Proximal pulmonary artery aneurysms in patients with pulmonary artery hypertension: complicated cases

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.

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.

Management of Pulmonary Artery Aneurysms in Pulmonary Hypertension: A Single-Center Review of 3 Cases

Pulmonary artery aneurysms (PAAs) are defined as having pulmonary artery diameter of greater than 40 mm. PAAs are rare and can occur in various pulmonary diseases. There are no clear-cut guidelines regarding the management of PAAs, and recommendations for management are made based on expert consensus opinion, case reports, and institutional experience. This series highlights three patients with pulmonary hypertension (PH) and PAA. The clinical course and diagnostic findings and the decision-making involved in the treatment are reviewed. An overview of three distinct management strategies including medical management, heart/lung transplant, and surgical aneurysm repair is presented.

Cardiac Outpouchings: A Multimodality Imaging Review

Cardiac outpouchings pose a diagnostic challenge when encountered in practice, as the signs, symptoms, and initial investigations, such as radiographs and electrocardiogram, are nonspecific. They may remain asymptomatic and be incidentally detected. However, a few may present with progressive shortness of breath, thromboembolic complications, arrhythmias, pressure effects, rupture, or even death. Imaging is of paramount importance in establishing an accurate diagnosis, delineating morphology and extent of the lesion along with its hemodynamic significance, planning management, and in the follow-up.

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

Aims

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

Methods and results

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

Conclusion

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

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

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

Bilateral multiple pulmonary artery aneurysms associated with cavitary pulmonary tuberculosis: a case report

BACKGROUND

Pulmonary artery aneurysms constitute <1% of aneurysms occurring in the thoracic cavity. Congenital cardiac defects are responsible for the majority (>50%) of cases, however, pulmonary artery aneurysm is a rare sequelae of pulmonary tuberculosis reported in about 5% of patients with chronic cavitary tuberculosis on autopsy. The natural history of this potentially fatal condition remains poorly understood and guidelines for optimal management are controversial.

CASE PRESENTATION

A 24-year-old man, a nursing student of African descent, was referred to us from an up-country regional hospital with a 4-week history of recurrent episodes of breathlessness, awareness of heartbeats and coughing blood 3 weeks after completing a 6-month course of anti-tuberculosis drugs. A physical examination revealed conjuctival and palmar pallor but there were no stigmata of connective tissue disorders, systemic vasculitides or congenital heart disease. An examination of the cardiovascular system revealed accentuated second heart sound (S2) with early diastolic (grade 1/6) and holosystolic (grade 2/6) murmurs at the pulmonic and tricuspid areas respectively. Blood tests showed iron deficiency anemia, prolonged bleeding time, and mild hyponatremia. A chest radiograph revealed bilateral ovoid-shaped perihilar opacities while a computed tomography scan showed bilateral multiple pulmonary artery pseudoaneurysms with surrounding hematoma together with adjacent cystic changes, consolidations, and tree-in-bud appearance. Our patient refused to undergo surgery and died of aneurismal rupture after 9 days of hospitalization.

CONCLUSIONS

The presence of intractable hemoptysis among patients with tuberculosis even after completion of anti-tuberculosis course should raise an index of suspicion for pulmonary artery aneurysm. Furthermore, despite of its rarity, early recognition and timely surgical intervention of pulmonary artery aneurysm is crucial to reducing morbidity and preventing the attributed mortality.

Huge idiopathic pulmonary artery aneurysm

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

Prophylactic Pulmonary Artery Reduction in a Young Female with Severe Pulmonary Hypertension from Complete Atrioventricular Septal Defect

Management of severely dilated pulmonary artery (PA) associated with severe pulmonary hypertension from congenital heart disease remains controversial, primarily due to its rare nature and concern for perioperative unpredictable complications. Herein, we report a 25 year-old female with a severely dilated PA (up to 73 mm), who was successfully treated by a PA graft replacement by creating a Y-shaped conduit using a 28 mm hemashield tube in the main PA and a 20 mm hemashield tube in both proximal parts of the branch PA.

Anesthesia for pulmonary trunk aneurysmorrhaphy

BACKGROUND AND OBJECTIVES

The aneurysm in the pulmonary trunk is a rare disease. Because of its location, a rupture can lead to right ventricular failure and sudden death. Aneurysmorraphy is the most widely used surgical treatment in these cases. The aim of this study is to report a successful balanced general anesthesia for aneurysmorraphy of pulmonary trunk.

CASE REPORT

Male patient, 28 years, asymptomatic, diagnosed with an aneurysm in the pulmonary trunk. According to the location of the aneurysm and the consequent failure of the pulmonary valve, an aneurysmorraphy was indicated, with implantation of vascular-valvular prosthesis (valved tube). We opted for a balanced general anesthesia, seeking to prevent an increase in systemic and pulmonary vascular resistances, thus avoiding to cause stress on the wall of the aneurysmal vessel.

CONCLUSIONS

A balanced general anesthesia, in combination with adequate ventilation to prevent elevation in pulmonary vascular pressure, was appropriate for surgical repair of an aneurysm in the pulmonary trunk.

[Anesthesia for pulmonary trunk aneurysmorrhaphy]

BACKGROUND AND OBJECTIVES

The aneurysm in the pulmonary trunk is a rare disease. Because of its location, a rupture can lead to right ventricular failure and sudden death. Aneurysmorraphy is the most widely used surgical treatment in these cases. The aim of this study is to report a successful balanced general anesthesia for aneurysmorraphy of pulmonary trunk.

CASE REPORT

Male patient, 28 years, asymptomatic, diagnosed with an aneurysm in the pulmonary trunk. According to the location of the aneurysm and the consequent failure of the pulmonary valve, an aneurysmorraphy was indicated, with implantation of vascular-valvular prosthesis (valved tube). We opted for a balanced general anesthesia, seeking to prevent an increase in systemic and pulmonary vascular resistances, thus avoiding to cause stress on the wall of the aneurysmal vessel.

CONCLUSIONS

A balanced general anesthesia, in combination with adequate ventilation to prevent elevation in pulmonary vascular pressure, was appropriate for surgical repair of an aneurysm in the pulmonary trunk.

Left Main Coronary Artery Stenting to Relieve Extrinsic Compression by a Giant Pulmonary Artery Aneurysm in a Patient with Idiopathic Pulmonary Artery Hypertension

Pulmonary artery aneurysm (PAA) is a rare but lethal disease. We present a female patient with idiopathic pulmonary artery hypertension (IPAH)-related PAA, who suffered from unstable angina pectoris. Multi-detector computed tomography and coronary angiogram revealed extrinsic compression of the left main coronary artery (LMCA) caused by a giant PAA with severe ostial stenosis. Intravascular ultrasound showed an oval-shaped ostium of the LMCA, indicating extrinsic compression. After successful LMCA stent implantation, chest pain was greatly relieved. This case illustrates that beyond right ventricle ischaemia and coronary atherosclerotic disease, LMCA compression by PAA should be considered in the differential diagnosis of angina in patients with IPAH related PAA. In addition, intravascular ultrasound can be used to confirm the diagnosis and guide the stent implantation safely.

Giant high-pressure pulmonary artery aneurysm in an elderly patient with chronic obstructive pulmonary disease

The authors report the case of a 74-year-old man, with a history of chronic obstructive pulmonary disease (COPD), GOLD grade 3, stable for the past two decades, who was admitted to our center with severe right heart failure. The chest radiograph showed moderate heart enlargement mainly of the right atrium and pulmonary artery, similar to previous chest radiographs in the previous 20 years. The transthoracic echocardiogram showed a pulmonary artery aneurysm (PAA), dilatation of the right chambers with pulmonary artery systolic pressure of 52 mmHg, and preserved right ventricular systolic function. A thoracic computed tomography scan confirmed the presence of a giant PAA 72 mm in diameter. The patient was started on high-dose diuretics, with significant clinical improvement. After optimization of medical therapy right heart catheterization was carried out with the patient in optimal clinical condition, which revealed mild precapillary pulmonary hypertension with a mean pulmonary artery pressure of 26 mmHg. On the basis of the clinical and imaging findings a stable, giant, high-pressure, PAA was diagnosed secondary to pulmonary hypertension induced by COPD, with a 20-year follow-up without need for surgical repair, which helped in our decision to maintain medical surveillance. The recent onset of heart failure is explained by the unfavorable evolution of COPD. This case may change the attitude expressed in previous studies favoring the choice of an invasive approach to treat giant high-pressure PAAs, instead supporting the maintenance of medical treatment.

Unusual Case of Left Bronchial Compression by Aneurysmal Pulmonary Arteries in a Child With Atrial Septal Defect

We report an uncommon case of large ostium secundum atrial septal defect (ASD) with severe pulmonary arterial hypertension, with associated aneurysmal dilatation of the pulmonary arteries (PAs) leading to compression of the left main bronchus and collapse of the entire left lung in a 15-month-old female child. The patient was managed by surgical closure of the ASD, translocation of the right PA anterior to the aorta with PA aneurysmorrhaphy. Left bronchial compression was relieved with complete lung expansion on the third postoperative day.

Giant pulmonary artery aneurysm in a patient with rheumatic mitral stenosis

Pulmonary artery (PA) aneurysm is a rare condition, frequently associated with pulmonary hypertension. However, the evolution and treatment of this pathology is still not clear. We report a case of a 45-year-old female patient with giant PA aneurysm associated with rheumatic mitral stenosis and severe pulmonary arterial hypertension. The patient had undergone balloon mitral valvotomy around 7 years back; aneurysm was first identified 3 years back during routine follow-up. The PA aneurysm size, however, had remained almost unchanged with associated severe pulmonary regurgitation. Surgical correction was advised but denied by the patient. To our knowledge, this is the first case report of such a large PA aneurysm in association with rheumatic heart disease. Although medical therapy for pulmonary hypertension was started, surgical correction of the aneurysm was advised in order to prevent the future complications.

Pulmonary artery aneurysms: four case reports and literature review

Aneurysms of the pulmonary artery are proven to be a very rare entity. Association with structural cardiac anomalies, structural vascular anomalies, pulmonary hypertension, vasculitis, and infection has been noted. Surgical intervention of symptomatic aneurysms is recommended. A more detailed study of the natural history of these aneurysms is needed. Here, we report four cases of pulmonary artery aneurysms as well as a brief review of the literature existing on this subject. The first case is of a 41-year-old woman with the aneurysm located 1 cm distal to the pulmonary valve extending to the bifurcation of the main pulmonary artery. The second case is of a 76-year-old woman with a large aneurysm of the main pulmonary artery and the left pulmonary artery. The third case is of a 61-year-old woman with an aneurysm of the common pulmonary artery and right pulmonary artery. The fourth case is of a 28-year-old woman with a 5-cm symptomatic aneurysm extending from the valve up to the pulmonary bifurcation. Surgical excision and reconstruction was ordered for cases 1, 2, and 4.

Low pressure pulmonary artery aneurysm with atrial septal defect

Pulmonary artery (PA) aneurysm is a rare finding in the thoracic cavity, accompanied by pulmonary hypertension. Clinical presentation of PA aneurysms is usually asymptomatic. The guideline for PA aneurysm treatment is unclear. We report an unusual case of low pressure PA aneurysm associated with atrial septal defect in a 69-year-old man.

Giant pulmonary artery aneurysm in a patient with vasoreactive pulmonary hypertension: a case report

Background

Pulmonary artery aneurysms are a rare condition, frequently associated with pulmonary hypertension. However, the evolution and treatment of this pathology is still not clear.

Case Presentation

The authors report a case of a 65-year old patient with pulmonary artery aneurysm associated with pulmonary arterial hypertension. Due to a positive vasoreactivity test, treatment with calcium channel blockers was started with near normalization of the right cardiac pressures. Nevertheless, after 20 months of treatment, the pulmonary artery aneurysm size remained unchanged with an associated severe pulmonary regurgitation and causing extrinsic compression of the main left coronary artery. Surgical correction was successfully performed.

Conclusions

This is the first case report of a pulmonary artery aneurysm described to be associated with vasoreactive pulmonary hypertension in a living patient. Although medical therapy for pulmonary hypertension was started, surgical correction of the aneurysm was executed in order to prevent its future complications.