Transcatheter embolization of a Rasmussen aneurysm via pulmonary artery with n-butyl cyanoacrylate and iodized oil mixture injection with balloon occlusion

Glue ablation of Rasmussen's aneurysm in a case of epituberculosis

A woman in her 40s presented with massive haemoptysis and breathlessness for 1 day. She had been diagnosed with pulmonary tuberculosis based on sputum CBNAAT (Cartridge Based Nucleic Acid Amplification Test) and was on antitubercular treatment for previous 2 weeks. Her chest X-ray showed right middle lobe lateral segment dense consolidation with bilateral nodular infiltrates. CT pulmonary angiography (CTPA) revealed a well-defined homogenously enhancing vascular lesion of size 10×11×13 mm in the right hilar region communicating with the descending branch of right pulmonary artery, suggesting a Rasmussen's aneurysm. It was in close proximity to the segmental bronchus that was almost completely occluded, suggesting epituberculosis. Transvenous pulmonary artery glue embolisation successfully achieved complete ablation of the aneurysm with preserved arterial flow. She has later completed 6 months of antitubercular treatment and is cured with no recurrence of haemoptysis. Her lung infiltrates have resolved with some lung scarring.

Pulmonary Artery Aneurysm in Behcet Disease: Medical, Endovascular or Surgical Intervention

Behçet's disease is a chronic inflammatory condition that predominantly affects the body's blood vessels, exhibiting various clinical manifestations and complications. The exact cause remains unclear, but genetic predisposition, immune responses, and vascular activation are believed to contribute to its development. This disease is more prevalent in certain geographic regions and primarily affects young adults, particularly males. Pulmonary aneurysm, a complication of Behçet's disease, is the leading cause of mortality in Behcet disease. In this review, we summarize the complications of Behcet disease with a focus on pulmonary artery aneurysms. We discussed the medical, endovascular, and surgical management of pulmonary aneurysms in Behcet disease and the indications and outcomes of the different treatment options. Corticosteroids and cyclophosphamide remain the preferred first-line therapy. However, clinical improvement with infliximab or adalimumab, tumor necrosis factor-alpha (TNFα) blocking agents, have been reported after treatment failure with recommended first-line agents. In patients who fail medical therapy or those with life-threatening hemoptysis, endovascular or surgical intervention is the next option. Endovascular interventions include pulmonary artery embolization with coils or acrylic glue and using plugs, occluders, or stents. Endovascular interventions usually have fewer adverse effects than surgery. Although the risk of surgical procedures is high in pulmonary artery aneurysms, it could be a life-saving procedure in patients with life-threatening hemoptysis. Surgical options, including pulmonary artery ligation, aneurysmorrhaphy, segmentectomy, lobectomy, or pneumonectomy are available. However, the results of surgical therapy for Behçet aneurysms are often disappointing.

Endovascular treatment for massive haemoptysis due to pulmonary pseudoaneurysm: report of 23 cases

PURPOSE

To evaluate the safety and effectiveness of endovascular treatment for massive haemoptysis caused by pulmonary pseudoaneurysm (PAP).

METHODS

The clinical data, imaging data, and endovascular treatment protocol of 23 patients with massive haemoptysis caused by continuous PAP were retrospectively analysed. The success, complications, postoperative recurrence rate, and influence of the treatment on pulmonary artery pressure were also evaluated.

RESULTS

Nineteen patients with a bronchial artery-pulmonary artery (BA-PA) and/or nonbronchial systemic artery-pulmonary artery (NBSA-PA) fistula underwent bronchial artery embolization (BAE) and/or nonbronchial systemic artery embolization (NBSAE) + pulmonary artery embolization (PAE). The pulmonary artery (PA) pressures before and after embolization were 52.11 ± 2.12 (35-69 cmH2O) and 33.58 ± 1.63 (22-44 cmH2O), respectively (P = 0.001). Four patients did not have a BA-PA and/or NBSA-PA fistula. Embolization was performed in two patients with a distal PAP of the pulmonalis lobar arteria. Bare stent-assisted microcoils embolization was performed in the other two patients with a PAP of the main pulmonary lobar arteries. The PA pressures of the four patients before and after treatment were 24.50 ± 1.32 (22-28 cmH2O) and 24.75 ± 1.70 (22-29 cmH2O), respectively (P = 0.850). The technique had a 100% success rate with no serious complications and a postoperative recurrence rate of 30%.

CONCLUSION

Endovascular treatment is safe and effective for massive haemoptysis caused by PAP. BAE and/or NBSAE can effectively reduce pulmonary hypertension in patients with a BA-PA and/or NBSA-PA fistula.

Rasmussen’s Aneurysm, Rare yet Acknowledged Cause of Massive Hemoptysis: Retrospective Review of 16 Cases

Objectives: Rasmussen’s aneurysm may cause life-threatening hemoptysis. We investigated the clinical characteristics and outcomes of patients with hemoptysis and Rasmussen’s aneurysm.Methods: We retrospectively investigated patients who clinically presented with hemoptysis and were diagnosed with a Rasmussen’s aneurysm on spiral chest computed tomography (CT).Results: Our study included 16 patients (men:women, 12:4; mean age, 65.25 ± 13.0 years). Massive hemoptysis was observed in nine patients (56%) and blood-tinged sputum in four patients (25%). Ten patients (62.5%) had a history of pulmonary tuberculosis, and three patients (18.7%) had underlying lung cancer. Chest CT revealed coexisting fungal balls in seven patients (43.7%). Bronchial artery embolization (BAE) was performed in 12 patients (75%). One patient died of uncontrolled massive hemoptysis.Conclusions: Patients with Rasmussen’s aneurysm showed hemoptysis during the course of the disease; however, bleeding can be controlled with conservative therapy and radiological interventions, such as BAE.

In Vivo Animal Study of a Highly Viscous N-butyl Cyanoacrylate Medical Adhesive for Intravenous Embolization

N-butyl cyanoacrylate (NBCA) is a liquid monomer that undergoes an exothermic polymerization reaction to form a solid upon initiation with hydroxyl anions. Recently, EGpresto, a highly viscous NBCA-based adhesive, has been developed for vascular-occlusion purposes. In this study, we investigated the heat of polymerization of EGpresto and compared the results with those of a low-viscosity NBCA glue. Results show that EGpresto exhibited a lower heat of polymerization (64 ± 7 °C vs. 34 ± 1 °C). This was due to its high viscosity, which resulted in a delayed polymerization time. To investigate the efficacy and safety of EGpresto for intravenous embolization, a 14 d in vivo animal test was conducted using three pigs. Five cc of EGpresto was injected into the epigastric vein of each animal. Complete postoperative vein occlusion was confirmed at 7 and 14 d by ultrasonographic visualization. After the animals were sacrificed, the operated and unoperated veins were exposed, and the injected adhesive was found without migration. During the histology, the injected adhesive was not found in the inner or outer vein walls, and the immune reactions seemed to be the only foreign-body reaction, showing that EGpresto is a non-toxic and safe intravascular embolic agent.

Percutaneous transthoracic embolisation for massive haemoptysis secondary to peripheral pulmonary artery pseudoaneurysms

OBJECTIVE

Pulmonary artery pseudoaneurysms (PAPs) are rare, but important and treatable cause of massive haemoptysis. Minimal data exists on their interventional radiology management due to their rarity, especially direct percutaneous injection. Here, we report our experience of direct percutaneous management of such pseudoaneurysms.

METHODS

Data of patients presenting to our department from January 2014 to November 2019 was retrospectively analysed, who presented with massive haemoptysis, and CT angiography positive for pulmonary artery pseudoaneurysms. Only patients treated with direct percutaneous intervention were included. Twelve patients who were managed endovascularly were excluded from the study. Observations were tabulated under age, sex, underlying pathology, lobe involved, number and size of the pseudoaneurysm, imaging guidance and embolising agent. Technical and clinical success and complications were then analysed.

RESULTS

Twenty-nine pseudoaneurysms were treated in 27 patients with a mean age of 41.4 years. The most common underlying aetiology was tuberculosis (85.1%), with the most common location being bilateral upper lobes (31% each). CT guidance was the most frequently used imaging guidance (26/29). N-butyl cyanoacrylate (NBCA) glue mixture was used in 79.3% and reconstituted thrombin in the remaining 20.7% pseudoaneurysms. Complete technical and clinical success rates were 93.1% and 88.9% respectively. No major complications were seen except for development of significant pneumothorax in one patient.

CONCLUSION

Pulmonary pseudoaneurysms are rare but fatal cause for massive haemoptysis. Interventional radiology management via direct percutaneous embolisation is a safe and minimally invasive treatment measure in selective patients, with successful outcomes and minimal complication and recurrence rates.

KEY POINTS

• Pulmonary artery pseudoaneurysms are rare but important and treatable cause of massive haemoptysis. • This study shows the advantages of percutaneous management of these pseudoaneurysms as an alternate to endovascular embolisation, in case endovascular embolisation is not feasible or practical. • It is a safe and minimally invasive treatment, with technical success of 93.1% and clinical success of 88.9% in this study.

Transcatheter Proximal Coil Blocking with n-Butyl-2-Cyanoacrylate Injection via the Pulmonary Artery Alone for Rasmussen's Aneurysm

Rasmussen's aneurysm is a peripheral pulmonary artery pseudoaneurysm (PAP) within a tuberculosis cavity. Because it can be perfused from the bronchial and pulmonary arterial circulations, combined embolization via the bronchial and pulmonary arteries is sometimes required. Herein, we present case of a 51-year-old man with Rasmussen's aneurysm that was successfully treated by proximal coil blocking with n-butyl-2-cyanoacrylate (NBCA) injection via the pulmonary artery alone. With proximal coil blocking, a sufficient amount of NBCA could be injected without unintended reflux of the NBCA cast to the proximal pulmonary artery. To our knowledge, there has been no report that attempted NBCA injection under proximal coil blocking for Rasmussen's aneurysm. Our treatment approach may be safe and effective for infectious lung disease-related PAP, which has to be treated from the pulmonary artery side.