Transpleural systemic artery to pulmonary vessel fistulas: Imaging characteristics and management of an uncommon entity

Systemic arterial to pulmonary vessel fistulas may develop in the setting of pleural inflammation and/or injury. Bronchial arteries are the most commonly involved vessels, with recruitment often occurring in chronic diseases such as tuberculosis and cystic fibrosis. Rarely, transpleural systemic arteries that directly communicate with the pulmonary vasculature may develop in the presence of pleural injury or chronic inflammation. The clinical presentation and management of three cases of transpleural systemic artery to pulmonary vessel fistulas are detailed. Given the atypical imaging appearance of these lesions, there is risk of misdiagnosis of these entities as a pulmonary arteriovenous malformation. Understanding the pathophysiology, complex anatomy, and treatment for these rare vascular malformations is crucial prior to angiographic intervention in order to improve outcomes, avoid misdiagnosis, and prevent inappropriate intervention.