Medical Pneumonectomy: Interventional Bronchoscopic and Endovascular Management of Massive Hemoptysis Due to Pulmonary Artery Pseudoaneurysm, a Consequence of Endobronchial Brachytherapy FREE TO VIEW

This case presentation reports on a 57-year-old man who was diagnosed with non-small cell lung carcinoma in April 2007 at an outside institution. He had other medical comorbidities, including COPD and systemic hypertension. At initial presentation, a diagnostic flexible bronchoscopy was performed for dyspnea, which revealed an obstruction of the right mainstem bronchus due to an endobronchial mass arising from the right upper lobe. The patient was treated with endobronchial brachytherapy followed by external beam radiation therapy and chemotherapy with good radiographic response. In February 2008, he presented to his local emergency room with dyspnea and hemoptysis, quantified to be approximately 250 mL, that continued in the emergency room with a noted drop in hemoglobin. The airway was secured with a double-lumen endotracheal tube, and flexible bronchoscopy revealed a right mainstem bronchus clot and possibly an underlying necrotic-appearing mass. Fibrin glue was instilled at this site, and the patient was transferred to our institution for further care.

On arrival to our ICU, the patient was sedated and mechanically ventilated. Initial chest radiograph revealed complete opacification of the right hemithorax (Fig 1). Because of the reported findings at flexible bronchoscopy, we elected to proceed immediately with diagnostic and therapeutic rigid bronchoscopy. The patient was brought to the operating room and easily intubated with a 13.2-mm outer diameter rigid bronchoscope. A large fibrin blood clot was seen occluding the right mainstem bronchus. The left-sided airways were grossly normal. The right-sided airways were cleared of clot with no visualized active bleeding. However, a large pulsatile lesion was noted along the medial aspect of the right-upper-lobe carina (online video content). A 50% stenosis of the bronchus intermedius was seen, with adequate patency to the right-middle-lobe and right-lower-lobe airways (Fig 2, top left, A). During the airway exam, a massive bleed ensued from this presumed pseudoaneurysm. With suctioning, instilled epinephrine, mechanical tamponade, and left mainstem rigid intubation, the airway was secured. Oxygenation and hemodynamics were stabilized. The left mainstem and trachea were then cleared of clot. A resultant right mainstem bronchus clot was left in place. The rigid bronchoscope was removed, and under direct laryngoscopy a 9.0-mm endotracheal tube was placed and then guided bronchoscopically into the left mainstem bronchus.

Immediately, the patient was transferred to the interventional radiology suite for directed pulmonary angiogram. Various views were obtained to reveal a small wide-necked pseudoaneurysm at the proximal superior portion of the right main pulmonary artery, just distal to the takeoff of the upper-lobe branch (Fig 3). Because of the changing caliber of the artery, no suitable covered stent was available to occlude the site. The only means of controlling flow into the pseudoaneurysm was complete embolization of the right pulmonary artery. This procedure was performed with a total of 44 0.035-inch embolization coils (Nester Embolization Coils; Cook Medica; Bloomington, IN) [Fig 4] of various sizes and confirmed by angiography (Fig 5). The patient was returned to the ICU in stable condition; however, periods of hypoxia ensued in the following days despite various ventilator maneuvers. Persistent dead-space ventilation had resulted as pulmonary arterial perfusion had been excluded, which therefore created physiologic mismatching in the right lung. After 7 days, we brought the patient back to the operating room with the goal of obliterating ventilation to the right lung.

Through an instillation catheter, 10 mL of fibrin glue was instilled to create a plug for the entire right-sided bronchial tree (Fig 2, top right, B). An 18 × 80-mm, covered, metallic stent (Ultraflex; Boston Scientific Corporation; Natick, MA) was then deployed in the distal left mainstem bronchus, overlying the established fibrin plug, and proximally in the trachea (Fig 2, bottom left, C, and bottom right, D). The patient was reintubated with an endotracheal tube and returned in stable condition to the ICU.

During the course of his ICU stay, the patient had a tracheostomy placed, was easily awakened with no neurologic deficits, and transferred to a facility for ventilator weaning and rehabilitation. He has since been weaned off the ventilator, decannulated successfully (Fig 6), rehabilitated to ambulation, and returned home capable of performing his activities of daily living.

Endobronchial brachytherapy serves well in treating residual or recurrent carcinoma. It can be effective for patients who have been treated with maximal doses of external beam radiation. However, it can be potentially dangerous. Massive hemoptysis and mediastinal fistulae are the most common complications.¹

Traumatic, infectious, rheumatologic, and malignant causes of pulmonary artery pseudoaneurysm have been well documented in the literature. It is an uncommon yet well-known iatrogenic complication of pulmonary artery catheter placement, tube thoracostomy, and right-heart catheterization.^2,3 Furthermore, it is a potential complication of endobronchial brachytherapy, presenting with massive hemoptysis, as in our patient.

Successful nonoperative management of a pulmonary artery pseudoaneurysm can be with either coil embolization or covered endovascular stenting. The technical aspects and anatomy will determine the appropriate solution.^3–5 In our case, endovascular stenting was not appropriate, and this resulted in the need for complete embolization of the right pulmonary artery. The consequent large physiologic mismatch was believed to be the etiology of the patient's hypoxia; therefore, we proceeded to obliteration of right lung ventilation. In a period of 2 months from presentation, the patient has been since decannulated and is progressing in rehabilitation.

Massive hemoptysis is a significant risk of endobronchial brachytherapy. Pulmonary artery pseudoaneurysm can result at a delayed time from initial therapy. This entity can be successfully managed through bronchoscopic and endovascular techniques.