Medical Image of the Week: Virtual Anatomical Dissociation During Electromagnetic Navigation Bronchoscopy

Figure 1. During the first navigation virtual bronchoscope image and 3D map (top left and bottom left) show the tip of the locatable guide in the posterior segment of the right upper lobe matching live video bronchoscope image.

Figure 2. Second navigation: the virtual bronchoscope image and 3D map (top left and bottom left) show the tip of the bronchoscope in the right main bronchus whereas the video bronchoscope shows the tip in the posterior segment of the right upper lobe.

A 59 year-old woman with a 40 pack-year smoking history was referred to our practice with a 2.5 cm spiculated right upper lobe lung nodule for a diagnostic bronchoscopy.

We performed electromagnetic navigation bronchoscopy under general anesthesia in the operating room. After successfully navigating to the lesion and obtaining 3 needle biopsy samples and two cytology brush samples we lost target alignment. After attempting to rotate and reposition the catheter several times it was decided to re-navigate from the trachea. Two images comparing virtual navigation to real anatomy during the first and second navigation attempts are provided bellow (Figures 1 and 2).

Why are the virtual images different? (Click on the correct answer for a discussion)

1. It is an artifact from respiratory movements
2. The locatable guide is outside the sensing volume
3. You should suspect a pneumothorax
4. Your registration procedure was suboptimal, you should repeat it.

Cite as: Vazquez-Guillamet R, Horn E, Sarver R, Melendres L. Medical image of the week: virtual anatomical dissociation during electromagnetic navigation bronchoscopy. Southwest J Pulm Crit Care. 2015;11(5):238-9. doi: http://dx.doi.org/10.13175/swjpcc111-15 PDF

Medical Image of the Week: Atherosclerotic Aneurysm of Great Vessels

Figure 1.Unsual appearance of the aortic root with irregular contours and a 41 x 37mm dilatation at the level of the sinuses of Valsalva.

Figure 2. Saccular outpouchings of the intrathoracic great vessels.

Figure 3. Video of the MRI images of the intrathoracic vascular abnormalities.

A 60 year-old man with a 33 pack-year history of tobacco abuse, presented with difficulty speaking and voice change for several weeks. His review of systems was positive for fatigue, night sweats and weight loss. Physical exam of the oropharynx with flexible laryngoscopy demonstrated immobile bilateral true and false vocal cords fixed in the para-median position without laryngeal lesions. Concern for intra-thoracic process with recurrent laryngeal nerve involvement, a computed tomography (CT) of the chest and thoracic vessels demonstrated unusual appearing arteries with multiple penetrating atherosclerotic ulcers versus saccular aneurysms scattered throughout the aorta and its major branches (Figures 1 and 2). A magnetic resonance imaging (MRI) with contrast, demonstrated multiple foci of saccular outpouchings involving the arch vessels distal to their origins with the largest dilatation measuring 26 x 25 mm in the case of proximal innominate (Figure 3). Although imaging lacked resolution, it was specialist opinion that patient likely had compression of recurrent laryngeal nerve leading to vocal cord dysfunction without significant airway compromise.

Atherosclerotic aneurysms of the great vessels are rare with evidence limited to case series (1,2). Patient presentation varies dependent on the structures involved including embolic phenomenon from atherosclerosis. Surgical intervention with endovascular approach remains treatment of choice with good success rate.

Given our patient’s poor nutritional status, multiple co-morbidities and diagnosis of large colonic mass, risks of surgery outweighed benefits of intervention and thus outpatient follow up was recommended.

Faraz Jaffer, MD and Don Leo Pepito, MD

Department of Internal Medicine

Banner-University Medical Center – South

Tucson, AZ

References

1. Cury M, Greenberg RK, Morales JP, Mohabbat W, Hernandez AV. Supra-aortic vessels aneurysms: diagnosis and prompt intervention. J Vasc Surg. 2009;49(1):4-10. [CrossRef] [PubMed]
2. Kasashima F, Urayama H, Ohtake H, Watanabe Y.Intrathoracic aneurysm of the innominate and right subclavian arteries: report of a case. Surg Today. 2001;31(1):51-4. [CrossRef] [PubMed] 

Cite as: Jaffer F, Pepito DL. Medical image of the week: athersclerotic aneurysm of great vessels. Southwest J Pulm Crit Care. 2015;11(5):231-2. doi: http://dx.doi.org/10.13175/swjpcc104-15 PDF