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Ann Thorac Surg 2009;87:1587-1589. doi:10.1016/j.athoracsur.2008.09.017
© 2009 The Society of Thoracic Surgeons
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Case Reports

Severe Calcified Saccular Pulmonary Artery Aneurysm

Xing-Hai Hao, MDa, Jian-Hua Liu, MDb, Chuan-Ming Bao, MDb, Jun Yang, MDb, Yong-Qiang Lai, MDa,*

a Division of Cardiac Surgery, Beijing Anzhen Hospital, Capital University of Medical Sciences, Beijing, China
b Department of Cardiac Surgery, Suizhou Central Hospital, Hubei Province, China

Accepted for publication September 3, 2008.

* Address correspondence to Dr Lai, Division of Cardiac Surgery, Beijing Anzhen Hospital, Capital University of Medical Sciences, 36 Wuluju Chaoyang District, Beijing, 100029, China (Email: yongqianglai{at}yahoo.com).


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Pulmonary artery aneurysm is a very rare entity. Severe calcified saccular pulmonary artery aneurysm is not reported in the literature. A 19-year-old man with a severe calcified saccular pulmonary artery aneurysm is described.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Aneurysm formation of the pulmonary artery is rare, and its natural history is not clear. The cause of pulmonary artery aneurysm (PAA) may be congenital or idiopathic. There is no definite guideline about its treatment.

A 19-year-old man was admitted because of a continuous parasternal murmur. He was asymptomatic. Transthoracic echocardiogram revealed a patent ductus arteriosus (PDA) with a continuous left-to-right shunt and a giant saccular PAA. A computed tomographic scan showed a severe calcified saccular PAA arising from 2 cm above the pulmonary valve (Fig 1).


Figure 1
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  		Fig 1. Computed tomographic scan showed a severe calcified saccular pulmonary artery aneurysm arising from the pulmonary artery.

 
Surgery was performed through a median sternotomy and hypothermic cardiopulmonary bypass. Pulmonary artery pressure was directly measured after opening the pericardium. Mean pulmonary artery pressure was 18 mm Hg. When the nasopharyngeal temperature was decreased to 20°C, hypo-volume circulation (10 mL/kg/min) was initiated. The PDA was closed with a mattress suture. Hypo-volume circulation time was 6 minutes. The PAA arose from the lateral wall of the main pulmonary artery, and it adhered with the right ventricular outflow tract. The diameter of the aneurysm orifice was 1.0 cm, and it was 2 cm above the pulmonary valve. Because the aneurysm was severely calcified, it was not difficult to separate the aneurysm from the adjacent tissues with electrocautery. The pulmonary artery was reconstructed with a pericardial patch after the PAA was removed. The aneurysm was 6 x 8 x 8 cm3, and there were no intraluminal thrombi and vegetations in the aneurysm (Fig 2). Histopathology revealed normal artery and calcification of the aneurysm wall. Postoperative recovery was uneventful. There were no adverse events at 12 months of follow-up.


Figure 2
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  		Fig 2. The severe calcified saccular pulmonary artery aneurysm was removed, and there was no thrombi and vegetations intraluminally.

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Pulmonary artery aneurysm is a rare anomaly. It may be idiopathic, and approximately half is associated with congenital heart disease. Patent ductus arteriosus is the most frequently associated congenital anomaly, followed by ventricular and atrial septal defect [1, 2]. Morphologically, pulmonary artery dilation is the most common form of PAA, especially when pulmonary hypertension and pulmonary valve lesion are associated. Saccular PAA was rarely reported [1, 3]. Severe calcified saccular PAA is not reported in the literature. Histopathologically, most patients demonstrate a decrease of elastic fibers in the media, medial degeneration, and an increase of collagen fibers with a decrease of smooth muscle cells. Cystic medial degeneration is the most important factor leading to the pathogenesis of PAA. A histopathologic examination shows a normal pulmonary artery history and calcification of the aneurysm wall in this patient. A similar finding has also been reported [4].

The natural history of PAA is poorly understood, and there are no definite guidelines for management. Pulmonary artery aneurysm can grow to an impressive size before identification. A large PAA can cause local compressive symptoms. It has been reported that the idiopathic PAA could be stable for many decades. When a patient is asymptomatic, without a causative cardiac lesion and pulmonary hypertension, conservative treatment is advocated [5, 6]. The most serious complications of PAA are dissection and rupture. We recommend surgical intervention when patients have compressive symptoms, progressive enlargement of the PAA, giant PAA (>6 cm), a causative cardiac lesion, or pulmonary hypertension.

Surgical procedures for the PAA include aneurysmorrhaphy, pericardial patch reconstruction, and interposition grafting with allograft or a Dacron graft (CryoLife Inc, Marietta, GA). Replacement of the pulmonary artery and arterial resection with reduction arterioplasty were equally effective [7]. Because of the limited cases, long-term results of these procedures are not clear. Resection of PAA and reconstruction of pulmonary artery with a pericardial patch is applied in this case with a good result.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Coard KC, Martin MP. Rupture saccular pulmonary artery aneurysm associated with persistent ductus arteriosus Arch Pathol Lab Med 1992;116:159-161.[Medline]
  2. Butto F, Lucas Jr RV, Edwards JE. Pulmonary arterial aneurysm. A pathologic study of five cases. Chest 1987;91:237-241.[Abstract/Free Full Text]
  3. Agarwal S, Chowdhury UK, Saxena A, Ray R, Sharma S, Airan B. Isolated idiopathic pulmonary artery aneurysm Asian Cardiovasc Thorac Ann 2002;10:167-169.[Abstract/Free Full Text]
  4. Casselman F, Deferm H, Peeters P, Vanermen H. Aneurysm of the left pulmonary artery: surgical allograft repair Ann Thorac Surg 1995;60:1423-1425.[Abstract/Free Full Text]
  5. Vural AH, Turk T, Ata Y, Goncu T, Ozyazicioglu A. Idiopathic asymptomatic main pulmonary artery aneurysm: surgery or conservative management? A case report Heart Surg Form 2007;10:E273-E275.
  6. van Rens MT, Westermann CJ, Postmus PE, Schramel FM. Untreated idiopathic aneurysm of the pulmonary artery; long-term follow-up Respir Med 2000;94:404-405.[Medline]
  7. Subrato JD, Kenton JZ, Raymond CS. Idiopathic pulmonary artery aneurysm Ann Thorac Surg 2005;80:1500-1502.[Abstract/Free Full Text]




This Article
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