Ann Thorac Surg 1997;64:1478-1480
© 1997 The Society of Thoracic Surgeons
Case Report
Pulmonary Artery Pseudoaneurysm After Tube Thoracostomy
Francis J. Podbielski, MD,
Irvin M. Wiesman, MD,
Babak Yaghmai, MD,
Charles A. Owens, MD,
Enrico Benedetti, MD,
Malek G. Massad, MD
Division of Cardiothoracic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
Accepted for publication June 13, 1997.
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Abstract
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Pulmonary artery pseudoaneurysm has been described as a complication of Swan-Ganz catheterization and right heart catheterization. Isolated cases of this condition occurring in blunt and penetrating chest trauma have been reported. In this communication, we describe the case of a patient with intracranial hemorrhage who required positive-pressure ventilation and in whom subsequent pneumothorax developed, necessitating tube thoracostomy. A persistent opacification of the lung field resulted in evaluation with computed chest tomography and color-flow Doppler ultrasonography. A pseudoaneurysm of the lingular segmental artery was identified and successfully obliterated by Gelfoam coil embolization.
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Introduction
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Pulmonary artery pseudoaneurysm is an uncommon sequela of pulmonary artery instrumentation and of blunt or penetrating thoracic trauma [1–5]. Development of this condition may be heralded by hemoptysis due to bronchial rupture. Evaluation of a solitary pulmonary nodule or an area of opacification in the light of a recent or remote trauma mandates consideration of this condition in the differential diagnosis. In this article, we describe the case of a patient in whom immediate radiologic opacification developed on plain chest radiography after tube thoracostomy. A persistent fever and an incision site hematoma led to further evaluation and the subsequent diagnosis of an iatrogenic pulmonary pseudoaneurysm.
A 64-year-old woman presented to another institution with complaints of severe left occipital headache, increasing lethargy, and emesis. Her past medical history was remarkable only for an excisional biopsy of a benign left lung nodule 25 years earlier. At the time of presentation, a computed head tomogram and cerebral angiography demonstrated a left frontal subarachnoid hemorrhage due to an anterior communicating artery aneurysm. Craniotomy for clot evacuation was performed.
Later that day, with the patient still sedated and mechanically ventilated, a significant amount of subcutaneous emphysema was noted over the left thorax with development of a left pneumothorax on the chest radiograph. A 32F chest tube was placed (at the referring institution) in the left fifth intercostal space along the anterior axillary line. Intrathoracic adhesions were lysed by digital dissection. A drop in the blood pressure was noted immediately after placement of the tube. A chest radiograph showed an area of opacification at the tube insertion site with no pneumothorax or effusion. An initial drop in the patient's hemoglobin level was noted and managed with a blood transfusion. The patient was then transferred to our institution, where she underwent clipping of the anterior communicating artery aneurysm. The procedure was performed without complications and she was extubated the following day. With resolution of the pneumothorax and the subcutaneous emphysema, the chest tube was removed.
On the fifth postoperative day, a low-grade fever and mild leukocytosis (white blood cell count, 15,000/µL) developed. The persistent opacification in the area of the left chest cavity (Fig 1A
) was further evaluated with computed tomography. A parenchymal mass with central contrast suggestive of a pseudoaneurysm was seen on computed tomography (Fig 2). Color Doppler flow study demonstrated the "yin-yang" pattern characteristic of a pseudoaneurysm (Fig 3). Further evaluation with a pulmonary angiogram delineated a pseudoaneurysm of a lingular segmental artery (Fig 4).
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Fig 1. . (A) Chest radiograph obtained after chest tube removal shows an area of lingular opacification at the tube insertion site. (B) A follow-up chest film obtained 9 weeks after embolotherapy shows a marked decrease in the area of parenchymal opacification.
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Fig 2. . Computed tomogram of the chest with intravenous contrast showing a parenchymal hematoma and blood flow within the pseudoaneurysm.
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Fig 3. . Color Doppler flow study demonstrates bidirectional blood flow and the yin-yang sign of a pseudoaneurysm.
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Fig 4. . Pulmonary angiogram demonstrates an intraparenchymal pseudoaneurysm. Note the neck of the aneurysm arising from a lingular lobe segmental branch.
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The patient underwent successful Gelfoam (Upjohn) coil embolization of the pseudoaneurysm. Repeat Doppler flow studies showed obliteration of the aneurysm. She was discharged home 3 days later, after her fever subsided and her white blood cell count returned to normal. A follow-up chest film obtained 9 weeks after embolotherapy showed a marked decrease in the area of parenchymal opacification (Fig 1B
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Comment
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Traumatic pseudoaneurysm of the pulmonary artery may be asymptomatic or may present with chest pain, fever, cough, or dyspnea. Left untreated this lesion can progressively dilate and rupture, resulting in exsanguination and death. The radiographic findings are variable, ranging from a solitary nodule to an ill-defined area of lung opacification. Computed tomography with intravenous contrast usually demonstrates a central contrast enhancement surrounded by a hematoma or a bruised pulmonary parenchyma. Color-flow Doppler echocardiography may demonstrate the classic yin-yang sign characteristic of bidirectional blood flow and may delineate the neck of the aneurysm. It has been suggested that control of hemorrhage from smaller lung vessels by tamponade occurs readily given the relatively low pressure in the pulmonary arterial system. Review of previous cases shows an interval of several days to more than 10 years from the time of injury until diagnosis [2, 5]. The development of a pseudoaneurysm rather than exsanguinating hemorrhage in this patient may have been explained by the dense pleural adhesions that resulted from her previous lung biopsy. Past treatment employed pulmonary angiography for diagnosis followed by surgical ligation or lobectomy. Although spontaneous resolution has been reported [6], current treatment of this condition may require angiographic localization of the culprit vessel followed by embolotherapy with detachable silicone balloons, steel coils, Gelfoam, polyvinyl alcohol particles, or n-butylcyanoacrylate glue [7]. Failure to thrombose the pseudoaneurysm and its feeding vessel may necessitate surgical intervention with direct suture ligation or lobectomy.
Although pulmonary artery pseudoaneurysm after blunt or penetrating injury is a rare occurrence and although thoracic vascular complications and pseudoaneurysm formation develop in less than 0.2% of patients undergoing pulmonary artery instrumentation, the potential for its occurrence must be acknowledged to provide effective treatment and avoid a potentially fatal outcome if left unrecognized.
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Footnotes
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Address reprint requests to Dr Massad, Division of Cardiothoracic Surgery, University of Illinois at Chicago, 840 S Wood St, M/C 958, Chicago, IL 60612.
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References
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- Cooper JP, Jackson J, Walker JM. False aneurysm of the pulmonary artery associated with cardiac catheterization. Br Heart J 1993;69:188–90.[Abstract/Free Full Text]
- Crivello MS, Hayes C, Thurer RL, et al. Traumatic pulmonary artery aneurysm: CT evaluation. J Comput Assist Tomogr 1986;10:503–5.[Medline]
- Bartter T, Irwin RS, Phillips DA, et al. Pulmonary artery pseudoaneurysm. A potential complication of pulmonary artery catheterization. Arch Intern Med 1988;148:471–3.[Abstract/Free Full Text]
- Kasai T, Kobayashi K. Bilateral pseudoaneurysms of the pulmonary arteries caused by blunt chest trauma. Intensive Care Med 1992;18:51–2.[Medline]
- Gavant ML, Winer-Muram HT. Traumatic pulmonary artery pseudoaneurysm. Can Assoc Radiol J 1986;37:108–9.[Medline]
- You CK, Whatley GS. Swan-Ganz catheter-induced pulmonary artery pseudoaneurysm: a case of complete resolution without intervention. Can J Surg 1994;37:420–4.[Medline]
- Markowitz DM, Hughes SH, Shaw C, et al. Transcatheter detachable balloon embolotherapy for catheter-induced pulmonary artery pseudoaneurysm. J Thorac Imag 1991;6:75–8.[Medline]
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Abstract
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