CTICasesCongenital Systemic-to-Pulmonary Artery Fistula — Internal Mammary Artery to Left PA
Imaging findings
CT in a young gunshot wound victim demonstrates left chest wall injury and a pleural drain. Importantly, the left internal thoracic (mammary) artery is enlarged and gives off multiple branches that form collaterals in the region of the left lower lobe, communicating with the left lower lobe pulmonary artery, creating a systemic-to-pulmonary arterial fistula. The inferior phrenic artery also contributes collateral supply to this fistula. A similar case from another institution shows an internal mammary to left PA fistula in a different patient in the identical location. Both cases are believed to be congenital given the size of the vessels and the improbability of developing vessels of this caliber within hours of trauma.
Key takeaways
A systemic-to-pulmonary arterial fistula between the internal mammary artery and the left pulmonary artery can be a congenital anomaly discovered incidentally in the setting of trauma when the penetrating injury occurs at or near the site of the fistula. The vessel size at the time of acute trauma imaging strongly argues against an acutely traumatic origin. A similar case from SLU at an identical anatomical location supports the concept that this is a recurrent congenital vascular connection. Congenital systemic-to-pulmonary fistulas at this location should be recognized and not attributed to trauma.
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