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J Thorac Cardiovasc Surg 2004;128:784-785
© 2004 The American Association for Thoracic Surgery

Brief communication

Endovascular coil embolization for acute management of traumatic pulmonary artery pseudoaneurysm

^a Department of Surgery, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
^b Department of Surgery, Medical University of South Carolina, Charleston, SCUSA,
^c Department of Radiology, Medical University of South Carolina, Charleston, SC, USA

Received for publication January 27, 2004; revisions received March 4, 2004; accepted for publication March 22, 2004.

^* Address for reprints: Mark Block, MD, Division of Cardiothoracic Surgery, 96 Jonathan Lucas St, 409 CSB, Medical University of South Carolina, Charleston, SC 29425, USA
blockm{at}musc.edu

Clinical summary

A 40-year-old woman with a history of depression presented with a self-inflicted gunshot wound to the left side of the chest. On arrival, she was alert and hemodynamically stable. An entrance and an exit wound were identified on the anterior and posterior chest, and there were no breath sounds on the left. A chest tube was placed and immediately drained of 360 mL of fresh blood. A chest x-ray film showed multiple rib fractures and opacification of the left side of the chest without mediastinal shift. Chest computed tomography (CT) with intravenous contrast showed extensive pulmonary contusion and consolidation, a small pleural effusion, a path of lung parenchymal destruction consistent with a bullet track, and 3 distinct areas of well-defined increased attenuation along the track suggestive of hemorrhage (Figure 1). The patient remained hemodynamically stable, and chest tube output was less than 100 mL/h, but she had occasional hemoptysis of fresh blood. Chest CT 18 hours later showed interval enlargement of the 3 areas of hemorrhage that now assumed clearly spherical shapes. Pulmonary angiography identified 3 pseudoaneurysms, 1 arising from the inferior lingular artery and 2 arising from the superior segmental artery (Figure 2). The patient remained hemodynamically stable with minimal chest tube output and no change in hemoptysis. Thoracotomy was considered, but a decision was made to attempt embolization.

View larger version (130K): [in this window] [in a new window]   Figure 1. Initial chest CT scan showing consolidation of the left lung and 3 areas of spherical increased attenuation along the bullet track (arrowheads)..

View larger version (125K): [in this window] [in a new window]   Figure 2. Pulmonary arteriogram demonstrating 2 spherical opacifications diagnostic of pseudoaneurysms.

Chest CT 1 month later showed continued improvement in left lung aeration, with no evidence of blood flow through any of the pseudoaneurysms. Eight weeks later, the patient felt well and had no hemoptysis. A chest x-ray film showed a near-normal left lung and pleural space.

Discussion

Pulmonary artery pseudoaneurysms are uncommon but carry a significant risk of rupture and death. They are identified most often as a complication of pulmonary artery catheter use and are estimated to occur at a rate of 0.5%.¹ Other nontraumatic causes include Bechet disease, Marfan syndrome, fungal infection, and tuberculosis. Traumatic pulmonary artery pseudoaneurysms are extremely rare despite the large number of patients with chest trauma. We identified 16 cases in the literature.^2-4 Of the 12 reported since 1963, 5 were diagnosed during the patient's initial hospitalization (4-14 days after injury), and 7 were diagnosed between 14 days and 30 years later. The clinical presentation is highly variable. In the acute setting, as in our case, hemoptysis and suspicious radiographic findings suggest the diagnosis. In the delayed setting 3 patients presented with hemoptysis, 2 were asymptomatic, 1 had dyspnea, and 1 had chest pain. There are no reports of massive hemoptysis and death from an unrecognized or untreated traumatic pulmonary artery pseudoaneurysm, and the only death among the 12 cases reported since 1963 was from complications after pneumonectomy.⁵ However, given the experience with pulmonary artery pseudoaneurysms from other causes, prompt diagnosis and therapy seem the most prudent management strategy.

Embolization was first reported by Savage and colleagues,² but because of persistent hemoptysis, a lobectomy was performed. Their patient presented 30 years after the injury. de Jonge and coworkers³ reported successful embolization therapy in a patient who was discharged from the hospital with a clearing chest x-ray film but who presented with dyspnea 14 days after the injury. Our patient was given a diagnosis early, and embolization enabled us to safely continue observation and avoid a pulmonary resection. A chest x-ray film 2 months later showed near-complete resolution of intrapleural and intraparenchymal blood and no evidence of a persistent aneurysm. The interval between injury and therapy might account for the success of embolization in our and de Jonge and coworkers'³ cases. With a short interval, tissue factors that promote healing are likely abundant. However, in the case of Savage and colleagues,² it is likely that the pseudoaneurysmal environment was completely mature and fibrotic. Embolization can be a safe and effective management strategy for traumatic pulmonary artery pseudoaneurysms that are discovered soon after the injury.

References

1. Poplausky MR, Rozenblit G, Rundback JH, Crea G, Maddineni S, Leonardo R. Swan-Ganz catheter-induced pulmonary artery pseudoaneurysm formation: three case reports and a review of the literature. Ches.. 2001;120(6):2105–2111
   
2. Savage C, Zwischenberger JB, Ventura KC, Wittich GR. Hemoptysis secondary to pulmonary pseudoaneurysm 30 years after a gunshot wound. Ann Thorac Sur.. 2001;71(3):1021–1023
   
3. de Jonge I, Vahl A, van der Hulst V. Coil embolization of a left pulmonary artery pseudoaneurysm after penetrating injury. J Endovasc The.. 2003;10(3):681–683
   
4. Donaldson B, Ngo-Nonga B. Traumatic pseudoaneurysm of the pulmonary artery: case report and review of the literature. Am Sur.. 2002;68(5):414–416
   
5. Dillon WP, Taylor AT, Mineau DE, Datz FL. Traumatic pulmonary artery pseudoaneurysm simulating pulmonary embolism. AJR Am J Roentgeno.. 1982;139(4):818–819[Free Full Text]
   

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				M. Kalina and F. Giberson Hemoptysis Secondary to Pulmonary Artery Pseudoaneurysm After Necrotizing Pneumonia Ann. Thorac. Surg., October 1, 2007; 84(4): 1386 - 1387. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mark Block Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Block, M. Articles by Hannegan, C. Search for Related Content PubMed PubMed Citation Articles by Block, M. Articles by Hannegan, C. Related Collections Lung - other