- Case Report
- Open Access
Ruptured pulmonary artery pseudoaneurysm treated with stent graft: case report and literature review
CVIR Endovascular volume 5, Article number: 59 (2022)
Hemoptysis is a severe condition, associated with a high mortality rate from asphyxiation. Less than 5% of cases come from the pulmonary arterial circulation and large pseudoaneurysm are rarely treatable by stent graft.
We present the case of a 74-year-old man who suffered from a new onset of hemoptysis despite a prior bronchial artery embolization. He underwent a rescue endovascular stent graft placement for a massive hemoptysis caused by a ruptured proximal pulmonary artery pseudoaneurysm. A short review of similar situations is provided.
Salvage endovascular stent graft placement for a massive hemoptysis caused by a ruptured proximal pulmonary artery pseudoaneurysm is a viable salvage technique for life-threatening hemoptysis.
Severe hemoptysis is a serious condition, associated with a high mortality rate from asphyxiation (Parrot et al. 2018). A large study on the French nationwide database found that the most frequent etiology was lung cancer, followed by active tuberculosis and bronchiectasis (Fartoukh et al. 2021). Most cases are related to the bronchial arterial supply of lung (Yoon et al. 2002) and can be treated with bronchial artery embolization (BAE). Less than 5% of cases come from the pulmonary arterial circulation (Rabkin et al. 1987). In 2022, the CIRSE established new guidelines for BAE, where it recommends embolization for patients with life threatening or recurrent hemoptysis (Kettenbach et al. 2022). Technical success rates range from 90 to 100% and clinical success rates range from 82 to 100% after 24 h (Chun and Belli 2010; Dorji et al. 2021). Despite these high early success rates, the recurrence rate remains high (47%) (Heuvel et al. 2007); one of the reasons for recurrence is the implication of the pulmonary arterial circulation in the bleeding origin (Chun et al. 2010).
A 74-year-old man treated for a stage IV lung adenocarcinoma initially presented with a mild hemoptysis (estimated volume: 100–200 mL over 24 h) and underwent a bronchial artery embolization at our institution. No complication was noted and the patient was discharged the day after. He presented with a severe recurrent hemoptysis one month later and was admitted in the intensive care unit for initial care. Nasal Oxygenotherapy was immediately administered at a 15 L/ minute flowrate for target oxygen saturation > 90%; invasive ventilation was considered unreasonable by the intensive care physician given the highly compromised health condition of the patient. Computed tomography angiography showed a pulmonary artery pseudoaneurysm arising from the left pulmonary artery adjacent to the lung tumor (Fig. 1), which was retrospectively not present one month prior to the recurrence. After a multidisciplinary discussion, a salvage treatment was proposed and the patient was transferred to the interventional radiology angiographic suite.
Access to the right femoral vein was performed using a 10-French vascular long sheath placed in the origin of the right atrium, under local anesthesia. The initial angiogram was performed in the left pulmonary artery using a pigtail 5-French catheter with an injection protocol of 30 mL of contrast injected at a rate of 15 mL/second. Cone-Beam computed tomography was not feasible given the overall patient agitation. Selective angiography within the inferior lobar artery using a multipurpose 5-French catheter confirmed the pseudoaneurysm arising from the posterior wall of the artery (Fig. 2). After careful selective catheterization of the pseudoaneurysm using a 2.4-French microcatheter, we injected a few mL of Onyx 34 (Medtronic) but the microcatheter instability did not allow us to inject enough to obtain a satisfactory filling. Subsequently an endovascular stent graft was deployed (11,5 × 33 mm LifeStream balloon expandable covered stent (Bard Medical)) to exclude the pseudoaneurysm. The stent was over dilated with the provided balloon at its origin to allow maximum coverage along its length and to prevent endoleak or material migration. The patient was immediately placed under an antiplatelet therapy (aspirin 75 mg daily).
Control angiography showed no immediate complication and confirmed the exclusion of the pseudoaneurysm, as reassessed by a second CT angiography (Fig. 3). There was no pulmonary infarction described on the postoperative scan. There were no acute complications and no recurrence during hospitalization and the patient was discharged on day 6. During the follow-up, the patient did not return to the hospital for an acute pathology. A CT scan performed one and a half months after this episode showed a permeable stent without pulmonary infarction.
Although the treatment of hemoptysis from the bronchial artery circulation is well known (Kettenbach et al. 2022), hemoptysis from the pulmonary artery circulation is a rare condition. Several case reports have been published regarding the treatment of pseudoaneurysms and various embolic materials have been used. Coils are the most common choice but may require the sacrifice of the feeding artery (O’Reilly et al. 2022; Yamakado et al. 2010; Law et al. 2022; Marcelin et al. 2018). This strategy is feasible if the pseudoaneurysm is relatively distal; however, in the present case, the target lesion was very proximal in the lobar artery. Onyx can be used in the pulmonary arterial circulation; Khalil et al. report a series of 12 cases (Khalil et al. 2012). Nevertheless, the use of such an embolic agent requires a narrow aneurysmal neck and the sacrifice of the parent artery in most cases. It was not possible in our case where the pseudoaneurysm originated from the trunk of the left pulmonary artery.
Covered stents allow the exclusion of the pseudoaneurysm while respecting the feeding artery (Klobuka and Short 2016; Park and Cwikiel 2007; Hannan et al. 2001; Wilson et al. 2000; Chou et al. 2006). The technical feasibility may be more complex due to the irregular caliber of the pulmonary arterial circulation, and could require proximal dilation to ensure optimal apposition of the stent graft against the arterial wall. In our case we used a femoral approach, although reports of distal embolization have been published using the brachial approach (Contegiacomo et al. 2021). Anecdotally, there are cases of pseudoaneurysms treated by direct percutaneous puncture and injection of thrombin or N-butyl cyanoacrylate (Lee et al. 2008). Marcelin and al (Marcelin et al. 2018) showed that embolization in the context of pulmonary artery hemoptysis was effective.
In the absence of sufficient data, the choice of embolization material is left to the clinician. Importantly, pulmonary artery embolization is a viable salvage technique for life-threatening hemoptysis, particularly in proximal lesions, where sacrifice of the parent artery is not an option.
Availability of data and materials
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.
Bronchial Artery Embolization
Cardiovascular and Interventional Radiological Society of Europe
Maximum Intensity Projection
Chou M, Liang H-L, Pan H-B, Yang C-F (2006) Percutaneous Stent-Graft Repair of a Mycotic Pulmonary Artery Pseudoaneurysm. Cardiovasc Intervent Radiol 29:890–892
Chun J-Y, Belli A-M (2010) Immediate and long-term outcomes of bronchial and non-bronchial systemic artery embolisation for the management of haemoptysis. Eur Radiol 20:558–565
Chun J-Y, Morgan R, Belli A-M (2010) Radiological Management of Hemoptysis: A Comprehensive Review of Diagnostic Imaging and Bronchial Arterial Embolization. Cardiovasc Intervent Radiol 33:240–250
Contegiacomo A, Attempati N, Scrofani AR, Punzi E, Rella R, Manfredi R (2021) Right brachial vein access for pulmonary arteriovenous malformation embolization. Diagn Interv Imaging 102:55–57
Dorji K, Hongsakul K, Jutidamrongphan W, Oofuvong M, Geater S (2021) Bronchial Artery Embolization in Life-Threatening Hemoptysis: Outcome and Predictive Factors. J Belg Soc Radiol 105:5
Fartoukh M, Demoule A, Sanchez O, Tuffet S, Bergot E, Godet C et al (2021) Randomised trial of first-line bronchial artery embolisation for non-severe haemoptysis of mild abundance. BMJ Open Respir Res. 8:e000949
Hannan RL, Miyaji K, Burke RP, Zahn EM (2001) Endovascular stent graft treatment of a pulmonary artery pseudoaneurysm. Ann Thorac Surg 71:727–729
Kettenbach J, Ittrich H, Gaubert JY, Gebauer B, Vos JA (2022) CIRSE Standards of Practice on Bronchial Artery Embolisation. Cardiovasc Intervent Radiol 45:721–732
Khalil A, Parrot A, Fartoukh M, Djibre M, Tassart M, Carette M-F (2012) Pulmonary Artery Occlusion With Ethylene Vinyl Alcohol Copolymer in Patients With Hemoptysis: Initial Experience in 12 Cases. Am J Roentgenol 198:207–212
Klobuka AJ, Short RF (2016) Endovascular Stent Graft Placement in the Left Main Pulmonary Artery for Management of a Giant Pulmonary Artery Pseudoaneurysm. J Vasc Interv Radiol 27:1706–1707
Law N, Quencer K, Kaufman C, Iravani A, Hardman R, Smith T (2022) Embolization of pulmonary artery aneurysms in a patient with Behçet’s disease complicated by coil erosion into the airway. J Vasc Surg Cases Innov Tech 8:193–195
Lee K, Shin T, Choi J, Kim Y (2008) Percutaneous Injection Therapy for a Peripheral Pulmonary Artery Pseudoaneurysm After Failed Transcatheter Coil Embolization. Cardiovasc Intervent Radiol 31:1038–1041
Marcelin C, Soussan J, Desmots F, Gaubert J-Y, Vidal V, Bartoli JM et al (2018) Outcomes of Pulmonary Artery Embolization and Stent Graft Placement for the Treatment of Hemoptysis Caused by Lung Tumors. J Vasc Interv Radiol 29:975–980
O’Reilly MF, Kennedy MP, Power SP (2022) Embolization of a Proximal Pulmonary Artery Pseudoaneurysm in a Cavitary Lung Cancer. J Vasc Interv Radiol 33:741
Park A, Cwikiel W (2007) Endovascular treatment of a pulmonary artery pseudoaneurysm with a stent graft: report of two cases. Acta Radiol 48:45–47
Parrot A, Tavolaro S, Voiriot G, Canellas A, Assouad J, Cadranel J et al (2018) Management of severe hemoptysis. Expert Rev Respir Med 12:817–829
Rabkin JE, Astafjev VI, Gothman LN, Grigorjev YG (1987) Transcatheter embolization in the management of pulmonary hemorrhage. Radiology 163:361–365
van den Heuvel MM, Els Z, Koegelenberg CF, Naidu KM, Bolliger CT, Diacon AH (2007) Risk factors for recurrence of haemoptysis following bronchial artery embolisation for life-threatening haemoptysis. Int J Tuberc Lung Dis off J Int Union Tuberc Lung Dis 11:909–914
Wilson N, McLeod K, Hallworth D (2000) Exclusion of a pulmonary artery aneurysm using a covered stent. Heart 83:438
Yamakado K, Takaki H, Takao M, Murashima S, Kodama H, Kashima M et al (2010) Massive Hemoptysis from Pulmonary Artery Pseudoaneurysm Caused by Lung Radiofrequency Ablation: Successful Treatment by Coil Embolization. Cardiovasc Intervent Radiol 33:410–412
Yoon W, Kim JK, Kim YH, Chung TW, Kang HK (2002) Bronchial and Nonbronchial Systemic Artery Embolization for Life-threatening Hemoptysis: A Comprehensive Review. Radiographics 22:1395–1409
This study was not supported by any funding.
Ethics approval and consent to participate
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
Consent for publication
Consent for publication was obtained for every individual person’s data included in the study.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Barrot, V., Pellerin, O., Reverdito, G. et al. Ruptured pulmonary artery pseudoaneurysm treated with stent graft: case report and literature review. CVIR Endovasc 5, 59 (2022). https://doi.org/10.1186/s42155-022-00339-6
- Aneurysm false
- Pulmonary artery