Ann Thorac Surg 2009;87:295-297. doi:10.1016/j.athoracsur.2008.05.061
© 2009 The Society of Thoracic Surgeons
Case Reports
Pulmonary Artery Pseudoaneurysm After a Vascular Access Port Catheter Implantation
Kursad Oz, MD,
Recep Demirhan, MD,
Burak Onan, MD*,
Irfan Sancakli, MD
Department of Thoracic Surgery, Dr Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey
Accepted for publication May 19, 2008.
* Address correspondence to Dr Onan, Department of Thoracic Surgery, Dr Lutfi Kirdar Kartal Research and Education Hospital, Semsi Denizer St, E–5 Karayolu Cevizli Mevkii, Istanbul, 34890-Kartal, Turkey (Email: burakonan{at}hotmail.com).
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Abstract
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Pulmonary artery pseudoaneurysm is an unusual complication of surgically implantable central venous port catheters. We experienced a case of a 57-year-old man with gastric malignancy, in which a port catheter had been previously implanted for chemotherapy. Because of a puncture site that was also medial for the subclavian vein, the catheter tip fractured between the first rib and the clavicle, and embolized in the left pulmonary artery, which caused a 5 x 4 cm pseudoaneurysm that mandated surgical resection with a lobectomy. The diagnostic work-up and a review of the literature are presented.
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Introduction
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The use of surgically implantable central venous access devices has greatly resolved and simplified the administration of chemotherapy and sampling of blood in patients with malignancies. Since Hickman's original description in 1979, the usage of implantable central venous access devices have increased [1]. Pulmonary artery pseudoaneurysm related to catheter embolization is an unusual and life-threatening event. Due to mechanical compression between the first rib and the clavicle, fracture of the catheter tip occurs leading to embolization [2]. We describe the evaluation and successful resection of a pulmonary artery pseudoaneurysm of the left lung.
A 57-year-old man was referred for evaluation of dyspnea and hemoptysis. The patient underwent a gastric operation 4 months ago due to gastric malignancy. After surgery, a venous port catheter was implanted for the delivery of chemotherapy. Two months later, he presented with dyspnea, chest pain, and fever. His sedimentation rate and hematocrit level were 77 mm for an hour and 35%, respectively. On a screening chest roentgenogram, he was noted to have a large consolidation on the left hemithorax. To help alleviate his fever, he was treated with a suspicion of pulmonary abcess. However, hemoptysis complicated the clinical picture. A contrast-enhanced computed tomographic scan revealed a posteriorly located cavitary lesion of 5 x 4 cm in diameter in the basal segment of the left inferior lobe (Fig 1). To clarify the diagnosis and relation of the lesion with the pulmonary artery, a computed tomographic angiography image of the chest demonstrated the foreign body situated in the superior segmental branch of the left inferior pulmonary artery (Fig 2). Surgical resection of the left lower lobe was performed rather than wedge resection through a left posterolateral thoracotomy. After detailed perioperative inspection of the specimen, a large cavitary lesion in the left inferior lobe and an embolized catheter piece were discovered. In addition, there was an infection of the embolized catheter piece. This was believed to be a predisposing factor for the pseudoaneurysm in the presence of a foreign body in the pulmonary artery. The pathologic and microbiologic examination comfirmed the diagnosis of pulmonary pseudoaneurysm and infection around the aneurysm sac, excluding a metastatic lesion of the pulmonary artery. From the patient's history, radiologic findings, and pathologic evaluation, the diagnosis of pulmonary artery pseudoaneurysm induced by catheter embolization was made. Port catheter was replaced with a new one, and the patient was discharged from the hospital with a favorable outcome.
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Fig 1. Contrast-enhanced computed tomographic image showing posteriorly located lesion of 5 x 4 cm in diameter, including a cavitary area with a regular border in the basal segment of the left inferior lobe.
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Fig 2. Computed tomographic angiography images of the chest demonstrating the foreign body (white arrow) situated in the superior segmental branch of the (left panel) left inferior pulmonary artery, and (right panel) pseudoaneurysm sac on the left lower hemithorax.
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Comment
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Pulmonary artery pseudoaneurysm related to catheter embolization is a rare and life-threatening complication. Catheter-related thromboembolic complications were found at a rate of 12% to 64% in literature, whereas catheter embolism to the right cardiac chambers or the branches of pulmonary artery occurs with the incidence ranging from 0.4% to 1% [3].
Technically, a venous port catheter is implanted subcutaneously through different central veins of which the subclavian vein is usual accessible in most cases. It is recommended that the puncture to the subclavian vein should be performed as laterally as possible. Besides, the tip of the catheter should be placed at the junction of the superior vena cava and the right atrium under radiological guidance. The other puncture sites include internal or external jugular veins, and the common femoral vein. Jugular veins provide a safe central venous access with a lower incidence of pneumothorax, cardiac injury, or catheter fracture leading to embolization [4]. Moreover, in patients with burns, trauma, or surgical procedures that involve the head, neck, and upper part of the thorax, the femoral vein provides a useful site for port catheter implantation.
Predisposing factors inducing the fracture of the port catheter implanted through a subclavian vein include either a shoulder trauma or an iatrogenic injury between the first rib and the medial part of the clavicle due to the mechanical compression, known as the "pinch-off syndrome" [2]. Thus, in this case, the cause of the catheter fracture is also a medial implantation site. The other causes of pseudoaneurysm include thoracic trauma, infection, vasculitis, and neoplasm. In the literature, pulmonary artery rupture and pseudoaneurysm related to Swan-Ganz catheters has been previously published [5]. We believe that this is the first reported case in which a port catheter was involved in such an event.
Presentation changes according to the localization and severity of pulmonary artery pseudoaneurysm includes fever, chest pain, dyspnea, and hemoptysis, which is the most frequent presenting symptom [6]. The diagnosis requires computed tomography with intravenous contrast or pulmonary artery angiogram, or both, to exclude an infection and metastasis. On imaging studies, the appearance of a pulmonary artery pseudoaneurysm is described as round, regular-bordered mass with varying sizes. In addition, the radio-opaque catheter-causing pseudoaneurysm can be seen. Therapeutic options include bronchoscopic coagulation, angiographic embolization, or surgical resection and repair [7].
Clinicians should be aware that a pulmonary artery pseudoaneurysm should be suspected in patients with previous port catheter implantation presenting with respiratory complaints. On diagnosis, contrast enhanced computed tomography and angiography are valuable modalities demonstrating the anatomic location of the pseudoaneurysm sac and the feeder vessel. When the diagnosis is clarified or suspected, evaluation of the patient by a thoracic and cardiovascular surgeon is required.
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References
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- Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED. A modified right atrial catheter for access to the venous system in marrow transplant recipients Surg Gynecol Obstet 1979;148:871-875.[Medline]
- Mirza B, Vanek VW, Kupensky DT. Pinch-off syndrome: case report and collective review of the literature Am Surg 2004;70:635-644.[Medline]
- Vescia S, Baumgärtner AK, Jacobs VR, et al. Management of venous port systems in oncology: a review of current evidence Ann Oncol 2008;19:9-15.[Abstract/Free Full Text]
- Boon JM, van Schoor AN, Abrahams PH, Meiring JH, Welch T, Shanahan D. Central venous catheterization—an anatomical review of a clinical skill—Part 1: subclavian vein via the infraclavicular approach Clin Anat 2007;20:602-611.[Medline]
- 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.[Abstract/Free Full Text]
- Michael Kalina, Frederick Giberson. Hemoptysis secondary to pulmonary artery pseudoaneurysm after necrotizing pneumonia Ann Thorac Surg 2007;84:1386-1387.[Abstract/Free Full Text]
- Donaldson B, Ngo-Nonga B. Traumatic pseudoaneurysm of the pulmonary artery: case report and review of the literature Am Surg 2002;68:414-416.[Medline]
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Abstract
Introduction
