Aneurysms of the Pulmonary Artery

Aortic and Pulmonary Valve Reconstruction Using Autologous Pericardium in Narrow Annuli

A 71-year-old woman with pulmonary artery aneurysm had a complication of pulmonary valve stenosis with estimated right ventricular pressure 135 mm Hg and severe aortic valve stenosis with peak pressure gradient 112 mmHg. Coronary angiography revealed stenosis of the left coronary arterial system. Because she presented with narrow pulmonary annulus (16.7 mm) and aortic annulus (19.7 mm), we decided to perform aortic and pulmonary valve reconstruction using autologous pericardium. We performed aneurysmorrhaphy of the pulmonary artery, dual-valve reconstruction, and coronary artery bypass grafting. Postoperative echocardiography showed good opening of dual valves without regurgitation; estimated right ventricular pressure was 23 mm Hg.

Giant right pulmonary artery aneurysm in a systemic-to-pulmonary artery shunt

Aneurysms of the pulmonary arteries and trunk are rare entities. The Waterston shunt is a palliative procedure for children with cyanotic CHD due to obstruction of the pulmonary outflow. Described complications are distortion of the pulmonary artery and pulmonary arterial hypertension. We report a patient with a giant right pulmonary artery aneurysm in relation to a Waterston shunt.

Extrinsic compression of left main coronary artery by aneurysmal pulmonary artery in severe pulmonary hypertension: its correlates, clinical impact, and management strategies

Aims

Although left main coronary artery (LMCA) compression (Co) by pulmonary artery (PA) aneurysm (A) has been reported in some pulmonary hypertension (PH) series, clinical importance and management of this complication remain to be determined. In this single-centre prospective study, we evaluated correlates, clinical impact, and management strategies of LMCA-Co in patients with PH.

Methods and results

Our study group comprised 269 (female 166, age 52.9 ± 17.3 years) out of 498 patients with confirmed PH who underwent coronary angiography (CA) because of the PAA on echocardiography, angina or incidentally detected LMCA-Co during diagnostic evaluation with multidetector computed tomography. The LMCA-Co ≥ 50% was documented in 22 patients (8.2%) who underwent CA, and stenosis were between 70% and 90% in 14 of these. Univariate comparisons revealed that a younger age, a D-shaped septum, a higher PA systolic, diastolic, and mean pressures and pulmonary vascular resistance, a larger PA diameter, a smaller aortic diameter and pulmonary arterial hypertension associated with patent-ductus arteriosus, atrial or ventricular septal defects were significantly associated with LMCA-Co. Bare-metal stents were implanted in 12 patients and 1 patient underwent PAA and atrial septal defect surgery and another one declined LMCA stenting procedure.

Conclusion

Our study demonstrates that LMCA-Co is one of the most important and potentially lethal complications of severe PH, and alertness for this risk seems to be necessary in specific circumstances related with PAA. However, long-term benefit from stenting in this setting remains as a controversy.

Pulmonary artery aneurysms: Preoperative, intraoperative, and postoperative findings

BACKGROUND

Pulmonary artery aneurysms (PAAs) are a rare but potentially lethal cardiovascular pathology. PAAs tend to develop in young patients with no gender discrepancy; they are most often associated with congenital heart disorders but also with systemic infections, vasculitis, pulmonary arterial hypertension, chronic pulmonary embolism, and malignancies. Dissection and rupture carry significant morbidity and mortality, thus patients require careful management, especially those with associated pulmonary hypertension. Given the rarity of this condition, physicians have yet to establish standard treatment guidelines. Most studies published to date are case reports with one or two patients; here, we describe our experience with six cases of large PAAs treated surgically at our institution.

METHODS

We identified and retrospectively analyzed clinical data for patients who underwent surgery for PAAs between 2009 and 2017.

RESULTS

The average age at surgery was 59.73 years, five patients were females, and 83.3% had baseline hypertension. Systolic murmurs were the most common clinical finding. The average aneurysmal size was 65.0 mm. We repaired the PAA with a woven Dacron graft (22-26 mm) in four patients. We performed concomitant pulmonary valve procedures on five patients: four replacements and one repair. Mean pump and cross-clamp times were 108.5 and 65 minutes. Operative and 30-day mortality was 0%. Average length of stay was 10.5 days.

CONCLUSIONS

Postoperative mortality was 0%; all patients showed improvement of symptoms after surgery. These findings confirm that PAA repair has an acceptable risk profile in select patients.

Minimally Invasive Pulmonary Artery Aneurysm Repair Through a Left Anterior Minithoracotomy-an Alternative Approach

The purpose in this case was to repair a less invasive approach than a standard sternotomy. Workup of asymptomatic patient with computerized tomography scan of chest revealed pulmonary artery aneurysm and transesophageal echocardiography demonstrated flow stagnation in aneurysm. An alternative minimally invasive approach was performed to repair the pulmonary artery aneurysm with plication through a left anterior minithoracotomy using normothermic cardiopulmonary bypass with percutaneous peripheral cannulation, instead of median sternotomy. Post-repair transesophageal echocardiography demonstrated normal flow in the pulmonary artery. The patient had an uneventful postoperative course and was seen in the outpatient clinic with excellent recovery. Minimally invasive repair of pulmonary artery aneurysm through a left anterior minithoracotomy is a feasible alternative approach. Minimally invasive repair of pulmonary artery aneurysm through a left anterior minithoracotomy is a feasible alternative approach.

Transcatheter embolization for idiopathic peripheral pulmonary arterial aneurysm: A case report

The natural history of idiopathic peripheral pulmonary arterial aneurysms (PAAs) is unclear; however, they can cause sudden death by rupture. Our case illustrates the utility and low invasiveness of transcatheter embolization using an AMPLATZER™ Vascular Plug 4 and hydrogel-coated metallic coils in patients with idiopathic peripheral PAAs.

Frequency, Predictors, and Prognostic Impact of Pulmonary Artery Aneurysms in Patients With Pulmonary Arterial Hypertension

Detection of pulmonary artery aneurysms (PAA) in pulmonary arterial hypertension (PAH) is increasing. We sought to determine the frequency of PAA in a PAH cohort, variables related to its development and its prognostic impact. We conducted a retrospective analysis of PAH patients who underwent a computed tomography or magnetic resonance. PAA was defined as a pulmonary artery >40 mm. Baseline, echocardiographic, and hemodynamic findings at PAH diagnosis were compared. Freedom from death or lung transplant was estimated by Kaplan-Meier method and compared by log-rank test. Predictors of PAA development were analyzed with multivariate models. Two-hundred patients underwent a computed tomography and/or magnetic resonance. In 77 (38%), a PAA (48.3 ± 7.2 mm) was detected. Time-course (months) of PAH was an independent risk factor for PAA (hazard ratio 1.01; 95% confidence interval 1.002 to 1.019; p = 0.016) whilst connective tissue disease was associated with a lower risk (hazard ratio 0.236; 95% confidence interval 0.060 to 0.920; p = 0.037). PAA patients showed lower rates of death and lung transplant from PAH diagnosis (p = 0.005), but no differences appeared when survival analysis was performed from first imaging test (p = 0.269). PAA patients presented a nonsignificant higher rate of sudden death (5% PAA vs 1% no-PAA; p = 0.073). In conclusion, the frequency of PAA was 38%. PAH time-course was an independent risk factor for PAA development whereas connective tissue disease -related PAH patients showed a lower risk. PAA patients showed lower rates of death or lung transplant from PAH diagnosis but no differences were found from imaging test. PAA patients had a nonsignificant higher rate of sudden death.

Improvement of lung function and pulmonary hypertension after pulmonary aneurysm repair: case series

Pulmonary artery aneurysms (PAA) can be complicated with pulmonary arterial hypertension (PAH), causing sudden death due to PA rupture and dissection. Because treatment with PAH-targeted drugs does not always prevent PAA progression, prophylactic surgical repair of the PAA seems a promising alternative. However, although it avoids rupture and dissection of the PAs, additional benefits have not been forthcoming. We therefore present two patients with co-existing PAH and a PAA who underwent surgical repair of the aneurysm. Following the surgery, their lung function and pulmonary hypertension improved. Optimal treatment of PAA remains uncertain, however, with no clear guidelines regarding the best therapeutic approach. This case series provides physicians with reasons to repair PAA surgically in patients with PAH.

Left main coronary artery compression by pulmonary artery aneurism in patients with long standing pulmonary arterial hypertension

This review focuses on a rare complication of pulmonary arterial hypertension (PAH), extravasation compression of the left coronary artery (LCA) dilated by the pulmonary artery. The review described clinical manifestations and methods for diagnostics of LCA compression, and advantages of the endovascular correction of this complication in patients with pulmonary hypertension. Selection of a device to be implanted during the endovascular intervention in these patients was discussed with due account for concomitant treatment with oral anticoagulants. As an illustration of the issue under discussion, a clinical case of acute coronary syndrome in a female patient from the PAH Registry of the V. A. Almazov National Medical Research Center was provided.

Isolated Congenital Dysgenesia of a Pulmonary Valve Cusp Presenting as a Pulmonary Artery Aneurysm

Pulmonary artery aneurysm is a rare disorder, with the underlying pathology remaining obscure in many instances. More common causes include pulmonary hypertension, poststenotic dilation, or vasculitis. In this case series, we report 3 patients presenting with isolated pulmonary artery aneurysms in whom multimodality imaging revealed the dysgenesia of a single pulmonary valve cusp as the cause of the huge pulmonary aneurysm.

Crucial role of angiography in the surgical planning of a pulmonary artery aneurysm

A 46-year-old woman was found to have an aneurysm of the superior segmental pulmonary artery in the right lower lung lobe on computed tomography images. Moreover, angiography revealed dilated bronchial arteries flowing into the aneurysm with neovascularization, and the contrast medium was partially pooled in the basal segment of the same lobe. The patient's hemoptysis could not be controlled by an interventional radiology procedure. Therefore, lobectomy was carried out instead of aneurysmectomy. There has been no recurrence for 4 years after surgery. We considered that that angiographic information allowed for the most appropriate operation in this case.

Left main coronary artery compression by a large pulmonary artery aneurysm in the absence of pulmonary hypertension: a case report

Background

Pulmonary artery aneurysms (PAAs) are rare and they are infrequently diagnosed due to the non-specificity of their symptoms. However, their related complications, mainly described in patients with pulmonary hypertension (PH), are associated with significant morbidity and mortality.

Case summary

We report the case of a 64-year-old woman previously operated on for pulmonary valve stenosis, who presented with rapid worsening of dyspnoea and sudden onset of chest pain. Physical examination did not show heart failure symptoms, and an echocardiogram showed significant but not severe pulmonary regurgitation with preserved right and left ventricular function. Estimated pulmonary artery (PA) pressure was normal. As myocardial ischaemia was suspected the patient underwent a coronary computed tomography angiography that showed compression of the left main coronary artery by a large PAA. Early diagnosis led to surgery that solved her symptoms.

Discussion

Comprehensive medical evaluation of symptomatic patients with PA dilatation, even in the absence of PH, is key to rule out the possibility of serious complications as soon as possible.

Bilateral semilunar perihilar opacities in a patient with pulmonary hypertension

Pulmonary arterial aneurysm is a rare entity with a high mortality if left untreated. Pulmonary arterial hypertension is an important cause of PAAs although other infective and auto-immune causes must be excluded when an aneurysm is identified.

The Pulmonary Artery in Pediatric Patients with Marfan Syndrome: An Underestimated Aspect of the Disease

Aortic root dilatation and its complications are known to be the most important and life limiting features in patients with Marfan syndrome (MFS). Since monitoring of patients, preventive medical and surgical treatments are available nowadays, other MFS pathologies are becoming more relevant for the outcome of the disease. Main pulmonary artery (MPA) dilatation is a cardiac finding, which has not been fully investigated in children. Due to the similarities in tissue composition of the aortic and pulmonary root, MPA dilatation may cause complications and require treatment. In addition, it may be a predictor for severe connective tissue involvement. We retrospectively examined 135 pediatric patients with MFS. 8.1% showed MPA dilatation. MPA dilatation was associated with earlier occurrence of aortic dilatation, mitral valve prolapse, and systemic manifestations of MFS compared with patients without MPA dilatation (p < 0.05). The presence of MPA dilatation was also associated with a higher incidence of ectopia lentis (p < 0.05). Medical treatment was started earlier in MPA dilatation patients than in those without (p < 0.05). We conclude that MPA dilatation is a sign of more severe vascular and connective tissue involvement. Regular examination of the pulmonary artery is essential in MFS to avoid complications. As medical treatment of life threatening MFS events has improved, other features of MFS need to be investigated to improve quality of life.

Prevalence and prognostic significance of pulmonary artery aneurysms in adults with congenital heart disease

BACKGROUND

Prevalence and prognostic significance of pulmonary artery (PA) dilatation in congenital heart disease (CHD) have never been studied systematically.

METHODS

Chest X-rays of 1192 consecutive adults with CHD were reviewed. Major diameter of the PA was determined by imaging techniques in those with PA dilatation. A value >29 mm was considered abnormal. Data on anatomy, hemodynamics, residual lesions and outcomes were retrospectively collected.

RESULTS

Overall prevalence of PA dilatation was 18%. A minority of patients (5.5%) reached 40 mm (aneurysm; PAA) and 1.8% exceeded 50 mm. The most common PAA underlying malformations were pulmonary stenosis (21%), and shunts (55%). Significantly larger diameters were observed in hypertensive shunts (40 mm; IQR 36.7-45 mm vs. 34 mm; IQR 32-36 mm) (p < 0.0001). However, the largest diameters were found in cono-truncal anomalies. There was no significant correlation between PA dimensions and systolic pulmonary pressure (r = -0.196), trans-pulmonary gradient (r = -0.203), pulmonary regurgitation (PR) (r = 0.071) or magnitude of shunt (r = 0.137) (p > 0.05 for all). Over follow-up, 1 sudden death (SD) occurred in one Eisenmenger patient. Complications included coronary (3), recurrent laryngeal nerve (1) and airway (1) compressions, progressive PR (1), and PA thrombosis (1). Coronary compression and SD were strongly associated (univariate analysis) with pulmonary hypertension (120 vs. 55 mm Hg; p = 0.002) but not with extreme PA dilatation (range: 40-65 mm).

CONCLUSIONS

PA dilatation in CHD is common but only a small percentage of patients have PAA. Clinical impact on outcomes is low. Complications occurred almost exclusively in patients with pulmonary hypertension whereas PA diameter alone was not associated with adverse outcomes.

Acquired peripheral pulmonary artery aneurysms: morphological spectrum of disease and multidetector computed tomography angiography findings-cases series and literature review

BACKGROUND

Acquired peripheral or intraparenchymal pulmonary artery aneurysms (PPAA) are rare entities but are important to recognize because of the associated morbidity. Hemoptysis is their principal complication and is a potentially fatal condition.

PURPOSE

To illustrate the causes, multidetector CT angiography (MDCTA) findings and differential diagnosis of acquired PPAA.

MATERIALS AND METHODS

The institutional review boards approved this study. We conducted a retrospective review of the demographic data and the results of clinical and laboratory examinations, and imaging studies of patients managed between January 2012 and January 2017 in two institutions.

RESULTS

A total of 19 patients had acquired PPAA that were detected at MDCTA, 9 patients with normal pulmonary artery pressures and 10 with pulmonary hypertension. Nine patients developed PPAA-related acute symptoms. MDCTA features of PPAA include: a lobulated vascular mass, an indistinct irregular arterial wall, aneurysmal thrombosis or wall calcification, findings of impending rupture including perianeurysmal edema, gas or a soft tissue mass.

CONCLUSION

PPAA are rare. In our series, endocarditis and pulmonary hypertension are the PPAA leading causes. The treatment modality preferred is embolization, especially as surgery poses a very high risk for patients with severe pulmonary hypertension. Further clarification of the natural history of these rare arterial aneurysms is needed.

Isolated large vessel pulmonary vasculitis leading to pulmonary artery aneurysm formation: a case report and literature review

Pulmonary artery (PA) vasculitis occurs in association with primary vasculitides—in particular, giant cell arteritis, Takayasu’s arteritis, or Behçet’s disease—or secondary vasculitis as a result of infections or malignancy. However, PA vasculitis in isolation and with concomitant aneurysmal dilation is an unusual finding. We present a rare case of PA aneurysm secondary to isolated PA vasculitis in an asymptomatic patient with no features of systemic vasculitis. This case highlights one of the first cases of PA vasculitis managed with surgical resection alone.

Acute and chronic dissection of pulmonary artery: new challenges in pulmonary arterial hypertension?

Right ventricular failure is a leading cause of mortality in patients with pulmonary arterial hypertension (PAH). However, up to 25% of such patients die unexpectedly, without warning signs of hemodynamical decompensation. We previously documented that pulmonary artery (PA) dilatation significantly increases the risk of those deaths. Some of them may be due to dissection of PA resulting in cardiac tamponade. However, direct confirmation of this mechanism is difficult as most of such deaths occur outside hospitals. We present 4 patients with severe PAH and PA dilatation in whom PA dissection has been confirmed. Three patients had IPAH, one had PAH associated with congenital heart disease. All patients had mean pulmonary artery pressure (PAP) > 50 mmHg at diagnosis and dissection occurred late in the course of apparently well controlled disease (6 to 14 years). Several clinical elements were common to our patients - high systolic PAP, long lasting PH, progressive dilatation of PA to more than 50 mm with chest pain prior to dissection. However, clinical course followed three different patterns: sudden death due to cardiac tamponade, hemopericarditis caused by blood leaking from dissected aneurysm with imminent but not immediate cardiac tamponade, or chronic asymptomatic PA dissection. Indeed, two of our patients are alive and on lung transplantation waiting list for more than 2 years now. Further research is needed to suggest optimal management strategies for patients with stable PAH but significantly dilated proximal pulmonary arteries or confirmed PA dissection depending on the clinical presentation and expected outcome.

A Rare Case of Hemopericardium From a Ruptured Dissecting Pulmonary Artery Aneurysm: Postmortem Computed Tomography Scan and Autopsy Findings

Nontraumatic hemopericardium is a potentially fatal pathology that is most commonly caused by myocardial wall rupture, ruptured aortic dissection, aortic aneurysm rupture, or a neoplastic process. A rare potential cause of hemopericardium is pulmonary artery dissection, with less than 100 reported cases in the literature. Pulmonary artery dissection is associated with pulmonary artery aneurysm, pulmonary artery hypertension, and congenital heart disease. We report a fatal case of nontraumatic hemopericardium caused by a ruptured dissecting pulmonary artery aneurysm in a 16-year-old girl with patent ductus arteriosus. The unenhanced postmortem computed tomography performed before autopsy was able to identify a large hemopericardium with a pulmonary artery aneurysm and lifting of mural calcification suggestive of a dissecting aneurysm. This enabled the pathologist to locate the exact rupture site that caused the hemopericardium.

[Use of endobronchial ultrasound in the management of cryptogenic haemoptysis]

Currently about 50% of cases of haemoptysis are thought to be cryptogenic. Haemorrhage from the pulmonary arterial system is rare and usually due to aneurysms or pseudoaneurysms, the radiological diagnosis of which is often difficult. We report here the case of a patient admitted with a heavy haemoptysis in whom the thoracic CT scan did not reveal the diagnosis. Bronchoscopy with endobronchial ultrasound showed a vascular malformation of a branch of the pulmonary artery allowing a radiological embolisation. This case underlines the importance of bronchoscopy and the role of ultrasound in the diagnosis of haemoptysis, considered ideopathic, complicating vascular malformations.

Aneurysms of the azygos vein

OBJECTIVE

Azygos vein aneurysms (AVAs) are uncommon and infrequently diagnosed. When confronted with a patient presenting with an AVA, physicians can rely on only a few case reports after an extensive literature search. To date, no guideline, no rule, and no review on the optimal treatment strategy for these patients exist.

METHODS

A PubMed and MEDLINE database search for papers and case reports describing AVA was performed. Cases from our own institutions were also reviewed.

RESULTS

The literature search identified 57 published case reports that were reviewed for inclusion. Of those published cases, etiologic factors can be classified into idiopathic, acquired, and traumatic causes. Most AVAs are limited to the azygos arch, a congenital anatomic weak point. Clinical symptoms generally remain nonspecific. Computed or magnetic resonance tomography scans are effective diagnostic tools, although the optimal therapeutic plan remains unclear. Complications include rupture, thromboembolism, mediastinal mass effects, and pulmonary artery hypertension.

CONCLUSIONS

Conservative treatment along with oral anticoagulation may be reasonable for some AVAs, but to date, there is no clear guideline or evidence-based threshold for surgical or interventional therapy. In review of the existing data and from our clinical and scientific knowledge, interventional or surgical treatment should strongly be considered in cases with clinical symptoms, pulmonary embolism or pulmonary arterial hypertension, thrombus formation within the AVA in patients with oral anticoagulation or for patients with a contraindication to oral anticoagulants, considerable increase in diameter or compression of adjacent structures, saccular AVA, or an underlying connective tissue disease. The most common procedure is surgical ligation of the AVA, although endovascular occlusion of the aneurysms is becoming more frequent.

Dehiscence of a pulmonary bioprosthesis with a focal dissection of the pulmonary artery in a patient with congenital pulmonic stenosis

Pulmonary valve replacement (PVR) is the most common adult congenital cardiac operation performed. Valve degeneration leading to prosthetic stenosis and/or regurgitation is a long-term risk in this population and may be associated with paravalvular leak (PVL). Complications involving the proximal pulmonary artery, including dissection, are less clearly defined. Herein, we report the case of a 30-year-old patient with a history of multiple pulmonary valve interventions secondary to congenital pulmonic stenosis, who developed dehiscence of a bioprosthetic PVR associated with significant paravalvular leak (PVL) and further complicated by a focal dissection of the proximal pulmonary artery.

Huge idiopathic pulmonary artery aneurysm

A pulmonary artery aneurysm is an uncommon anomaly. The clinical manifestations are mostly nonspecific, and management is controversial. We report a case of a 67-year-old woman with a main pulmonary artery aneurysm who did not take surgical intervention. Subsequently, there was no increase in size for 3 years.

Cardiac dysfunction of pulmonary artery aneurysm in patients with pulmonary arterial hypertension

BACKGROUND

Pulmonary artery aneurysm (PAA) occurs in some patients with pulmonary arterial hypertension (PAH). We evaluated the characteristics of cardiac dysfunction in patients with PAH complicated by PAA.

METHODS

Echocardiography and right-heart catheterization were performed in 130 PAH patients to measure the maximum dimensions of the main pulmonary artery (MPA) trunk and evaluate right ventricular (RV) and left ventricular (LV) function.

RESULTS

A diameter of >40mm was defined as PAA in the MPA trunk. The maximum MPA diameter was >40mm in 32 of 130 PAH patients (24.6%: Group PAA). Systolic pulmonary artery pressure (68.0±18.5 vs. 58.9±21.6mm Hg, P=0.0354) and pulmonary capillary wedge pressure (10.8±3.9 vs. 7.7±2.6mm Hg, P<0.0001) were significantly higher in Group PAA than in Group non-PAA. RV end-diastolic area index (19.6±6.8 vs. 14.9±5.1 cm²/m², P<0.0001), and RV fractional area change (32.3±7.8 vs. 37.3±8.8%, P=0.0048) and RV longitudinal strain (-15.4±5.1 vs. -20.4±6.1, P=0.0012) were significantly lower, and E/e' was significantly higher (8.1±2.2 vs. 6.7±1.4, P=0.0002) in Group PAA than in Group non-PAA.

CONCLUSIONS

In PAH patients with PAA, RV was larger and RV dysfunction was more severe, and LV diastolic dysfunction appeared. It is important to investigate the appearance of PAA and the severity of RV and LV dysfunction in PAH patients with PAA.

Development of Pulmonary Artery Aneurysms Due to Behçet's Disease and Resolution after Treatment

We herein describe a patient with Behçet's disease in whom we followed the development and resolution of pulmonary artery aneurysms. He presented with intermittent hemoptysis, pulmonary thromboembolism was initially diagnosed, and anticoagulant therapy was started. Over the next several months, the expansion of pulmonary arteries was noted. Five months after his initial admission, he was readmitted for massive hemoptysis, and further examinations revealed that he had Behçet's disease. Corticosteroids and intravenous cyclophosphamide were started. Over the next five months, the pulmonary artery aneurysms and thrombosis resolved. The development of pulmonary artery aneurysms led to the diagnosis of Behçet's disease, and they resolved after immunosuppressive therapy.