Ann Thorac Surg 2001;71:727-729
© 2001 The Society of Thoracic Surgeons
Case report
Endovascular stent graft treatment of a pulmonary artery pseudoaneurysm
Robert L. Hannan, MDa,
Kagami Miyaji, MDa,
Redmond P. Burke, MDa,
Evan M. Zahn, MDa
a Divisions of Cardiology and Cardiovascular Surgery, Miami Children’s Hospital, Miami, Florida, USA
Accepted for publication April 5, 2000.
Address reprint requests to Dr Hannan, Division of Cardiovascular Surgery, Miami Children’s Hospital, 3200 SW 60th Ct, Suite 102, Miami, FL, USA 33155
e-mail: rhannan001{at}aol.com
 |
Abstract
|
|---|
A 5-year-old girl with pulmonary atresia, ventricular septal defect, hypoplastic pulmonary arteries, and multiple pulmonary artery reconstructive procedures presented with an enlarging pulmonary artery pseudoaneurysm. A previous attempt to occlude the aneurysm was unsuccessful and the aneurysm continued to enlarge. We describe the percutaneous placement of an endovascular stent graft to occlude the aneurysm. This novel use of a covered graft effectively treated a potentially lethal problem without reoperative thoracotomy or sternotomy.
|
Introduction
|
|---|
Aneurysms of the branch pulmonary arteries are uncommon lesions. Their causes include Behçet’s disease [1], erosion of emphysematous bullae [2], infected carcinomas [3], or rarely postsurgical issues such as chest tubes [4] or systemic to pulmonary shunts [5, 6]. These aneurysms may rupture, cause intrapulmonary erosion, hemoptysis, or pulmonary embolism. Treatment of distal aneurysms is difficult, may require pneumonectomy, and can be fatal [1, 5]. Some pulmonary artery pseudoaneurysms have been treated successfully with coil embolization [2–4].
A 5-year-old girl, weighing 14.4 kg, with pulmonary atresia, ventricular septal defect, hypoplastic pulmonary arteries, and multiple aortopulmonary collaterals was brought to our institution by her parents for a second opinion. The child had undergone three previous left thoracotomies (left modified Blalock-Taussig shunt, left hemi-diaphragm plication, left pulmonary artery thrombectomy and patch arterioplasty), two right thoracotomies (exploratory thoracotomy and right modified Blalock-Taussig shunt), and a median sternotomy (right ventricular to pulmonary artery conduit), all at a single distant institution. Her last surgical procedure, at 3
years of age, was a left pulmonary artery thrombectomy and patch arterioplasty with a Gortex patch (W. L. Gore, Flagstaff, AZ). Six weeks after that procedure she underwent percutaneous balloon dilation of her right and left pulmonary arteries, including the area of surgical patch arterioplasty. Nine months later she was noted to have an enlarging mass on chest radiograph and computed tomography demonstrated a large distal left pulmonary artery pseudoaneurysm in the region of the previous arterioplasty/balloon angioplasty. Cardiac catheterization at that time confirmed the diagnosis and 22 steel Gianturco coils (Cook, Bloomington, IN) were implanted in the aneurysm in an attempt to occlude it. Six months after this procedure she was evaluated at our institution.
Repeat cardiac catheterization revealed systemic oxygen saturation of 75%, proximal pulmonary artery pressures equal to systemic levels, and a long segment distal left pulmonary artery stenosis in the area of a large left lower lobe pulmonary artery aneurysm (Figs 1A and 1B). The aneurysm had increased in size by approximately 20% since placement of the coils. The enlargement of the aneurysm (which was subjected to systemic arterial pressure) over a period of 6 months suggested that the risk of rupture was significant. The distal location of the aneurysm, the child’s multiple previous surgical procedures, and the presence of cyanosis were thought to increase the risk of surgical repair of the aneurysm significantly. Therefore, the decision was made to proceed with percutaneous implantation of an endovascular stent graft across the lesion. Compassionate release of two devices was granted from our institutional review board and the supplying companies. Informed consent was obtained from the family. At angiography a clearly identifiable aneurysm neck was identified as well as a residual pulmonary artery stenosis. An attempt to pass a 10 mm x 5 cm Hemobahn endovascular device (W. L. Gore, Flagstaff, AZ) was unsuccessful because of the rigidity of the device. A 10 mm x 30 mm self-expanding Wallgraft (Boston Scientific, Boston, MA) was then positioned across the area of stenosis, straddling the neck of the aneurysm. A single branch supplying a posterior basal segment of the left lower lobe arose in close proximity to the aneurysm neck. After angiographic confirmation of positioning, the device was deployed, resulting in complete exclusion of the aneurysm and improvement of the left pulmonary artery stenosis (Figs 2A and 2B). The posterior basal segmental branch no longer filled with contrast suggesting occlusion by the device. Further expansion of the graft was performed with a 10 mm angioplasty balloon to eliminate residual pulmonary artery stenosis. The procedure was well tolerated and the patient was discharged 48 hours later.
View larger version (89K):
[in this window]
[in a new window]
|
Fig 1. (A) Selective left pulmonary artery angiogram performed in right anterior oblique projection. Note the long segment stenosis and the discrete pseuduaneurysm neck (*). (B) Lateral projection of same injection demonstrates the posterior location of the aneurysm. In both projections the ineffectiveness of the previously placed steel coils is seen.
|
|
View larger version (85K):
[in this window]
[in a new window]
|
Fig 2. Right anterior oblique (A) and lateral (B) angiography of the left pulmonary artery following placement of the stent graft demonstrates complete exclusion of the aneurysm with no residual flow into it. There has been a marked improvement in the diameter of the stenotic left pulmonary artery in the area of the graft.
|
|
|
Comment
|
|---|
Endovascular grafts have been used for many indications, including aortopulmonary fistulas and aortic, iliac, and femoral aneurysms [7, 8]. This patient presented after six previous operations and multiple percutaneous procedures with an enlarging and potentially lethal pulmonary artery pseudoaneurysm. Attempted closure with coil embolization had been unsuccessful. Her underlying problem of pulmonary atresia with ventricular septal defect had not been corrected, resulting in significant desaturation and pulmonary hypertension increasing her surgical risk. Given the size and location of the aneurysm, a left thoracotomy and aneurysm repair or pneumonectomy were suboptimal choices. The ability to exclude the aneurysm while simultaneously improving the left pulmonary artery stenosis made delivery of an endovascular graft attractive. This case represents a novel use of an endovascular stent graft and underscores the need for access to these newer prostheses for treatment of life-threatening problems in the pediatric population.
|
References
|
|---|
-
Gebitekin C., Yilmaz M., Senkaya I., Saba D., Sagdic K., Ozer G. Fatal haemoptysis due to pulmonary artery aneurysm in Behçet’s disease. Eur J Vasc Endovasc Surg 1997;13:233-236.[Medline]
-
Bowler R.P., Durham J., Schwarz M.I. Massive hemoptysis from a pulmonary artery aneurysm associated with an emphysematous bulla. Chest 1998;113:1130-1131.[Abstract/Free Full Text]
-
Oliver T.B., Stevenson A.J., Gillespie I.N. Pulmonary artery pseudoaneurysm due to bronchial carcinoma. Br J Radiol 1997;70:950-951.[Abstract]
-
Podbielski F.J., Wiesman I.M., Yaghmai B., Owens C.A., Benedetti E., Massad M.G. Pulmonary artery pseudoaneurysm after tube thoracostomy. Ann Thorac Surg 1997;64:1478-1480.[Abstract/Free Full Text]
-
Boubaker A., Payot M., Genton C.Y. Fatal rupture of an acquired aneurysm of the pulmonary artery: rare complication after surgical palliation of tricuspid atresia. Pediatr Cardiol 1997;18:392-395.[Medline]
-
Boulden T.F., Tonkin I.L., Burton E.M., et al. Case of the day: pediatric mycotic pseudoaneurysm and thrombosis of modified left Blalock-Taussig shunt. Radiographics 1990;10:119-121.[Medline]
-
Miyata T., Ohara N., Shigematsu H., et al. Endovascular stent graft repair of aortopulmonary fistula. J Vasc Surg 1999;29:557-560.[Medline]
-
Campagna A.C., Wehner J.H., Kirsch C.M., et al. Endovascular stenting of an aortopulmonary fistula presenting with hemoptysis: a case report. J Cardiovasc Surg (Torino) 1996;37:643-646.[Medline]
This article has been cited by other articles:
|
|
|
|
 
I. Dimarakis, J. A.C. Thorpe, and K. Papagiannopoulos
Successful Treatment of a Posttraumatic Pulmonary Artery Pseudoaneurysm With Coil Embolization
Ann. Thorac. Surg.,
June 1, 2005;
79(6):
2134 - 2136.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
I. Daehnert, M. Wiener, and M. Kostelka
Covered Stent Treatment of Right Pulmonary Artery Stenosis and Waterston Shunt
Ann. Thorac. Surg.,
May 1, 2005;
79(5):
1754 - 1755.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
