A rare cause of unilateral rib notching.

From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, India. Manuscript received September 27, 2012; accepted October 2, 2012. A19-year-old male with cyanosis and clubbing was diagnosed with tetralogy of Fallot (TOF). Chest x-ray (A) showed prominent rib notching involving the left hemithorax (arrow). Major aortopulmonary collaterals (arrows) suggested by the rib notching were confirmed by a computerized tomogram (B, C, Online Video 1). Post-operatively he had pulmonary edema, secondary to these collaterals. Aortic angiogram (H, Online Video 2) showed tortuous posterior intercostal arteries eroding the lower margins of the corresponding ribs. Indirect collaterals arising from these vessels were supplying the left lung that were successfully coil embolized (I, Online Video 3). The TOF anatomy is demonstrated from D to G. Rib notching secondary to Major aortopulmonary collaterals is rare, as they do not run in the intercostal grooves (1), but when they arise from the inter costal arteries, notching of ribs could be expected as in this case. @ infundibular pulmonary stenosis; IVS interventricular septum; LA left atrium; LPA left pulmonary artery; LV left ventricle; PA pulmonary artery; RPA right pulmonary artery; RV right ventricle; VSD ventricular septal defect. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.10.062