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surgical procedures &#40;post cardiothoracic or chest drainage tube procedures&#41; or neoplasic causes&#46; However&#44; the young age in which some of the reported cases of these fistulae were detected&#44; suggests that these may be rare congenital anomalies&#44; with only described 20 cases of arterio-arterial fistulae from congenital etiology&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;6</span></a> Patients with this type of anomalies may present dyspnea&#44; hemoptysis and&#47;or symptoms of congestive heart failure or may be asymptomatic and usually when there are no symptoms&#44; sometimes it is the presence of a hum or murmur in the cardiopulmonary auscultation that triggers imaging and diagnostic investigation&#46; In this context&#44; a chest X-ray may reveal changes such as rib notching or pulmonary infiltrate&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8&#44;5&#44;3</span></a> Potential consequences of this kind of vascular fistulae include heart failure from volume overload&#44; pulmonary hypertension and infectious complications and&#47;or severe bleeding from rupture&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The authors present a case report of a young male who&#44; based on imaging findings&#44; was diagnosed with an arterial fistula between intercostal arteries and pulmonary artery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A Caucasian male of 35 years of age&#44; and a construction worker&#44; was admitted in the emergency room of our hospital with sudden dyspnea&#46; There was no history of any other symptoms or signs of respiratory tract &#40;such as hemoptysis&#41; or cardiac system &#40;palpitations&#41;&#46; The patient mentioned prior sporadic episodes of sudden dyspnea and stated he was not taking any medication&#46; There was no relevant personal or family medical background&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient denied smoking&#44; alcoholic or drug habits and there was no history of previous admissions&#46; Clinical evaluation of the patient revealed only discrete bronchospasm after pulmonary auscultation&#46; A chest X-ray showed unilateral inferior rib notching of the 4&#8211;7th left ribs&#44; inferior left lung hypotransparency and prominent vasculature &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Angio-CT of the chest was performed and revealed relative reduction of enhancement of the left branch of the pulmonary artery &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; homolateral dilatation and tortuosity of the intercostal arteries &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4&#44; 6 and 7</a>&#41; with a tangle of arterial blood vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41; &#40;partially extrapleural&#44; transpleural and intraparenchymal&#41; draining to the left pulmonary artery&#46; Adjacent lung parenchymal changes as traction bronchiectasis were also observed &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; No CT signs of pulmonary hypertension were present and the caliber of the bronchial arteries was normal&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Selective arterial angiography of the 4&#8211;7th intercostal arteries was performed to confirm that the diagnosed vascular malformation was exclusively arterial &#40;<a class="elsevierStyleCrossRefs" href="#fig0045">Figs&#46; 9 and 10</a>&#41;&#44; demonstrating dilated intercostal arteries and an exclusive arterial fistula between left systemic and pulmonary arteries through a tangle of arterial blood vessels &#40;<a class="elsevierStyleCrossRefs" href="#fig0050">Figs&#46; 10 and 11</a>&#41;&#46; Bronchial arteries were not evaluated&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="fig0050"></elsevierMultimedia><elsevierMultimedia ident="fig0055"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">During this evaluation time&#44; the patient remained asymptomatic and a therapeutic approach &#40;embolization versus surgical approach&#41; has not yet been defined&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Clinical manifestations of the systemic-pulmonary arterial fistulae may be misinterpreted as patency of the ductus arterious or arterio-venous malformations and the symptoms depend&#44; in part&#44; on the functional repercussion that is proportional to the vessel size involved in the abnormal vascular anastomosis and heart distance&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a> Chest X-ray in this type of vascular malformations demonstrates unilateral inferior rib notching and lung hypotransparency&#44; suggesting pulmonary infiltrates and&#47;or increased blood vessels &#40;as in our case report&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the case reports described in the literature&#44; systemic pulmonary arterial anastomosis typically are multiple and arterio-venous malformations may be present with cardiovascular consequences&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In our case report&#44; there is no radiological sign of cardiovascular consequence since ICT &#40;cardiothoracic ratio&#41; and the caliber of the common pulmonary artery are normal and the fistula is exclusively arterial&#44; a finding that was angiographically confirmed by showing the arterial anastomosis between left intercostals arteries and left pulmonary artery&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">As far as systemic-pulmonary arterial anastomosis is concerned&#44; this case report represents an exceptional case&#44; regarding the exuberance of the shunt&#44; drainage pattern &#40;exclusively arterial&#41; and with no known functional consequences&#46; Transcatheter arterial embolization or surgical resection may be considered as therapeutic approaches in this type of vascular malformations&#44; however recurrences have been described in post-embolization procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Arterial systemic-pulmonary fistulae may present themselves via symptoms or may be asymptomatic and can be acquired or congenital&#46; The authors describe an exceptional case of arterio-arterial fistula&#44; remarkable for its radiological exuberance&#44; type of malformation that is an exclusive arterial fistula between intercostal systemic arteries and pulmonary artery with no pulmonary arteriovenous communication&#46; In our case&#44; the presence of parenchymal abnormalities&#44; such as bronchiectasis adjacent to the tangle of blood vessels&#44; may suggest a history of previous inflammatory&#47;infectious etiology&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors present a clinical case of a 35-year-old patient who was diagnosed with intercostal artery-to-pulmonary artery fistula and review the literature of systemic-to-pulmonary fistulae based on radiological findings of an exceptional case report&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores apresentam um caso cl&#237;nico de um doente de 35 anos a quem foi efetuado o diagn&#243;stico de f&#237;stula arterio-arterial sist&#233;mico-pulmonar e fazem uma revis&#227;o da literatura sobre f&#237;stulas arterio-arteriais sist&#233;mico-pulmonares baseado nos achados radiol&#243;gicos de um caso excecional&#46;</p></span>"
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