Pulmonary sling | Figure 1

Pulmonary sling

Axial contrast enhanced chest CT (image 1) shows the left pulmonary artery (arrow) arising from the right pulmonary artery and passing posterior to the trachea (arrowhead). The trachea has a circular configuration and small caliber consistent with complete tracheal rings. Coronal image from 3D volumetric reformat (image 2) and coronal minimum intensity projection (image 3) shows the impression (arrow) on the inferior and right lateral aspect of the trachea as well as the small caliber (arrowhead) of the lower trachea. Pulmonary sling refers to an apparent left pulmonary artery arising from the right pulmonary artery. The anomalous vessel can compress the right mainstem bronchus causing hyperinflation. Pulmonary sling is often associated with complete tracheal rings.

Image description
Coronal minimum intensity projection from chest CT shows both upper lobe bronchi (arrow) arising directly from the trachea in a patient with asplenia.

Teaching point
A tracheal bronchus is a congenital airway anomaly in which a bronchus arises directly from the trachea and is almost always unilateral and right-sided. Bilateral tracheal bronchi are rare and are more commonly encountered in patients with heterotaxy syndromes. Asplenia is associated with right isomerism, which results in bilateral right-sided thoracic anatomy, including eparterial bronchi. In this setting, bilateral tracheal bronchi represent a manifestation of right isomerism. Recognition of a tracheal bronchus is important due to potential implications for recurrent pulmonary infections and airway management, particularly during intubation.

3-D reformatted CT image of the trachea (image 1) and coronal minimum intensity projection images (image 2 and 3) of the chest show a duplicated trachea and bronchial tree. The duplicated trachea arises from the anterior aspect of the trachea above the level of the carina. The first carina gives rise to the right and left upper lobe bronchi. The second trachea then has a second carina living rise to the right middle and lower lobe and the left lower lobe. A duplicated trachea has only rarely been described. The small caliber, circular nature of the duplicated trachea suggests the presence of complete tracheal rings. CT bronchoscopy and coronal minimum intensity projection images are useful tools to identify tracheal anomalies.

Axial contrast enhanced CT of the chest shows a pulmonary sling. The main pulmonary artery (red *) gives rise only to the right pulmonary artery (blue *). The left pulmonary artery (arrowhead) arises from the right pulmonary artery. It courses between the trachea (anterior) and esophagus (posterior). If an upper GI was performed, we would see an anterior indentation on the esophagus at this level. #ThoraxThursday

Coronal image from a chest CT shows a tracheal bronchus (arrow). A tracheal bronchus is an anatomic variant where an accessory bronchus or displaced bronchus arises from the trachea. The tracheal bronchus almost always supplies the right upper lobe. Patients with a tracheal bronchus are usually asymptomatic but may present with recurrent right upper lobe pneumonia or recurrent right upper lobe atelectasis if intubated. #ThoraxThursday #ThoracicThursday

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