Ann Thorac Surg 2003;76:942-944
© 2003 The Society of Thoracic Surgeons
Case report
Traumatic pulmonary arteriovenous malformation presenting with massive hemoptysis 30 years after penetrating chest injury
Con Manganas, FRACS*a,
Jim Iliopoulos, MBBSa,
Leo Pang, MBBSa,
Peter W. Grant, FRACSa
a Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, Australia
Accepted for publication January 17, 2003.
* Address reprint requests to Dr Manganas, Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney 2031, Australia
e-mail: conmanganas{at}hotmail.com
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Abstract
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A 39-year-old man presented with massive hemoptysis requiring emergency double lumen endobronchial intubation, bronchial arteriography and embolization, and subsequent right lower lobectomy. He had suffered a shrapnel blast injury to the right chest as a 9-year-old boy. Pathology of the resected specimen revealed lodged metallic foreign body with traumatic arteriovenous malformation. We present this case to alert thoracic surgeons to this extremely rare clinical entity that can present itself many years after the penetrating trauma, which requires urgent surgery.
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Introduction
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Traumatic pulmonary arteriovenous malformations (AVMs) after penetrating chest trauma are rarely described. We present the following clinical case requiring urgent surgery to remind thoracic surgeons of this unusual but life-threatening entity in patients presenting with massive hemoptysis after penetrating chest injury.
A 39-year-old man presented to our institution in July 2001 with two episodes of copious hemoptysis. He had suffered hemoptysis 5 years earlier and was investigated at another institution where a conservative approach was undertaken. He was previously fit and healthy, a nonsmoker, with no history of previous pulmonary infections, including tuberculosis. He had sustained a penetrating shrapnel injury to the right chest at the age of 9 years from a bomb blast in Bangladesh. Clinically there were no specific findings on examination except for a scar over the posterior right chest. Chest roentgenogram and computer tomographic imaging suggested a lesion in the right lower lobe with a calcific density in the
right peribronchial region (Figs 1, 2).
After initial admission to a respiratory unit he experienced a further 400 to 500 mL fresh hemoptysis on the same day. Preparations to further his management by way of emergency bronchial artery angiography and embolization were carried out after airway protection was established with double lumen endobronchial intubation. Thoracic operating rooms were on standby at this stage. Arteriography was performed which suggested the presence of abnormal arterial vessels feeding the right lower lobe lesion, and these were successfully embolized using microfoam particles. The patient was successfully extubated the next morning and had no further hemoptysis for the remaining 5 days until discharge. He was scheduled to return for semi-elective right lower lobectomy 1 month later. Interestingly he had minor hemoptysis develop approximately 3 weeks after embolization, whereby his surgery was expedited and he proceeded to have an uncomplicated right lower lobectomy approximately 4 weeks after his acute presentation. He remains well on follow-up at 10 months with no further hemoptysis.
Pathology of the resected right lower lobe showed a lodged metallic foreign body and a traumatic arteriovenous malformation with surrounding nonspecific chronic inflammatory changes and mild lower lobe bronchiectasis. There was evidence of recently placed embolic material in two large abnormal arteries in this arteriovenous complex.
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Comment
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Reports of traumatic pulmonary AVMs after penetrating chest injury are extremely rare, even though penetrating chest trauma is common [1, 2].
Patients may present with symptoms and signs related to fistulous communication including dyspnea, cyanosis, clubbing, usually with a chest roentgenogram or computed tomographic image showing an intrapulmonary opacification with an historical reference to penetrating injury. The reason for infrequent diagnosis of traumatic pulmonary AVM is unknown, but it may be postulated that there is a physiologically low pressure differential between the pulmonary artery and the pulmonary vein [1].
In our case, hemoptysis occurred almost 30 years after original injury, and the patient was otherwise asymptomatic with no signs referable to the pulmonary AVM, an extremely rare and unusual presentation.
The diagnosis was retrospectively made after lobectomy, whereas previous case descriptions have diagnosed the pulmonary AVMs preoperatively by way of pulmonary angiography in symptomatic patients with clinical signs [1–4, 5]. We did not proceed to pulmonary angiography in our patient, as aberrant vessels were identified and embolized on selective bronchial catheterization and arteriography. Interestingly hemoptysis recurred within 1 month of embolization, confirming other experiences suggesting early benefit of bronchial artery embolization for hemoptysis, but with a significant recurrence rate [6].
Traumatic pulmonary AVMs should be suspected in any patient who has massive hemoptysis, previous penetrating chest trauma, and evidence of a persistent metallic foreign body on chest roentgenogram. There may be no symptoms or signs referable to shunting. Bronchial angiography and embolization provide stabilization of hemoptysis in the short term, but do not address the underlying pathology that requires surgery for effective treatment.
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References
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- Loebl E.C., Platt M.R., Mills L.J., et al. Pulmonary resection for a traumatic pulmonary arteriovenous fistula. J Thorac Cardiovasc Surg 1979;77:674-676.[Medline]
- Symbas P.N., Goldman M.D., Erbesfield M.H., et al. Pulmonary arteriovenous fistula, pulmonary artery aneurysm, and other vascular. Changes of the lung from penetrating trauma. Ann Surg 1980;191:336-340.[Medline]
- Sheikhzadeh A., Paydar M.H., Ghabussi P., et al. Pulmonary arteriovenous fistulas. Case presentations and clinical recognition. Herz 1983;8:179-186.[Medline]
- Arom K.V., Lyons G.W. Traumatic pulmonary arteriovenous fistula. J Thorac Cardiovasc Surg 1975;70:918-920.[Abstract]
- Shields TW. Congenital vascular lesions of the lungs. In: Shields, et al. General thoracic surgery, vol. 24, 1994;895–906
- Taylor B.G. Therapeutic embolization of the pulmonary artery in pulmonary arteriovenous fistula. Am J Med 1978;64:360.[Medline]
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Abstract
Introduction
