Endovascular stent graft treatment of a pulmonary artery pseudoaneurysm

Rasmussen aneurysm: Case series of a rare complication of Pulmonary Tuberculosis

Rasmussen aneurysm refers specifically to a pseudoaneursysmal dilatation of a branch of the pulmonary artery adjacent or within a tuberculous cavity. The incidence of pulmonary vascular complication secondary to tuberculosis is very rare hence underdiagnosed by many clinicians. It can present with life threatening haemoptysis and CT angiography plays an important role in localizing the lesion and guiding treatment. On contrary the most common cause of massive haemoptysis is of bronchial artery origin. Early diagnosis and proper interventions are essential as it is associated with high mortality. Herein we report three cases of Rasmussen aneurysm in patients with haemoptysis. Only one patient underwent emergency trans-arterial embolization of the involved pulmonary artery.

Ruptured pulmonary artery pseudoaneurysm treated with stent graft: case report and literature review

Background

Hemoptysis is a severe condition, associated with a high mortality rate from asphyxiation. Less than 5% of cases come from the pulmonary arterial circulation and large pseudoaneurysm are rarely treatable by stent graft.

Case presentation

We present the case of a 74-year-old man who suffered from a new onset of hemoptysis despite a prior bronchial artery embolization. He underwent a rescue endovascular stent graft placement for a massive hemoptysis caused by a ruptured proximal pulmonary artery pseudoaneurysm. A short review of similar situations is provided.

Conclusion

Salvage endovascular stent graft placement for a massive hemoptysis caused by a ruptured proximal pulmonary artery pseudoaneurysm is a viable salvage technique for life-threatening hemoptysis.

Rasmussen's pseudoaneurysm- case report

Background

Pulmonary aneurysms and pseudoaneurysms have various etiologies; however, the term Rasmussen's pseudoaneurysm refers specifically to a focal dilatation of a branch of the pulmonary artery into adjacent tuberculous cavity. The incidence of such tuberculosis related pulmonary vascular complication is extremely rare, hence, under recognized by many physicians. Management of pulmonary pseudoaneurysms is challenging as they present by life-threatening hemoptysis. Furthermore, contrary to the most causes of massive hemoptysis their bleeding is of pulmonary rather than bronchial artery origin. Prompt diagnosis and early interventions are needed as a very high mortality rate is associated with this illness.

Case description

We are reporting on a case of a young male who was presented to our hospital with recurrent episodes of massive hemoptysis and was diagnosed to have pulmonary tuberculosis. Despite being actively treated, his hemoptysis persisted. We describe in this case the role of different diagnostic modalities and the available therapeutic options.

Conclusion

Rasmussen's psudoaneurysm is rare and potentially lethal pulmonary vascular complication of tuberculosis. It should be considered in the differential diagnosis of hemoptysis in patients known or suspected to have pulmonary tuberculosis. In such cases, multidetector computed tomography (MDCT) scanning is the investigation of choice to confirm the diagnosis and to localize the source of bleeding prior to the therapeutic interventions. Head to head comparison between interventional radiology procedures and surgery in treatment of pulmonary psudoaneurysms is lacking, thus, choice depend on the availability and local expertise.

A Case of Ruptured Aneurysm of the Proper Esophageal Artery with Symptomatic Mediastinal Hematoma

Mediastinal aneurysms are rare but potentially life-threatening. Among these, bronchial artery aneurysms are most frequently reported, whereas up to now aneurysms of the proper esophageal artery had never been reported. A 69-year-old woman was referred to our hospital for treatment of a massive mediastinal hematoma. Enhanced computed tomography and selective proper esophageal arteriography revealed a 5-mm aneurysm in the proper esophageal artery that arises from the thoracic aorta at the Th8 level and has an anastomotic branch with the bronchial artery peripherally. Transcatheter arterial embolization was successfully performed using a mixture of N-butyl cyanoacrylate and lipiodol (1:3 ratio, 0.3 ml). Post-embolization angiography showed no filling into the aneurysm. The patient recovered with no complications and was discharged on the 25th post-procedure day.

Innovative endovascular technique for treatment of rare cause of haemoptysis in young

A 17-year-old boy reported for evaluation of two episodes of massive haemoptysis. His clinical examination was unremarkable and investigations (haemogram, coagulogram, serological tests for connective tissue disorders) were normal. A 64-slice CT angiography revealed a saccular aneurysm of 3.8×3.7×3.3 cm arising from the right lower lobe pulmonary artery which was confirmed by cardiac catheterisation. The aneurysm was successfully blocked with a 16-14 Amplatzer duct occluder. A repeat CT angiogram performed after 15 days revealed the device in situ obliterating the aneurysm. Pulmonary artery aneurysm is an extremely rare cause of massive haemoptysis and indicates imminent rupture of the aneurysm which can be rapidly fatal. This case highlights the importance of using an innovative endovascular technique for treatment of a rare cause of haemoptysis.

Pulmonary pseudoaneurysm: uncommon complication after total aortic arch operation

Pulmonary pseudoaneurysms are an uncommon but life-threatening condition of congenital or acquired cause, most commonly involving the branch pulmonary arteries and generally requiring emergent intervention. We describe a case of postoperative main pulmonary artery pseudoaneurysm after a complex aortic arch procedure, in which thoracic computed tomography provided full information for its definition before surgical correction.

Percutaneous Thrombin Injection of a Pulmonary Artery Pseudoaneurysm Refractory to Coil Embolization

A 57-year-old white man with a hypermetabolic right upper-lobe mass underwent treatment with wedge resection. During the immediate postoperative period, a right middle-lobe pulmonary artery pseudoaneurysm developed. After unsuccessful transcatheter coil embolization, fluoroscopically and sonographically guided percutaneous thrombin injection was performed, with complete thrombosis of the pseudoaneurysm.

Percutaneous Stent-Graft Repair of a Mycotic Pulmonary Artery Pseudoaneurysm

Ruptured mycotic pulmonary pseudoaneurysm is a lethal complication. Emergent surgical repair is usually recommended, but still associated with a high mortality rate. We present a patient in whom mycotic pulmonary pseudoaneurysm was a complication after surgical lobectomy 2 weeks earlier. This patient had suffered from repeated massive hemoptysis. After emergent surgical repair of the ruptured pulmonary artery stump, another episode of massive hemorrhage occurred. The pulmonary arteriogram revealed a segmental stenosis and a large, wide-necked, lobulated pseudoaneurysm at the left proximal pulmonary artery. We deployed a balloon-expandable stent-graft (48 mm in length mounted on a 12 mm x 40 mm angioplasty balloon) across the stenotic segment and the neck of the pulmonary pseudoaneurysm. Hemostasis was achieved immediately and, under a 4-week antibiotic treatment, patient was transferred to a local hospital for medical care. This case report demonstrates the benefit of minimally invasive endovascular therapy in a critically ill patient. A literature review of the etiology and management of mycotic pulmonary pseudoaneurysm is included.

Endograft stenting in the adolescent population for traumatic aortic injuries

Traumatic thoracic aortic transections are uncommon in the pediatric population. These injuries are currently treated by open operative repair via thoracotomies. We present 2 adolescent patients with traumatic thoracic aortic transections who were repaired by endovascular techniques. Both adolescents, aged 16 and 17 years, were in high-speed motor vehicle collisions and presented with multisystem trauma. Patient 1 had a transection of the descending aorta and was repaired with two 23-mm (diameter), 3-cm-long endograft cuffs at 48 hours after injury because of her multiple organ injuries. She was hospitalized for 40 days. Patient 2 had a thoracic aortic transection just distal to the aortic arch. He was repaired within 12 hours of injury with a 24-mm and two 22-mm AneuRx endograft cuffs. He was hospitalized for 8 days. Both patients have recovered without complications at 13 and 21 months, respectively. Endovascular stenting, especially in critically ill patients, allows for definitive treatment of the vascular injury without the need for bypass and reduces the recovery time that is associated with thoracotomies. Short-term recovery and follow-up are encouraging for endovascular stenting in the adolescent population; however, further long-term follow-up is required.

Successful Treatment of a Posttraumatic Pulmonary Artery Pseudoaneurysm With Coil Embolization

A 29-year-old man presented to the emergency department after having been stabbed in the posterior right hemithorax twice. He underwent thoracotomy for hemodynamic instability and continuous bleeding. His postoperative recovery was complicated by the incidental finding of a posttraumatic pseudoaneurysm of the pulmonary artery. We describe successful coil embolization of the aneurysmal sac avoiding any further surgical intervention.

Covered Stent Treatment of Right Pulmonary Artery Stenosis and Waterston Shunt

A 35-year-old man with residual Waterston shunt and concomitant right pulmonary artery stenosis after multiple surgery for tetralogy of Fallot presented with significant left to right shunt and left heart failure. We describe the percutaneous placement of an endovascular stent graft to occlude the Waterston shunt and relieve the right pulmonary artery stenosis simultaneously. This novel use of a covered stent effectively treated a residual problem without reoperative thoracotomy.

Endovascular stent-graft repair of a pulmonary artery-bronchial fistula

Herein the authors present a case of a 51-year-old man who presented with dramatic angiographically demonstrated massive hemorrhage from a pulmonary artery-to-bronchial stump fistula 3 months after right upper lobectomy. The patient was successfully treated with endovascular placement of a covered stent.

Transcatheter coil embolization of large pulmonary artery pseudoaneurysms in a child

The authors report a case of a 5-year-old boy who initially presented with mastoiditis, underwent successful surgical treatment, and during the immediate postoperative period developed multiple, bilateral pulmonary artery pseudoaneurysms. The large size and multiplicity of the pseudoaneurysms precluded the patient from undergoing thoracic surgery. Successful endovascular coil and wire embolization was performed in a staged set of procedures with use of more than 30 m of wire and coils.

Stenting for pulmonary artery stenosis due to a recurrent primary leiomyosarcoma

PURPOSE

To report stent implantation for a malignant obstruction within the pulmonary artery (PA) caused by a recurrent leiomyosarcoma in the pulmonary trunk.

CASE REPORT

A 62-year-old man with a non-metastatic primary leiomyosarcoma of the right PA underwent pneumectomy of the right lung and postoperative radiotherapy in 1994. Six years later, he presented with symptoms of progressive right ventricular dysfunction. Computed tomography (CT) identified a high-grade stenosis of the left PA due to recurrent tumor within the pulmonary trunk extending into the left PA. Transthoracic ultrasound documented severe pulmonary hypertension with a high pressure gradient across the stenosis. A stent was deployed percutaneously, successfully establishing PA patency. Pressure measurements showed a significantly reduced gradient across the stented area. In follow-up, the patient reported subjective improvement of symptoms; CT scans revealed a fully patent stent. His status remained stable 11 months after stent implantation.

CONCLUSIONS

PA leiomyosarcoma is a rare and highly malignant tumor. In most cases, surgery can only prolong survival for the short term. Palliative interventional PA stenting performed under local anesthesia can offer improvement in quality of life by reducing excessive pulmonary hypertension.