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Iatrogenic Pulmonary Pseudoaneurysm Treated with Percutaneous Coil and Glue Embolization
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Iatrogenic Pulmonary Pseudoaneurysm Treated with Percutaneous Coil and Glue Embolization Vittorio Pedicini, MD, Orazio Giuseppe Santonocito, MD, Dario Poretti, MD, Marco Tramarin, MD, and Ezio Lanza, MD A 76-year-old female patient experienced recurrent hemoptysis in the first 48 hours after thoracotomy for mitral valve replacement. On multidetector computed tomography (CT), a large lung pseudoaneurysm of the right middle lobe was detected (Fig 1), which showed contrast enhancement similar to that of the aorta. The patient was, therefore, referred to the interventional radiology service to undergo endovascular embolization. Despite selective angiography of multiple bronchial arteries, no feeding vessels were detected. Pulmonary angiography (Fig 2) ruled out supply from the pulmonary arteries. Therefore, the pseudoaneurysm was directly punctured with a Chiba needle under fluoroscopic guidance, and a small amount (0.5 mL) of n-butyl cyanoacrylate (NBCA; Glubran 2; GEM, Viareggio, Italy) was injected in the pseudoaneurysm sac. However,
Figure 2. Pulmonary angiogram of the right lung shows no feeding vessels to the pseudoaneurysm.
Figure 1. Contrast-enhanced CT scan of the thorax acquired 20 seconds after contrast medium injection. The arrow indicates a pseudoaneurysm in the middle lobe measuring 3 4 cm with the same enhancement (194 HU) as the aorta (A; 179 HU). The pulmonary trunk (P) has an average density of 416 HU.
From the Department of Radiology and Interventional Radiology (V.P., D.P., M.T., E.L.), Humanitas Research Hospital, Rozzano (MI), Italy; and Residency Program in Radiology (O.G.S.), Humanitas University, Rozzano (MI), Italy. Received March 29, 2017; final revision received June 12, 2017; accepted June 13, 2017. Address correspondence to E.L., Department of Radiology and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089 Rozzano, Milan, Italy; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2017 J Vasc Interv Radiol 2017; 28:1444–1445 http://dx.doi.org/10.1016/j.jvir.2017.06.020
Figure 3. Glue deposits are seen (arrows) after the first failed attempt at percutaneous embolization with NBCA. The pseudoaneurysm is still perfused.
Volume 28 ▪ Number 10 ▪ October ▪ 2017
Figure 4. Image of the second attempt at percutaneous embolization of the pseudoaneurysm. A 4-F introducer sheath is placed inside the pseudoaneurysm (large arrow). Contrast medium injection into the sac shows a high-flow shunt with a pulmonary vein (small arrows).
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Figure 6. The coil scaffold is filled with approximately 7 mL of NBCA/Lipiodol mixture (1:3 ratio), which completely fills the pseudoaneurysm sac, showing no leakage toward the heart (white arrows). The access route is also sealed with glue to avoid bleeding and reduce the risk of pneumothorax (gray arrows).
Figure 7. Contrast-enhanced CT scan 4 days after treatment (a) shows successful sealing of the pseudoaneurysm. The same examination ruled out nontarget glue embolization. Follow-up CT after 8 months (b) confirms the findings and shows an 11% size reduction (31 45 mm vs 35 51 mm); the pleural effusion has also been reabsorbed.
Figure 5. The pseudoaneurysm sac is filled with multiple metallic coils (white arrows; Interlock-35 12–14 mm; Boston Scientific). The gray arrow indicates the introducer sheath still in place. postoperative multidetector CT showed no changes (Fig 3). The patient was then admitted to the intensive care unit for worsening respiratory status as a result of increasing pleural effusion. After stabilization of hemodynamic parameters, a second percutaneous puncture was performed by placing a 4-F introducer sheath into the sac; subsequent contrast medium injection clearly demonstrated a shunt with a
pulmonary vein (Fig 4). To prevent nontarget embolization, a scaffolding of the sac was created with the use of large coils (12–14-mm Interlock-35 coils; Boston Scientific, Marlborough, Massachusetts) until the shunt was closed (Fig 5); the pseudoaneurysm was finally sealed with a mixture of NBCA and Lipiodol (Guerbet, Roissy, France; 1:3 ratio; Fig 6). A follow-up multidetector CT 4 days later confirmed complete sealing of the pseudoaneurysm, and the patient was discharged after 1 week. At 8 months’ follow-up, the patient remained asymptomatic, and multidetector CT confirmed successful embolization and showed an 11% size reduction of the sealed sac (Fig 7).
ACKNOWLEDGMENTS The authors would like to thank Alexia Rossi, MD, and Kim Shin-Young, MD.
Iatrogenic Pulmonary Pseudoaneurysm Treated with Percutaneous Coil and Glue Embolization Vittorio Pedicini, MD, Orazio Giuseppe Santonocito, MD, Dario Poretti, MD, Marco Tramarin, MD, and Ezio Lanza, MD A 76-year-old female patient experienced recurrent hemoptysis in the first 48 hours after thoracotomy for mitral valve replacement. On multidetector computed tomography (CT), a large lung pseudoaneurysm of the right middle lobe was detected (Fig 1), which showed contrast enhancement similar to that of the aorta. The patient was, therefore, referred to the interventional radiology service to undergo endovascular embolization. Despite selective angiography of multiple bronchial arteries, no feeding vessels were detected. Pulmonary angiography (Fig 2) ruled out supply from the pulmonary arteries. Therefore, the pseudoaneurysm was directly punctured with a Chiba needle under fluoroscopic guidance, and a small amount (0.5 mL) of n-butyl cyanoacrylate (NBCA; Glubran 2; GEM, Viareggio, Italy) was injected in the pseudoaneurysm sac. However,
Figure 2. Pulmonary angiogram of the right lung shows no feeding vessels to the pseudoaneurysm.
Figure 1. Contrast-enhanced CT scan of the thorax acquired 20 seconds after contrast medium injection. The arrow indicates a pseudoaneurysm in the middle lobe measuring 3 4 cm with the same enhancement (194 HU) as the aorta (A; 179 HU). The pulmonary trunk (P) has an average density of 416 HU.
From the Department of Radiology and Interventional Radiology (V.P., D.P., M.T., E.L.), Humanitas Research Hospital, Rozzano (MI), Italy; and Residency Program in Radiology (O.G.S.), Humanitas University, Rozzano (MI), Italy. Received March 29, 2017; final revision received June 12, 2017; accepted June 13, 2017. Address correspondence to E.L., Department of Radiology and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089 Rozzano, Milan, Italy; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2017 J Vasc Interv Radiol 2017; 28:1444–1445 http://dx.doi.org/10.1016/j.jvir.2017.06.020
Figure 3. Glue deposits are seen (arrows) after the first failed attempt at percutaneous embolization with NBCA. The pseudoaneurysm is still perfused.
Volume 28 ▪ Number 10 ▪ October ▪ 2017
Figure 4. Image of the second attempt at percutaneous embolization of the pseudoaneurysm. A 4-F introducer sheath is placed inside the pseudoaneurysm (large arrow). Contrast medium injection into the sac shows a high-flow shunt with a pulmonary vein (small arrows).
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Figure 6. The coil scaffold is filled with approximately 7 mL of NBCA/Lipiodol mixture (1:3 ratio), which completely fills the pseudoaneurysm sac, showing no leakage toward the heart (white arrows). The access route is also sealed with glue to avoid bleeding and reduce the risk of pneumothorax (gray arrows).
Figure 7. Contrast-enhanced CT scan 4 days after treatment (a) shows successful sealing of the pseudoaneurysm. The same examination ruled out nontarget glue embolization. Follow-up CT after 8 months (b) confirms the findings and shows an 11% size reduction (31 45 mm vs 35 51 mm); the pleural effusion has also been reabsorbed.
Figure 5. The pseudoaneurysm sac is filled with multiple metallic coils (white arrows; Interlock-35 12–14 mm; Boston Scientific). The gray arrow indicates the introducer sheath still in place. postoperative multidetector CT showed no changes (Fig 3). The patient was then admitted to the intensive care unit for worsening respiratory status as a result of increasing pleural effusion. After stabilization of hemodynamic parameters, a second percutaneous puncture was performed by placing a 4-F introducer sheath into the sac; subsequent contrast medium injection clearly demonstrated a shunt with a
pulmonary vein (Fig 4). To prevent nontarget embolization, a scaffolding of the sac was created with the use of large coils (12–14-mm Interlock-35 coils; Boston Scientific, Marlborough, Massachusetts) until the shunt was closed (Fig 5); the pseudoaneurysm was finally sealed with a mixture of NBCA and Lipiodol (Guerbet, Roissy, France; 1:3 ratio; Fig 6). A follow-up multidetector CT 4 days later confirmed complete sealing of the pseudoaneurysm, and the patient was discharged after 1 week. At 8 months’ follow-up, the patient remained asymptomatic, and multidetector CT confirmed successful embolization and showed an 11% size reduction of the sealed sac (Fig 7).
ACKNOWLEDGMENTS The authors would like to thank Alexia Rossi, MD, and Kim Shin-Young, MD.