Ann Thorac Surg 2007;83:693-695
© 2007 The Society of Thoracic Surgeons
Case Reports
Bronchial Artery Aneurysm Treated With Aortic Stent Graft and Fibrin Sealant
Eladio Sanchez, MDa,*,
Pedro Alados, MD, PhDa,
Luis Zurera, MDb,
Miguel Canis, MDa,
Ignacio Muñoz, MDa,
Jaime Casares, MDa,
Manuel G. Eguaras, MD, PhDa
a Department of Cardiovascular Surgery, Hospital Reina Sofia, Cordoba, Spain
b Department of Radiology, Hospital Reina Sofia, Cordoba, Spain
Accepted for publication June 30, 2006.
* Address correspondence to Dr Sanchez, 16th Damasco Street 2-2, 14004 Cordoba, Spain. (Email: esando77{at}hotmail.com).
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Abstract
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Bronchial artery aneurysm occurs rarely but can cause a life-threatening hemorrhage when it ruptures. The traditional therapy has been aneurysm resection or transcatheter arterial embolization. We report a case of mediastinal bronchial artery aneurysm which could not be occluded with transcatheter arterial embolization and instead was treated with a thoracic aortic stent graft and embolization with fibrin sealant.
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Introduction
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Bronchial artery aneurysm (BAA) is a rare entity that bronchial arteriography detects in less than 1% of patients [1]. BAA can be intrapulmonary or mediastinal. Intrapulmonary BAA usually presents as hemoptysis. The mediastinal localization may manifest symptoms related to compression or rupture into contiguous structures [1–3].
A 69-year-old woman, with a history of childhood tuberculosis, high blood pressure, and a papillary thyroid cancer, presented with dysphagia. A chest computed tomographic (CT) scan showed a mass adjacent to the descending aorta with clear enhancement by contrast medium (Fig 1A).
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Fig 1. (A) Chest computed tomography (CT) demonstrates a saccular mass adjacent to the descending aorta enhanced by contrast medium that displaces the esophagus to the right. (B) CT after treatment shows complete thrombosis of the bronchial artery aneurysm.
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The patient was admitted to our hospital so a thoracic arteriography could be performed. It confirmed the diagnosis of mediastinal BAA and showed a 40-mm-diameter saccular aneurysm, with a wide neck, joining the anterior wall of the thoracic aorta. It had calcification in the borders, and its origin was the right and left enlarged tortuous bronchial arteries (Fig 2).
We decided to treat the patient with transcatheter arterial embolization (TAE). The two bronchial arteries that originated from the BAA could not be treated from a right femoral approach, because they were very tortuous. The neck of the BAA was located on the anterior wall of the descending aorta, so it was not treated because of the risk of distal embolization. We then decided to exclude the BAA with an aortic stent graft (Fig 3A).
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Fig 3. (A) Thoracic aortography. (B) Thoracic aortography shows late enhancement of contrast in the aneurysmal sac. Visible are the catheter placed in the bronchial artery aneurysm and the aortic stent graft. (C) Thoracic aortography after stent-graft placement and embolization with fibrin sealant demonstrates no enhancement of the bronchial artery aneurysm.
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In the operating room the right femoral artery was exposed. By puncture into the left femoral artery, a catheter (Torcon NB, Cook, Bjaeverskov, Denmark) was placed in the BAA. The aortic stent graft (Valiant, Medtronic, Minneapolis, Minn) was inserted into the right femoral artery, positioned through the aneurysm, and deployed into the descending thoracic aorta, covering the origin of the BAA. The stent graft used was 150-mm long and had a 30-mm diameter, with a proximal straight FreeFlo. Aortography showed a later enhancement of the aneurysm and a type II endoleak (Fig 3B).
We intended to use the catheter left in the BAA to embolize the aneurysm sac with bovine-derived thrombin (FloSeal, Baxter, Fremont, Calif), but the catheter was obstructed because it was too thick. We decided to change the catheter over a guidewire and to embolize with fibrin sealant (Tissucol Duo, Baxter, Vienna, Austria). The catheter was removed, and a balloon catheter (Reliant, Medtronic) was used to improve expansion of the stent graft.
The control aortography showed the complete exclusion of the BAA (Fig 3C), and the right femoral artery was closed. A CT scan 3 days latter confirmed the exclusion of the BAA (Fig 1B), and the patient was discharged from medical care without any symptoms.
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Comment
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Little is known about the etiology of BAA. It has been associated with congenital causes and acquired causes such as atherosclerosis, trauma, inflammatory lung disease, bronchiectasis, tuberculosis, sepsis, and Osler-Weber-Rendu disease [1,2]. The cause of the present case was of unknown.
BAA should be treated once the diagnosis is confirmed, whether or not there are symptoms, because the diameter was not an incremental risk factor in reported cases [2]. Open surgical treatment may include surgical extirpation of the lesion, pneumonectomy, or ligation of the bronchial artery [5]. This could be the first choice for ruptured BAA, although several cases have been reported of ruptured BAA successfully treated with TAE [6]. In cases of mediastinal BAA manifested by hemoptysis, some patients have been treated with lobectomy [1], but TAE has been the most common approach in recent years [2].
Different embolic materials have been used to treat BAA, such as steel coils, gelatin particles, occlusion balloons, and N-butyl-2-cyanoacrylate [6]. It is necessary to occlude not only the feeding vessel but also efferent branches to avoid retrograde filling of the aneurysm. Several reports comment on the failed embolization of a bronchial artery if the origin of the aneurysm is too close to the aorta [6, 7]. Kasashima and colleagues [4] and Sakai and colleagues [5] have each reported the treatment of BAA with an aortic stent graft, both were located near the origin of the artery, and TAE was not feasible. The present study is the third reported case in which an aortic stent graft has been used.
The efferent branches of the aneurysm could not be treated, a type II endoleak was demonstrated in the aortography, and fibrin sealant was injected through a catheter placed in the aneurysm sac. A variety of techniques [8], such as laparoscopic clipping of patent branches and direct injection of embolic agents, have been designed to treat type II endoleaks of abdominal aortic aneurysm, most of which have only been used in animal models and never in the thoracic aorta.
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References
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- Kalangos A, Khatchatourian G, Panos A, Faidutti B. Ruptured mediastinal bronchial artery aneurysm: a dilemma of diagnosis and therapeutic approach J Thorac Cardiovasc Surg 1997;114:853-856.[Free Full Text]
- Tanaka K, Ihaya A, Horiuci T, et al. Giant mediastinal bronchial artery aneurysm mimicking benign esophageal tumor: a case report and review of 26 cases from literatura J Vasc Surg 2003;38:1125-1129.[Medline]
- Tringali S, Tiffet O, Berger JL, Cuilleret J. Bronchial artery aneurysm disguised as a leiomyoma of the esophagus Ann Thorac Surg 2002;73:632-633.[Abstract/Free Full Text]
- Kasashima F, Endo M, Kosugi I, et al. Mediastinal bronchial artery aneurysm treated with a stent-graft J Endovasc Ther 2003;10:381-385.[Medline]
- Sakai T, Razavi MK, Semba CP, Kee ST, Sze DY, Dake, MD. Percutaneous treatment of bronchial artery aneurysm with use of transcatheter coil embolization and thoracic aortic stent-graft placement J Vasc Interv Radiol 1998;9:1025-1028.[Medline]
- Pugnale M, Portier F, Lamarre A, et al. Hemomediastinum caused by rupture of a bronchial artery aneurysm: successful treatment by embolization with N-butyl-2-cyanoacrylate J Vasc Interv Radiol 2001;12:1351-1352.[Medline]
- Yanagihara K, Ueno Y, Kobayashi T, Isobe J, Itoh M. Bronchial artery aneurysm Ann Thorac Surg 1999;67:854-855.[Abstract/Free Full Text]
- Rhee JY, Trocciola SM, Dayal R, et al. Treatment of type II endoleaks with a novel polyurethane thrombogenic foam: induction of endoleak thrombosis and elimination of intra-aneurysmal pressure in the canine model J Vasc Surg 2005;42:321-328.[Medline]
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Abstract
Introduction
