Aneurysms of the Pulmonary Artery

UK, M.L. J, Newaskar AA, Shetty AU, Sridhar SL. Percutaneous Closure of Bilateral Pulmonary Artery Aneurysms in Behcet's Disease

Behcet's disease is a multisystemic vasculitis. It can affect the pulmonary artery in 2% to 5% cases. We discuss a case of a young male diagnosed with Behcet's disease on immunosuppressive therapy who presented with bilateral pulmonary artery aneurysms which were closed with covered stent and other devices.

[Hughes-Stovin syndrome: a life-threatening manifestation of Behçet's syndrome]

Hughes-Stovin syndrome (HSS) is a systemic inflammatory condition of unknown origin that is considered to be part of the Behçet's syndrome (BS) spectrum. Recurrent venous thrombosis and superficial thrombophlebitis in combination with bilateral pulmonary artery aneurysms (PAA) represent the hallmark of HSS. The diagnostic evaluation includes computed tomography pulmonary angiography to detect signs of pulmonary vasculitis. The management of HSS is based on the European Alliance of Associations for Rheumatology (EULAR) recommendations for BS and mainly comprises immunosuppressive therapy with glucocorticoids and cyclophosphamide. In addition to drug therapy, PAA should be evaluated for interventional treatment. Spontaneous PAA rupture due to fragile vessel architecture can occur even in cases of remission and/or PAA regression.

Giant pulmonary artery aneurysm associated with SARS-CoV-2 infection and Actinomyces odontolyticus sepsis: A case report

Giant septic pulmonary artery aneurysms (PAAs) are rare but important entities, with few cases having been reported worldwide. Early diagnosis and prompt treatment are crucial in the management of such cases. We report a 56-year-old female patient presenting with fatigue, nausea and vomiting who was first diagnosed with diabetic ketoacidosis (DKA) and developed life-threatening giant infectious PAA secondary to SARS-CoV-2 infection and Actinomyces odontolyticus sepsis. The patient did not develop any specific symptoms, and enhanced computed tomography (CT) revealed a massive PAA of 5.6 × 4.9 cm in size at the left pulmonary hilar with normal pulmonary artery (PA) pressures. After multidisciplinary discussion and after considering the critical condition accompanied by sepsis increased the risk of surgery, endovascular treatment was the first therapy of choice for the patient; nevertheless, the patient ultimately opted for hospice care. This case report aims to raise awareness of PAAs, which are rare but potentially fatal complications of infectious diseases such as COVID-19 pneumonia and Actinomyces odontolyticus sepsis.

Pulmonary Artery Aneurysm in a Patient with Nontuberculous Mycobacteria Infection

Nontuberculous mycobacterial (NTM) infection sometimes leads to the development of pulmonary artery aneurysm (PAA), a rare but life-threatening complication. We herein report a 64-year-old woman with a history of NTM infection who presented with severe hemoptysis. Computed tomography revealed a ruptured PAA, which was treated successfully with pulmonary artery embolization. Subsequent right total pneumonectomy was performed to control infection. This case emphasizes the need to consider PAA in patients with NTM infection who present with hemoptysis. Early detection and appropriate management are critical for preventing this fatal complication.

Mycotic Pulmonary Artery Aneurysm a Rare Complication of Ventricular Septal Defect With Infective Endocarditis: A Case Report

Introduction

Pulmonary artery aneurysms encompass a wide range of presentations and forms. Mycotic aneurysms represent a particular subset of focal dilatation of the vessel wall with high morbidity and mortality rates. Herein, we report the case of a 32 year old patient, with a prior history of ventricular septal defect presenting with a mycotic pulmonary artery aneurysm associated with infective endocarditis and septic emboli.

Case presentation

We present the case of a 32 year old male with known history of congenital ventricular septal defect presented to the emergency department with signs of sepsis and dyspnea. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. An echocardiogram found evidence of endocarditis with multiples intra cavitary vegetations. A CT angiogram demonstrated major right ventricular dilatation, multiple nodules and peripheral opacities, scattered throughout the lungs, indicative of septic emboli. Segmental saccular dilatation of the left lateral basal pulmonary artery consistent with a mycotic aneurysm formation was found. The patient was started on intravenous antibiotics and given the overall satisfactory evolution a conservative approach was pursued. The patient was discharged with antibiotics and scheduled for surgical repair of the ventricular septal defect.

Conclusion

To our knowledge, mycotic aneurysms associated to congenital heart malformation like ventricular septal wall defect remains a rare condition with few reported cases in the literature. Being aware of this entity is important for every practicing radiologist to allow for early diagnosis and treatment.

Infectious Pulmonary Artery Pseudoaneurysm Secondary to a Lung Abscess Treated With Pulmonary Artery Coil Embolization: A Case Report

Pulmonary artery pseudoaneurysms (PAPs) are uncommon, yet they frequently result in hemoptysis and are associated with a poor prognosis. We report a case of an 87-year-old male patient. Initially, he was admitted to a previous hospital, and diagnosed with a lung abscess in the left lower lobe. On the second hospital day, he developed hemoptysis. A contrast-enhanced chest computed tomography (CT) identified an infectious pulmonary artery pseudoaneurysm. On the ninth hospital day, pulmonary artery coil embolization was successfully performed, significantly improving the patient's condition.

Large main pulmonary artery aneurysm: Case report and brief review of the literature

Pulmonary artery aneurysms are a rare but often fatal clinical entity with an estimated incidence of 1 in 14,000 individuals in postmortem studies. They can be congenital or acquired. No specific guidelines regarding their optimal management, medical or surgical, currently exist and treatment is planned on a case-by-case basis since data regarding their clinical course and prognosis are limited. We present the case of a 77-year-old male patient who presented at the Emergency Department of our hospital with a complaint of exertional dyspnea and dull substernal pain over 1 week. Upon investigation, a main pulmonary artery true aneurysm measuring 61 mm on Computed Tomography was detected. The patient's history was remarkable for heavy smoking, arterial hypertension, dyslipidemia, known ascending aortic aneurysm, moderate COPD, and past tuberculosis. He was admitted to the Cardiology unit and treated as a case of decompensated heart failure with preserved ejection fraction. His symptoms improved with intravenous diuretics. A past chest MRI report, 7 years before his current event, described the main PA aneurysm measuring 51-52 mm. Regarding the main PA aneurysm, the heart team decided to follow a conservative approach with regular follow-up visits based on the patient's comorbidities, functional status, and slow growth rate of the PA aneurysm. Management of pulmonary artery aneurysms requires a heart-team approach in the context of the patient's underlying conditions and symptoms. More data are required in order to guide a treatment plan with an acceptable risk - benefit profile for each patient.

Case Report: Surgical management of idiopathic pulmonary aneurysms and review surgical approaches

Idiopathic pulmonary aneurysm is a clinically rare condition characterized by an unknown etiology and episodic occurrence. Despite its rarity, idiopathic pulmonary artery aneurysm poses potential risks to patients. Currently, there is a lack of established clinical guidelines and consensus regarding its management, leading to ongoing controversies in treatment strategies. Particularly, the optimal approach for addressing the main pulmonary artery, its branches, and the pulmonary artery valve remains uncertain. A 57-year-old female patient presented with chest pain and tightness, leading to the diagnosis of idiopathic pulmonary artery aneurysm after excluding other potential causes. Subsequently, she underwent surgical treatment. However, during the surgery, the pulmonary artery wall was found to be extremely weak, prompting us to employ a surgical approach involving the utilization of autologous vessel wrapping with artificial grafts. By summarizing almost all surgical treatment strategies reported in recent years, including the management of pulmonary artery vessels and the pulmonary valve, we have developed a treatment flow chart. This flowchart serves as a valuable guide for the management of future cases presenting similar challenges, offering clinicians valuable insights and evidence-based recommendations.

Endovascular treatment of pulmonary artery aneurysm: Single case experience

A peripheral pulmonary artery aneurysm (PAA) is a dilatation involving all 3-vessel wall layers (the intima, media, and adventitia) of a distal pulmonary artery. It represents a rare but potentially life-threatening condition. There are only some reviews of transcatheter embolization of unruptured idiopathic peripheral PAAs. Association with cardiac diseases, infections, vascular anomalies, pulmonary hypertension, and vasculitis has been noted. We report a case of a 38-year-old woman, with a history of third-degree atrioventricular (AV) block, treated with pacemaker placement, who presented a PAA in the left pulmonary lobe. Transcatheter coil embolization was performed, using a triple coaxial catheter system (a 6F outer, a 5F intermediate, and a 2.4F inner catheter) to prevent rupture and the aneurysm was successfully embolized. Although there is no consensus on the treatment for unruptured idiopathic peripheral PAAs, transcatheter embolization may be a promising treatment option.

Mogul in a Baby

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Pulmonary artery aneurysm caused by infective endarteritis attributed to patent ductus arteriosus in children: a case report and literature review

We report a case of a 10-year-old male patient with pulmonary artery aneurysm (PAA) caused by infective endarteritis of the pulmonary artery attributed to patent ductus arteriosus. He was found to have patent ductus arteriosus at the age of 2, but he was not treated because of the absence of symptoms and normal physical development. He sought medical attention for fever and cough in August 2022. Echocardiography showed pulmonary artery aneurysm, intrapulmonary artery bulge, patent ductus arteriosus, and pericardial effusion. Contrast-enhanced CT showed pulmonary artery aneurysm, patent ductus arteriosus, and a slight compression of the left main bronchus. Surgery was performed to reconstruct the main pulmonary trunk and repair the ductus arteriosus in November 2022. The surgical outcomes were satisfactory.

Reconstruction of a Giant Main Pulmonary Artery Aneurysm Using a Porcine Root in an Adult Patient

Pulmonary artery aneurysm (PAA) is a rare disorder with a difficult diagnosis and debated management in literature due to the limited number of cases. Even if the definitive treatment of PAA is surgery, consistent guidelines still need to be developed to help surgeons determine when intervention is appropriate. We report a case of a 77-year-old female diagnosed with central PAA measuring 61 mm at contrast-enhanced computerized tomography scan which was treated surgically. The patient underwent a successful elective complete pulmonary root replacement with a Medtronic Freestyle (Medtronic Inc, Minneapolis, MN) porcine root. Postprocedural recovery and follow-up at 12 months were uneventful.

Giant pulmonary artery aneurysm in a child: Rare complication of congenital heart disease

Key Clinical Message

This case report aims to increase awareness that pulmonary artery aneurysms may occur as a complication of neglected patent ductus arteriosus and should be sought in children with ill-treated congenital heart diseases.

Abstract

Pulmonary artery aneurysm is a rare anomaly with an autopsy prevalence of 1:14,000. These aneurysms can arise secondary to various etiologies, with congenital causes identified in 25% of cases and congenital heart diseases (CHD) responsible for more than half of these cases. A 12-year-old boy with CHD in the form of patent ductus arteriosus (PDA) and irregular clinical follow-up presented with new onset fatigue of 3 months duration. A physical examination revealed anterior chest wall bulging and a continuous murmur. A chest radiograph showed a smooth left hilar region opacity that has a close relation with the left cardiac border. Transthoracic echocardiogram shows no progression from the previous one; there was a large PDA and pulmonary hypertension, but no further information was available. Computed tomography angiography revealed a giant aneurysm of the main pulmonary artery (PA), with a maximum diameter of 8.6 cm, and dilatation of its branches of 3.4 and 2.9 cm for the right and left PA, respectively.

Pulmonary Artery Pseudoaneurysms Embolization: Bicentric Experience and Review of the Literature

The purpose of this bicentric case series was to report the safety, efficacy, and clinical outcome of transcatheter embolization in pulmonary artery pseudoaneurysms (PAPAs). Between January 2016 and June 2021, eight patients with PAPA were subjected to transcatheter embolization. The total number of patients was eight, of which five were female, with a mean age of 62 ± 14 years (average ± standard deviation). Etiology was traumatic in 2/8 cases and iatrogenic in 6/8 cases (after positioning a Swan-Ganz catheter in 5/6 cases and a temporary pacemaker in the latter case). In a single case, the PAPA was incidentally discovered during a routine X-ray, in the remaining 7 cases, the procedure was performed in emergency settings. PAPA embolization was performed using detachable coils alone in 3 cases; coils and glue in 1 case; coils, glue, and vascular plug in 1 case; coils and non-adhesive liquid embolic agents (Onyx and Squid respectively) in 2 cases; and non-adhesive liquid embolic agent alone (Onyx) in 1 case. No peri-procedural or post-procedural complications were recorded. Both the technical and clinical success rates were 100.0%. In conclusion, endovascular embolization is a technically feasible and safe therapeutic option for patients with PAPAs.

The impact of Behcet syndrome on total knee arthroplasty outcomes: a retrospective matched cohort study

PURPOSE

Articu lar involvement is a common manifestation of Behcet syndrome (BS), which can eventually result in significant arthralgia and necessitate total knee arthroplasty (TKA). However, outcomes of BS patients after TKA are still poorly documented in the literature. The purpose of this study was to evaluate BS as a potential risk factor for complications after TKA.

METHODS

BS patients undergoing primary TKA were identified from the PearlDiver Mariner database from 2010 to 2021 and compared to 10:1 matched controls. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to two years. Ninety-day emergency department (ED) visit and inpatient readmission were also documented.

RESULTS

A total of 4286 patients undergoing primary TKA were queried, of which 390 had BS. Patients with BS demonstrated significantly higher rates of medical complications, including deep venous thrombosis. The rates of surgical complications were similar between the two groups with the exception of periprosthetic instability, aseptic loosening, and wound complications in BS patients. Additionally, a significantly higher rate of ED visits but markedly lower rates of 90-day readmissions were noted in patients with BS.

CONCLUSION

Patients with BS undergoing TKA are at higher risks of medical and surgical complications. Special considerations for a unique postoperative course with the higher complications should be made. It is crucial for orthopedic surgeons and patients alike to consider these risks when determining the expected course after TKA for patients with BS.

Pulmonary Artery Aneurysm: A Rarity and Surgical Enigma

Given the low incidence of pulmonary artery aneurysms (PAAs), proven surgical indications do not yet exist. We present a patient with a 6.3 cm PAA who underwent an open sternotomy, pulmonary artery aneurysmectomy, and repair with an aortic homograft. We discuss surgical indications, including pain, growth in diameter, and diameter of 5.5 cm and larger. The current recommended surgical indication for the size of PAAs is based on recommendations for aortic aneurysms and observation in a small number of operable patients, highlighting the need for more discussion and reporting of this rare presentation.

A Novel Approach for the Treatment of Pulmonary Artery Aneurysm Repair Using Inclusion Technique: A Case Report

Pulmonary artery aneurysm (PAA) is a rare disease with life-threatening complications, especially when accompanied by pulmonary artery hypertension. Due to its rarity, there are currently no specific guidelines for the treatment of PAA. Several surgical techniques have been described to be beneficial in the treatment of PAA originating at the pulmonary trunk. However, several adverse complications have been described for traditional techniques. In this case, we present the first successful repair of PAA with idiopathic pulmonary artery hypertension using a graft inclusion technique.

Endovascular Plug for Endobronchial Management of an Expectorated Pulmonary Artery Embolization Coil: A Case Report

Pulmonary artery aneurysms are frequently managed with endovascular embolization. Rare but serious complications of coil embolization are erosion and migration of the coils into the adjacent airways, posing a risk for massive hemoptysis. We report the case of a medically complex patient with a left main pulmonary artery aneurysm treated with coil embolization who ultimately experienced transbronchial migration and expectoration of the coil. We discuss the challenging anesthetic and surgical management of these serious complications, including the use of an endovascular plug to occlude the erosion site and distal airways.

Left Pulmonary Artery Aneurysm: A Post-stenotic Pulmonary Aneurysm Related to Pulmonary Valve Stenosis

Aneurysms of the pulmonary artery are uncommon vascular pathologies that are associated with congenital structural cardiac anomalies, pulmonary hypertension, vasculitis, neoplasm, iatrogenic, and infection. PAAs are commonly asymptomatic and accidentally diagnosed, however, if symptomatic, clinical features are generally non-specific and depend on the etiology of PAA. CT pulmonary angiography remains the gold standard imaging modality and other diagnostic imaging tests include transthoracic echocardiography and right heart catheterization. Definitive treatment of PAA is surgery, however, conservative management with close monitoring should be practiced in patients with poor surgical candidates or surgery is unlikely to improve survival. Here, we report a case of pulmonary artery aneurysm secondary to congenital pulmonary valve stenosis as well as a brief review of the literature regarding pulmonary artery aneurysms.

Chest discomfort leading to the diagnosis of pulmonary artery aneurysm due to isolated main pulmonary arteritis involving giant cells: a case report

BACKGROUND

Isolated pulmonary artery vasculitis is an uncommon cause of pulmonary artery aneurysm with very few reported cases in the literature.

PATIENTS AND METHODS

We hereby present the case of a 70-year-old man with occasional episodes of exertional chest discomfort. Our investigations revealed an expanding aneurysm of the main pulmonary artery extending to the proximal portion of the right branch. The patient successfully underwent replacement of the main pulmonary artery with a homograft.

RESULTS

Histopathological examination revealed images of vasculitis with numerous multinucleated giant cells. The patient's postoperative course was uneventful.

CONCLUSION

Management of pulmonary artery aneurysm secondary to isolated pulmonary artery vasculitis is not well studied, and no clear guidelines currently exist in the literature.

Risk of pulmonary artery dissection in adults with congenital heart disease

BACKGROUND

There are limited data about the risk of pulmonary artery (PA) dissection in adults with congenital heart disease (CHD), and the purpose of this study was to estimate the incidence of PA dissection in this population.

METHODS

Retrospective cohort study of adults with CHD that underwent cross-sectional imaging (2003-2020). PA aneurysm was defined as main or branch PA diameter > 40 mm or > 30 mm respectively, and severe PA aneurysm was defined as main or branch PA diameter > 50 mm.

RESULTS

Of 1, 673 patients (41 ± 10 years; male 58%), 493 (24%), 286 (19%), and 306 (20%) had aneurysms of the main, right, and left PA respectively, while 66 (4%) had severe PA aneurysm. During a median follow-up of 8.2 (interquartile range 3.7-10.3) years, there was one PA dissection in a patient with Eisenmenger syndrome, thus the incidence of PA dissection was 14 per 100,000 patient-years. Of 779 females, 163 had one or more pregnancies during follow-up, and 41 (25%) of these patients had known PA aneurysm at the time of conception. There was no PA dissection during pregnancy. Of the 163 patients, 91 (56%) had cross-sectional imaging before and after pregnancy, there was no significant difference in PA dimension before versus after pregnancy (main PA 35 ± 5 versus 36 ± 4 mm, p = 0.6; right PA 21 ± 3 versus 33 ± 4 mm, p = 0.1; and left PA 23 ± 4 versus 22 ± 4 mm, p = 0.4).

CONCLUSIONS

The risk of PA dissection was extremely low even in patients with severe PA aneurysm, or in patients with PA aneurysm that became pregnant. Collectively, these data suggest a benign natural history for patients without severe pulmonary hypertension and encourage and a conservative approach in managing patients with PA aneurysm.

Incidental case of an idiopathic pulmonary arterial aneurysm masquerading as a stable pulmonary nodule for 17 years

A true pulmonary arterial aneurysm is the dilation of all three vascular walls in a pulmonary artery. True pulmonary arterial aneurysms are very rare, and the relatively minor cases on this topic present with symptoms pertaining to the causes of trauma, Behçet’s disease, pulmonary vasculitis, granulomatous lung infections, and cartilage instability. A rupture of the pulmonary arterial aneurysm can be life-threatening and often requires surgical repair. Our case presents a 70-year-old male who was referred to pulmonary clinic for evaluation of an asymptomatic, incidental finding in his right lower lobe that was considered to represent a pulmonary nodule based on its presentation on computed tomography imaging. The referring provider had requested a possible biopsy. Before proceeding with a biopsy, the presence of the pulmonary aneurysm was confirmed only after the fluorodeoxyglucose-positron emission tomography scan and a computed tomography angiography were performed. Our case illustrates the importance of including pulmonary aneurysm in the differential during work-up of a pulmonary nodule, as diagnostic sampling could have been detrimental.

Giant Rasmussen's aneurysm in a 9-year-old boy: A case report

Rasmussen's aneurysm is a pseudoaneurysm caused by tuberculosis, when cavitation occurs adjacent to a pulmonary artery, which can be lethal. It is a rare complication usually affecting adults. This is a case of an 9-year-old boy initially admitted for pneumonia that developed hemoptysis during admission. Chest X-ray done after this episode showed development of a left hilar mass not present in the previous studies. A chest CT with contrast subsequently revealed a saccular aneurysm arising from the left lower lobe pulmonary artery adjacent to a cavity, a Rasmussen's aneurysm. The patient was treated conservatively with continuation of anti-TB medication and serial monitoring due to the size of the aneurysm being less than 6 cm and spontaneous resolution of the hemoptysis. This report stresses that a Rasmussen's aneurysm should always be in the differential diagnosis of a hilar mass in a patient with hemoptysis, regardless of the patient's age.

Congenital Absence of the Portal Vein as a Rare Cause of Portopulmonary Hypertension-A Case Study Series

Background. Congenital absence of the portal vein (CAPV) is an extremely rare malformation that is caused by aberrant venous development during embryogenesis and is usually associated with congenital portosystemic shunts (CPSS). This hemodynamic allows mesenteric blood to bypass the liver metabolism and causes an imbalance between vasodilators and vasoconstrictors in the pulmonary circulation, which, again, might lead to the development of secondary portopulmonary hypertension (PoPH). Establishing the exact morphology of the splanchnic venous system is important when evaluating possible therapeutic options (differentiating type I and II CAPV), because some variants enable the closure of the shunt, and this represents a potential cure for pulmonary arterial hypertension (PAH). Once PoPH is diagnosed, complex care in a specialized expert centre is necessary. If possible, CPSS closure is recommended. For long-term successful patient management, specific targeted PAH therapy administration is crucial. Significant morbidity and mortality in these patients may result not only from PAH itself but also due to specific PoPH complications, such as compression of the left main coronary artery by pulmonary artery aneurysm. Case Report. We report on two patients with PoPH due to CAPV and CPSS (without any liver disease) who presented as severe PAH and who, before admission to our expert centre, were misdiagnosed as idiopathic PAH. The case reports also represent our experience with respect to the long-term follow-up and PAH-specific medical treatment of these patients, as well as the possible (even fatal) complications of these rare and complex patients.

Right ventricle outflow tract dilatation and pulmonary artery aneurysm, rare cardiac conditions

We describe a rare case of simultaneous idiopathic right ventricular outflow tract dilatation and idiopathic main pulmonary artery aneurysm. A 59-year-old male presented with complaints of exertional shortness of breath and a cardiac murmur since childhood. CT pulmonary angiogram showed main pulmonary artery dilatation with a diameter of 5.8 cm. Cardiac MRI revealed right ventricular outflow tract dilatation with a diameter of 5.4 cm and a main pulmonary artery aneurysm with a 5.6 cm diameter. Cardiothoracic surgery was consulted for surgical repair. Definitive management of right ventricular outflow tract dilatation and pulmonary artery aneurysms is challenging due to their infrequent diagnosis and lack of established guidelines. The treatment for central aneurysms is surgery which includes aneurysmectomy and right ventricular outflow tract repair or replacement.

A Rare Case of Peripheral Pulmonary Artery Aneurysm and Cavitating Pneumonia in a Patient with COVID-19 Managed with an Endovascular Method

Peripheral pulmonary artery aneurysm (PAA), being a rare condition, is considered extremely rare following coronavirus disease 2019 (COVID-19). We present a 58-year-old male who presented with fever, malaise, and dry cough. SARS-CoV-RNA transcription-mediated amplification test was positive for the patient. After 2 days, he developed hemoptysis and back pain, and a CT scan revealed a pulmonary aneurysm, evidence of alveolar hemorrhage, and Necrotizing pneumonia. He was scheduled for pulmonary artery angiography. The angiography confirmed a fusiform aneurysm and partial coiling of the aneurysmal sac, and indoor and backdoor embolization was performed. In the follow-up, a CT scan showed complete thrombosis of the aneurysmal sac, and the patient was free of symptoms. Peripheral PAAs can show a variety of symptoms. They can even be asymptomatic. The infectious pathologies of this condition are less common than the other. COVID-19 is an extremely rare pathology. To the best of our knowledge, this is the first case of necrotizing pneumonia and peripheral PPA in an adult. Moreover, it was followed by COVID-19. A vital takeaway note for physicians is to consider PAAs as a complication when treating COVID-19 patients who don't show signs of improvement or even show signs of exacerbation.

Differential Diagnosis of Multiple Systemic Aneurysms

Atherosclerosis and systemic hypertension are the most common pathogeneses of solitary acquired arterial aneurysms. The rare occurrence of multiple synchronous or metachronous arterial aneurysms requires considering alternative underlying causes. We present the unusual case of a male patient who sequentially developed multiple co-existing arterial aneurysms between the ages of 51 and 59. The sites of involvement included high-pressure systemic arteries and low-pressure pulmonary arteries. We discuss the broad differential diagnosis that includes heritable and non-inheritable etiologies. A keen clinical awareness of this broader array of arterial aneurysms is essential for accurate early diagnosis and proper management.

A gray zone in the literature: indications, options, and outcomes for surgical repair of pulmonary artery aneurysms

Pulmonary artery aneurysms are rare. They are characterised by an aneurysmatic dilatation of the pulmonary vascular bed, including the main pulmonary artery or the accompanying pulmonary artery branches. Increases in pulmonary flow and pulmonary artery pressure increase the risk of rupture: when these conditions are detected, surgical intervention is necessary.This study is a retrospective analysis of 33 patients treated in our paediatric cardiac surgery clinic from 2012 to 2020. Aneurysms and pseudoaneurysms in patients who were patched for right ventricular outflow tract reconstruction and corrected with a conduit were excluded from the study. Seventeen (51.5%) of the patients included in the study were female and 16 (48.5%) were male. The patients were aged between 23 and 61 years (mean 30.66 ± 12.72 years). Graft interpositions were performed in 10 patients (30.3%) and pulmonary artery plications were performed in 23 patients (69.7%) to repair aneurysms. There was no significant difference in mortality between the two groups (p > 0.05).Pulmonary artery aneurysm interventions are safe, life-saving treatments that prevent fatal complications such as ruptures, but at present there is no clear guidance regarding surgical timing or treatment strategies. Pulmonary artery interventions should be performed in symptomatic patients with dilations ≥5 cm or asymptomatic patients with dilations ≥8 cm; pulmonary artery pressure, right ventricular systolic pressure, and pulmonary artery aneurysm diameter must be considered when planning surgeries, their timing, and making decisions regarding indications. Experienced surgical teams can achieve satisfactory results using one of the following surgical techniques: reduction pulmonary arterioplasty, plication, or graft replacement.

Overlapping-plasty technique for pulmonary artery aneurysm

Massive pulmonary artery aneurysms, while extremely rare, might require surgical intervention. Most previous cases have been repaired either by pulmonary artery plication or synthetic graft replacement. We report a case of massive pulmonary artery aneurysm that was successfully repaired using an 'overlapping-plasty' technique with the help of 3D image simulation. This specially designed procedure might be useful as a surgical option for pulmonary artery aneurysms.

Pulmonary valve perforation with multiple cardiac anomalies: a case report

Background

Large pulmonary valve perforation, which is rarely seen with infective endocarditis, general atrophy, or congenital fenestration, often leads to potentially fatal outcomes, including heart failure.

Case presentation

Transthoracic and transesophageal echocardiographic evaluation of a 69-year-old woman revealed a severely eccentric pulmonary regurgitation with concomitant pulmonary valve stenosis, patent ductus arteriosus, patent foramen ovale, and pulmonary artery aneurysm. In the operation, a large perforation was found in the pulmonary valve leaflet. She underwent complicated surgery that involved closure of the congenital heart defects and replacement of a pulmonary valve with successful results. But the cause of her pulmonary valve perforation remained undetermined.

Conclusion

This case highlights two important points: the need for timely management of congenital heart disease and being aware of the possibility of pulmonary valve perforation, which in this case was indicated by an eccentric pulmonary regurgitant jet seen on echocardiography.

Eisenmenger syndrome with left main compression syndrome: a case report

Background

Left main coronary artery disease secondary to pulmonary artery compression related to Eisenmenger syndrome is an under-suspected condition that can cause fatal outcomes if left untreated. It presents with typical angina but is frequently mistaken for pulmonary hypertension (PH) symptoms. It is now recognized as one of the few important causes of angina in PH.

Case presentation

A 37-year-old man with a history of unoperated atrial septal defect and Eisenmenger syndrome came to the outpatient department with a chief complaint of angina on exertion. Electrocardiogram showed regular sinus rhythm with right axis deviation, right ventricular hypertrophy, deep T-wave inversion in inferior and anterior leads suggestive of ischemia or strain, and incomplete right bundle branch block. Cardiac CT showed compression of the left main coronary artery due to a dilated main pulmonary artery. Therefore, this patient was diagnosed with Eisenmenger syndrome with left main compression due to dilated pulmonary artery. He was treated successfully with IVUS-guided stent implantation. The patient experienced marked improvement in regular activities, with no recurrence of angina symptoms. Angiography 3 months after the procedure revealed good patency of the stent, without significant stenosis.

Conclusions

Left main coronary artery compression is a complication that should be suspected in patients with Eisenmenger syndrome presenting with angina symptoms. Non-invasive modalities are recommended for diagnostic evaluation, but the gold-standard technique remains coronary angiography. The best treatment is not well-established, with either myocardial revascularization or PH treatment, but a left main coronary artery stenting procedure is considered an ideal emergent treatment to provide a better quality of life for patients in this condition.

Giant high-pressure pulmonary artery aneurysm (PAA) in a patient with COPD and chronic pulmonary embolism (PE)

A woman in her 60s with a history of known severe chronic obstructive pulmonary disease (COPD), former smoker of 50 pack-years and small patent foramen ovale (PFO) without significant shunt was admitted for acute on chronic hypoxic respiratory failure. Diagnostic workup showed severe dilatation of main pulmonary artery (MPA) (75.5 mm axial view and 86.6 mm sagittal view) and left and right PAs measuring 40 mm and 34 mm, respectively, on CT angiography of the chest. Right heart catheterisation showed severe pulmonary hypertension (PH). A diagnosis of giant high-pressure pulmonary arterial aneurysm (PAA) secondary to PH, induced by COPD, and chronic pulmonary embolism was made. Despite aggressive medical management, she passed away on comfort care. Giant high-pressure PAAs are rarely reported. This is a unique case that demonstrates this very rare condition in a living patient. The management of giant PAA is controversial. Experts recommend medical management or aneurysmectomy for sizes of >55-60 mm. Death could have been prevented if our patient was screened earlier and received appropriate medical care.

Misdiagnosis of pulmonary artery aneurysm with eroding thrombus into the airways. A fatal case of suffocation

We present a fatal case of hemoptysis following a thrombus-eroding pulmonary artery aneurysm into the left upper bronchus of a 79-year-old male with a history of multiple hospital contacts and examinations due to cough, hemoptysis, and reflux symptoms.

A postmortem computed tomography (CT) scan revealed a hyperdense, condensed area in the left lung in relation to the lung hilus. At autopsy, the forensic specialist discovered a large, organized thrombus in a pulmonary artery aneurysm. The thrombus was adherent to the pulmonary artery aneurysm wall with an underlying defect directly communicating to the left upper bronchus. The cause of death was asphyxia due to blood in the airways (i.e., suffocation).

The combination of pulmonary artery hypertension, previous pulmonary embolism, and hemoptysis should lead to a particularly thorough inspection of the lungs with a focus on the pulmonary circulation. This case report emphasizes the importance of early detection of patients at risk of pulmonary artery rupture and attentiveness when performing biopsies during bronchoscopy to prevent communication between the artery and the airway. The risk of rupturing an aneurysm should be taken into account when performing biopsies on excrescence intruding into the bronchus in patients with medical histories of pulmonary hypertension, cough, and sporadic hemoptysis.

Surgical management of giant pulmonary artery aneurysms in patients with severe pulmonary arterial hypertension

BACKGROUND AND AIM

Giant aneurysm of the pulmonary artery (PAA) is an extremely rare condition that may develop in patients with pulmonary arterial hypertension (PAH) which may be complicated by rupture, dissection or intravascular thrombus formation. The aim of this study was to examine available literature with regard to surgical strategies in patients undergoing transplantation for PAH with PAA.

RESULTS

These patients were traditionally considered for heart-lung transplantation but more recently, there have been reports of successful lung transplantation with reconstruction of the pulmonary artery.

CONCLUSIONS

Unless there is a mandatory indication for heart-lung transplantation, patients with PAH and PAA can undergo lung transplantation and reconstruction of the pulmonary artery without compromising the outcome.

Extrinsic compression of coronary and pulmonary vasculature

Coronary artery disease from atherosclerosis induced stenosis remains the leading cause of acute coronary syndrome (ACS) and death worldwide, however extrinsic compression of coronary arteries from adjacent anatomical and pathological structures is an infrequent but important diagnosis to be aware of, especially given the nonspecific symptoms of chest pain that mimic angina in patients with pulmonary hypertension (PHT) and congenital heart disease. Non-invasive CT angiography is an invaluable diagnostic tool for detection of coronary artery compression, pulmonary artery dilatation and pulmonary vascular compression. Although established guidelines are not available for management of left main coronary artery (LMCA) compression syndrome, percutaneous coronary intervention and stent implantation remain a feasible option for the treatment, specifically for patients with a high surgical risk. Treatment of pulmonary vein or artery compression is more varied and determined by etiology. This review article is focused on detailed discussion of extrinsic compression of coronary arteries, mainly the LMCA and brief discussion on pulmonary vasculature compression by surrounding anatomical and pathological entities, with focus on pathophysiology, clinical features, complications and role of imaging in its diagnosis and management.

A 58-Year-Old Woman With a History of Cardiac Myxoma Presents With Pulmonary Nodules

CASE PRESENTATION

A 58-year-old woman presented to a pulmonology clinic for evaluation of bilateral pulmonary nodules. Two years previously, she had presented with atrioventricular nodal reentrant tachycardia. During evaluation for her tachyarrhythmia, transthoracic echocardiogram (TTE) revealed a large, homogenous, highly mobile right atrial and ventricular mass. She underwent electrophysiologic ablation, tricuspid valve annular ring replacement, and resection of the mass, which pathology confirmed to be a myxoma. Now, a recent abdomen and pelvis CT study obtained for history of nephrolithiasis incidentally noted bilateral lower lobe pulmonary nodules. Follow-up noncontrast chest CT confirmed bilateral peribronchovascular solid pulmonary nodules up to 8 mm in diameter throughout all lobes. The nodules appeared contiguous with the segmental and subsegmental bronchovascular bundles, and many occurred at branch points. There was no mediastinal or hilar lymphadenopathy. To evaluate the pulmonary nodules, she was referred to a pulmonology clinic. She reported only stable, nonlimiting dyspnea on exertion. She did not have a cough. She denied a history of fevers, weight loss, or night sweats. She had no rash or skin changes, visual changes, joint pain or swelling, or palpitations. She had no history of oropharyngeal or genital ulcerations. Social history was notable for a 40-pack-year smoking history, with quit date 2 years prior. She had no risk factors for TB exposure and no exposures to sandblasting, stone cutting, or other environmental risk factors for silicosis. Family history was negative for autoimmune conditions, sarcoidosis, and lymphoproliferative disorders.

Mycotic Pulmonary Aneurysm Managed With Covered Stent

Mycotic aneurysms are vascular dilations caused by fungal or bacterial infections. The involvement of the pulmonary artery or its branches is extremely rare with only a few cases reported in the literature posing a diagnostic challenge. We present the case of a young adult patient with acute myeloid leukemia undergoing chemotherapy, who presented with febrile neutropenia, recurrent bacteremia due to Pseudomona Aeruginosa and Klebsiella Pneumonie and hemoptysis. The management was unconventional, opting for the placement of a covered endovascular stent, being the first successful case with this reported technique. Rapid detection of this pathology and individualization in the management of each patient is essential because of high risk of mortality due to sepsis and rupture of the aneurysm.

Paediatric haemoptysis from multiple pulmonary artery aneurysms

The case of multiple peripheral pulmonary artery aneurysms in children presenting with haemoptysis following an episode of bacterial endocarditis is presented. They are extremely rare and clinically non-specific but critical because early diagnosis is crucial for preventing sudden death from their rupture. Computed tomography pulmonary angiography remains the investigation of choice. Despite no consensus recommendation on the management, a multidisciplinary team should plan the beneficial approach with minimal procedure-related morbidity and mortality to improve survival. This case report aimed to emphasize the recognition of this rare cause of haemoptysis in children.

Management of Incidental Peripheral Pulmonary Arterial Aneurysm by Interventional Radiology

A peripheral pulmonary arterial aneurysm (PAA) is an abnormal dilatation of the distal pulmonary artery consisting of all three vessel wall layers (the intima, media, and adventitia). It is a rare, potentially life-threatening entity. There is no defined standard for an abnormal amount of dilation of the distal pulmonary vasculature, however, the most common criteria used is a diameter greater than 1.5 times the upper limit of a normal or proximal portion. Despite the rarity of peripheral PAAs, the ability to recognize and diagnose them is important for both radiologists and clinicians. Early recognition is needed because of the high mortality associated with rupture. Consistent guidelines still need to be developed to help clinicians determine when intervention is appropriate. In the interim, endovascular coil embolization has become a mainstay of treatment due to its minimally invasive nature and lower risk of complications when compared to open surgical approaches.

Chronic Thromboembolic Pulmonary Hypertension Complicated by Giant Pulmonary Artery Aneurysm

A pulmonary artery (PA) aneurysm is an extremely rare condition that can be idiopathic or secondary. Only a few reports on giant PA aneurysms associated with chronic thromboembolic pulmonary hypertension (CTEPH) are available in the literature. Here, we present a case of CTEPH associated with a secondary giant PA aneurysm detected by autopsy. A 68-year-old woman was diagnosed with pulmonary hypertension (PH) and a PA aneurysm with a diameter of 7.5 cm 7 years before admission. CTEPH was suspected as the cause of PH; however, she refused to undergo surgical treatment. Although her condition improved temporarily with pulmonary vasodilators, she had recurrence of heart failure and died because of the deterioration of her general condition. An autopsy revealed a giant PA aneurysm without medial degeneration, suggesting a secondary PA aneurysm associated with PH. Histological findings indicated multiple organized thrombi with recanalization in the PA bilaterally, and CTEPH was diagnosed as the cause of PH. Although rare, when a PA aneurysm is detected, it is important to consider that CTEPH might be associated with a giant PA aneurysm. A better understanding of this condition is necessary to improve the therapeutic strategy.