1Noor Badrawi,1Ayman Alsibaie

1Rashid Hospital and Trauma Center, Dubai Health Authority

Background(s):

Pulmonary artery aneurysm is an uncommon condition that can be congenital or acquired. Aneurysms are defined as localized dilatation of a blood vessel which involves part or all three layers of the vessel wall. The clinical appearance is often non-specific, thus early detection and appropriate management are critical for avoiding morbidity and death from the potentially fatal rupture and massive hemoptysis. In such conditions, endovascular therapies are becoming more common. We present a case series with our experience with endovascular management of pulmonary artery aneurysm including the clinical presentation, endovascular approach, and outcomes of four patients.

Material(s) and Method(s):

Case I: A 52 years old gentleman, known case of diabetes mellitus type II & ischemic heart disease, presented with a three days history of a productive cough with bloody streaks and fever.

He was found to have an abnormal chest radiograph that showed lung consolidations and cavitary lesions which was later diagnosed as pulmonary tuberculosis with a positive tuberculosis mycoplasma PCR test. Further imaging with a contrast-enhanced CT scan identified a large cavity with intra-cavitary small aneurysmal dilatation in the anterolateral aspect of the cavity at the upper lobe of the right lung. The presence of a pseudo-aneurysm arising from the anterior segmental branch of the right upper pulmonary artery was confirmed by a conventional angiography (DSA) of the upper branch of the right pulmonary artery and coils were used to selectively embolize the aneurysm’s feeding branch.

The patient tolerated the procedure and his symptoms subsided. The patient was started on anti-tuberculosis medications and later discharged with outpatient clinic follow-up.

Case II: A 50-year-old gentleman, known case of diabetes mellitus type II, presented with a one-week history of cough, shortness of breath, five episodes of hemoptysis associated with generalized body aches, and night sweats. The patient’s vitals revealed tachycardia (115 beats/min), and physical examination of the chest revealed reduced air entry in the right middle and lower chest. Laboratory investigations showed raised white blood cells, decreased hemoglobin, and raised inflammatory markers. Suspicion of tuberculosis was raised and results showed positive acid-fast bacilli & sputum & bronchoalveolar lavage (BAL) was positive for mycobacterium tuberculosis.

Contrast-enhanced CT scan of the chest showed a cavity with surrounding consolidation containing an enhancing round lesion representing an aneurysmal dilation at a branch of the pulmonary artery supplying the right lower lobe. Selective DSA at the right pulmonary artery demonstrated an aneurysmal dilatation at a posterior segmental branch of the right lower lobe. The feeding branch of the aneurysm was successfully embolized using coils. The procedure was well tolerated by the patient, who had an uncomplicated hospital stay.

Case III: A 45 years old Asian male, recently diagnosed with pulmonary tuberculosis and started on anti-tuberculosis medication, presented with a one-day history of multiple episodes of hemoptysis. He also complained of weight loss (30 Kg) and progressive abdominal distension in the past 7 months. On physical examination, he had tachypnea and tachycardia (110 beats/min) and had reduced air entry bilaterally mostly over the left side of the chest.

Contrast-enhanced CT scan of the chest revealed widespread multifocal consolidations in both lungs, tree in bud nodules, bronchiectasis, and a cavitary lesion at the posterior segment of the right upper lobe with an aneurysmal dilatation of a sub-segmental pulmonary artery branch. Conventional angiography of the right pulmonary artery confirmed the presence of the aneurysm at the posterior segmental arterial branch of the right upper lobe. The feeding branch of the aneurysm was embolized using coils.

Unfortunately, few days after the procedure, the patient’s clinical status deteriorated with hypotension and oxygen desaturation, and had to be intubated. Laboratory investigations revealed raised septic markers and the patient was escalated to intravenous antibiotics and inotropic support. The patient continued to deteriorate and passed away.

Case IV: A 45 years old gentleman presented with three months history of multiple episodes of hemoptysis increasing in amount. On physical examination, he had tachycardia and tachypnea requiring supportive high-flow nasal oxygen to maintain saturation.

Chest radiograph showed extensive bilateral lung consolidations. Contrast-enhanced CT scan revealed bilateral patchy lung consolidations with tree-in-bud nodules, bronchiectasis, and cavitary lesions, particularly over the apical segment of the right lower lobe. An additional finding of a pulmonary artery aneurysm at the posterior segment of the right lower lobe.

Conventional pulmonary angiography was performed and the feeding segmental branch of the aneurysm at the right lower lobe was selectively embolized using coils.

Unfortunately, two days after the procedure, the patient experienced fresh blood hemoptysis, became hypotensive with oxygen saturation & GCS drop requiring blood transfusion and intubation. The patient was kept on continuous monitoring in the intensive care unit and kept on intravenous antibiotics and inotropic support. However, the patient kept deteriorating and passed away.

Result(s):

All of the presented cases underwent endovascular treatment using coil embolization of the feeding vessel and have tolerated the procedure well with no complications within the first 24hrs. Unfortunately, half of our patients have clinically deteriorated and have passed away.

Conclusion(s):

Pulmonary artery aneurysm are rare and may be of congenital or acquired etiology. One of the most common causes is post-infection Rasmussen’s aneurysm formation secondary to pulmonary tuberculosis. Endovascular therapies aim to occlude these aneurysms and prevent life-threatening massive hemoptysis in case of rupture. The selection of the appropriate management depends on the clinical presentation and outcomes of these procedures tend to vary.