Ann Thorac Surg 2007;84:1386-1387
© 2007 The Society of Thoracic Surgeons
Case Reports
Hemoptysis Secondary to Pulmonary Artery Pseudoaneurysm After Necrotizing Pneumonia
Michael Kalina, DO*,
Frederick Giberson, MD
Department of Surgical Critical Care and Trauma, Christiana Care Health System, Christiana Hospital, Newark, Delaware
Accepted for publication May 7, 2007.
* Address correspondence to Dr Kalina, Christiana Hospital, Surgical Critical Care and Trauma, 4755 Ogletown-Stanton Rd, Newark DE 19718 (Email: mkalina{at}christianacare.org).
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Abstract
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This case documents the occurrence of hemoptysis secondary to pulmonary artery pseudoaneurysm in a 19-year-old man who was admitted for hypertriglyceridemic pancreatitis. The pseudoaneurysm derived from a necrotizing pneumonia within the same pulmonary segment. After an extensive workup, the pseudoaneurysm was diagnosed by pulmonary angiography and treated with coil embolization.
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Introduction
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Pulmonary artery pseudoaneurysm is a rare vascular anomaly. Bronchi and arteries have a common connective tissue sheath. If an aneurysm ruptures and is not contained by surrounding tissues or by clotting, blood can enter the bronchus with resultant hemoptysis [1]. Causes include penetrating or blunt chest trauma, Swan-Ganz catheter placement, vasculitis, and neoplasms [1–3]. There have been few reports associating pulmonary artery pseudoaneurysm with necrotizing pneumonia. We present a case of pseudoaneurysm formation after a necrotizing pneumonia treated successfully with coil embolization.
A 19-year-old man was admitted to the hospital with complaints of abdominal pain, nausea, and vomiting for 4 days. Blood testing revealed a serum lipase of 10,788 units/L and serum triglycerides of 6,742 mg/dL. He was diagnosed with acute pancreatitis secondary to hypertriglyceridemia. The patient was admitted to the surgical intensive care unit, intubated for respiratory insufficiency, and underwent a decompressive laparotomy for abdominal compartment syndrome. An abdominal computed tomographic scan revealed pancreatic necrosis, and the patient underwent a pancreatic necrosectomy. The patient suffered refractory hypoxemia associated with bilateral pulmonary infiltrates, and a PaO2/FiO2 ratio of 108, denoting acute respiratory distress syndrome. The patient later had ventilator-associated pneumonia develop, Pseudomonas aeruginosa, abdominal fluid collections, and enterocutaneous fistulas. A chest computed tomographic scan revealed right lower and middle lobe pneumonia (Fig 1).
Subsequent chest roentgenograms revealed two air fluid levels in the right chest, suggesting necrotizing pneumonia with pneumatocele formation versus empyema or lung abscess. Percutaneous catheters were placed within the cavities, draining only air, with no pus or blood.
Two weeks later, after a tracheostomy tube was placed for ventilator-dependent respiratory failure, the patient experienced an episode of hemoptysis. Bronchoscopy revealed multiple blood clots within the right lower and middle lobe bronchial segments; however no active bleeding was noted. A second episode of hemoptysis occurred after 1 week, and a repeat bronchoscopy was performed. Again, blood clots were seen in the right lower and middle lobe bronchial segments, with no signs of active hemorrhage. A fiberoptic nasotracheal assessment was performed to evaluate for tracheo-innominate fistula with no evidence found. A further workup included a computed tomographic angiogram of the chest to exclude a pulmonary arteriovenous malformation. The scan revealed no diagnostic abnormalities.
Two days later, a third episode of hemoptysis occurred. A pulmonary and aortic arch angiogram was performed to exclude an arteriovenous malformation or tracheo-innominate fistula unrecognized by bronchoscopy, laryngoscopy, and computed tomographic angiogram of the chest. A right lower pulmonary artery pseudoaneurysm was found (Fig 2). The patient underwent angiographic coiling of the pseudoaneurysm with no further episodes of hemoptysis (Fig 3).
Six months after admission, the patient was transferred from the surgical intensive care unit to the surgical ward. Two months later, the patient returned to the operating room for resection of all enterocutaneous fistulas and reanastomosis. Intestinal continuity was achieved. The patient was discharged to a rehabilitation facility 9 months after admission. The tracheostomy tube was removed and he was tolerating a regular diet and ambulating with assistance.
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Comment
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Hemoptysis can be a life-threatening event. Bleeding usually derives from pulmonary or bronchial arteries. Causative factors include tracheobronchial disease, foreign bodies, neoplasms, tracheo-innominate fistula, arteriovenous malformation, pulmonary embolism, or coagulopathies. The workup consists of bronchoscopy, computed tomographic scan, and possibly magnetic resonance imaging of the chest [1–3]. Kierse and colleagues [4] described the benefits of multi-slice chest computed tomography in diagnosing a pulmonary artery pseudoaneurysm and anatomic mapping of the feeding vessel.
Therapeutic options include bronchoscopic coagulation, angiographic embolization, or surgical resection and repair [5]. Renie and colleagues [6] reported a case of mycotic aneurysm after an acute pneumonia in a 52-year-old woman admitted for hemoptysis. They found a pulmonary artery aneurysm on arteriography, which they treated with balloon embolization [6]. Markowitz and colleagues [7] reported two cases of pulmonary artery pseudoaneurysm developing after pulmonary artery catheter placement. In both instances, the pseudoaneurysms were diagnosed and treated by pulmonary angiography with transcatheter detachable balloon embolotherapy [7]. Khan and colleagues [8] reported a case of pulmonary artery pseudoaneurysm from penetrating chest trauma, primarily treated by surgical ligation, in a patient who presented weeks later with hemoptysis. The patient was found to have a recurrent pseudoaneurysm and was treated with coil embolization [8].
Pseudoaneurysm of a pulmonary artery is an uncommon cause of hemoptysis secondary to a specific trauma, intervention, or medical condition. In this patient, there were no causing factors usually associated with its occurrence. In this case, the pseudoaneurysm presented after a necrotizing pneumonia with pneumatocele formation in a patient with a recent history of acute respiratory distress syndrome. The active inflammatory process of the necrotizing pneumonia may have potentiated erosion of the feeding vessel into the bronchi. Continued inflammatory and mechanical insults resulted in rupture of the pseudoaneurysm and subsequent hemoptysis. Diagnosis and treatment was achieved by pulmonary angiography with coil embolization in lieu of multiple noninvasive and invasive diagnostic studies and without necessitating surgical intervention.
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References
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- Murray JF. Pulmonary artery aneurysmsIn: Mason RJ, Broaddus VC, Nadel JA, editors. Textbook of Respiratory Medicine, 4th ed. Philadelphia, PA: Elsevier Inc; 2005. pp. 1493-1497.
- 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 Chest 2001;120:2105-2111.[Medline]
- Agarwal PP, Dennie CJ, Matzinger FR, Peterson RA, Seely JM. Pulmonary artery pseudoaneurysm secondary to metastatic angiosarcoma Thorax 2006;61:366.[Free Full Text]
- Kierse R, Jensen U, Helmberger H, Muth G, Rieber A. Value of multislice CT in the diagnosis of pulmonary artery pseudoaneurysm from Swan-Ganz catheter placement J Vasc Interv Radiol 2004;15:1133-1137.[Medline]
- Block M, Lefkowitz T, Ravenel J, Leon S, Hannegan C. Endovascular coil embolization for acute management of traumatic pulmonary artery pseudoaneurysm J Thorac Cardiovasc Surg 2004;128:784-785.[Free Full Text]
- Renie WA, Rodeheffer RJ, Mitchell S, Balke WC, White RI. Balloon embolization of a mycotic pulmonary artery aneurysm Am Rev Respir Dis 1982;126:1107-1110.[Medline]
- Markowitz DM, Hughes SH, Shaw C, Denny DF, Wilkinson LA, White RI. Transcatheter detachable balloon embolotherapy for catheter-induced pulmonary artery pseudoaneurysm J Thorac Imaging 1991;6:75-78.[Medline]
- Khan AA, Bauer TL, Garcia MJ, Panasuk, Davies AL. Angiographic embolization of a traumatic pulmonary pseudoaneurysm Ann Thorac Surg 2005;79:2136-2138.[Abstract/Free Full Text]
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Abstract
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