Embolization of Pulmonary Catheter-Induced Pulmonary Artery Pseudoaneurysms

Embolization of Pulmonary Catheter-Induced Pulmonary Artery Pseudoaneurysms*

Table !-Pulmonary Artery PSA Embolization: Methods

Charles E. Ray, Jr. , MD; John A. Kaufnwn, MD; Stuart C. Geller, MD; S. Mitchell Rivitz, MD; David]. Kanarek, MD; and Arthur C. Waltman, MD

Study objectives: To determine the outcome of patients with pulmonary catheter-induced pulmonary artery pseudoansurysms (PSAs) treated with embolization. Design: Retrospective outcomes review. Setting: Large urban tertiary-care hospital. Patients: All patients who presented to diagnostic angiography for rupturedpulmonary artery PSA caused by pulmonary artery catheters (PACs) from November 1990 to September 1995. A total of six patients were examined. Interventions: Transcatheter embolotherapywith coils, absorbable gelatin sponges (Gelfoam), and suture material. Results: These procedures were technically successful in all patients, and none had recurrent hemoptysis. Four of the six patients were discharged from the hospital. Conclusion: Embolotherapy is a useful alternative to surgery for some patients with PAC-induced pulmonary PSA. (CHEST 1996; 110:1370-73)

Age, yr/ Sex

Interval Between Insertion of PAC and Hemoptysis

Interval Between Hemoptysis and Embolization, d

75/F

Immediately

9

SliM 66/F

1d Immediately

18 Unknown

76/M

Immediately

4

76/F

16 d

3

79/F

Im mediately

5

Therapeutic Agents 3- and 5-mm coils, Gelfoam 3-mm coils 8-mm coils, Gelfoarn 5-mm coils, suture 8 -,7-, 3-mm coils, Gelfoam 8-, 5-, -3mm coils, suture

bolization of PAC-induced PSA also have been reported.2·5-10 The following series d escribes transcatheter embolization of PAC-induced PSA in six patients using coils, absorbable gelatin Gelfoam sponges; (Upjohn; Kalamazoo, Mich), and suture material as embolic agents. METHODS

Between November 1 990 and September 1995, six patients were referred f or diagnostic pulmonary arteriography and embolotherapy of pulmonary PSA following PAC placement. The course o fone of the patients has been previously described elsewhere.7 A r etrospective review of m edical records was undertaken to evaluate recurrent symptoms and survival periods of all patients. The 6 p taients consisted of 4 women and 2 m en, with an age

Key words: arteries; catheterization, Swan-Ganz; pulmonary artery; therapeutic blockade Abbreviations: PAC =pulmonary artery catheter; PSA=pseudoaneurysm

1 in

work by Swan and associates Since thethepioneering use of flow-directed balloon-tipped pulmonary

1970, artery catheters (PACs) has escalated rapidly as a diagnostic tool in the hemodynamic assessment of critically ill patients. Complications can arise during any stage of catheter placement. Pneumothorax or cardiac dysrhythmia can result from the initial insertion, while pulmonary infarction can occur later due to catheters being placed too distally in the pulmonary arteries. 2 Traumatic pulmonary artery pseudoaneurysms (PSAs) can also occur with an estimated incidence of 1 per 1,600 PAC placements.3 If ruptured, PSAs can be a serious and life-threatening complication.2 Transcatheter coil embolization of PSA is an accepted m ethod of treatment in other v ascular b eds such as the kidney and liver, and coil embolization of pulmonary artery PSA caused by inflammation has been d escribed.4 Case reports of coil em*From the Division of Angiography and Interventional Radiology, Roswell Park Cancer Institute, Buffalo, NY (Dr. Ray); and t1ie Divisions of Vascular R adiology (Drs. Kaufman, Geller, Rivitz, and Waltman) and Pulmonary Medicine (Dr. Kanarek), Massachusetts General Hospital, Boston. Manuscript received April S, 1996/· revision accepted June 4l 1996. Reprint r equests: Dr. Hay, Roswel Park Cancer Institute, E m a nd Carleton Streets, Buffalo, NY 14263 1370

FIGURE l. A 76-year-old white woman had severe coronary artery disease and cardiogenic shock r equiring intraaortic balloon pump therapy prior to insertion of Swan-Ganz catheter. She was receiving intravenously administered h eparin during Swan-Ganz insertion. Preoperative chest radiograph (lordotic view) demonstrated peripheral location of the Swan-Ganz catheter tip in a pulmonary artery of the upper lobe of the right lung (arrow). Selected Reports

FIGURE 3. Digital subtraction angiography following superselective catheterization of the branch of the anterior division of the artery in the upper lobe of the right lung demonstrated the focal PSA. delay between hemoptysis and embolization was due to either misdiagnosis or cessation of .hemoptysis and an initial conservative approach to the PSA. The procedure was technically successful in all six patients with immediate occlusion of the PSA by angiographic criteria. There were no additional patients who presented during the study time period with angiographically confirmed pulmonary artery PSAs who did not undergo embolization. FIGURE 2. Scanogram from a chest CT obtained 16 days after the chest radiograph in Figure 1 demonstrated focal 2 em mass in the right midlung field (arrows). range of 66 to 81 years. Congestive heart failure was the indication for PAC placement and hemoptysis was the presenting symptom of the PSA in all cases. All patients underwent diagnostic pulmonary arteriography prior to embolization procedures. Following the diagnostic study, selective catheterization of the blood vessel supplying the PSA was performed. Although the technique varied depending upon the preference of the primary angiographer, in most instances 5 to 7F catheters were used for both the diagnostic and therapeutic examinations. Guiding catheters occasionally were used, as were coaxial microcatheters; however, in most cases a single catheter system proved adequate. The embolization materials used included coils in all patients, with Gelfoam pledgets and 3-0 Ethibond suture material (braided nonabsorbable polyester suture coated with polybutilate [Ethicon; Sommerville, NJ]) was used in some instances (Table 1, Fig 1-4). While coils were used as the primary occluding agent, Gelfoam material was also used to allow more rapid thrombosis of the PSA. Suture material was placed directly into one large PSA to potentiate thrombosis. Coils were sized according to measurements of the fe eding artery, and occlusion of the feeding artery usually was pe1formed rather than superselection and embolization of the PSA itself. Embolization was considered complete after the PSA was no longer visualized during postembolization angiography. Nonionic contrast material was used in all patients; the amount of contrast material used varied but averaged approximately 150 mL. All patients underwent the embolization procedure on an elective basis, with a time interval between the onset of hemoptysis and embolization ranging from 3 to 18 days (Table 1). In most instances,

RESULTS

Table 2 outlines the follow-up period, complications, and survival outcomes of all six patients.

FIGURE 4. Cut film angiogram of the main right pulmonary artery following embolization of the anterior division of the artery in the upper lobe of the right lung with coils (3, 7, and 8 mm) and Gelfoam. CHEST I 110 I 5 I NOVEMBER, 1996

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Table 2--Pulmonary Artery PSA Embolization: Results Age, yr/Sex

Follow-up Period

Recurrent Hemoptysis

75/F

55mo

None

None

81/M

15mo

None

None

66/F

10 d

None

82/M

1d

None

76/F

Swk

None

Contrast-induced renal failure (creatinine, l.l mgldL preembolization; 2.8 mgldL 2 d later; 1.7 mgldL at death) Creatinine, 1.3 to 2.6 mgldL (multiorgan failure) Fluid overload requiring 24-h intubation None

76/F

30d

None

Four patients survived the hospitalization. The average follow-up time in these 4 patients was 19 months. Additionally, there were no instances of recurrent hemoptysis following embolization. Causes of death were varied; however, no patients died of massive hemoptysis, cor pulmonale, or complications directly related to the pulmonary artery embolization. One patient presented to the angiography department 4 weeks following embolization for a subsequent pulmonary angiogram during evaluation for pulmonary embolism. At that time, diagnostic angiography demonstrated complete thrombosis of the previously embolized artery. Two patients had complications related to the angiogram or embolization procedure (Table 2). One patient had pulmonary edema due to fluid overload immediately after the angiogram, necessitating intubation and aggressive diuresis; the patient was extubated 24 h later. A second patient had nephrotoxicity likely related to the angiographic contrast medium; her plasma creatinine level rose from 1.1 to 2.8 mgldL 2 days after the procedure; however, 9 days after embolization, her creatinine level measured 1. 7 mgldL. A third patient also demonstrated an elevated plasma creatinine level after embolization; however, multiorgan failure was occurring at the time, and the patient died from cardiogenic shock within hours after the creatinine level rose. DISCUSSION

Pulmonary artery PSAs are a known complication of pulmonary artery catheterization. Although the exact mechanism of arterial injury remains unknown, several hypotheses have been suggested, including direct injury by the balloon or injury of the vessel wall by the catheter tip once the balloon is inflated. 11 .12 Hardy et al13 demonstrated pulmonary artery rupture following balloon-generated pressures of as little as 975 mm Hg. The incidence of traumatic pulmonary artery PSA is increased in patients undergoing cardiopulmonary bypass procedures. 3.1 4 This may be secondary to manipulation of the catheter as it courses through the emfty heart and a less pliable condition of the cold catheter. 1 In addition, pulmonary artery hypertension is a known predis1372

Complications

Comments Surviving; subsequent pulmonary artery angiogram 4 wk later; no PSA flow Discharged; died of congestive heart failure Died of cardiogenic shock during hospitalization

Died of cardiogenic shock during hospitalization Discharged; died of acute myocardial infarction Discharged

posing factor for PSA, occurring in up to 90% of patients with PAC-induced pulmonary artery mpture.l 6 Hemoptysis is the usual presenting symptom of pulmonary PSA and represents the major cause of mortality. While concomitant medical issues may aid in determining whether or not pulmonary PSA should be treated, a conservative expectant approach is not usually recommended due to the potential catastrophic outcome of life-threatening hemoptysis. In one series, 20% of patients with untreated PAC-induced pulmonary PSA died from hemoptysis while another 60% died of other causes during the same hospitalization. 2 Only one patient underwent transcatheter embolotherapy in this series. Other reports of patients treated conservatively also have demonstrated poor outcomes. 11 .17 In the current series, none of the patients treated with embolization died of massive hemoptysis, four survived the hospitalization, and two lived for longer than a year. Embolization was performed in 1 patient 30 days prior to submission of this article for publication and continues to do well clinically. Although imaging studies such as CT scanning may prove helpful in the diagnostic workup for patients suspected of having PSA, 7 pulmonary angiography remains the gold standard diagnostic study and the least invasive therapeutic option currently available (Fig 3). Due to the peripheral location of PSA induced by PAC, selective embolotherapy presents little added risk to the patient in terms of decreasing cardiopulmonary reserve. In the current study, five of six instances of embolization were performed in segmental or more distal branches, and no patients suffered an acute worsening of their cardiopulmonary status following embolization. Detachable balloons have been effectively used in the past in the treatment of catheter-induced pulmonary artery PSAs 6 as well as in the treatment of other PSAs. 18.19 However, detachable balloons are no longer commercially available in the United States. In patients with Swan-Ganz-catheter-induced PSAs, 2·5-10 coils represent a readily available alternative embolic agent to balloon therapy. While surgical wedge resection is one treatment option, particularly in patients with massive acute endobronchial hemorrhage during cardiopulmonary bypass procedures, it Selected Reports

is the most invasive therapeutic option with potentially significant associated morbidity. 12 ,1 4 ,1 7•20 Intraoperative positive end-expiratory pressure has been used as a stabilizing procedure during episodes of acute hemorrhage; 3 however, this is a temporizing measure only and cannot be considered a definitive therapy. Some authors advocate urgent thoracotomy in patients presenting with hemothorax; however, overall survival is not significantly improved with such therapyY Technical considerations for embolization of PACinduced PSA include timing of the embolization procedure and the type of embolic materials used. Based upon our experience, coil embolization is generally adequate, although combination therapy utilizing other embolic agents such as Gelfoam or suture material may decrease the time required for successful vascular occlusion. Embolization should be performed urgently, either at the time of diagnostic angiography or closely thereafter, to decrease the potential complication of serious interval pulmonary hemorrhage. Although a rare complication, PAC-induced PSA carries a significant morbidity and mortality if not treated aggressively. Surgical resection, although definitive, places an already compromised patient at further risk associated with thoracotomy and lung resection. The current series demonstrates the efficacy of transcatheter embolotherapy, while exposing the patient to minimal intra- or post-procedural risk. Endovascular embolotherapy should be considered in cases of pulmonary PSA as a definitive and potentially lifesaving therapeutic procedure. REFERENCES

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143:963-69 5 Bartter T, Irwin RS, Phillips DA, et al. Pulmonary artery pseudoaneurysm: a potential complication of pulmonary artery catheterization. Arch Intern Med 1988; 148:471-73 6 Markowitz DM, Hughes SH, Shaw C, et al. Transcatheter detachable balloon embolotherapy for catheter-induced pulmonary artery pseudoaneurysm. J Thorac Imaging 1991; 6:75-8 7 Guttentag AR, Shepard JAO, McLoud TC. Catheter-induced pulmonary artery pseudoaneurysm: the halo sign on CT. AJR 1992; 158:637-39 8 Kirton OC, Varon AJ, Henry RP, et al. Flow-directed, pulmonary artery catheter-induced pseudoaneurysm: urgent diagnosis and endovascular obliteration. Crit Care Med 1992; 20:1178-80 9 Cooper JP, Jackson J, Walker JM. False aneurysm of the pulmonary artery associated with cardiac catheterisation. Br Heart J 1993; 69:188-90 10 Rosenblum HM. Management of endobronchial hemorrhage and pulmonary arterypseudoaneurysm. J Thorac Cardiovasc Surg 1993; 106:946-48 11 Yellin LV, Filler JJ, Barnette RE. Nominal hemoptysis heralds pseudoaneurysm induced by a pulmonary artery catheter. Anesthesiology 1991; 74:370-73 12 Bolton JWR, Aldea GS. Pulmonary artery laceration by a pulmonary artery catheter: a case report and review of the literature. Military Med 1994; 159:357-60 13 Hardy JF, Morissette M, Taillefer J, et al. Pathophysiology of rupture of the pulmonary artery by pulmonary artery balloontipped catheters. Anesth Analg 1983; 62:925-30 14 Olearchyk AS, Varada A. Perforation of the right pulmonary artery branch to the right middle lobe with a Swan-Ganz catheter during cardiopulmonary bypass, resulting in endobronchial hemorrhage. J Thorac Cardiovasc Surg 1991; 102:807-08 15 Carlson TA, Goldenberg IF, Murray PD, et al. Catheter induced delayed recurrent pulmonary artery hemorrhage. JAMA 1989; 261:1943-45 16 Hannan AT, Brown M, Bigman 0. Pulmonary artery catheterinduced hemorrhage. Chest 1984; 85:128-31 17 Kearney TJ, Shabot MM. Pulmonary artery rupture associated with the Swan-Ganz catheter. Chest 1995; 108:1349-52 18 Renie WA, Rodeheffer RJ, MitchellS, et al. Balloon embolization of a mycotic pulmonary artery aneurysm. Am Rev Respir Dis 1982; 126:1107-10 19 Sharma RP, Sherry PC, Burke TH, et al. Treatment of false aneurysm by using a detachable balloon. AJR 1987; 149:1279-80 20 DiNardo JA. Traumatic pseudoaneurysn of a pulmonary artery: anesthetic considerations. Anesthesiology 1986; 65:334-38

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