Procedures: Fellow Case Report Poster - Procedures |

Endobronchial Nd:YAP Laser Ablation of a Bleeding Dieulafoy Lesion of the Bronchus FREE TO VIEW

Robert Lentz, MD; Christopher Merrick, MD; Otis Rickman, DO; Fabien Maldonado, MD
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Vanderbilt University Medical Center, Nashville, TN

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):989A. doi:10.1016/j.chest.2016.08.1095
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SESSION TITLE: Fellow Case Report Poster - Procedures

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Dieulafoy lesions, hypertrophic submucosal arteries most associated with GI hemorrhage, are rarely reported in the lung1. Optimal management is unclear.

CASE PRESENTATION: A 51 year-old woman never smoker with Alagille syndrome (branch pulmonary artery stenoses, patent ductus arteriosus, ventricular septal defect, severe pulmonary hypertension, renal dysplasia) presented with episodic massive hemoptysis. Brisk bleeding was encountered at flexible bronchoscopy. A 5 mm nodular lesion ejecting bright red blood was identified in the left lower lobe (panel A). After hemostasis, a pulsatile superficial vessel running along a secondary carina with protruding white-capped tortuous loop or aneurysmal dilation was clearly visible (panels B-D). The lesion was obliterated with Nd:YAP laser (panels E, F). The patient discharged the next day with no further hemoptysis at 4 months follow-up.

DISCUSSION: Fewer than 35 reports of Dieulafoy lesions of the bronchus exist. Lesion appearance and clinical history in this case are consistent with prior reports1. Most are bronchial arteries but several reported cases derived from the pulmonary circulation; pulsatile bright red blood in this patient with left-to-right shunt and pulmonary hypertension did not reliably distinguish between circulations. These may be congenital malformations; many are also associated with inflammation. A submucosal vessel hypertrophied to provide collateral circulation for pulmonic (bypassing pulmonic stenoses) or bronchial (compensating for impaired pulmonic flow) systems is another possibility in this case. Endobronchial therapy has previously been employed twice: a bleed temporized by cautery but requiring lobectomy2 and a lesion ablated with argon plasma coagulation3. Our successful laser ablation supports the use of advanced bronchoscopic therapies in select patients with this rare finding.

CONCLUSIONS: We present a bronchial Dieulafoy lesion unique in two aspects: 1) comorbid congenital heart disease which might have played a pathogenic role and 2) endobronchial Nd:YAP laser obliteration.

Reference #1: Fang Y, Wu Q, Wang B. Dieulafoy’s disease of the bronchus: report of a case and review of the literature. J Cardiothorac Surg 2014;9(1):1-5

Reference #2: Stoopen E, Baquera-Heredia J, Cortes D, Green L. Dieulafoy’s Disease of the Bronchus in Association With a Paravertebral Neurilemoma. CHEST J 2001;119(1):292-294

Reference #3: Dalar L, Sokucu SN, Ozdemir C, Buyukkale S, Altin S. Endobronchial Argon Plasma Coagulation for Treatment of Dieulafoy Disease. Respir Care 2015;60(1):e11-e13

DISCLOSURE: The following authors have nothing to disclose: Robert Lentz, Christopher Merrick, Otis Rickman, Fabien Maldonado

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