- Email: [email protected]
Ultrasound- and Fluoroscopic-Guided Embolization of a Bronchial Artery Pseudoaneurysm in a Patient with Lung Cancer
Volume 28 ▪ Number 9 ▪ September ▪ 2017
1323
€derlund C, et al. Covered versus uncovered self2. Kullman E, Frozanpor F, So expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study. Gastrointest Endosc 2010; 72:915–923. 3. Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60:721–731. 4. Inchingolo R, Antonucci M, Pinto F, Cina A. Proximal ureteric obstruction caused by glue migration following selective renal artery embolization. J Vasc Interv Radiol 2015; 26:448–450.
Ultrasound- and FluoroscopicGuided Embolization of a Bronchial Artery Pseudoaneurysm in a Patient with Lung Cancer From: Thijs August Johan Urlings, MD Farah Gillan Irani, FRCR, MBBS, FAMS Jyothirmayi Velaga, FRCR, MBBS Chow Wei Too, FRCR, MBBS, FAMS Department of Diagnostic Radiology Singapore General Hospital Outram Road Singapore 169608, Singapore
Figure 1. CT image of the chest revealing the pseudoaneurysm (arrow) and atelectasis (asterisk) of the left lower lobe.
Editor: We report a case of ultrasound- and fluoroscopic-guided embolization of a bronchial artery pseudoaneurysm (PSA) in a patient with lung cancer. This report received exemption from the institutional review board. A 71-year-old man presented with a 2-week history of cough and progressive shortness of breath and 3 episodes of hemoptysis measuring 10–20 mL, which subsequently increased to 100–200 mL just before the procedure. A computed tomography (CT) scan of the chest demonstrated a left lower lobe lung mass with postobstructive atelectasis and a PSA within (Fig 1). It was decided at the multidisciplinary meeting to schedule the patient for endovascular embolization before obtaining histologic diagnosis. The CT scan was reviewed on a 3dimensional workstation, and the PSA was thought to be of pulmonary artery origin. However, a pulmonary digital subtraction angiogram demonstrated no aneurysm. As the procedure was performed in the hybrid CT-angiography room, an intraarterial CT scan was obtained via the diagnostic catheter, which showed the PSA to be faintly enhancing. Embolization of 2 subsegmental pulmonary branches closest to the PSA was performed with coils, but a follow-up CT scan still showed enhancement of the PSA. Another endovascular attempt at superselective embolization of the PSA via the bronchial artery was unsuccessful, due to extremely gracile arteries, despite using several diagnostic catheters (C2, S1, and H1; Cordis Corp, Miami
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2017.04.015
Figure 2. Bronchial artery angiography revealing the PSA fed by the lower lobe branches of the bronchial arteries. Coils were from the previous attempt of coiling the pulmonary arterial branches.
Lakes, Florida) and a 2.2 F Progreat catheter (Terumo, Tokyo, Japan) (Fig 2). Finally, percutaneous embolization of the PSA was attempted. Owing to surrounding consolidation, the PSA was well seen on ultrasound and could be targeted with a 21-gauge Chiba needle (Fig 3). Through this needle, an angiogram was obtained (Fig 4), which showed no communication with pulmonary veins or arteries, although retrograde filling of bronchial arteries was seen. After injection of 2 mL of a 1:3 mixture of N-butyl cyanoacrylate (Histoacryl; B. Braun Melsungen AG, Melsungen, Germany) and ethiodized oil (Lipiodol;
1324 ▪ Special Letters Section
Urlings et al ▪ JVIR
Figure 3. Ultrasound image of the bronchial artery PSA (arrow), well seen owing to consolidation of surrounding lung (asterisk).
Figure 5. Fluoroscopy performed after the procedure shows glue cast within the bronchial artery aneurysm after embolization through the 21-gauge Chiba needle (arrowhead), with glue cast in PSA (asterisk) and glue in bronchial arteries (black arrow). Coils (white arrow) from previous pulmonary artery embolization are seen.
Figure 4. Angiogram of the bronchial artery aneurysm obtained by injecting contrast material through the Chiba needle directly into the aneurysm.
Guerbet, Villepinte, France) through the Chiba needle under fluoroscopic guidance, the whole PSA was filled with the glue mixture along with the supplying bronchial arteries (Fig 5). No pneumothorax was seen after the procedure, and the hemoptysis ceased; a follow-up CT scan after 1 week also showed the PSA to be thrombosed. A transbronchial biopsy was later performed, which confirmed the diagnosis of squamous cell carcinoma. Bronchial artery PSAs are rare but can be life-threatening should they rupture. Most authors suggest treating both symptomatic and asymptomatic patients, as rupture can be unpredictable and unrelated to aneurysmal size (1). The treatment of bronchial artery aneurysms is well described in the literature, albeit comprising mainly relatively small case series and reports. Endovascular embolization is currently the treatment of choice because it is minimally invasive and effective, with the ability for careful study of the inflow
and outflow vessels. Various embolic materials have been described, such as coils, gelatin sponge, and N-butyl cyanoacrylate (1). In a related report, Sheehy et al (2) reported a case of ultrasound-guided transthoracic embolization of a pulmonary artery PSA with coils. As with the endovascular approach, a careful study of the vasculature supply and drainage of the PSA is crucial when performing the percutaneous approach to minimize the risk of nontarget embolization. Additional risks of the percutaneous approach include pneumothorax, air embolism, and rupture of the aneurysm during puncture. This percutaneous technique can be an option to treat such bronchial artery PSAs, particularly in the setting of failed endovascular therapy. It can also be performed with CT guidance if the PSA is not visible on ultrasound. For such a scenario, a hybrid CT-angiography room or cone-beam CT equipped with targeting software would be particularly useful.
REFERENCES 1. Lu PH, Wang LF, Su YS, et al. Endovascular therapy of bronchial artery aneurysm: five cases with six aneurysms. Cardiovasc Intervent Radiol 2011; 34:508–512.
Volume 28 ▪ Number 9 ▪ September ▪ 2017
1325
2. Sheehy N, Ford S, Mc Dermott R, Young V, Ryan M. Ultrasonographically guided percutaneous embolization of a pulmonary aneurysm. J Vasc Interv Radiol 2006; 17:895–898.
Successful Thoracic Duct Embolization for Treatment of an Iatrogenic Left Chylothorax in a Neonate after Repair of a Tracheoesophageal Fistula and Esophageal Atresia From: Jeffrey Forris Beecham Chick, MD, MPH, DABR Joseph J. Gemmete, MD, FSIR Michael Cline, MD Ravi N. Srinivasa, MD Division of Vascular and Interventional Radiology, Department of Radiology University of Michigan Health Systems 1500 East Medical Center Drive Ann Arbor, MI 48109
Editor: Chylothorax is an uncommon complication of thoracic surgery in a child. Lymphatic interventions, including injection of sclerosing and liquid embolic agents and coil
Figure 2. Frontal fluoroscopic image of the abdomen showing ethiodized oil in the abdominal lymphatics. The site of percutaneous access into the lymphatic system is marked (arrow).
Figure 1. Initial frontal chest radiograph showing complete opacification of the left hemithorax with a left apical drainage catheter.
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2017.05.004
embolization, are well described in adults but not in children (1–3). Thoracic duct embolization (TDE) has been reported in infants as young as 1 month of age (4). This report describes a 19-day-old neonate with a left chylothorax after repair of a tracheoesophageal fistula and esophageal atresia who underwent successful TDE with resolution of the chylothorax. Institutional review board approval was not required for preparation of this report. A 19-day-old, 2.4-kg boy with double aortic arch underwent ligation of an atretic left aortic arch with a tracheoesophageal fistula and esophageal atresia repair that was complicated by left chylothorax. Chest radiography demonstrated a large left pleural effusion with complete opacification of the left hemithorax (Fig 1). A left basilar chest tube was placed. Daily output of the chest tube ranged from 48 to 247 mL/d over 6 days. The fluid was milky yellow; triglycerides were 22 mg/dL and lymphocytes were 71%–78% while the patient was fasting and total parenteral nutrition was withheld. Interventional radiology was consulted for TDE. Under ultrasound guidance, 25-gauge spinal needles were placed into bilateral groin lymph nodes. A total of 3 mL of
1323
€derlund C, et al. Covered versus uncovered self2. Kullman E, Frozanpor F, So expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study. Gastrointest Endosc 2010; 72:915–923. 3. Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60:721–731. 4. Inchingolo R, Antonucci M, Pinto F, Cina A. Proximal ureteric obstruction caused by glue migration following selective renal artery embolization. J Vasc Interv Radiol 2015; 26:448–450.
Ultrasound- and FluoroscopicGuided Embolization of a Bronchial Artery Pseudoaneurysm in a Patient with Lung Cancer From: Thijs August Johan Urlings, MD Farah Gillan Irani, FRCR, MBBS, FAMS Jyothirmayi Velaga, FRCR, MBBS Chow Wei Too, FRCR, MBBS, FAMS Department of Diagnostic Radiology Singapore General Hospital Outram Road Singapore 169608, Singapore
Figure 1. CT image of the chest revealing the pseudoaneurysm (arrow) and atelectasis (asterisk) of the left lower lobe.
Editor: We report a case of ultrasound- and fluoroscopic-guided embolization of a bronchial artery pseudoaneurysm (PSA) in a patient with lung cancer. This report received exemption from the institutional review board. A 71-year-old man presented with a 2-week history of cough and progressive shortness of breath and 3 episodes of hemoptysis measuring 10–20 mL, which subsequently increased to 100–200 mL just before the procedure. A computed tomography (CT) scan of the chest demonstrated a left lower lobe lung mass with postobstructive atelectasis and a PSA within (Fig 1). It was decided at the multidisciplinary meeting to schedule the patient for endovascular embolization before obtaining histologic diagnosis. The CT scan was reviewed on a 3dimensional workstation, and the PSA was thought to be of pulmonary artery origin. However, a pulmonary digital subtraction angiogram demonstrated no aneurysm. As the procedure was performed in the hybrid CT-angiography room, an intraarterial CT scan was obtained via the diagnostic catheter, which showed the PSA to be faintly enhancing. Embolization of 2 subsegmental pulmonary branches closest to the PSA was performed with coils, but a follow-up CT scan still showed enhancement of the PSA. Another endovascular attempt at superselective embolization of the PSA via the bronchial artery was unsuccessful, due to extremely gracile arteries, despite using several diagnostic catheters (C2, S1, and H1; Cordis Corp, Miami
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2017.04.015
Figure 2. Bronchial artery angiography revealing the PSA fed by the lower lobe branches of the bronchial arteries. Coils were from the previous attempt of coiling the pulmonary arterial branches.
Lakes, Florida) and a 2.2 F Progreat catheter (Terumo, Tokyo, Japan) (Fig 2). Finally, percutaneous embolization of the PSA was attempted. Owing to surrounding consolidation, the PSA was well seen on ultrasound and could be targeted with a 21-gauge Chiba needle (Fig 3). Through this needle, an angiogram was obtained (Fig 4), which showed no communication with pulmonary veins or arteries, although retrograde filling of bronchial arteries was seen. After injection of 2 mL of a 1:3 mixture of N-butyl cyanoacrylate (Histoacryl; B. Braun Melsungen AG, Melsungen, Germany) and ethiodized oil (Lipiodol;
1324 ▪ Special Letters Section
Urlings et al ▪ JVIR
Figure 3. Ultrasound image of the bronchial artery PSA (arrow), well seen owing to consolidation of surrounding lung (asterisk).
Figure 5. Fluoroscopy performed after the procedure shows glue cast within the bronchial artery aneurysm after embolization through the 21-gauge Chiba needle (arrowhead), with glue cast in PSA (asterisk) and glue in bronchial arteries (black arrow). Coils (white arrow) from previous pulmonary artery embolization are seen.
Figure 4. Angiogram of the bronchial artery aneurysm obtained by injecting contrast material through the Chiba needle directly into the aneurysm.
Guerbet, Villepinte, France) through the Chiba needle under fluoroscopic guidance, the whole PSA was filled with the glue mixture along with the supplying bronchial arteries (Fig 5). No pneumothorax was seen after the procedure, and the hemoptysis ceased; a follow-up CT scan after 1 week also showed the PSA to be thrombosed. A transbronchial biopsy was later performed, which confirmed the diagnosis of squamous cell carcinoma. Bronchial artery PSAs are rare but can be life-threatening should they rupture. Most authors suggest treating both symptomatic and asymptomatic patients, as rupture can be unpredictable and unrelated to aneurysmal size (1). The treatment of bronchial artery aneurysms is well described in the literature, albeit comprising mainly relatively small case series and reports. Endovascular embolization is currently the treatment of choice because it is minimally invasive and effective, with the ability for careful study of the inflow
and outflow vessels. Various embolic materials have been described, such as coils, gelatin sponge, and N-butyl cyanoacrylate (1). In a related report, Sheehy et al (2) reported a case of ultrasound-guided transthoracic embolization of a pulmonary artery PSA with coils. As with the endovascular approach, a careful study of the vasculature supply and drainage of the PSA is crucial when performing the percutaneous approach to minimize the risk of nontarget embolization. Additional risks of the percutaneous approach include pneumothorax, air embolism, and rupture of the aneurysm during puncture. This percutaneous technique can be an option to treat such bronchial artery PSAs, particularly in the setting of failed endovascular therapy. It can also be performed with CT guidance if the PSA is not visible on ultrasound. For such a scenario, a hybrid CT-angiography room or cone-beam CT equipped with targeting software would be particularly useful.
REFERENCES 1. Lu PH, Wang LF, Su YS, et al. Endovascular therapy of bronchial artery aneurysm: five cases with six aneurysms. Cardiovasc Intervent Radiol 2011; 34:508–512.
Volume 28 ▪ Number 9 ▪ September ▪ 2017
1325
2. Sheehy N, Ford S, Mc Dermott R, Young V, Ryan M. Ultrasonographically guided percutaneous embolization of a pulmonary aneurysm. J Vasc Interv Radiol 2006; 17:895–898.
Successful Thoracic Duct Embolization for Treatment of an Iatrogenic Left Chylothorax in a Neonate after Repair of a Tracheoesophageal Fistula and Esophageal Atresia From: Jeffrey Forris Beecham Chick, MD, MPH, DABR Joseph J. Gemmete, MD, FSIR Michael Cline, MD Ravi N. Srinivasa, MD Division of Vascular and Interventional Radiology, Department of Radiology University of Michigan Health Systems 1500 East Medical Center Drive Ann Arbor, MI 48109
Editor: Chylothorax is an uncommon complication of thoracic surgery in a child. Lymphatic interventions, including injection of sclerosing and liquid embolic agents and coil
Figure 2. Frontal fluoroscopic image of the abdomen showing ethiodized oil in the abdominal lymphatics. The site of percutaneous access into the lymphatic system is marked (arrow).
Figure 1. Initial frontal chest radiograph showing complete opacification of the left hemithorax with a left apical drainage catheter.
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2017.05.004
embolization, are well described in adults but not in children (1–3). Thoracic duct embolization (TDE) has been reported in infants as young as 1 month of age (4). This report describes a 19-day-old neonate with a left chylothorax after repair of a tracheoesophageal fistula and esophageal atresia who underwent successful TDE with resolution of the chylothorax. Institutional review board approval was not required for preparation of this report. A 19-day-old, 2.4-kg boy with double aortic arch underwent ligation of an atretic left aortic arch with a tracheoesophageal fistula and esophageal atresia repair that was complicated by left chylothorax. Chest radiography demonstrated a large left pleural effusion with complete opacification of the left hemithorax (Fig 1). A left basilar chest tube was placed. Daily output of the chest tube ranged from 48 to 247 mL/d over 6 days. The fluid was milky yellow; triglycerides were 22 mg/dL and lymphocytes were 71%–78% while the patient was fasting and total parenteral nutrition was withheld. Interventional radiology was consulted for TDE. Under ultrasound guidance, 25-gauge spinal needles were placed into bilateral groin lymph nodes. A total of 3 mL of