Pulmonary artery aneurysm: a review

A rare case of large true main pulmonary artery aneurysm managed surgically: A case report

INTRODUCTION & IMPORTANCE

Pulmonary Artery Aneurysm is defined as the localized dilation of the pulmonary artery >1.5 times the upper normal limit or pulmonary artery measuring 4 cm. Pulmonary artery aneurysm is considered as a rare disorder having an incidence of 1 in 14,000 post-mortem examinations.

CASE PRESENTATION

Presented below is a case of a 28 year old gentleman, who presented with exertional dyspnea and orthopnea and was diagnosed with having a pulmonary artery aneurysm of 76 cm × 56 cm × 53 cm arising from the main pulmonary artery upon Computed Tomography Scan which is a rare finding according to the available literature.

CLINICAL DISCUSSION

Clinical manifestations of pulmonary artery aneurysm are varying and rarely occur. However the use of radiological imaging has aided in the diagnosis. No specific treatment guidelines have been mentioned yet in the literature however, medical management, surgical resection and endovascular therapy are one of the multiple options available.

CONCLUSION

Pulmonary Artery Aneurysm presents with non-specific symptoms which makes the diagnosis very challenging for the physicians, in process, delaying the accurate management of the disease. However, pulmonary artery aneurysm must be considered as a differential diagnosis and appropriate management options, whether medical or surgical should be opted for keeping in mind the size and the complications of the disease.

Analysis of angiographic findings and short-term recurrence factors in patients presenting with hemoptysis

OBJECTIVES

The abnormal anatomical alterations of blood vessels during DSA angiography in patients with hematological disorders were retrospectively examined, and the influencing factors of short-term (≤ 6 months) recurrent hemoptysis were statistically analyzed, and the consistency between admission diagnosis and intraoperative diagnosis was evaluated.

METHODS

The intraoperative angiography data of patients who underwent selective bronchial artery embolization for hemoptysis in our hospital from January 2022 to December 2022 were reviewed. They were divided into the observation group and the control group based on whether there was recurrent hemoptysis. The Logistic regression model and forest map were employed to analyze the factors influencing the recurrence rate.

RESULTS

A total of 104 patients were encompassed in this study (12 cases of tuberculosis, 35 cases of infection, 4 cases of lung cancer, 8 cases of bronchiectasis, 22 cases of arteriovenous fistula, 16 cases of aneurysm, and 7 cases of pulmonary hypertension). The coincidence rate of preoperative and intraoperative diagnoses was 73.1%. Pulmonary arteriovenous fistula and aneurysm were the predominant types of diseases that were misdiagnosed. The short-term recurrence rate was 16.3%, mainly attributed to the reopening of responsible vessels related to embolization, angiography leakage, and leaky embolization of specific types of vessels. The recurrence rate of only patients with arteriovenous fistula and aneurysm accounted for 47% of the total recurrence rate. The right bronchial artery, right internal thoracic artery, right thyroid neck trunk, and age were the independent factors influencing the recurrence of hemoptysis (p < 0.05).

CONCLUSIONS

The main reason for angiographic leakage and embolization leakage in cases of hemoptysis is the lack of understanding of the anatomic variations of the vessels responsible. Careful examination of the specific types and locations of the vessels is the principal approach to reducing secondary operations.

Pulmonary artery aneurysm: computed tomography (CT) imaging findings and diagnosis

Pulmonary artery aneurysm (PAA) is a rare pulmonary vascular disease with nonspecific symptoms and various etiologies. As the disease progresses, in addition to the dilation of the pulmonary arteries, it may be accompanied by remodeling of the cardiac structure and changes in the morphology of the aorta. Recognizing the cause of PAA is therefore a clinically challenging task. In this review article, we provide an overview of various causes of PAA with the support of corresponding imaging findings on computed tomography pulmonary angiography (CTPA) examination. Firstly, from the perspective of hemodynamics, a logical diagnosis is provided according to whether the main pulmonary artery (MPA) is dilated, and whether the PA is dilated locally or diffusely. Secondly, for the imaging examination of vascular wall lesions, due to the limitations of ultrasound examination and interventional procedures, the irreplaceability of dual-phase CTPA examination in disease assessment is especially emphasized. Finally, for highly suspected disorders, it is necessary to comprehensively check with the patient whether there is a family history or past medical history. For patients with PAA, especially those with Marfan syndrome (MFS) or arteritis, adequate preoperative imaging evaluation, regular postoperative radiographic follow-up, and concurrent treatment of the underlying disease (if necessary) are crucial, which are related to the prognosis and long-term quality of life of such patients. Despite the nonspecific features of PAA presentation, a thorough examination of the patient's clinical history and imaging characteristics will play an important role in diagnosing PAA and planning patient management strategies.

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.

A Case of Preoperative Diagnosis of Pulmonary Artery Aneurysm Resected by Segmentectomy

A pulmonary artery aneurysm (PAA) is a rare condition. It is treated in various ways, depending on its location and size. Herein, we describe the preoperative diagnosis of a PAA that was resected by segmentectomy. A 44-year-old female underwent CT, which revealed a 15-mm saccular protrusion in the right pulmonary artery and was diagnosed with PAA. The patient was initially observed without requiring further treatment, but a gradual increase in size led to therapeutic intervention. Because the PAA was located just peripheral to the right A8 bifurcation, embolization using interventional radiology was deemed too difficult. Therefore, a surgical intervention was planned. Subsequently, S8 segmentectomy, basal segmentectomy, and basilar pulmonary artery ligation were all considered. Ultimately, basal segmentectomy was selected because it allowed the resection of the pulmonary artery and did not result in invalid ventilation of the basal segment. A basal segmentectomy was performed, and the PAA was safely removed without hemorrhage. Histopathological examination revealed arterial and venous wall-like areas, and the patient was diagnosed with pulmonary artery malformation. A PAA is typically treated with coil embolization, ligation of the pulmonary artery, aneurysmectomy, and lung resection; however, no clear treatment guidelines exist. After discussion, we selected basal segmentectomy as a safe and minimally invasive procedure, and we resected the PAA without complications. The optimal treatment strategy for PAAs varies according to location and size, and a careful treatment plan should be established.

Pulmonary Artery Aneurysm Associated with Sarcoidosis in a 75-year-old with Heart Failure: The Challenges of Diagnosis and Management

Introduction

Pulmonary artery aneurysm (PAA) is a rare abnormality of pulmonary vasculature. It can be idiopathic or secondary to various pathologies, frequently with multiple factors leading to its formation. We report the case of a man with concomitant sarcoidosis and PAA.

Case description

A 75-year-old male with a diagnosis of pulmonary sarcoidosis was referred to the Cardiology department due to heart failure with reduced left ventricular ejection fraction (LVEF). The transthoracic echocardiogram revealed mildly reduced LVEF, aortic root and pulmonary artery (PA) dilatation, and no signs of pulmonary hypertension (PH). Cardiac magnetic resonance imaging was performed, revealing mild left ventricular dilation, LVEF of 40%, main PA dilation (43 mm) and a pattern of late gadolinium enhancement suggestive of cardiac sarcoidosis. At follow-up, a thoracic computed tomography (CT) angiography scan revealed ascending aorta ectasia and giant main PA aneurysm (60 mm). A right heart catheterisation was performed, and a mean PA pressure of 34 mmHg was obtained. Given the clinical context, the patient was considered to have PH due to lung disease and left heart disease, and PAA was possible due to vascular granulomatous involvement by sarcoidosis.

Conclusion

PAA is a rare finding and mostly occurs in the setting of PH. Sarcoidosis is a granulomatous disease that mostly affects the lungs, but the sarcoid involvement of great vessels has been described. In this clinical case, the probable cause for the PA fragility leading to aneurysm formation remains sarcoid vascular infiltration, regarding the discrepancy between the PA dimensions and mildly elevated PA pressure.

LEARNING POINTS

Pulmonary artery aneurysm is a rare abnormality of pulmonary vasculature that can be idiopathic or a consequence of pulmonary hypertension, congenital heart disease, infection, vasculitis or collagenopathies.Due to the low incidence of this disease, there are no guidelines for its diagnosis, management or follow-up, and treatment is based on the underlying aetiology, aneurysm dimensions and occurrence of symptoms.Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-caseating granulomas that mostly involve the lungs, but can also affect skin, eyes, and lymph nodes. Sarcoid involvement of great vessels has been rarely described.

Unusual Cause of Hemoptysis in a Woman With Cystic Fibrosis

CASE PRESENTATION

A 20-year-old patient with cystic fibrosis (CF) complicated by pansinusitis, pancreatic insufficiency, and diabetes presented to the local ED after an episode of large-volume hemoptysis at home. At baseline, she had advanced lung disease (FEV1, 0.97 L; 31% predicted) and upper lobe-predominant fibrocavitary changes. She was intermittently followed at a regional lung transplant center. She was previously evaluated for transplant but was not listed at the time of this presentation because of nontuberculous mycobacteria infection. She had never used tobacco, without reports of recreational inhaled drug use. Her mother had CF, and one of her brothers died in 2018 at age 24 of respiratory failure resulting from the disease.

Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography

Echocardiography is a fundamental component of pediatric cardiology, and appropriate indications have been established for its use in the setting of suspected, congenital, or acquired heart disease in children. Since the publication of guidelines for pediatric transthoracic echocardiography in 2006 and 2010, advances in knowledge and technology have expanded the scope of practice beyond the use of traditional modalities such as two-dimensional, M-mode, and Doppler echocardiography to evaluate the cardiac segmental structures and their function. Adjunct modalities such as contrast, three-dimensional, and speckle-tracking echocardiography are now used routinely at many pediatric centers. Guidelines and recommendations for the use of traditional and newer adjunct modalities in children are described in detail in this document. In addition, suggested protocols related to standard operations, infection control, sedation, and quality assurance and improvement are included to provide an organizational structure for centers performing pediatric transthoracic echocardiograms.

Congenital pulmonary malformations

There are many congenital anomalies of the lung, some of which have no clinical symptoms and are detected incidentally, while others, particularly in the neonatal and infant period, are recognized by their typical signs, symptoms, and radiological appearance. Some congenital lung anomalies are so important that they can cause the death of the patient if not diagnosed and treated early. Classification of congenital lung anomalies is difficult since these anomalies may be related to the airway, arterial and venous vascular system, pulmonary parenchyma, and primitive anterior intestinal anomalies from which the lung originates, and some anomalies may have several etiologic origins. In this review, all subgroups of congenital pulmonary malformations will be discussed.

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.

Surgical management of a giant pulmonary artery aneurysm in a patient with ischaemic heart disease - a case report

Association of Pulmonary Artery Aneurysm with Ischemic Heart Disease is uncommon, and its surgical management has been rarely described in the literature. Surgical intervention should be individualised according to the coexisting diseases and comorbidities to achieve optimal outcome. We report a case of a 76-year-old man with background history of coronary artery stenting due to ischaemic heart disease. The patient presented with features of coronary compression due to giant pulmonary artery aneurysm. He was operated with replacement of aneurysmal pulmonary trunk with 25 mm Hancock conduit.

Hughes-Stovin Syndrome: A Case Report on a Rare, Life-Threatening Vasculitis

Hughes-Stovin Syndrome (HSS) is a rare vasculitic disorder characterised by widespread pulmonary artery aneurysms. It shares some features with Behçet disease. Currently, the diagnosis is based on clinical suspicion. Our case describes a young male who presented with haemoptysis and previous history of pulmonary embolism. Workup was essentially unremarkable, but imaging revealed multiple pulmonary artery aneurysms. Timely initiation of glucocorticoids and immunosuppression with cyclophosphamide led to improvement. High-dose glucocorticoids and immunosuppressants are the mainstays of treatment. Untreated cases can result in fatal outcomes.

Management of Giant Pulmonary Artery Aneurysm with Quadricuspid Valve Stenosis

The pulmonary artery aneurysm (PAA) is a rare disease with no well-defined guidelines about the diagnostic criteria and its management. In fact, the indications for surgical treatment and the type of surgical approach are not clear. However, in case of giant PAAs with hypertension and pulmonary valve abnormalities, surgery should be considered as an effective and safe approach to prevent dissections or ruptures. In this report, we describe a successful case of surgical repair, using a Bioconduit with a pericardial patch to recreate the pulmonary artery bifurcation in a 72-year-old male with aneurysm of the pulmonary artery (max diameter: 72 mm), associated with quadricuspid pulmonary valve stenosis and pulmonary hypertension. The procedure was uncomplicated and the follow-up computed tomography scan at 4 months showed correct positioning of the graft with no sign of contrast leakage.

Pulmonary artery aneurysm protruding into the bronchus as an endobronchial mass: A case report

BACKGROUND

Pulmonary artery (PA) aneurysms are usually diagnosed radiographically and present as small or large lesions resembling inflammation or a neoplasm on chest radiography. It has rarely been reported as an endobronchial mass.

CASE SUMMARY

We report the case of a 64-year-old man who presented with recurrent hemoptysis. Bronchoscopy revealed a tumorous protrusion blocking the right middle lobe bronchus, which was confirmed to be a PA aneurysm using endobronchial ultrasound bronchoscopy and computed tomography angiography.

CONCLUSION

Although endobronchial PA aneurysms are rare, bronchoscopists need to add this lesion to the list of endobronchial masses for which a biopsy is to be assiduously avoided.

Endovascular management of massive hemoptysis due to pulmonary artery pseudoaneurysm in a COVID-19 patient in Vietnam: A case report

Pulmonary artery pseudoaneurysm with massive hemoptysis is extremely rare in patients with coronavirus disease 2019 (COVID-19)-induced pneumonia, especially in its late stage. We report a case who presented with massive hemoptysis and pulmonary artery pseudoaneurysm without pulmonary thromboembolism in their ninth week of COVID-19 infection, which was treated by endovascular embolization. The endovascular intervention was technically and clinically successful, with complete hemoptysis cessation after the procedure. This is the first case reported in Vietnam.

Endovascular embolization with EVOH for the treatment of a Rasmussen aneurysm

First-line treatment of pulmonary artery aneurysms/pseudoaneurysms (PAA/PAPA) is percutaneous or endovascular embolization. The present case of a Rasmussen aneurysm, a PAPA caused by Tuberculosis (TB), was successfully treated with ethylene-vinyl alcohol (EVOH), a radiopaque liquid embolic agent with favorable characteristics. A 35-year-old man presented as a new patient with hemoptysis, and CT imaging revealed multiple cavitary lesions and a 2.1 cm aneurysm in the upper right lobe. Endovascular treatment was delivered and a complete lack of filling of the lesion was noted on post-treatment angiography. The patient's history includes risk factors and past TB infection. Despite the suspicious imaging, diagnostic tests were negative for active TB in this patient. He was then found to have MRSA bacteremia and a mediastinal lymph node positive for M. avium. The etiology of this aneurysm is suspicious for the superinfection of a chronic tuberculous cavity with M. avium, MRSA, or both.

Concurrent Pulmonary Artery Aneurysm, Pulmonary Thrombosis, and Intracardiac Thrombus in Behçet's Disease: A Case Report

Behçet's disease is a systematic, inflammatory disorder affecting vessels of all sizes. It affects both venous and arterial systems. Vascular involvement carries a high risk of morbidity and mortality. Knowing that Behçet's disease is the most common vasculitides that causes pulmonary artery aneurysms, with a mortality rate of around 25%, makes early detection crucial. Thrombosis in Behçet's disease is mainly caused by an inflammatory process rather than a thrombophilic state, thus vascular thrombosis control is achieved with immunosuppressant medications rather than anticoagulants. An exception to the use of anticoagulants in Behçet's disease appears to be due to cerebral venous thrombosis. The occurrence of multiple site thrombosis and aneurysm simultaneously makes the management very challenging, as we will highlight in our case. We present a case of a 31-year-old female patient with many prior hospitalizations due to cerebral venous thrombosis, bilateral pulmonary thrombi, right ventricular thrombus, and right pulmonary artery aneurysm. The patient was diagnosed with Behçet's disease according to the Behçet's Syndrome International Study Group criteria and then managed with the prophylactic low molecular weight heparin, cyclophosphamide, and prednisolone, resulting in significant improvement in the patient's symptoms. Presentation with cerebral venous thrombosis, pulmonary thrombosis, and aneurysm simultaneously is very rare in Behçet's disease. This made this case distinct and challenging in achieving good control of thrombosis and aneurysm simultaneously, which needs close monitoring and a multidisciplinary team to deal with the case.

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.

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.

An 80-Year-Old Woman With Dyspnea and a Lung Mass

CASE PRESENTATION

An 84-year-old woman presented to the interventional pulmonary clinic for evaluation of a right middle lobe lung mass. Her medical history was notable for atrial fibrillation on rivaroxaban and recurrent bilateral breast cancer that had required multiple lumpectomies, radiation, and chemotherapy. She is a former smoker of five-pack years. She underwent a right and left heart catheterization at an outside facility 2 months prior to her presentation for evaluation of dyspnea that showed minimal coronary artery disease but elevated pulmonary artery pressures of 55/24 mm Hg. The procedure itself was complicated by hemoptysis that required hospital admission for observation. She underwent a chest radiography during her hospitalization (Fig 1) There was no recent imaging for comparison. She was seen by a pulmonologist as an outpatient and underwent bronchoscopy with BAL and bronchial brushing for concerns of malignancy. The results were not diagnostic. She was then referred to the interventional pulmonary service for further evaluation.

Issues in Medicine

Rasmussen aneurysms are abnormalities of the pulmonary arterial system caused by tuberculosis (TB). They are associated with a highmortality rate when they cause life-threatening haemoptysis. High TB-prevalence regions have a large burden of TB-related haemoptysisbut often limited resources. This series of 25 patients who presented with life-threatening haemoptysis from current and/or previous TBwere found to have abnormal pulmonary arteries on computed tomography pulmonary angiogram (CTPA), which were judged to belikely contributors to their bleeding, either in isolation or with concomitant abnormal bronchial or systemic vasculature. These patientsunderwent transcatheter placement of Amplatzer vascular plugs in the feeder pulmonary artery. Bronchial and systemic lesions wereaddressed separately as needed. Immediate technical success was achieved in all patients, but four of them experienced intraoperativehaemoptysis related to dislodgement of the occluding platelet plug by the high-pressure automatic injector and wire. At 48 hours after theprocedure, 18 (72%) remained haemoptysis-free. Six of these experienced recurrence within 1 year of their procedure. Pulmonary arteryplacement of an Amplatzer vascular plug is a feasible option for treating bleeding Rasmussen aneurysms, but should be part of a combinedapproach to addressing suspected culprit vascular lesions in all intrathoracic vascular systems.

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.

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.

Successful transcatheter embolization of an unruptured idiopathic peripheral pulmonary artery aneurysm

Pulmonary artery aneurysms (PAAs) occurring in the distal branch of the pulmonary artery are rare, and there are only a few reports of transcatheter embolization of unruptured idiopathic peripheral PAAs. We report a case of a 66-year-old woman with a history of surgery for pulmonary arteriovenous malformations who presented with an idiopathic peripheral PAA of A10 confirmed by contrast-enhanced computed tomography and pulmonary artery angiography. Transcatheter embolization was performed to prevent rupture, and the aneurysm was successfully embolized. Although there is no consensus on the indications and treatment for unruptured idiopathic peripheral PAAs, transcatheter embolization may be a favorable treatment option.

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.

Hemoptysis after COVID: Pulmonary artery pseudoaneurysm treated with endovascular coiling

Pulmonary artery pseudoaneurysms are a rare but life-threatening cause of hemoptysis. These are saccular dilatations of the pulmonary artery which do not involve all the three layers of the vessel and are prone to rupture. PAPAs are most commonly associated with infections but may also be caused by vasculitis, lung fibrosis, pulmonary hypertension and a multitude of other causes. CT pulmonary angiography is the diagnostic modality of choice allowing delineation of the PAPA, underlying cause and allowing planning of further management. Although treating the underlying cause is an important part of management, endovascular intervention is required in cases with hemoptysis. Long COVID is an entity that is still under evaluation. It has multisystem involvement. We describe the case of a 30-year-old teacher with hemoptysis after COVID who was diagnosed with a PAPA of segmental branch of left upper lobar pulmonary artery and treated with endovascular embolization with coils and glue. His hemoptysis has stopped since then. He also had pulmonary fibrosis and growth of multidrug resistant Klebsiella pneumoniae in sputum. These were treated medically and he has resumed his work as a teacher.

Endovascular Repair of an Iatrogenic Pulmonary Artery Pseudoaneurysm

Pulmonary pseudoaneurysms have various causes and typically arise from the main pulmonary artery. Surgical and endovascular options may be considered for treatment. We report the case of a man with a pseudoaneurysm arising from the right pulmonary artery, treated with a septal occlusion device and percutaneous thrombin injection. (Level of Difficulty: Advanced.)

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.

Pulmonary Arteriovenous Malformation and Its Vascular Mimickers

Pulmonary arteriovenous malformation (AVM) is a congenital vascular disease in which interventional radiologists can play both diagnostic and therapeutic roles in patient management. The diagnosis of pulmonary AVM is simple and can usually be made based on CT images. Endovascular treatment, that is, selective embolization of the pulmonary artery feeding the nidus of the pulmonary AVM, and/or selectively either the nidus or draining vein, has become a first-line treatment with advances in interventional devices. However, some vascular diseases can simulate pulmonary AVMs on CT and pulmonary angiography. This subset can confuse interventional radiologists and referring physicians. Vascular mimickers of pulmonary AVM have not been widely known and described in detail in the literature, although some of these require surgical correction, while others require regular follow-up. This article reviews the clinical and radiologic features of pulmonary AVMs and their mimickers.

Multiple Pulmonary Artery Pseudoaneurysms Secondary to Metastatic Uterine Leiomyosarcoma

Teaching point: The probable mechanism of pseudoaneurysm formation related to metastatic neoplasm is a tumor embolus penetrating and destroying the vessel wall.

Pulmonary artery pseudoaneurysm (PAP) related to metastatic neoplasm is rare. We describe a unique case of multiple PAPs secondary to metastatic uterine leiomyosarcoma and demonstrate the serial chest computed tomography to support the theory that the tumor begins as a tumor embolus, followed by infiltration and breakdown of the vessel wall, leading to aneurysmal dilatation and invading the perivascular tissue.

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.

Pulmonary artery aneurysm associated with a nonstenotic bicuspid pulmonic valve: A role for genetics?

BACKGROUND

Bicuspid pulmonic valves are quite uncommon, being described in only 0.1% of donor's hearts, while pulmonary artery aneurysms (PAAs) are even rarer, having been found in 8 out of 109,571 autopsies. This rarity makes it difficult to characterize the relationship between them.

MATERIALS AND METHODS

We describe the case of a 66-year-old female who was found to have a bicuspid pulmonic valve and PAA (5.1 cm) on imaging by her cardiologist.

DISCUSSION AND CONCLUSION

This case raises the question of whether the association between bicuspid semilunar valve disease and vascular wall anomalies is more genetic or hemodynamic. Even on the aortic side, despite the robust association between bicuspid aortic valves and thoracic aortic aneurysms, the mechanism still remains unclear. In our patient there was no significant gradient across the bicuspid pulmonic valve, suggesting that hemodynamics are not the primum mobile of this association.

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.

Operative intervention for a central pulmonary artery pseudoaneurysm

Pulmonary artery (PA) pseudoaneurysms are a rare but potentially lethal diagnosis. They can be further categorized by etiology or location and are typically successfully treated with endovascular therapies. However, they occasionally require operative intervention. Here, we present a case of a patient who presented with a central PA pseudoaneurysm on computed tomography scan with unclear etiology that was initially treated with conservative management. However, this was noted to have rapid enlargement on interval imaging necessitating urgent surgical intervention. The patient underwent a median sternotomy, anterior PA arteriotomy for exposure, exclusion of the posterior artery pseudoaneurysm with a bovine pericardial patch, and closure of the anterior arteriotomy with a bovine pericardial patch. The patient did well and was discharged on postoperative day 11 with repeat imaging showing resolution.

Late presentation of pulmonary artery pseudoaneurysm following bronchovascular sleeve resection of lung

A 43-year-old man with a history of double sleeve right upper lobectomy for pulmonary sarcoma, presented with worsening haemoptysis. Bronchoscopic and positron emission tomography (PET)CT appearances were suspicious for disease recurrence; however, on attending for CT-guided biopsy, he was found to have a large pseudoaneurysm of his right pulmonary artery. The patient underwent placement of endovascular covered stent with fluoroscopic confirmation of pseudoaneurysm occlusion, and was discharged home on lifelong antiplatelet therapy. To our knowledge, this is the first reported case of pulmonary artery pseudoaneurysm following double (bronchovascular) sleeve resection of the lung, successfully treated by endovascular stenting.

Transcatheter Intervention for Congenital Defects Involving the Great Vessels: JACC Review Topic of the Week

Since the development of balloon angioplasty and balloon-expandable endovascular stent technology in the 1970s and 1980s, percutaneous transcatheter intervention has emerged as a mainstay of therapy for congenital heart disease (CHD) lesions throughout the systemic and pulmonary vascular beds. Congenital lesions of the great vessels, including the aorta, pulmonary arteries, and patent ductus arteriosus, are each amenable to transcatheter intervention throughout the lifespan, from neonate to adult. In many cases, on-label devices now exist to facilitate these therapies. In this review, we seek to describe the contemporary approach to and outcomes from transcatheter management of major CHD lesions of the great vessels, with a focus on coarctation of the aorta, single- or multiple-branch pulmonary artery stenoses, and persistent patent ductus arteriosus. We further comment on the future of transcatheter therapies for these CHD lesions.