemothorax. She reported normal exercise tolerance. Physical examination revealed a continuous bruit along the right parasternal border. No heart
From: Yan Yan, BS Brian A. Tweddale, MD Scott O. Trerotola, MD Division of Interventional Radiology Department of Radiology Hospital of the University of Pennsylvania 1 Silverstein, 3400 Spruce St. Philadelphia, PA 19104
Editor: Systemic artery–to–pulmonary vessel fistula (SAPVF) is a rare abnormal communication between a nonbronchial systemic artery and a pulmonary vessel. SAPVFs are
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.05.063
1. Chang J, Rubin GD. Solitary intercostal arterial trunk: a previously unreported anatomical variant. Circ Cardiovasc Imaging 2009; 2: e49–e50. 2. Koshino T, Murakami G, Morishita K, Mawatari T, Abe T. Does the Adamkiewicz artery originate from the larger segmental arteries? J Thorac Cardiovasc Surg 1999; 117:898–905.