Pulmonary Artery Pseudoaneurysms: Clinical Features and CT Findings

Interventional management of aspergillus-related pulmonary artery pseudoaneurysm and hemoptysis

Pulmonary artery pseudoaneurysms are rare but life-threatening vascular abnormalities. Only less than 10% hemoptysis cases are of pulmonary artery origin while most cases arise from bronchial arteries. When diagnosed, they are mostly found to accompany pre-existing cardiovascular disease, infection, (i.e. Tuberculosis or Aspergillosis), vasculitis, trauma and/or neoplastic conditions. There are rare reports of pulmonary artery pseudoaneurysms being caused by direct extension of invasive fungal infections. We report a case of a rapidly growing pulmonary artery pseudoaneurysm in a 20-year-old female with lymphoma involving the lung and mediastinum. The patient was hospitalized with complications, including hemoptysis in the setting of Aspergillus Pneumonia and respiratory failure requiring intubation. Interventional Radiology was consulted after multiple bronchoscopic interventions failed to stabilize the bleeding. Patient then underwent embolization of the left subsegmental pulmonary artery pseudoaneurysm, with resolution of hemoptysis the next day.

Clinical and radiological features associated with rupture of pulmonary artery pseudoaneurysm: a retrospective study

BACKGROUND

Hemoptysis resulting from rupture of the pulmonary artery pseudoaneurysm (PAP) is massive and fatal, while factor contributing to the rupture of pseudoaneurysm remains elusive. This study aimed to elucidate the clinical and radiological features of PAP and identify the risk factors associated with rupture.

METHODS

Patients who developed hemoptysis with PAP were collected from January 2019 to December 2022 retrospectively. Clinical data of the demographic characteristics, radiological findings, treatment strategies, and prognosis were collected. A comparative analysis was performed on the characteristics in the ruptured and non-ruptured cases.

RESULTS

A total of 58 PAPs were identified in the 50 patients. The most common causes were infection (86%) and cancer (8%). The PAPs were located predominantly in the upper lobes of both lungs, and 57 (99.3%) were distributed in the segmental or subsegmental pulmonary arteries. The median diameter was 6.1(4.3-8.7) mm. A total of 29 PAPs were identified adjacent to pulmonary cavitations, with the median diameter of the cavity being 18.9 (12.4-34.8) mm. Rupture of pseudoaneurysm occurred in 21 cases (42%). Compared to unruptured group, the ruptured group had a significantly higher proportion of massive hemoptysis (57.1% vs. 6.9%, p < 0.001), larger pseudoaneurysm diameter (8.1 ± 3.2 mm vs. 6.0 ± 2.3 mm, p = 0.012), higher incidence of pulmonary cavitation (76.2% vs. 44.8%, p = 0.027), and larger cavitation diameters (32.9 ± 18.8 mm vs. 15.7 ± 8.4 mm, p = 0.005). The mean pulmonary artery pressure (mPAP) in the ruptured group was also significantly higher than that in the unruptured group [23.9 ± 7.4 mmHg vs. 19.2 ± 5.0 mmHg, p = 0.011]. Endovascular treatment was successfully performed in all 21 patients with ruptured PAP, of which the clinical success rate was 96.0%. Five patients experienced recurrent hemoptysis within one year.

CONCLUSIONS

Massive hemoptysis, pseudoaneurysm diameter, pulmonary cavitation, and elevated mPAP were the risk factors for rupture of pseudoaneurysm. Our findings facilitate early identification and timely intervention of PAP at high risk of rupture.

Mechanical Thrombectomy Complicated by Pulmonary Artery Pseudoaneurysm Treated With Endovascular Thrombin Injection

Pulmonary thrombectomy for acute pulmonary arterial embolism has emerged as an effective endovascular therapy for high-risk patients. While the procedure is typically performed safely and efficaciously, given the nature of the treatment, complications may rarely occur. Pulmonary pseudoaneurysm is a rare condition occurring in a variety of settings, including pulmonary thrombectomy. To our knowledge, we present the first published case of pulmonary artery pseudoaneurysm following percutaneous thrombectomy, along with its successful endovascular management.

Mycotic pulmonary artery pseudoaneurysm following total arch replacement: a case report

BACKGROUND

Although the true prevalence and incidence are not clearly known, mycotic pulmonary artery aneurysm is a potentially devastating condition that leads to high mortality, over 60% if untreated. Among them, mycotic pulmonary artery pseudoaneurysm, which occurs in relatively central areas, has rarely been reported. We report an extremely rare case of a late complication with a mycotic pulmonary artery pseudoaneurysm, presumably due to infective endocarditis, in a 68-year-old woman 4 months after total arch replacement.

CASE PRESENTATION

A 68-year-old woman was referred to our department for 2 weeks with fever of unknown origin. She had a history of emergency total arch replacement for an acute type A aortic dissection 4 months earlier and chronic rheumatoid arthritis on monthly subcutaneous tocilizumab treatment for several years. Blood culture was positive for Enterococcus faecalis. Transthoracic and transesophageal echocardiography revealed a left ventricular ejection fraction of 58%, severe mitral regurgitation with a 15-mm diameter vegetation on the anterior mitral leaflet, and severe aortic insufficiency with string-like structures. Contrast computed tomography showed a focal saccular outpouching from the right pulmonary artery. On 18F-fluorodeoxyglucose (FDG) positron emission tomography, focal uptake of FDGs was observed along the same lesion of the pulmonary artery and ascending-arch graft. The patient eventually recovered after the surgical intervention of mitral and aortic valve replacement, re-total arch replacement, pulmonary artery repair, application of omental flap, and antibiotics without any evidence of re-infection after 1 year.

CONCLUSIONS

We report a successful surgical repair of mycotic pulmonary artery pseudoaneurysm 4 months after total arch replacement for acute type A aortic dissection. This report describes an effective treatment for an extremely rare postoperative condition.

An unusual case of metastatic trophoblastic neoplasm presenting with diffuse cystic lung disease and pulmonary artery pseudoaneurysms in a teenager

Diffuse cystic lung diseases (DCLDs) are a diverse group of lung disorders characterized by the presence of multiple air filled cysts within the lung tissue. These cysts are thin walled and surrounded by normal lung tissue. In adults, DCLD can be associated with various conditions such as lymphangioleiomyomatosis (LAM), Langerhans cell histiocytosis, cancers, and more. In children, DCLD is often linked to lung developmental abnormalities, with bronchopulmonary dysplasia being a common cause. Patients with pulmonary cysts are typically asymptomatic, but some may experience mild symptoms or pneumothorax. While DCLD in children is rarely due to malignancy, metastatic lung disease can be a cause. It is important for clinicians to be aware of the possibility of metastatic lung disease when encountering DCLD.

Pulmonary artery pseudoaneurysm after thoracic radiation therapy: A case report and review of the literature

Pulmonary artery pseudoaneurysm (PAP) is a rare cause of hemoptysis. Potential causes include trauma, infection, or medical interventions. There is a risk of rupture, which is associated with a high mortality rate. We describe a 72-year-old patient, with a past medical history of a lung carcinoma for which she was treated with chemoradiotherapy 6 years prior, who presented with hemoptysis. She was hemodynamically stable and there were no other complaints. CT angiography of the thorax showed a PAP originating from a branch of the right pulmonary artery in the previously irradiated area. The patient was successfully treated by an embolization with plugs. Treatment of lung carcinoma with chemoradiotherapy can result in the development of a PAP. Clinicians should be aware of this complication, even years after the therapy. In literature, only a few cases of PAP in patients treated with (chemo)radiotherapy for lung cancer are described, with a maximum interval up to 7 years.

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.

Successful Endovascular Management of Recurrent Hemoptysis due to Multiple Rasmussen Aneurysms in a Case of Pulmonary Tuberculosis: A Rare Case Scenario

Background

Hemoptysis is defined as coughing out of blood. Pulmonary tuberculosis is the most common cause of hemoptysis in tuberculosis-endemic countries like India. Rasmussen aneurysm is a pseudoaneurysm arising from the pulmonary artery adjacent to or within a tuberculous cavity. Chest radiographs, chest computed tomography angiography (CTA), and digital subtraction angiography (DSA) are the imaging tools for evaluating a case of hemoptysis.

Case

A 32-year-old man with a history of pulmonary tuberculosis presented with complaints of recurrent hemoptysis. On imaging evaluation, multiple pulmonary artery pseudoaneurysms were seen in the left lung. The patient was shifted to the DSA lab and the pseudoaneurysms were subsequently treated by endovascular coil embolization. Hemoptysis resolved following the procedure and the patient was again started on anti-tubercular therapy.

Conclusion

Endovascular coiling is minimally invasive, safe, and effective management of multiple Rasmussen aneurysms for preventing possible torrential blood loss and unfortunate death.

Bronchial embolisation for infected pulmonary artery pseudoaneurysms causing haemoptysis

AIM

To report the authors' experience of bronchial artery embolisation (BAE) in a series of patients to control haemoptysis associated with infected pulmonary artery pseudoaneurysms (PAPs).

MATERIALS AND METHODS

All patients who underwent BAE based on computed tomography angiography (CTA) findings indicative of haemoptysis between February 2019 and September 2022 at Xiangyang Central Hospital were identified. Charts of patients with haemoptysis and infectious PAPs were reviewed retrospectively. Data were collected data on age, sex, underlying pathology, source pulmonary artery of the PAP, association with cavitary lesions or consolidation, systemic angiography findings, technical and clinical success, and follow-up.

RESULTS

Seventeen PAPs were treated in 16 patients, with a mean age of 60.3 years (range: 37-82 years). The most common underlying cause was tuberculosis (15/16, 93.8%). Imaging by CTA did not identify the source pulmonary artery for 15 (88.2%) PAPs; all were associated with cavitary lesions or consolidation. All PAPs were visualised on systemic angiography. The technical and clinical success rates were both 87.5%. Two patients who experienced a recurrence of haemoptysis during follow-up underwent repeat CTA, which confirmed the elimination of the previous PAP.

CONCLUSION

BAE may be a valuable technique to control haemoptysis associated with infectious PAPs that are visualised on systemic angiography. A possible contributing factor is PAPs arising from very small pulmonary arteries.

Pulmonary artery pseudoaneurysm arising from primary lung neoplasm: A proposed mechanism

Pulmonary artery pseudoaneurysms (PAPs) are rare and life-threatening occurrences. We present a 57-year-old male patient with squamous cell lung cancer, who presented with hemoptysis. Bronchoscopy did not reveal ongoing bleeding. Imaging showed a left lower lobe tumor, a cavitary lesion communicating with the bronchus, and a pulmonary artery pseudoaneurysm. Successful embolization of the originating segmental branch of the pulmonary artery was performed. The pathogenesis of PAPs associated with primary lung malignancies remains poorly understood. We propose a four-step mechanism involving primary tumor expansion, central cavitary necrosis, direct arterial invasion, inflammatory response, vessel wall damage, pseudoaneurysm formation, and subsequent filling of the former cavitary lesion. This case emphasizes the importance of considering PAPs in primary lung malignancies, particularly in male patients with squamous cell pathology. Understanding the proposed pathogenic mechanism could lead to early detection, prompt intervention, and improved outcomes.

Pulmonary artery pseudoaneurysms: a single-center experience of endovascular occlusion

The technique and outcomes of pulmonary artery pseudoaneurysm (PAP) embolization was retrospectively evaluated in 13 patients undergoing 14 PAP embolizations between January 2014 and September 2023. The etiology of the PAP was iatrogenic (4/13), tumor (3/13), chronic lung (2/13), idiopathic (2/13) and mycotic (2/13). Clinical presentation was massive hemorrhage (6/13), incidental (4/13), and non-massive hemoptysis (3/13). The average PAP size was 13.5 mm. Coil embolization of the PAP sac was performed in all but two extenuating cases (11/13). Follow-up of 12 patients over an average 5.3-months showed persistent occlusion in all cases. There were no major adverse events attributed to the embolization. Five out of ten patients with procedures performed at least one year before this study were noted to be deceased after an average seven-month time. PAPs of various etiologies may be safely and effectively treated by occluding the aneurysm inflow, outflow, and sac.

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.

Pulmonary Artery Embolization in the Management of Hemoptysis Related to Lung Tumors

(1) Background: Bronchial artery embolization has been shown to be effective in the management of neoplastic hemoptysis. However, knowledge of pulmonary artery embolization is lacking. The aim of this study was to evaluate the safety and efficacy of pulmonary artery embolization in patients presenting with hemoptysis related to lung tumors. (2) Methods: This retrospective study reviewed all consecutive patients with cancer and at least one episode of hemoptysis that required pulmonary artery embolization from December 2008 to December 2020. The endpoints of the study were technical success, clinical success, recurrence of hemoptysis and complications. (3) Results: A total of 92 patients were treated with pulmonary artery embolization (63.1 years ± 9.9; 70 men). Most patients had stage III or IV advanced disease. Pulmonary artery embolization was technically successful in 82 (89%) patients and clinically successful in 77 (84%) patients. Recurrence occurred in 49% of patients. Infectious complications occurred in 15 patients (16%). The 30-day mortality rate was 31%. At 3 years, the survival rate was 3.6%. Tumor size, tumor cavitation and necrosis and pulmonary artery pseudoaneurysm were significantly associated with recurrence and higher mortality. (4) Conclusions: Pulmonary artery embolization is an effective treatment to initially control hemoptysis in patients with lung carcinoma, but the recurrence rate remains high and overall survival remains poor.

Delayed diagnosis of Lemierre's syndrome in a patient with severe coronavirus disease 2019: importance of comprehensive oral and neck examination - a case report

BACKGROUND

Given the widespread prevalence of the coronavirus disease 2019 (COVID-19), oral and neck examinations tend to be avoided in patients with suspected or confirmed COVID-19. This might delay the diagnosis of conditions such as Lemierre's syndrome, which involves symptoms resembling COVID-19-related throat manifestations.

CASE PRESENTATION

A 24-year-old man without any underlying conditions was diagnosed with COVID-19 7 days before presentation. He was admitted to another hospital 1 day before presentation with severe COVID-19 and suspected bacterial pneumonia; accordingly, he was started on treatment with remdesivir and meropenem. Owing to bacteremic complications, the patient was transferred to our hospital for intensive care. On the sixth day, the patient experienced hemoptysis; further, a computed tomography (CT) scan revealed new pulmonary artery pseudoaneurysms. Successful embolization was performed to achieve hemostasis. In blood cultures conducted at the previous hospital, Fusobacterium nucleatum was isolated, suggesting a cervical origin of the infection. A neck CT scan confirmed a peritonsillar abscess and left internal jugular vein thrombus; accordingly, he was diagnosed with Lemierre's syndrome. The treatment was switched to ampicillin/sulbactam, based on the drug susceptibility results. After 6 weeks of treatment, the patient completely recovered without complications.

CONCLUSION

This case highlights the significance of thorough oral and neck examinations in patients with suspected or diagnosed COVID-19 for the detection of throat and neck symptoms caused by other conditions.

Pulmonary pseudoaneurysm in the setting of concurrent COVID-19 and pulmonary mucormycosis: A rare case report

Key Clinical Message

This case illustrates the possible danger of PAP emergence in individuals with a confluence of conditions capable of inducing vascular impairment, like COVID-19, pulmonary mucormycosis (PM), and diabetes.

Abstract

Pulmonary mucormycosis (PM) is a highly lethal invasive infection. It is a rare complication of COVID-19 and is associated with a high mortality rate. Pulmonary pseudoaneurysm (PAP) is a severe manifestation of this condition, often resulting in death. Management involves endovascular therapy followed by surgery and appropriate antifungal treatment.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Rare but life-threatening cause of massive haemoptysis in an adolscent with tuberculosis: Rasmussen's aneurysm

Rasmussen's aneurysm is a rare yet fatal cause of massive haemoptysis in pulmonary tuberculosis. Early identification and timely intervention are of utmost importance to reduce the associated mortality. A girl in early adolescence presented with persistent fever and massive haemoptysis who required intubation and was subsequently confirmed to have tuberculosis. CT pulmonary angiogram showed the presence of pseudoaneurysms in the left upper and lower lobes. The haemoptysis resolved following the embolisation of the culprit's vessel. Residual lung destruction was evident on CT after a 12-month course of antituberculosis therapy. Rasmussen's aneurysm is a significant vascular complication of cavitary tuberculosis and needs to be considered in patients presenting with massive haemoptysis.

Left Pulmonary Artery Aneurysm Secondary to Metastatic Lung Sarcoma: A Case Report

Aneurysms are characterized by focal dilation of the blood vessel wall due to weakening. The involvement of two layers of the vessel wall is classified as a pseudoaneurysm while the involvement of all three layers is called a true aneurysm. Involvement of neoplastic lesions is rare, but the few reported cases have been associated with pulmonary artery pseudoaneurysms as opposed to true pulmonary artery aneurysms (PAAs). Our case of a true left PAA of a patient with metastatic sarcoma of the lung shows an association that has previously not been reported to the best of our knowledge.

Embolization of pulmonary and systemic mycotic pseudoaneurysms in a pediatric patient

Mycotic pseudoaneurysm is a rare complication of systemic infection in children. We report a case of a previously healthy 11-year-old female with methicillin-resistant staph aureus (MRSA) bacteremia who developed both pulmonary and systemic arterial pseudoaneurysms. These were detected on magnetic resonance (MR) and computed tomography (CT) imaging and treated with coil embolization.

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.

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.

A Case of the Unveiling of Pulmonary Pseudoaneurysm Masquerading as a Lung Mass

Pulmonary artery pseudoaneurysm (PAP) is an abnormal dilatation of the pulmonary vessels. They can mimic the appearance of lung nodules on chest X-rays and noncontrast CT imaging of the chest. We present a case of PAP masquerading as a lung mass for five years before presenting as a pulmonary hematoma. Our patient was an elderly male who presented to the emergency department with dizziness and weakness. He had been on regular follow-ups with annual noncontrast CT scans for a stable lung mass for the past five years. A contrast-enhanced chest CT scan on presentation showed a right lower lobe pseudoaneurysm ruptured into the pleural space with hemothorax, which was confirmed on subsequent chest CTA. The patient underwent an emergent right lower lobe resection and recovered uneventfully. Differentiating a PAP from a lung nodule is challenging and is often missed even by radiologists. A nodule or mass along the pulmonary arterial tree should raise suspicion and trigger further contrast-enhanced imaging, especially angiography, to confirm the diagnosis.

Same Clinical Reality of Spontaneous Rupture of the Common Iliac Artery with Pseudoaneurysm Formation-Comparison of Two Therapeutical Solutions, Endovascular Stent-Graft and Open Surgical Correction, for Two Cases and Review of the Literature

The incidence of isolated iliac artery aneurysms is approximately 2% and common iliac artery pseudoaneurysms are even rarer. A pseudoaneurysm is a localized hemorrhage as opposed to an actual aneurysm, which affects the entire vascular wall. They are typically asymptomatic and only detectable accidentally while looking for other causes. If large and symptomatic, they typically exhibit pressure symptoms as a result of the compression of the structures around them. Common symptoms include generalized stomach pain, urological problems, gastrointestinal bleeding, and neurological symptoms such as leg paralysis or sciatica-like back pain. Rarely, they may exhibit hemodynamic instability together with an aneurysm rupture, which has a high fatality rate. Due to the unique presentation, the diagnosis is typically rarely made and there is little experience with treating it. We report two cases of common iliac artery pseudoaneurysm found in two patients who had no notable medical history and who we chose to repair through the endovascular technique in the first case, an approach that has gained more ground for vascular repair worldwide, making it the current go-to method, and for the second case we chose a more traditional approach, through open surgery.

Successful Intrasaccular Coil Embolization of Mycotic Pulmonary Artery Pseudoaneurysm Using the Balloon Remodeling Technique

A 66-year-old man with ventricular septal defect was hospitalized for fever, dyspnea, and hemoptysis. Infectious endocarditis by Streptococcus parasanguinis was suspected. At 3 weeks after admission, massive hemoptysis suddenly occurred. Contrast-enhanced computed tomography showed a 2-cm aneurysmal formation in the right lower pulmonary artery. Rupture of a mycotic pulmonary artery pseudoaneurysm was diagnosed. Pulmonary angiography showed a wide-necked pseudoaneurysm at the trifurcation of the anterior, lateral, and posterior basal segmental arteries of the right lower lobe. Intrasaccular coil embolization with the balloon remodeling technique was successfully performed, preserving residual pulmonary function distal to the pseudoaneurysm.

Infectious Pulmonary Artery Pseudoaneurysm That Resolved with Conservative Treatment

Pulmonary artery pseudoaneurysms (PAPs) are rare but can cause massive hemoptysis if they rupture. Infectious PAPs are often treated by surgery or transcatheter embolization and are rarely treated conservatively with antibiotics. We herein report a case of PAP treated conservatively in a 21-year-old woman with lung abscess. Except for one massive hemoptysis early in the course, the patient responded well to the empirical therapy with ampicillin/sulbactam and systemic hemostatic agents. After six weeks of antibiotics, the pseudoaneurysm disappeared. Conservative therapy with careful observation can be considered in small infectious PAPs when there is a good clinical response to initial conservative therapy.

Treatment of pulmonary artery pseudoaneurysms and stenosis with balloon-expandable stents

We describe our use of balloon-expandable stents in pulmonary arteries for a variety of indications. This is an endovascular technique that provides an alternative treatment option to treat some forms of complex pulmonary artery disease when standard surgical or other endovascular options are not possible. This case series describes the successful treatment of four patients with different pulmonary artery diseases. Indications for stent placement include multiple broad-necked pulmonary artery pseudoaneurysms, symptomatic malignant pulmonary artery narrowing and post-surgical iatrogenic pulmonary artery stenosis. No stent-related complication had been identified from 3 months to 4 years of follow-up. All surviving patients have experienced sustained symptomatic improvement.

Transcatheter closure of main pulmonary artery pseudoaneurysm using atrial septal occluder device in an infant

We present a case of percutaneous closure of main pulmonary artery pseudoaneurysm using an atrial septal occluder device in a seven-month-old infant. The infant had tetralogy of Fallot repair followed by transcatheter left pulmonary artery stenting. The occlusion of the wide neck of the pseudoaneurysm was performed successfully using the atrial septal occluder with no detected complications in his six-month follow-up post-catheterisation.

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.

Embolic Pneumonectomy for the Treatment of Proximal Pulmonary Artery Pseudoaneurysm

Pulmonary artery pseudoaneurysm is an uncommon and potentially fatal abnormality. It has been described from a wide variety of etiologies, including infectious, iatrogenic, neoplastic, congenital, and traumatic causes. There are currently no published consensus guidelines for the diagnostic testing and management of pulmonary artery pseudoaneurysm. This case report presents an uncommon case of pulmonary artery pseudoaneurysm emerging from a non-small cell lung cancer that was successfully managed using coil embolization.

Transcatheter coil embolization of a complex pulmonary artery pseudoaneurysm with thyrocervical trunk-pulmonary arterial fistulization in a patient with cystic fibrosis and massive hemoptysis

Pulmonary artery pseudoaneurysm (PAP) is a rare cause of life-threatening hemoptysis and tends to develop in the setting of infection, neoplasm, or trauma. Successful endovascular coil embolization has demonstrated effectiveness in treating PAPs and is now the treatment of choice for these patients. Vascular supply to PAPs is highly variable and often requires embolization of both the systemic and pulmonary feeding vessels. This is a case report of a successful transcatheter coil embolization of a complex PAP with a thyrocervical trunk-pulmonary arterial fistula in a patient with massive hemoptysis in the setting of advanced cystic fibrosis.

Pulmonary pseudoaneurysm presented as a lung nodule after recovering from Covid ‐19 pneumonia

Pulmonary pseudoaneurysms (PAPs) are an uncommon complication of severe acute respiratory syndrome coronavirus 2 infection, although they are a potentially life‐threatening condition. We present this interesting condition of severe coronavirus disease 2019 (Covid‐19) pneumonia. The patient presented with abnormal lung nodule and developed massive haemoptysis after recovering from Covid‐19 pneumonia. PAP was diagnosed by computed tomography angiography. Endovascular embolization was performed and the bleeding was stopped.

A 58-Year-Old Man With Hemoptysis After COVID-19 Infection

A 58-year-old man presented to us with a 1-week history of high-grade fever and progressive dry cough. Four weeks before his presentation, he was diagnosed with COVID-19 infection and needed non-ICU hospital admission with no supplemental oxygen requirements for 6 days and was treated with a 5-day course of remdesivir and 3 weeks of dexamethasone. His steroid dose was commenced on dexamethasone 12 mg bid (four times the recommended dose) for 14 days and then gradually tapered over the remaining 7 days. His history was unremarkable, except for well-controlled asthma. He did not complain of any shortness of breath, weight loss, or loss of appetite. He was never a smoker and denied any alcohol use.

SK, Talwade R, Lokeshwaran S, K. PV. Endovascular Treatment of Pulmonary Artery Pseudoaneurysms Post-COVID-19 Pneumonitis

Pulmonary artery pseudoaneurysms (PAPs) are uncommon entities consisting of contained rupture of the pulmonary artery and are a potentially fatal cause of hemoptysis. We describe two index cases of left lower lobe PAPs and arterial ectasia post-COVID-19 pneumonitis and their endovascular treatment with Amplatzer vascular plug, coils, and glue.

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.

An unusual case of hemoptysis: Pulmonary artery pseudoaneurysm secondary to a lung abscess

Massive hemoptysis may originate from injured pulmonary arteries, such as from pulmonary artery pseudoaneurysms (PAPs). A 93-year-old man, diagnosed with pneumonia, was hospitalized; he later developed a lung abscess (controlled with intravenous antibiotics). On post-hospitalization day 29, he suddenly developed hemoptysis. Multi-detector computed tomography angiography (MDCTA) showed an enhanced nodule, diagnosed as a PAP, inside the lung abscess. The hemoptysis resolved, without recurrence, following transcatheter arterial embolization (TAE) of the PAP and its feeding arteries. PAPs should be considered in patients with lung abscesses and delayed massive hemoptysis. In these patients, MDCTA and TAE are effective diagnostic and treatment modalities.

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Massive hemoptysis can originate from pulmonary artery pseudoaneurysms (PAPs).

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PAPs should be considered in patients with delayed hemoptysis and lung abscesses.

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Multi-detector computed tomography angiography can identify origin of hemoptysis.

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It is useful for diagnosing and treating PAPs secondary to lung abscesses.

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Transcatheter arterial embolization can treat PAPs secondary to lung abscesses.

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.

Images of the month 2: Pulmonary artery pseudoaneurysm formation within uterine leiomyosarcoma metastases

We present a rare case of pulmonary artery pseudoaneurysm formation in leiomyosarcoma metastases with evidence of acute bleeding and subsequent interventional radiological management.

CT-guided percutaneous approach for the treatment of peripheral pulmonary artery pseudoaneurysm: A case report

Pulmonary artery pseudoaneurysm is a rare but life threatening complication of pulmonary tuberculosis, considered as a diagnosis and therapeutic emergency. Transarterial embolization approach has become more widespread over the last few decades, and is now considered the first-line treatment over surgery. Percutaneous embolization under computed tomography (CT) or CT scan control has recently been reported by one centre as a first-line treatment for persistent peripheral Pulmonary artery pseudoaneurysm under certain conditions. We report the case of a 23-year-old female patient admitted in emergency for moderate haemoptysis, in a context of relapsing of tuberculosis. CT scan angiogram showed a peripheral pulmonary artery pseudoaneurysm of the lower left lobe, and persisted seven days later. After multidisciplinary meeting, a minimal invasive approach was decided. The patient was treated in first-line treatment by percutaneous transthoracic embolization, under CT-guidance, using N butyl-cyanoacrylate and Lipiodol mixture, without any complication. The percutaneous minimal invasive treatment seems to be a reliable approach to treat persistent peripheral pulmonary artery pseudoaneurysm.

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.

CT for Evaluation of Hemoptysis

Hemoptysis, which is defined as expectoration of blood from the alveoli or airways of the lower respiratory tract, is an alarming clinical symptom with an extensive differential diagnosis. CT has emerged as an important noninvasive tool in the evaluation of patients with hemoptysis, and the authors present a systematic but flexible approach to CT interpretation. The first step in this approach involves identifying findings of parenchymal and airway hemorrhage. The second step is aimed at determining the mechanism of hemoptysis and whether a specific vascular supply can be implicated. Hemoptysis can have primary vascular and secondary vascular causes. Primary vascular mechanisms include chronic systemic vascular hypertrophy, focally damaged vessels, a dysplastic lung parenchyma with systemic arterial supply, arteriovenous malformations and fistulas, and bleeding at the capillary level. Evaluating vascular mechanisms of hemoptysis at CT also entails determining if a specific vascular source can be implicated. Although the bronchial arteries are responsible for most cases of hemoptysis, nonbronchial systemic arteries and the pulmonary arteries are important potential sources of hemoptysis that must be recognized. Secondary vascular mechanisms of hemoptysis include processes that directly destroy the lung parenchyma and processes that directly invade the airway. Understanding and employing this approach allow the diagnostic radiologist to interpret CT examinations accurately in patients with hemoptysis and provide information that is best suited to directing subsequent treatment. ^©RSNA, 2021.

Pulmonary artery pseudoaneurysm secondary to COVID-19 treated with endovascular embolisation

Pulmonary artery pseudoaneurysms are uncommon and can cause severe, life-threatening haemoptysis. We present a case of a 74-year-old gentleman who was being treated for COVID-19 pneumonitis and a concomitant segmental pulmonary artery thrombus with conventional treatment and anticoagulation. The patient developed significant haemoptysis during admission. A repeat computed tomography pulmonary angiogram revealed an 8 mm left upper lobe pulmonary artery pseudoaneurysm. Anticoagulation was withheld and the pseudoaneurysm was successfully treated with endovascular embolisation with an Amplatzer® IV plug, leading to resolution of the haemoptysis. To our knowledge this is the first case of a pulmonary artery pseudoaneurysm secondary to COVID-19.

Successful embolization of giant pulmonary artery pseudoaneurysm using coils and ethylene vinyl alcohol copolymer (Onyx)

Hemoptysis could be a life-threatening event, especially when the bleeding originates from the arterial pulmonary circulation. The main cause of this type of bleeding is pulmonary artery pseudoaneurysm (PAP), which can be managed by surgical, medical or minimally invasive techniques. This study reports the case of massive hemoptysis in a 75-year-old male patient, with a former history of lobectomy. The initial CT scan showed a giant PAP from a branch of the right middle lobar pulmonary artery, within the right lower lobectomy cavity. An endovascular approach was decided. Subsequently, the feeding artery of the PAP was embolized with detachable coils. The control CT scan showed a persistent opacification of the PAP. The embolization was then completed by injection of Onyx within coils packing, with a complete thrombose of the PAP on control CT scan. This report confirms the safety and efficacy profile of an endovascular approach to treat giant PAP, using a combination of coils and Onyx.