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Contents : Hemoptysis Secondary to Pulmonary Artery Pseudoaneurysm After Necrotizing Pneumonia Michael Kalina and Frederick Giberson Ann Thorac Surg 2007 84:1386-1387 DOI: 10.1016/j.athoracsur.2007.05.024 The online version of this article along with updated information and services is located on the World Wide Web at: http://ats.ctsnetjournals.org/cgi/content/full/84/4/1386 The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association. Copyright 2007 by The Society of Thoracic Surgeons. Print ISSN: 0003-4975 eISSN: 1552-6259. Downloaded from ats.ctsnetjournals.org by on March 28 2013 1386 CASE REPORT KALINA AND GIBERSON HEMOPTYSIS SECONDARY TO PULMONARY ARTERY PSEUDOANEURYSM Ann Thorac Surg 2007 84:1386 7 5. Lin J Iannettoni MD. Closure of bronchopleural fistulas using albumin-glutaraldehyde tissue adhesive. Ann Thorac Surg 2004 77:326 8. 6. Lang-Lazdunski L. Closure of bronchopleural fistula after extended right pneumonectomy after induction chemotherapy with BioGlue surgical adhesive. J Thorac Cardiovasc Surg 2006 132:1497 8. 7. Oelschlager BK Barreca M Chang L Pellegrini CA. The use of small intestine submucosa in the repair of paraesophageal hernias: Initial observations of a new technique. Am J Surg 2003 186:4 8. 8. Dalla Vecchia L Engum SA Kogan B Jenson E Davis M Grosfeld J. Evaluation of small intestine submucosa and acellular dermis as diaphragmatic prosthesis. J Pediatr Surg 1999 34:167 71. Hemoptysis Secondary to Pulmonary Artery Pseudoaneurysm After Necrotizing Pneumonia Michael Kalina DO and Frederick Giberson MD Department of Surgical Critical Care and Trauma Christiana Care Health System Christiana Hospital Newark Delaware FEATURE ARTICLES This case documents the occurrence of hemoptysis secondary to pulmonary artery pseudoaneurysm in a 19year-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. (Ann Thorac Surg 2007 84:1386 7) 2007 by The Society of Thoracic Surgeons ulmonary 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 comAccepted for publication May 7 2007. Address correspondence to Dr Kalina Christiana Hospital Surgical Critical Care and Trauma 4755 Ogletown-Stanton Rd Newark DE 19718 e-mail: mkalina@christianacare.org. P puted 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 tracheoinnominate 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). Fig 1. Computed tomographic scan of the chest with right lower and middle lobe pneumonia. 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.05.024 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc Downloaded from ats.ctsnetjournals.org by on March 28 2013 Ann Thorac Surg 2007 84:1386 7 CASE REPORT KALINA AND GIBERSON HEMOPTYSIS SECONDARY TO PULMONARY ARTERY PSEUDOANEURYSM 1387 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. Comment 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-yearold 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 . Fig 3. Angiographic coil embolization of pseudoaneurysm. 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. References 1. Murray JF. Pulmonary artery aneurysms. In: Mason RJ Broaddus VC Nadel JA eds. Textbook of Respiratory Medicine 4th ed. Philadelphia PA: Elsevier Inc 2005:1493 97. 2. 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 11. 3. Agarwal PP Dennie CJ Matzinger FR Peterson RA Seely JM. Pulmonary artery pseudoaneurysm secondary to metastatic angiosarcoma. Thorax 2006 61:366. 4. 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 7. 5. 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 5. 6. 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 10. 7. 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 8. 8. Khan AA Bauer TL Garcia MJ Panasuk Davies AL. Angiographic embolization of a traumatic pulmonary pseudoaneurysm. Ann Thorac Surg 2005 79:2136 8. Fig 2. Angiogram of right pulmonary artery and right lower pulmonary artery pseudoaneurysm. Downloaded from ats.ctsnetjournals.org by on March 28 2013 FEATURE ARTICLES Hemoptysis Secondary to Pulmonary Artery Pseudoaneurysm After Necrotizing Pneumonia Michael Kalina and Frederick Giberson Ann Thorac Surg 2007 84:1386-1387 DOI: 10.1016/j.athoracsur.2007.05.024 Updated Information & Services References Citations including high-resolution figures can be found at: http://ats.ctsnetjournals.org/cgi/content/full/84/4/1386 This article cites 7 articles 3 of which you can access for free at: http://ats.ctsnetjournals.org/cgi/content/full/84/4/1386#BIBL This article has been cited by 1 HighWire-hosted articles: http://ats.ctsnetjournals.org/cgi/content/full/84/4/1386#otherarticle s This article along with others on similar topics appears in the following collection(s): Lung - other http://ats.ctsnetjournals.org/cgi/collection/lung other Requests about reproducing this article in parts (figures tables) or in its entirety should be submitted to: http://www.us.elsevierhealth.com/Licensing/permissions.jsp or email: healthpermissions@elsevier.com. 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