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Pulmonary Artery Pseudoaneurysm in a Patient With Aortic Valve Stenosis
Pulmonary Artery Pseudoaneurysm in a Patient With Aortic Valve Stenosis Mitsuru Asano,1,2 Gabor G€ abel,1,2 Omar Allham,3 Norbert Weiss,2,4 and Hendrik Bergert,1,2 Dresden, Germany
A 77-year-old, high-risk woman with symptomatic aortic valve stenosis (aortic valve area 0.77 cm2) underwent coronary artery catheterization and right heart catheterization. After catheterization, she suddenly developed hemoptysis, and became hypoxic and hypotonic. She was intubated and the bleeding was stopped using positive end-expiratory pressure. Chest X-ray and computed tomography showed a pulmonary artery (PA) pseudoaneurysm with a maximum diameter of 40 mm at the right middle lobe. Endovascular treatment approaches by coil embolization failed, so surgical resection was indicated. In preparation for the procedure and to reduce perioperative risk, transapical aortic valve implantation was performed. The operation took about 40 minutes and the intraoperative activated clotting time was controlled at 180e200 sec. After successful transapical aortic valve implantation, aneurysmectomy was performed. Intraoperatively, the PA pseudoaneurysm was found to occupy nearly the entire middle lobe. A right middle lobectomy was performed. The operative course was uneventful. Transapical aortic valve implantation may have eliminated the risk of rupture or re-bleeding in such bleeding-prone patient.
Right heart catheterization, introduced into clinical medicine in 1970, is used widely for evaluation and management in cardiac patients.1 The complication rate is generally low. Procedure-associated pulmonary artery (PA) perforation, followed by pseudoaneurysm formation, has been described and may result in a fatal course due to rupture.1 Primary treatment consists of coil embolization, which is a minimally invasive procedure and can be performed in a timely manner. In cases of unsuccessful 1
Department of Visceral, Thoracic, and Vascular Surgery, Dresden University Hospital, Dresden, Germany. 2 University Center of Vascular Medicine, Dresden University Hospital, Dresden, Germany. 3 Heart Center Dresden, Dresden University Hospital, Dresden, Germany. 4 Department of Angiology, Dresden University Hospital, Dresden, Germany.
Correspondence to: Mitsuru Asano, MD, Department of Visceral, Thoracic, and Vascular Surgery, University Center of Vascular Medicine, Audenkellerhofstrasse 14, Homburg, Germany; E-mail: [email protected] Ann Vasc Surg 2013; 27: 238.e5e238.e7 http://dx.doi.org/10.1016/j.avsg.2012.08.001 Ó 2013 Elsevier Inc. All rights reserved. Manuscript received: October 9, 2010; manuscript accepted: September 11, 2011.
coil embolization, however, surgical resection must be considered. This operation is far more invasive. Its use is controversial due to high mortality rate in patients with coexisting cardiovascular disease.2 Transapical aortic valve implantation (TAVI) was first reported in 2006 and seems to be effective for aortic valve stenosis in high-risk patients.3e5 We report a case of PA pseudoaneurysm formation after right heart catheterization in work-up of heart failure related to severe aortic valve stenosis, which was successfully treated by right middle lobectomy after TAVI. A 77-year-old woman with heart failure associated with aortic valve stenosis (aortic valve area 0.77 cm2) underwent coronary artery catheterization and right heart catheterization at another hospital. The patient was in poor condition with renal failure (stage III), chronic obstructive pulmonary disease with pulmonary hypertension, tricuspid regurgitation, atrial fibrillation, and low left ventricular ejection fraction (31%). She had undergone mitral valve replacement with a mechanical valve 14 years earlier and needed long-term anticoagulation therapy. After catheterization, she suddenly developed hemoptysis, and became hypoxic and hypotonic. She was intubated 238.e5
238.e6 Case reports
Fig. 1. CT showing a PA pseudoaneurysm with a size of 40 mm. The thrombus was seen in the aneurysm, which was inadequately enhanced with contrast medium.
and referred to our institution. After stabilization using positive end-expiratory pressure to hemostasis, no further hemoptysis or blood loss was found. Chest X-ray showed a large, round shadow projecting from the right middle lobe. Computed tomography (CT) showed a PA pseudoaneurysm formation with a maximum diameter of 40 mm, which was enhanced by contrast medium (Fig. 1). Endovascular treatment approaches by coil embolization failed because it was not possible to visualize a feeding artery to the pseudoaneurysm. Surgical resection was considered. Operative risk, however, was estimated to be unacceptably high due to severe aortic valve stenosis, low left ventricular ejection fraction, and general condition. During 3 weeks of followup, as an anticoagulation therapy, continuous heparin infusion was administered to adjust the activated partial thromboplastin time to a target range of 1.5e2.5 times control level and the PA pseudoaneurysm remained stable. Due to its size, the pseudoaneurysm was considered rupture-prone as well as carrying a high risk of recurrent bleeding, and therefore resection was indicated. Considering severe concomitant diseases, the operations had to be performed in a step-by-step manner. In preparation for the procedure and to reduce perioperative risk, instead of conventional aortic valve replacement, TAVI with an internally mounted three-leaflet equine pericardial valve (Sapien Transcatheter; Edwards Lifesciences, Irvine, CA, USA) was placed. Intraoperatively, heparin was administered and the activated clotting time was controlled at 180e200 sec. The operation took about 40 minutes. Perioperatively, neither recurrence of hemoptysis nor an increased size of the PA pseudoaneurysm was noted. After successful TAVI, the patient
Annals of Vascular Surgery
Fig. 2. Surgical finding showing that the PA pseudoaneurysm occupied most of the middle lobe.
strongly rejected surgical resection of the pseudoaneurysm and was discharged. Anticoagulation therapy was switched from heparin to warfarin with a relatively low international normalized ratio (INR) prothrombin time (2.0e2.5). One month later, follow-up CT scan showed enlargement of the PA pseudoaneurym with a maximum diameter of 55 mm, although there was no thromboembolic or bleeding event. At this point the patient could accept the procedure. Aneurysmectomy was performed via a right anterolateral thoracotomy through the fourth intercostal space. Intraoperatively, the PA pseudoaneurysm was found to occupy nearly the entire middle lobe. Considering the difficulty in saving the unaffected portions of the middle lobe parenchyma and the risk of parenchymal rebleeding, a right middle lobectomy was performed (Fig. 2). The operative course was uncomplicated. On postoperative day 3, rethoracotomy was needed because of diffuse bleeding from the thoracic wall due to the high-intensity anticoagulation therapy necessary after mechanical mitral valve replacement. Bleeding could be controlled and the subsequent clinical course was uneventful.
DISCUSSION Since its introduction in 1970, right heart catheterization has been used widely and found to be helpful in the evaluation and management of critically ill patients, such as those with cardiac disease.1 Some complications of right heart catheterization may occur. Among them, PA perforation, followed by pseudoaneurysm formation, is a relatively rare but sometimes fatal complication. The incidence of PA perforation due to Swan-Ganz catheterization was
Vol. 27, No. 2, February 2013
reported at between 0.001% and 0.47%.1,2,6 Clinically, PA perforation may present with abrupt hemoptysis and sometimes progressive hypoxemia. The mortality of the PA perforation has been reported to reach 42e50%.1 Patients who survive the initial hemoptysis from PA rupture are predisposed to the development of PA pseudoaneurysm formation, especially in settings such as PA hypertension, systemic anticoagulation therapy, longterm steroid use, surgically induced hypothermia, age >60 years, female gender, cardiac decompression, and cardiac manipulation during surgery.7 Even if the patient is stable and has no sign of aneurysm growth in the chronic phase, the PA pseudoaneurysm must be treated. Recurrent hemorrhage of pseudoaneurysm is frequent and occurs in 30e40% of cases. It is associated with a mortality rate of 40e70%.1 Coil embolization is commonly used as the first-choice treatment. This procedure can be performed in a timely manner and is minimally invasive. Embolization is successful in 75% of cases, with a rebleeding rate of about 20%.8 In our case, the cause of failure was not clear, and therefore surgical treatment options were considered. Several aspects of surgical treatment are still under discussiondone being related to the order of the treatment. The patient in our study had many concomitant diseases; therefore, combined surgery, which means resternotomy aortic valve replacement and middle lobectomy, appeared to be too invasive and increase the risk of operation. The question arises as to whether the underlying disease should be treated before treating the PA pseudoaneurysm. In the present case, aortic valve operation was performed before the PA pseudoaneurysm resection because the size of the PA pseudoaneurysm had not increased within a 3-month period. To reduce the intraoperative risk of aneurysmal bleeding, we chose transapical aortic valve implantation instead of conventional aortic valve replacement. The TAVI for humans was first reported in 2006.3 Since that time, this method has been used in highrisk patients, with good clinical results.4,5 The advantages of TAVI include the need for less intensive anticoagulation during the procedure with a targeted activated clotting time of 180e200 sec,5 and the lessened invasiveness of the procedure compared with conventional aortic valve replacement. On the other hand, intraoperative PA pseudoaneurysm rupture would is very dangerous without cardiopulmonary bypass. In our experience the operations have ended successfully, but controversy remains. In cases of expanding PA pseudoaneurysms, persistent hemoptysis, and
Case reports 238.e7
more invasive cardiac surgery, resection of the PA pseudoaneurysm should be performed simultaneously or before treatment of the underlying disease. A second aspect of treatment of PA pseudoaneuryms under discussion is the choice of surgical technique. Lobectomy with video-assisted thoracic surgery is less invasive, but it is not suitable in cases of massive bleeding intraoperatively. Surgical interventions may include pneumonectomy, lobectomy, lingulectomy, direct arterial repair, and PA ligation.1 In the case presented herein, we decided to perform right middle lobectomy because pneumonectomy would have been more invasive than lobectomy and lingulectomy, and the aneurysm was confined to a single pulmonary lobe. We did not perform direct arterial repair and/or PA ligation as these procedures have been associated with a risk of recurrent of pseudoaneurysm in patients requiring life-long anticoagulation therapy, as demonstrated in the current report. In conclusion, the primary treatment for PA pseudoaneurysm is coil embolization. In cases of failure, however, surgical treatment must be considered despite its higher invasiveness. As PA perforation and pseudoaneurym formation after right heart catheterization tends to occur in high-risk patients, treatment of this complication remains challenging. The TAVI could make the risk of lobectomy lower in such high-risk patients. REFERENCES 1. Poplausky MR, Rozenblit G, Rundback JH, Crea G, Maddineni S, Leonardo R. Swan-Ganz catheter-induced pulmonary artery pseudoaneurysm formation. Chest 2001;120:2105e11. 2. Sirivella S, Gielchinsky I, Parsonnet V. Management of catheter-induced pulmonary artery perforation: a rare complication in cardiovascular operations. Ann Thorac Surg 2001;72:2056e9. 3. Ye J, Cheung A, Lichtenstein SV, et al. Transapical aortic valve implantation in humans. J Thorac Cardiovasc Surg 2006;131:1194e6. 4. Lichtenstein SV, Cheung A, Ye J, et al. Transapical transcatheter aortic valve implantation in humans. Initial clinical experience. Circulation 2006;114:591e6. 5. Walter T, Falk V, Borger MA, et al. Minimally invasive transapical beating heart aortic valve implantationd proof of concept. Eur J Cardiothorac Surg 2007;31: 9e15. 6. Boyd KD, Thomas SJ, Gold J, Boyd AD. A prospective study of complication of pulmonary artery catheterizations in 500 consecutive patients. Chest 1983;84:245e9. 7. Kearney TJ, Shabot MM. Pulmonary artery rupture associated with the Swan-Ganz catheter. Chest 1995;108:1349e52. 8. Bussieres JS. Iatrogenic pulmonary artery rupture. Curr Opin Anaesthesiol 2007;20:48e50.
A 77-year-old, high-risk woman with symptomatic aortic valve stenosis (aortic valve area 0.77 cm2) underwent coronary artery catheterization and right heart catheterization. After catheterization, she suddenly developed hemoptysis, and became hypoxic and hypotonic. She was intubated and the bleeding was stopped using positive end-expiratory pressure. Chest X-ray and computed tomography showed a pulmonary artery (PA) pseudoaneurysm with a maximum diameter of 40 mm at the right middle lobe. Endovascular treatment approaches by coil embolization failed, so surgical resection was indicated. In preparation for the procedure and to reduce perioperative risk, transapical aortic valve implantation was performed. The operation took about 40 minutes and the intraoperative activated clotting time was controlled at 180e200 sec. After successful transapical aortic valve implantation, aneurysmectomy was performed. Intraoperatively, the PA pseudoaneurysm was found to occupy nearly the entire middle lobe. A right middle lobectomy was performed. The operative course was uneventful. Transapical aortic valve implantation may have eliminated the risk of rupture or re-bleeding in such bleeding-prone patient.
Right heart catheterization, introduced into clinical medicine in 1970, is used widely for evaluation and management in cardiac patients.1 The complication rate is generally low. Procedure-associated pulmonary artery (PA) perforation, followed by pseudoaneurysm formation, has been described and may result in a fatal course due to rupture.1 Primary treatment consists of coil embolization, which is a minimally invasive procedure and can be performed in a timely manner. In cases of unsuccessful 1
Department of Visceral, Thoracic, and Vascular Surgery, Dresden University Hospital, Dresden, Germany. 2 University Center of Vascular Medicine, Dresden University Hospital, Dresden, Germany. 3 Heart Center Dresden, Dresden University Hospital, Dresden, Germany. 4 Department of Angiology, Dresden University Hospital, Dresden, Germany.
Correspondence to: Mitsuru Asano, MD, Department of Visceral, Thoracic, and Vascular Surgery, University Center of Vascular Medicine, Audenkellerhofstrasse 14, Homburg, Germany; E-mail: [email protected] Ann Vasc Surg 2013; 27: 238.e5e238.e7 http://dx.doi.org/10.1016/j.avsg.2012.08.001 Ó 2013 Elsevier Inc. All rights reserved. Manuscript received: October 9, 2010; manuscript accepted: September 11, 2011.
coil embolization, however, surgical resection must be considered. This operation is far more invasive. Its use is controversial due to high mortality rate in patients with coexisting cardiovascular disease.2 Transapical aortic valve implantation (TAVI) was first reported in 2006 and seems to be effective for aortic valve stenosis in high-risk patients.3e5 We report a case of PA pseudoaneurysm formation after right heart catheterization in work-up of heart failure related to severe aortic valve stenosis, which was successfully treated by right middle lobectomy after TAVI. A 77-year-old woman with heart failure associated with aortic valve stenosis (aortic valve area 0.77 cm2) underwent coronary artery catheterization and right heart catheterization at another hospital. The patient was in poor condition with renal failure (stage III), chronic obstructive pulmonary disease with pulmonary hypertension, tricuspid regurgitation, atrial fibrillation, and low left ventricular ejection fraction (31%). She had undergone mitral valve replacement with a mechanical valve 14 years earlier and needed long-term anticoagulation therapy. After catheterization, she suddenly developed hemoptysis, and became hypoxic and hypotonic. She was intubated 238.e5
238.e6 Case reports
Fig. 1. CT showing a PA pseudoaneurysm with a size of 40 mm. The thrombus was seen in the aneurysm, which was inadequately enhanced with contrast medium.
and referred to our institution. After stabilization using positive end-expiratory pressure to hemostasis, no further hemoptysis or blood loss was found. Chest X-ray showed a large, round shadow projecting from the right middle lobe. Computed tomography (CT) showed a PA pseudoaneurysm formation with a maximum diameter of 40 mm, which was enhanced by contrast medium (Fig. 1). Endovascular treatment approaches by coil embolization failed because it was not possible to visualize a feeding artery to the pseudoaneurysm. Surgical resection was considered. Operative risk, however, was estimated to be unacceptably high due to severe aortic valve stenosis, low left ventricular ejection fraction, and general condition. During 3 weeks of followup, as an anticoagulation therapy, continuous heparin infusion was administered to adjust the activated partial thromboplastin time to a target range of 1.5e2.5 times control level and the PA pseudoaneurysm remained stable. Due to its size, the pseudoaneurysm was considered rupture-prone as well as carrying a high risk of recurrent bleeding, and therefore resection was indicated. Considering severe concomitant diseases, the operations had to be performed in a step-by-step manner. In preparation for the procedure and to reduce perioperative risk, instead of conventional aortic valve replacement, TAVI with an internally mounted three-leaflet equine pericardial valve (Sapien Transcatheter; Edwards Lifesciences, Irvine, CA, USA) was placed. Intraoperatively, heparin was administered and the activated clotting time was controlled at 180e200 sec. The operation took about 40 minutes. Perioperatively, neither recurrence of hemoptysis nor an increased size of the PA pseudoaneurysm was noted. After successful TAVI, the patient
Annals of Vascular Surgery
Fig. 2. Surgical finding showing that the PA pseudoaneurysm occupied most of the middle lobe.
strongly rejected surgical resection of the pseudoaneurysm and was discharged. Anticoagulation therapy was switched from heparin to warfarin with a relatively low international normalized ratio (INR) prothrombin time (2.0e2.5). One month later, follow-up CT scan showed enlargement of the PA pseudoaneurym with a maximum diameter of 55 mm, although there was no thromboembolic or bleeding event. At this point the patient could accept the procedure. Aneurysmectomy was performed via a right anterolateral thoracotomy through the fourth intercostal space. Intraoperatively, the PA pseudoaneurysm was found to occupy nearly the entire middle lobe. Considering the difficulty in saving the unaffected portions of the middle lobe parenchyma and the risk of parenchymal rebleeding, a right middle lobectomy was performed (Fig. 2). The operative course was uncomplicated. On postoperative day 3, rethoracotomy was needed because of diffuse bleeding from the thoracic wall due to the high-intensity anticoagulation therapy necessary after mechanical mitral valve replacement. Bleeding could be controlled and the subsequent clinical course was uneventful.
DISCUSSION Since its introduction in 1970, right heart catheterization has been used widely and found to be helpful in the evaluation and management of critically ill patients, such as those with cardiac disease.1 Some complications of right heart catheterization may occur. Among them, PA perforation, followed by pseudoaneurysm formation, is a relatively rare but sometimes fatal complication. The incidence of PA perforation due to Swan-Ganz catheterization was
Vol. 27, No. 2, February 2013
reported at between 0.001% and 0.47%.1,2,6 Clinically, PA perforation may present with abrupt hemoptysis and sometimes progressive hypoxemia. The mortality of the PA perforation has been reported to reach 42e50%.1 Patients who survive the initial hemoptysis from PA rupture are predisposed to the development of PA pseudoaneurysm formation, especially in settings such as PA hypertension, systemic anticoagulation therapy, longterm steroid use, surgically induced hypothermia, age >60 years, female gender, cardiac decompression, and cardiac manipulation during surgery.7 Even if the patient is stable and has no sign of aneurysm growth in the chronic phase, the PA pseudoaneurysm must be treated. Recurrent hemorrhage of pseudoaneurysm is frequent and occurs in 30e40% of cases. It is associated with a mortality rate of 40e70%.1 Coil embolization is commonly used as the first-choice treatment. This procedure can be performed in a timely manner and is minimally invasive. Embolization is successful in 75% of cases, with a rebleeding rate of about 20%.8 In our case, the cause of failure was not clear, and therefore surgical treatment options were considered. Several aspects of surgical treatment are still under discussiondone being related to the order of the treatment. The patient in our study had many concomitant diseases; therefore, combined surgery, which means resternotomy aortic valve replacement and middle lobectomy, appeared to be too invasive and increase the risk of operation. The question arises as to whether the underlying disease should be treated before treating the PA pseudoaneurysm. In the present case, aortic valve operation was performed before the PA pseudoaneurysm resection because the size of the PA pseudoaneurysm had not increased within a 3-month period. To reduce the intraoperative risk of aneurysmal bleeding, we chose transapical aortic valve implantation instead of conventional aortic valve replacement. The TAVI for humans was first reported in 2006.3 Since that time, this method has been used in highrisk patients, with good clinical results.4,5 The advantages of TAVI include the need for less intensive anticoagulation during the procedure with a targeted activated clotting time of 180e200 sec,5 and the lessened invasiveness of the procedure compared with conventional aortic valve replacement. On the other hand, intraoperative PA pseudoaneurysm rupture would is very dangerous without cardiopulmonary bypass. In our experience the operations have ended successfully, but controversy remains. In cases of expanding PA pseudoaneurysms, persistent hemoptysis, and
Case reports 238.e7
more invasive cardiac surgery, resection of the PA pseudoaneurysm should be performed simultaneously or before treatment of the underlying disease. A second aspect of treatment of PA pseudoaneuryms under discussion is the choice of surgical technique. Lobectomy with video-assisted thoracic surgery is less invasive, but it is not suitable in cases of massive bleeding intraoperatively. Surgical interventions may include pneumonectomy, lobectomy, lingulectomy, direct arterial repair, and PA ligation.1 In the case presented herein, we decided to perform right middle lobectomy because pneumonectomy would have been more invasive than lobectomy and lingulectomy, and the aneurysm was confined to a single pulmonary lobe. We did not perform direct arterial repair and/or PA ligation as these procedures have been associated with a risk of recurrent of pseudoaneurysm in patients requiring life-long anticoagulation therapy, as demonstrated in the current report. In conclusion, the primary treatment for PA pseudoaneurysm is coil embolization. In cases of failure, however, surgical treatment must be considered despite its higher invasiveness. As PA perforation and pseudoaneurym formation after right heart catheterization tends to occur in high-risk patients, treatment of this complication remains challenging. The TAVI could make the risk of lobectomy lower in such high-risk patients. REFERENCES 1. Poplausky MR, Rozenblit G, Rundback JH, Crea G, Maddineni S, Leonardo R. Swan-Ganz catheter-induced pulmonary artery pseudoaneurysm formation. Chest 2001;120:2105e11. 2. Sirivella S, Gielchinsky I, Parsonnet V. Management of catheter-induced pulmonary artery perforation: a rare complication in cardiovascular operations. Ann Thorac Surg 2001;72:2056e9. 3. Ye J, Cheung A, Lichtenstein SV, et al. Transapical aortic valve implantation in humans. J Thorac Cardiovasc Surg 2006;131:1194e6. 4. Lichtenstein SV, Cheung A, Ye J, et al. Transapical transcatheter aortic valve implantation in humans. Initial clinical experience. Circulation 2006;114:591e6. 5. Walter T, Falk V, Borger MA, et al. Minimally invasive transapical beating heart aortic valve implantationd proof of concept. Eur J Cardiothorac Surg 2007;31: 9e15. 6. Boyd KD, Thomas SJ, Gold J, Boyd AD. A prospective study of complication of pulmonary artery catheterizations in 500 consecutive patients. Chest 1983;84:245e9. 7. Kearney TJ, Shabot MM. Pulmonary artery rupture associated with the Swan-Ganz catheter. Chest 1995;108:1349e52. 8. Bussieres JS. Iatrogenic pulmonary artery rupture. Curr Opin Anaesthesiol 2007;20:48e50.