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

Mohit Chawla, MD; Todd Getzen, MD; Michael J. Simoff, MD
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From the Section of Interventional Pulmonology and Bronchoscopy, Division of Pulmonary and Critical Care Medicine, Department of Medicine (Drs. Chawla and Simoff), and Division of Interventional Radiology, Department of Radiology (Dr. Getzen), Henry Ford Hospital, Detroit, MI.

Correspondence to: Mohit Chawla, MD, Department of Medicine, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202; e-mail: chawlam1@mskcc.org


No conflict of interest exists for any of the authors.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(5):1355-1358. doi:10.1378/chest.08-2091
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Endobronchial brachytherapy serves as an excellent adjunct to standard external beam radiation therapy. The high dose of local radiation is still used to manage airway obstructions at some institutions, despite the well-known risks of airway fistulae to the esophagus or cardiovascular structures. A less reported complication is the development of a pulmonary artery pseudoaneurysm into the mainstem bronchi. The formation of an arterial pseudoaneurysm can lead to massive hemoptysis, which often is fatal. We present a case of massive hemoptysis due to this complication of brachytherapy managed entirely through bronchoscopic and endovascular techniques.

Figures in this Article

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.

Figure Jump LinkFigure 1 Complete opacification of the right hemithorax at initial presentation to our institution.Grahic Jump Location

Figure Jump LinkFigure 2 Top left, A: Pulmonary artery pseudoaneurysm is seen at the right upper-lobe orifice. Distally, the bronchus intermedius is seen occluded with clot. A rigid suction catheter is seen within the airway. Top right, B: Fibrin glue plug occluding the right bronchial tree. Bottom left, C: Covered metallic stent extending from the distal left mainstem bronchus. Bottom right, D: Covered metallic stent crossing the right mainstem fibrin plug into the mid-trachea.Grahic Jump Location

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.

Figure Jump LinkFigure 3 Right pulmonary angiogram showing pyramidal-shaped outpouching (pseudoaneurysm) from main trunk to middle- and lower-lobe branches corresponding in location to pulsatile mass (arrows) noted on bronchoscopy, shown in two projections.Grahic Jump Location

Figure Jump LinkFigure 4 Nester Embolization Coil. Photograph courtesy of Cook Medical.Grahic Jump Location

Figure Jump LinkFigure 5 Top left, A: long 7F Rabbe Sheath (Cook Medical) advanced distally into the middle- and lower-lobe branches of the right pulmonary. Coiling started from this point to build a stable coil pack and prevent proximal coils from migrating outward and reestablishing flow past the pseudoaneurysm. Top right, B: the distal middle- and lower-lobe branches are occluded, and the catheter is used to select the upper-lobe branch for embolization. Bottom left, C: the upper-lobe branch is occluded. The catheter is repositioned to complete embolization of the middle- and lower-lobe trunk. Bottom right, D: coil pack now extends proximal to the upper-lobe branch into the right main pulmonary artery. There is no flow into any right pulmonary artery branch. Approximate location of pseudoaneurysm is depicted by arrow.Grahic Jump Location

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.

Figure Jump LinkFigure 6 Left: 1 week postembolization of right pulmonary artery before airway stenting. Center: 1 day poststenting and obliteration of right lung ventilation. Right: 2 months after intervention just before hospital discharge.Grahic Jump Location

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.35 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.

Villanueva AG, Lo TC, Beamis JF Jr. Endobronchial brachytherapy. Clin Chest Med. 1995;16:445-454. [PubMed]
 
Lafita V, Borge MA, Demos TC. Pulmonary artery pseudoaneurysm: etiology, presentation, diagnosis, and treatment. Semin Intervent Radiol. 2007;24:119-123. [PubMed] [CrossRef]
 
Pelage JP, El Hajjam M, Lagrange C, et al. Pulmonary artery interventions: an overview. Radiographics. 2005;25:1653-1667. [PubMed]
 
Park A, Cwikiel W. Endovascular treatment of a pulmonary artery pseudoaneurysm with a stent graft: report of two cases. Acta Radiol. 2007;48:45-47. [PubMed]
 
Davison BD, Ring DH, Bueno R, et al. Endovascular stent-graft repair of a pulmonary artery-bronchial fistula. J Vasc Interv Radiol. 2003;14:929-932. [PubMed]
 

Figures

Figure Jump LinkFigure 1 Complete opacification of the right hemithorax at initial presentation to our institution.Grahic Jump Location
Figure Jump LinkFigure 2 Top left, A: Pulmonary artery pseudoaneurysm is seen at the right upper-lobe orifice. Distally, the bronchus intermedius is seen occluded with clot. A rigid suction catheter is seen within the airway. Top right, B: Fibrin glue plug occluding the right bronchial tree. Bottom left, C: Covered metallic stent extending from the distal left mainstem bronchus. Bottom right, D: Covered metallic stent crossing the right mainstem fibrin plug into the mid-trachea.Grahic Jump Location
Figure Jump LinkFigure 3 Right pulmonary angiogram showing pyramidal-shaped outpouching (pseudoaneurysm) from main trunk to middle- and lower-lobe branches corresponding in location to pulsatile mass (arrows) noted on bronchoscopy, shown in two projections.Grahic Jump Location
Figure Jump LinkFigure 4 Nester Embolization Coil. Photograph courtesy of Cook Medical.Grahic Jump Location
Figure Jump LinkFigure 5 Top left, A: long 7F Rabbe Sheath (Cook Medical) advanced distally into the middle- and lower-lobe branches of the right pulmonary. Coiling started from this point to build a stable coil pack and prevent proximal coils from migrating outward and reestablishing flow past the pseudoaneurysm. Top right, B: the distal middle- and lower-lobe branches are occluded, and the catheter is used to select the upper-lobe branch for embolization. Bottom left, C: the upper-lobe branch is occluded. The catheter is repositioned to complete embolization of the middle- and lower-lobe trunk. Bottom right, D: coil pack now extends proximal to the upper-lobe branch into the right main pulmonary artery. There is no flow into any right pulmonary artery branch. Approximate location of pseudoaneurysm is depicted by arrow.Grahic Jump Location
Figure Jump LinkFigure 6 Left: 1 week postembolization of right pulmonary artery before airway stenting. Center: 1 day poststenting and obliteration of right lung ventilation. Right: 2 months after intervention just before hospital discharge.Grahic Jump Location

Tables

References

Villanueva AG, Lo TC, Beamis JF Jr. Endobronchial brachytherapy. Clin Chest Med. 1995;16:445-454. [PubMed]
 
Lafita V, Borge MA, Demos TC. Pulmonary artery pseudoaneurysm: etiology, presentation, diagnosis, and treatment. Semin Intervent Radiol. 2007;24:119-123. [PubMed] [CrossRef]
 
Pelage JP, El Hajjam M, Lagrange C, et al. Pulmonary artery interventions: an overview. Radiographics. 2005;25:1653-1667. [PubMed]
 
Park A, Cwikiel W. Endovascular treatment of a pulmonary artery pseudoaneurysm with a stent graft: report of two cases. Acta Radiol. 2007;48:45-47. [PubMed]
 
Davison BD, Ring DH, Bueno R, et al. Endovascular stent-graft repair of a pulmonary artery-bronchial fistula. J Vasc Interv Radiol. 2003;14:929-932. [PubMed]
 
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