Case Study
Successful endovascular treatment of ruptured bronchial artery aneurysm
Asian Cardiovascular & Thoracic Annals 21(5) 615–617 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312463369 aan.sagepub.com
Daijiro Hori, Kenichiro Noguchi, Yohei Nomura and Hiroyuki Tanaka
Abstract Rupture of a bronchial artery aneurysm occurs rarely and may mimic aortic dissection. A 78-year-old-man was admitted with sudden chest pain. Chest radiography showed widening of the mediastinum, suggestive of aortic dissection, but contrast-enhanced computed tomography revealed hemomediastinum and bronchial artery aneurysm. Although open surgery has been the first choice for ruptured bronchial artery aneurysm, this case was successfully treated by an endovascular procedure with the combined use of coils and a gelatin sponge.
Keywords Aneurysm, ruptured, bronchial arteries, embolization, therapeutic, hemothorax
Introduction Bronchial artery aneurysm is a rare condition observed in less than 1% of all cases of selective bronchial arteriography.1 Immediate treatment by open surgery or an endovascular procedure is recommended because of the risk of rupture, which does not seem to be related to the aneurysmal dimensions.2 We report a case of ruptured bronchial artery aneurysm that was successfully treated with coils and a gelatin sponge.
Case report A 78-year-old-man with no past medical history was admitted with sudden chest pain refractory to nitroglycerine. Chest radiography showed widening of the mediastinum mimicking aortic dissection. Contrastenhanced computed tomography revealed hemomediastinum with a bronchial artery aneurysm of 10-mm in diameter (Figure 1(a)–(c)). The laboratory data did not show any sign of coagulopathy or a bleeding tendency, and he had no history of medication. Angiography was performed for further study and treatment. A 4F sheath catheter was inserted through the right femoral artery. Angiography with a Mikaelsson catheter (Mayo Healthcare Pty. Ltd., Australia) revealed 3 aneurysms originating from the bronchial artery at the aortic arch (Figure 2(a)).
There was no sign of aortic dissection or bronchial artery dissection. A microcatheter was inserted through the guide catheter, for full catheterization of the aneurysm. However, due to a tortuous artery, catheterization past the first aneurysm could not be achieved. A gelatin sponge was inserted through the microcatheter to reduce the blood flow into the aneurysm. A 2 mm/ 3 mm coil (Cook Medical, Inc., IN, USA) was deployed to occlude the efferent artery. A 2 mm/5 mm coil was placed at the proximal neck for anchoring, and a 2 mm/ 3 mm coil was added for occlusion of the afferent artery (Figure 2(b)). Postprocedural angiography revealed no filling of contrast medium into the aneurysm (Figure 2(c)). Computed tomography performed 1 week after the intervention revealed total obliteration of the bronchial artery aneurysm (Figure 3(a) and (b)). The patient was discharged from the hospital without any major complication.
Department of Cardiovascular Surgery, Fujigaoka Hospital, Showa University, Kanagawa, Japan Corresponding author: Daijiro Hori, MD, Department of Cardiovascular Surgery, Showa University, Fujigaoka Hospital, 1-30 Fujikaoka, Aoba, Yokohama city, Kanagawa 227-8501, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at The University of Hong Kong Libraries on May 9, 2015
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Asian Cardiovascular & Thoracic Annals 21(5)
Figure 1. (a) Chest radiograph on admission showed widening of the mediastinum, mimicking aortic dissection. (b) and (c) Computed tomography revealing hemomediastinum and a bronchial artery aneurysm just below the aortic arch.
Figure 2. (a) Selective bronchial arteriography revealing 3 bronchial artery aneurysms originating from the aortic arch. (b) Endovascular repair with a gelatin sponge and coils. (c) Postprocedural angiography showing no filling of contrast medium into the aneurysm.
Discussion The etiology of mediastinal hematomas can be divided into traumatic and nontraumatic causes. Traumatic causes include blunt chest trauma, penetrating chest trauma, and iatrogenic causes such as malposition of a central venous catheter. Patients with nontraumatic spontaneous mediastinal hematomas may have underlying predisposing factors such as anticoagulant medication, thrombolytic therapy, cervical neoplasms, or vasculopathies including aortic dissection and aneurysm. Parathyroid hemorrhage and esophageal hemorrhage may also present as mediastinal hematoma.3 Patients may present with the triad of acute superior mediastinal compression, widening of the superior
mediastinum on chest radiography, and neck bruises. The diagnosis should be performed by contrastenhanced computed tomography because of its accessibility, noninvasiveness, rapid acquisition, and ability to evaluate the entire thorax at once.3 In our case, it revealed mediastinal hematoma with 3 bronchial artery aneurysms. Bronchial artery aneurysm is known to be associated with pulmonary agenesis, chronic inflammation of the lung, bronchiectasis, and vascular abnormalities such as Osler-Weber-Rendu or Behc¸et disease, which were not present in this case. Increased blood flow and blood pressure are believed to play a role in aneurysm formation, and immediate treatment by open surgery or an endovascular procedure should be considered because
Downloaded from aan.sagepub.com at The University of Hong Kong Libraries on May 9, 2015
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617
Figure 3. Postoperative computed tomography demonstrating no filling of contrast medium into the aneurysm.
the risk of rupture is unrelated to its size.1 Open surgical treatment may include excision of the aneurysm, pneumonectomy, or bronchial artery ligation.4 Endovascular treatment includes embolization with gelatin sponge, detachable coils, steel coils, occlusion balloons, or N-butyl-2-cyanoacrylate.5 Recent reports have suggested combined treatment with stent grafting and embolization in patients with a short inflow segment.6 Endovascular treatment in patients with a tortuous artery is often challenging due to difficulty in catheterization, as in our patient. Although treatment with a stent graft was considered, it could not be performed due to insufficient landing zone. We managed to treat this patient by a combination of coils and a gelatin sponge, which allowed blood flow control, thus preventing overly distal occlusion and restriction of the treatment area. Transcatheter embolization with the combined use of embolic material was useful and could be considered an option for treating ruptured bronchial artery aneurysm. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement
References 1. Kalangos A, Khatchatourian G, Panos A and Faidutti B. Ruptured mediastinal bronchial artery aneurysm: a dilemma of diagnosis and a therapeutic approach. J Thorac Cardiovasc Surg 1997; 114: 853–856. 2. Tanaka K, Ihaya A, Horiuci T, Morioka K, Kimura T, Uesaka T, et al. Giant mediastinal bronchial artery aneurysm mimicking benign esophageal tumor: a case report and review of 26 cases from literature. J Vasc Surg 2003; 38: 1125–1129. 3. Rojas CA and Restrepo CS. Mediastinal hematomas: aortic injury and beyond [Review]. J Comput Assist Tomogr 2009; 33: 218–224. 4. Pugnale M, Portier F, Lamarre A, Halkic N, Riis HB and Wicky S. Hemomediastinum caused by rupture of a bronchial artery aneurysm: successful treatment by embolization with N-butyl-2-cyanoacrylate. J Vasc Interv Radiol 2001; 12: 1351–1352. 5. Sakai T, Razavi MK, Semba CP, Kee ST, Sze DY and Dake MD. Percutaneous treatment of bronchial artery aneurysm with use of transcatheter coil embolization and thoracic aortic stent-graft placement. J Vasc Interv Radiol 1998; 9: 1025–1028. 6. Lu PH, Wang LF, Su YS, Lee DH, Wang SX, Sun L, et al. Endovascular therapy of bronchial artery aneurysm: five cases with six aneurysms. Cardiovasc Intervent Radiol 2011; 34: 508–512.
None declared.
Downloaded from aan.sagepub.com at The University of Hong Kong Libraries on May 9, 2015
Successful endovascular treatment of ruptured bronchial artery aneurysm
Asian Cardiovascular & Thoracic Annals 21(5) 615–617 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312463369 aan.sagepub.com
Daijiro Hori, Kenichiro Noguchi, Yohei Nomura and Hiroyuki Tanaka
Abstract Rupture of a bronchial artery aneurysm occurs rarely and may mimic aortic dissection. A 78-year-old-man was admitted with sudden chest pain. Chest radiography showed widening of the mediastinum, suggestive of aortic dissection, but contrast-enhanced computed tomography revealed hemomediastinum and bronchial artery aneurysm. Although open surgery has been the first choice for ruptured bronchial artery aneurysm, this case was successfully treated by an endovascular procedure with the combined use of coils and a gelatin sponge.
Keywords Aneurysm, ruptured, bronchial arteries, embolization, therapeutic, hemothorax
Introduction Bronchial artery aneurysm is a rare condition observed in less than 1% of all cases of selective bronchial arteriography.1 Immediate treatment by open surgery or an endovascular procedure is recommended because of the risk of rupture, which does not seem to be related to the aneurysmal dimensions.2 We report a case of ruptured bronchial artery aneurysm that was successfully treated with coils and a gelatin sponge.
Case report A 78-year-old-man with no past medical history was admitted with sudden chest pain refractory to nitroglycerine. Chest radiography showed widening of the mediastinum mimicking aortic dissection. Contrastenhanced computed tomography revealed hemomediastinum with a bronchial artery aneurysm of 10-mm in diameter (Figure 1(a)–(c)). The laboratory data did not show any sign of coagulopathy or a bleeding tendency, and he had no history of medication. Angiography was performed for further study and treatment. A 4F sheath catheter was inserted through the right femoral artery. Angiography with a Mikaelsson catheter (Mayo Healthcare Pty. Ltd., Australia) revealed 3 aneurysms originating from the bronchial artery at the aortic arch (Figure 2(a)).
There was no sign of aortic dissection or bronchial artery dissection. A microcatheter was inserted through the guide catheter, for full catheterization of the aneurysm. However, due to a tortuous artery, catheterization past the first aneurysm could not be achieved. A gelatin sponge was inserted through the microcatheter to reduce the blood flow into the aneurysm. A 2 mm/ 3 mm coil (Cook Medical, Inc., IN, USA) was deployed to occlude the efferent artery. A 2 mm/5 mm coil was placed at the proximal neck for anchoring, and a 2 mm/ 3 mm coil was added for occlusion of the afferent artery (Figure 2(b)). Postprocedural angiography revealed no filling of contrast medium into the aneurysm (Figure 2(c)). Computed tomography performed 1 week after the intervention revealed total obliteration of the bronchial artery aneurysm (Figure 3(a) and (b)). The patient was discharged from the hospital without any major complication.
Department of Cardiovascular Surgery, Fujigaoka Hospital, Showa University, Kanagawa, Japan Corresponding author: Daijiro Hori, MD, Department of Cardiovascular Surgery, Showa University, Fujigaoka Hospital, 1-30 Fujikaoka, Aoba, Yokohama city, Kanagawa 227-8501, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at The University of Hong Kong Libraries on May 9, 2015
616
Asian Cardiovascular & Thoracic Annals 21(5)
Figure 1. (a) Chest radiograph on admission showed widening of the mediastinum, mimicking aortic dissection. (b) and (c) Computed tomography revealing hemomediastinum and a bronchial artery aneurysm just below the aortic arch.
Figure 2. (a) Selective bronchial arteriography revealing 3 bronchial artery aneurysms originating from the aortic arch. (b) Endovascular repair with a gelatin sponge and coils. (c) Postprocedural angiography showing no filling of contrast medium into the aneurysm.
Discussion The etiology of mediastinal hematomas can be divided into traumatic and nontraumatic causes. Traumatic causes include blunt chest trauma, penetrating chest trauma, and iatrogenic causes such as malposition of a central venous catheter. Patients with nontraumatic spontaneous mediastinal hematomas may have underlying predisposing factors such as anticoagulant medication, thrombolytic therapy, cervical neoplasms, or vasculopathies including aortic dissection and aneurysm. Parathyroid hemorrhage and esophageal hemorrhage may also present as mediastinal hematoma.3 Patients may present with the triad of acute superior mediastinal compression, widening of the superior
mediastinum on chest radiography, and neck bruises. The diagnosis should be performed by contrastenhanced computed tomography because of its accessibility, noninvasiveness, rapid acquisition, and ability to evaluate the entire thorax at once.3 In our case, it revealed mediastinal hematoma with 3 bronchial artery aneurysms. Bronchial artery aneurysm is known to be associated with pulmonary agenesis, chronic inflammation of the lung, bronchiectasis, and vascular abnormalities such as Osler-Weber-Rendu or Behc¸et disease, which were not present in this case. Increased blood flow and blood pressure are believed to play a role in aneurysm formation, and immediate treatment by open surgery or an endovascular procedure should be considered because
Downloaded from aan.sagepub.com at The University of Hong Kong Libraries on May 9, 2015
Hori et al.
617
Figure 3. Postoperative computed tomography demonstrating no filling of contrast medium into the aneurysm.
the risk of rupture is unrelated to its size.1 Open surgical treatment may include excision of the aneurysm, pneumonectomy, or bronchial artery ligation.4 Endovascular treatment includes embolization with gelatin sponge, detachable coils, steel coils, occlusion balloons, or N-butyl-2-cyanoacrylate.5 Recent reports have suggested combined treatment with stent grafting and embolization in patients with a short inflow segment.6 Endovascular treatment in patients with a tortuous artery is often challenging due to difficulty in catheterization, as in our patient. Although treatment with a stent graft was considered, it could not be performed due to insufficient landing zone. We managed to treat this patient by a combination of coils and a gelatin sponge, which allowed blood flow control, thus preventing overly distal occlusion and restriction of the treatment area. Transcatheter embolization with the combined use of embolic material was useful and could be considered an option for treating ruptured bronchial artery aneurysm. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement
References 1. Kalangos A, Khatchatourian G, Panos A and Faidutti B. Ruptured mediastinal bronchial artery aneurysm: a dilemma of diagnosis and a therapeutic approach. J Thorac Cardiovasc Surg 1997; 114: 853–856. 2. Tanaka K, Ihaya A, Horiuci T, Morioka K, Kimura T, Uesaka T, et al. Giant mediastinal bronchial artery aneurysm mimicking benign esophageal tumor: a case report and review of 26 cases from literature. J Vasc Surg 2003; 38: 1125–1129. 3. Rojas CA and Restrepo CS. Mediastinal hematomas: aortic injury and beyond [Review]. J Comput Assist Tomogr 2009; 33: 218–224. 4. Pugnale M, Portier F, Lamarre A, Halkic N, Riis HB and Wicky S. Hemomediastinum caused by rupture of a bronchial artery aneurysm: successful treatment by embolization with N-butyl-2-cyanoacrylate. J Vasc Interv Radiol 2001; 12: 1351–1352. 5. Sakai T, Razavi MK, Semba CP, Kee ST, Sze DY and Dake MD. Percutaneous treatment of bronchial artery aneurysm with use of transcatheter coil embolization and thoracic aortic stent-graft placement. J Vasc Interv Radiol 1998; 9: 1025–1028. 6. Lu PH, Wang LF, Su YS, Lee DH, Wang SX, Sun L, et al. Endovascular therapy of bronchial artery aneurysm: five cases with six aneurysms. Cardiovasc Intervent Radiol 2011; 34: 508–512.
None declared.
Downloaded from aan.sagepub.com at The University of Hong Kong Libraries on May 9, 2015
