DOI: 10.1148/rg.256055516
RadioGraphics 2005;25:1653-1667
© RSNA, 2005
Pulmonary Artery Interventions: An Overview1
Jean-Pierre Pelage, MD, PhD,
Mostafa El Hajjam, MD,
Christine Lagrange, MD,
Thierry Chinet, MD,
Antoine Vieillard-Baron, MD,
Sophie Chagnon, MD and
Pascal Lacombe, MD
1 From the Departments of Radiology (J.P.P., M.E.H., C.L., S.C., P.L.), Pulmonology (T.C.), and Critical Care (A.V.B.), Hôpital Ambroise Paré, 9 ave Charles-de-Gaulle, 92104 Boulogne Cedex, France. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received March 28, 2005; revision requested April 25 and received July 26; accepted August 1. All authors have no financial relationships to disclose.
Address correspondence to J.P.P. (e-mail: jean-pierre.pelage{at}apr.aphp.fr).
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Abstract
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Interventional radiologists should be familiar with minimally invasive procedures used to treat various abnormalities of the pulmonary arteries. These well-established techniques, which obviate open surgery, are safe and effective when performed by an experienced interventionalist. Catheter-based thrombolysis with intrapulmonary arterial infusion of thrombolytic drugs, percutaneous thrombectomy, or embolus fragmentation can be performed in patients with life-threatening pulmonary embolism. Pulmonary artery stenoses, mainly encountered in patients with pulmonary vasculitis (as in Behçet disease or Takayasu arteritis), may be treated with balloon angioplasty and stent placement. Transcatheter embolization of pulmonary arteriovenous malformation is the standard treatment for hereditary hemorrhagic telangiectasia and is a very effective alternative to surgery to correct an aneurysm or pseudoaneurysm. In cases of hemoptysis that originates in the pulmonary artery, early diagnosis is mandatory for treatment with embolization. Percutaneous retrieval of foreign bodies from the heart or the pulmonary arteries and endovascular biopsy should also be part of the armamentarium of interventional radiologists.
© RSNA, 2005
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Introduction
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Percutaneous catheter-based treatment for hemoptysis of the bronchial and pulmonary arteries and transcatheter embolization of pulmonary arteriovenous malformations, aneurysms, and pseudoaneurysms were first reported in the 1970s (1). When adequate vascular catheters, guide-wires, and snare loops became available, percutaneous foreign body retrieval from the heart or pulmonary arteries and endovascular biopsy became applicable (1). With the development of angioplasty and stent placement via balloon catheter, severe pulmonary artery stenoses could be successfully treated (1). Catheter-based thrombolysis with intrapulmonary artery infusion of thrombolytic drugs, percutaneous thrombectomy, or embolus fragmentation was offered to patients with life-threatening pulmonary embolism (2). All of these minimally invasive techniques obviate open surgery. The procedures are well established, safe, and effective when performed by experienced interventionalists. This article provides a comprehensive overview of interventional radiology techniques that may be used to correct abnormalities in pulmonary arterial circulation.
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Pulmonary Embolism
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In most developed countries, venous thromboembolism remains one of the leading causes of death due to cardiovascular disease (2,3). The general mortality rate for massive pulmonary embolism with resultant systemic shock is approximately 30%, but values as high as 70% have been reported in some patient series (3,4). When pulmonary embolism occurs in a patient with underlying cardiopulmonary disease, it is often associated with right ventricular dysfunction and compromised hemodynamics of the cardiopulmonary system and, thus, requires more aggressive treatment than anticoagulation (2). Survival depends on rapid recanalization of the pulmonary arterial obstruction and reduction of the right ventricular afterload (2,3). Medical thrombolysis combined with anticoagulation is the established standard treatment for massive and/or life-threatening pulmonary embolism (2). Percutaneous catheter-based treatment is a possible alternative to surgical embolectomy in high-risk patients or in patients with contraindications to thrombolytic drugs (2,5,6).
Catheter-based thrombolysis performed with intra–pulmonary arterial infusion of thrombolytic drugs accelerates clot lysis and hastens the reestablishment of normal pulmonary artery circulation (Fig 1) (2). Percutaneous thrombectomy and embolus fragmentation techniques include thrombus removal with aspiration, extraction, or fragmentation (2,5,6). Finally, pulmonary artery stent placement has been offered to patients with cor pulmonale, profound hypoxemia, and hypotension that do not respond to thrombolytic therapy and embolus fragmentation techniques (2). The development and implementation of protocols for treatment of massive pulmonary embolism may improve outcomes; however, the respective roles of the new devices and available thrombolytic techniques are not yet fully understood (2,5).
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Figure 1a. Massive pulmonary embolism in a 65-year-old man. (a) Angiogram obtained with selective left pulmonary artery injection depicts multiple filling defects (arrows). (b) Angiogram obtained after catheter-based thrombolysis performed by using streptokinase shows reestablished perfusion via the left descending pulmonary artery (arrows).
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Figure 1b. Massive pulmonary embolism in a 65-year-old man. (a) Angiogram obtained with selective left pulmonary artery injection depicts multiple filling defects (arrows). (b) Angiogram obtained after catheter-based thrombolysis performed by using streptokinase shows reestablished perfusion via the left descending pulmonary artery (arrows).
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Pulmonary Artery Stenosis
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Intravascular stent implantation has become the first-line treatment for pulmonary artery stenosis that occurs as a complication of a cardiac anomaly and causes right ventricular outflow obstruction (7). Percutaneous transluminal balloon angioplasty, performed because of concerns about a potential mismatch between stent and blood vessel size after somatic growth and about the long-term safety of metallic stents in young children, also has been successful (8).
Pulmonary artery stenosis in adults is encountered mainly in patients with pulmonary vasculitis and rarely is associated with other conditions (9–13). Pulmonary vasculitis is defined by an inflammatory process that causes vessel destruction and ischemic damage to distant organs. Patients with systemic vasculitis such as that in Behçet disease or Takayasu arteritis have been reported to have pulmonary arterial involvement, with consequent aneurysms, pseudoaneurysms, and stenoses (9,10,12). Pulmonary artery stenosis may cause hemoptysis because of the development of systemic hypervascularization (Fig 2). In patients with progressive dyspnea and elevation of pulmonary arterial pressure, the finding of unmatched segmental perfusion defects of the lungs frequently has led to an incorrect diagnosis of chronic thromboembolic disease (11). The recognition of isolated pulmonary artery stenosis, particularly in patients with a previous diagnosis of chronic thromboembolic disease, radically changes the management plan (11,12). Angioplasty may be performed to redistribute pulmonary arterial flow toward low-resistance territories, reduce right ventricular pressure, and alleviate symptoms (Fig 3 ) (11–13).
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Figure 2a. Massive hemoptysis in a 50-year-old woman with Takayasu arteritis and systemic hypervascularization of the upper lobe of the right lung depicted at aortography. (a) Anteroposterior projection obtained at angiography with selective injection in the right coronary artery (RCA) depicts an enlarged atrial artery branch (AB) supplying collateral flow to the right pulmonary artery (arrow). Embolization of the atrial artery was successfully performed with n-butyl-cyanoacrylate. (b) Angiogram obtained in the same session as a shows a stenosis (arrow) of the right pulmonary artery (A) that was subsequently treated with balloon angioplasty. (c, d) Angiograms obtained 13 years later, before mitral valve replacement, show no residual stenosis in the right pulmonary artery (c) and patency of the right coronary artery (arrowhead) with persistent occlusion of the atrial artery (arrow) (d).
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Figure 2b. Massive hemoptysis in a 50-year-old woman with Takayasu arteritis and systemic hypervascularization of the upper lobe of the right lung depicted at aortography. (a) Anteroposterior projection obtained at angiography with selective injection in the right coronary artery (RCA) depicts an enlarged atrial artery branch (AB) supplying collateral flow to the right pulmonary artery (arrow). Embolization of the atrial artery was successfully performed with n-butyl-cyanoacrylate. (b) Angiogram obtained in the same session as a shows a stenosis (arrow) of the right pulmonary artery (A) that was subsequently treated with balloon angioplasty. (c, d) Angiograms obtained 13 years later, before mitral valve replacement, show no residual stenosis in the right pulmonary artery (c) and patency of the right coronary artery (arrowhead) with persistent occlusion of the atrial artery (arrow) (d).
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Figure 2c. Massive hemoptysis in a 50-year-old woman with Takayasu arteritis and systemic hypervascularization of the upper lobe of the right lung depicted at aortography. (a) Anteroposterior projection obtained at angiography with selective injection in the right coronary artery (RCA) depicts an enlarged atrial artery branch (AB) supplying collateral flow to the right pulmonary artery (arrow). Embolization of the atrial artery was successfully performed with n-butyl-cyanoacrylate. (b) Angiogram obtained in the same session as a shows a stenosis (arrow) of the right pulmonary artery (A) that was subsequently treated with balloon angioplasty. (c, d) Angiograms obtained 13 years later, before mitral valve replacement, show no residual stenosis in the right pulmonary artery (c) and patency of the right coronary artery (arrowhead) with persistent occlusion of the atrial artery (arrow) (d).
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Figure 2d. Massive hemoptysis in a 50-year-old woman with Takayasu arteritis and systemic hypervascularization of the upper lobe of the right lung depicted at aortography. (a) Anteroposterior projection obtained at angiography with selective injection in the right coronary artery (RCA) depicts an enlarged atrial artery branch (AB) supplying collateral flow to the right pulmonary artery (arrow). Embolization of the atrial artery was successfully performed with n-butyl-cyanoacrylate. (b) Angiogram obtained in the same session as a shows a stenosis (arrow) of the right pulmonary artery (A) that was subsequently treated with balloon angioplasty. (c, d) Angiograms obtained 13 years later, before mitral valve replacement, show no residual stenosis in the right pulmonary artery (c) and patency of the right coronary artery (arrowhead) with persistent occlusion of the atrial artery (arrow) (d).
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Figure 3a. Chronic thromboembolic disease in a 70-year-old woman with equal high pulmonary artery and arterial pressures. (a) Angiogram shows marked stenosis (arrow) of the pulmonary artery in the middle lobe of the right lung and a poststenotic aneurysm (A). Because surgery was considered too risky, balloon angioplasty was performed. (b) Angiogram shows inflation of the balloon during angioplasty. (c) Angiogram obtained after angioplasty shows improved enhancement (arrows) that corresponds to a marked redistribution of blood flow throughout the middle lobe of the lung. The patient died of severe reperfusion edema 7 days after angioplasty.
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Figure 3b. Chronic thromboembolic disease in a 70-year-old woman with equal high pulmonary artery and arterial pressures. (a) Angiogram shows marked stenosis (arrow) of the pulmonary artery in the middle lobe of the right lung and a poststenotic aneurysm (A). Because surgery was considered too risky, balloon angioplasty was performed. (b) Angiogram shows inflation of the balloon during angioplasty. (c) Angiogram obtained after angioplasty shows improved enhancement (arrows) that corresponds to a marked redistribution of blood flow throughout the middle lobe of the lung. The patient died of severe reperfusion edema 7 days after angioplasty.
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Figure 3c. Chronic thromboembolic disease in a 70-year-old woman with equal high pulmonary artery and arterial pressures. (a) Angiogram shows marked stenosis (arrow) of the pulmonary artery in the middle lobe of the right lung and a poststenotic aneurysm (A). Because surgery was considered too risky, balloon angioplasty was performed. (b) Angiogram shows inflation of the balloon during angioplasty. (c) Angiogram obtained after angioplasty shows improved enhancement (arrows) that corresponds to a marked redistribution of blood flow throughout the middle lobe of the lung. The patient died of severe reperfusion edema 7 days after angioplasty.
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Pulmonary Artery Pseudoaneurysms
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Pulmonary artery pseudoaneurysms are rare (1,14–21). The primary symptom of pulmonary artery pseudoaneurysms is hemoptysis, which is often massive (14–21). Bronchoscopy or computed tomography (CT) usually is performed for localization of the hemorrhage in a specific lobe, knowledge that enables selective angiographic evaluation (1). Several potential causes of hemoptysis have been described. They include necrotizing pneumonia, bacterial endocarditis, mucormycosis, tuberculosis, and vasculitis (as in Behçet disease) (14–21). Rasmussen aneurysm, which results from the destruction of the media in segmental pulmonary arteries by granulation tissue, is associated with hemoptysis in patients with active tuberculosis (1,17–19). Rarely, pulmonary artery pseudoaneurysms are associated with trauma (from use of a Swan-Ganz or Cournand catheter), congenital heart disease, necrotic cavitary lung carcinoma, or other factors (15–23). Because of the risk of pseudoaneurysm enlargement and rupture, which leads to death in approximately 50% of patients, prompt therapy is required (1). Percutaneous embolization is a minimally invasive alternative to open thoracotomy and resection of both the pseudoaneurysm and the affected lobe (1).
Pseudoaneurysm Due to Lung Cancer
Massive hemoptysis in patients with carcinoma of the lung can be successfully managed with transcatheter embolization of either the bronchial arteries or collateral arteries to the affected lung (21). Significant bleeding from the pulmonary artery is rare and usually is secondary to an erosive pulmonary artery pseudoaneurysm associated with a necrotic cavitary lesion (Fig 4 ) (21).
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Figure 4a. Carcinoma of the lung in a 50-year-old man. (a) Chest radiograph depicts upper-lobe consolidation and central excavation in the right lung. (b, c) Contrast-enhanced axial (b) and coronal (c) CT scans of the chest show a cavitated perihilar mass (* in b) with nodular enhancement inside the cavity (arrow), findings that are consistent with a pseudoaneurysm. (d) Angiogram of the right pulmonary artery helps confirm the presence of a pseudoaneurysm (arrow). (e) Digital subtraction angiogram shows reduction of blood flow in the arterial branches to the lower and middle lobes with coil embolization, and packing of the pseudoaneurysm (arrow) with n-butyl-cyanoacrylate and coils. (f) Unenhanced chest CT scan (mediastinal window settings), obtained after embolization, depicts complete occlusion of the pseudoaneurysm.
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Figure 4b. Carcinoma of the lung in a 50-year-old man. (a) Chest radiograph depicts upper-lobe consolidation and central excavation in the right lung. (b, c) Contrast-enhanced axial (b) and coronal (c) CT scans of the chest show a cavitated perihilar mass (* in b) with nodular enhancement inside the cavity (arrow), findings that are consistent with a pseudoaneurysm. (d) Angiogram of the right pulmonary artery helps confirm the presence of a pseudoaneurysm (arrow). (e) Digital subtraction angiogram shows reduction of blood flow in the arterial branches to the lower and middle lobes with coil embolization, and packing of the pseudoaneurysm (arrow) with n-butyl-cyanoacrylate and coils. (f) Unenhanced chest CT scan (mediastinal window settings), obtained after embolization, depicts complete occlusion of the pseudoaneurysm.
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Figure 4c. Carcinoma of the lung in a 50-year-old man. (a) Chest radiograph depicts upper-lobe consolidation and central excavation in the right lung. (b, c) Contrast-enhanced axial (b) and coronal (c) CT scans of the chest show a cavitated perihilar mass (* in b) with nodular enhancement inside the cavity (arrow), findings that are consistent with a pseudoaneurysm. (d) Angiogram of the right pulmonary artery helps confirm the presence of a pseudoaneurysm (arrow). (e) Digital subtraction angiogram shows reduction of blood flow in the arterial branches to the lower and middle lobes with coil embolization, and packing of the pseudoaneurysm (arrow) with n-butyl-cyanoacrylate and coils. (f) Unenhanced chest CT scan (mediastinal window settings), obtained after embolization, depicts complete occlusion of the pseudoaneurysm.
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Figure 4d. Carcinoma of the lung in a 50-year-old man. (a) Chest radiograph depicts upper-lobe consolidation and central excavation in the right lung. (b, c) Contrast-enhanced axial (b) and coronal (c) CT scans of the chest show a cavitated perihilar mass (* in b) with nodular enhancement inside the cavity (arrow), findings that are consistent with a pseudoaneurysm. (d) Angiogram of the right pulmonary artery helps confirm the presence of a pseudoaneurysm (arrow). (e) Digital subtraction angiogram shows reduction of blood flow in the arterial branches to the lower and middle lobes with coil embolization, and packing of the pseudoaneurysm (arrow) with n-butyl-cyanoacrylate and coils. (f) Unenhanced chest CT scan (mediastinal window settings), obtained after embolization, depicts complete occlusion of the pseudoaneurysm.
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Figure 4e. Carcinoma of the lung in a 50-year-old man. (a) Chest radiograph depicts upper-lobe consolidation and central excavation in the right lung. (b, c) Contrast-enhanced axial (b) and coronal (c) CT scans of the chest show a cavitated perihilar mass (* in b) with nodular enhancement inside the cavity (arrow), findings that are consistent with a pseudoaneurysm. (d) Angiogram of the right pulmonary artery helps confirm the presence of a pseudoaneurysm (arrow). (e) Digital subtraction angiogram shows reduction of blood flow in the arterial branches to the lower and middle lobes with coil embolization, and packing of the pseudoaneurysm (arrow) with n-butyl-cyanoacrylate and coils. (f) Unenhanced chest CT scan (mediastinal window settings), obtained after embolization, depicts complete occlusion of the pseudoaneurysm.
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Figure 4f. Carcinoma of the lung in a 50-year-old man. (a) Chest radiograph depicts upper-lobe consolidation and central excavation in the right lung. (b, c) Contrast-enhanced axial (b) and coronal (c) CT scans of the chest show a cavitated perihilar mass (* in b) with nodular enhancement inside the cavity (arrow), findings that are consistent with a pseudoaneurysm. (d) Angiogram of the right pulmonary artery helps confirm the presence of a pseudoaneurysm (arrow). (e) Digital subtraction angiogram shows reduction of blood flow in the arterial branches to the lower and middle lobes with coil embolization, and packing of the pseudoaneurysm (arrow) with n-butyl-cyanoacrylate and coils. (f) Unenhanced chest CT scan (mediastinal window settings), obtained after embolization, depicts complete occlusion of the pseudoaneurysm.
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Pseudoaneurysm from Manipulation of a Swan-Ganz Catheter
Rupture of the pulmonary artery or one of its branches during right heart catheterization is a rare complication encountered in 0.001%–0.5% of cases (1,23,24). The mortality rate associated with pulmonary artery rupture, however, is as high as 50% (1,24). Potential mechanisms that may account for pulmonary artery rupture secondary to Swan-Ganz catheter manipulation include penetration of the pulmonary artery by the catheter tip, distal migration of the catheter during balloon deflation, retraction of an inflated balloon, and high-pressure inflation of the balloon in excess of the tensile strength of the vessel wall (24). Sudden hemoptysis or hemothorax may result and requires emergent management (1,15, 16,24). Risk factors include pulmonary hypertension, systemic anticoagulation therapy, long-term steroid use, surgically induced hypothermia, age older than 60 years, female sex, and cardiac manipulation during surgery (24). Delayed hemoptysis related to a pseudoaneurysm also has been reported (15,16,24). To correct these complications, embolization may be performed with n-butyl-cyanoacrylate and/or metal coils (Fig 5 ) (1,15,16,25).
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Figure 5a. Cardiac failure due to pulmonary artery rupture in an 89-year-old man after Swan-Ganz catheterization. (a) Chest radiograph shows an apparent nodule (arrow) in the middle lobe, a finding that is consistent with a pseudoaneurysm. (b) Contrast-enhanced CT scan of the chest (mediastinal window settings) helps confirm the presence and location of the pseudoaneurysm (arrow). (c) Pulmonary angiogram obtained after selective injection in the feeding artery clearly shows the extent of the pseudoaneurysm (arrow). (d) Postembolization digital subtraction angiogram depicts complete occlusion of the pseudoaneurysm (arrow) with coils.
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Figure 5b. Cardiac failure due to pulmonary artery rupture in an 89-year-old man after Swan-Ganz catheterization. (a) Chest radiograph shows an apparent nodule (arrow) in the middle lobe, a finding that is consistent with a pseudoaneurysm. (b) Contrast-enhanced CT scan of the chest (mediastinal window settings) helps confirm the presence and location of the pseudoaneurysm (arrow). (c) Pulmonary angiogram obtained after selective injection in the feeding artery clearly shows the extent of the pseudoaneurysm (arrow). (d) Postembolization digital subtraction angiogram depicts complete occlusion of the pseudoaneurysm (arrow) with coils.
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Figure 5c. Cardiac failure due to pulmonary artery rupture in an 89-year-old man after Swan-Ganz catheterization. (a) Chest radiograph shows an apparent nodule (arrow) in the middle lobe, a finding that is consistent with a pseudoaneurysm. (b) Contrast-enhanced CT scan of the chest (mediastinal window settings) helps confirm the presence and location of the pseudoaneurysm (arrow). (c) Pulmonary angiogram obtained after selective injection in the feeding artery clearly shows the extent of the pseudoaneurysm (arrow). (d) Postembolization digital subtraction angiogram depicts complete occlusion of the pseudoaneurysm (arrow) with coils.
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Figure 5d. Cardiac failure due to pulmonary artery rupture in an 89-year-old man after Swan-Ganz catheterization. (a) Chest radiograph shows an apparent nodule (arrow) in the middle lobe, a finding that is consistent with a pseudoaneurysm. (b) Contrast-enhanced CT scan of the chest (mediastinal window settings) helps confirm the presence and location of the pseudoaneurysm (arrow). (c) Pulmonary angiogram obtained after selective injection in the feeding artery clearly shows the extent of the pseudoaneurysm (arrow). (d) Postembolization digital subtraction angiogram depicts complete occlusion of the pseudoaneurysm (arrow) with coils.
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Mycotic Pseudoaneurysm
Mycotic pseudoaneurysms are associated with bacterial infection of the vessel wall (1). The pseudoaneurysm forms as a result of erosion of the vessel wall caused by bacteremia in the adjacent lung (1,17–20). Infectious processes that may lead to the formation of a mycotic pseudo-aneurysm include right-sided endocarditis, necrotizing pneumonia, syphilis, and tuberculosis (Rasmussen pseudoaneurysm) (17–20,26). Pulmonary hypertension, anticoagulation therapy, coagulopathy, long-term steroid therapy, age older than 60 years, and cardiopulmonary surgery are among the risk factors that predispose people to mycotic pseudoaneurysm (26). A Rasmussen pseudoaneurysm typically forms months to years after the initial exposure to tuberculosis or reactivation of the disease and the development of cavitation (17–20). Even if the majority of patients with hemoptysis and active tuberculosis bleed from the bronchial circulation, the pulmonary arterial circulation should be evaluated, particularly in case of a normal bronchial angiogram or if the pseudoaneurysm has been diagnosed at CT (17). Detachable balloon and steel coils placed in an arterial segment proximal to the lesion have been used successfully to treat pulmonary artery pseudoaneurysms (17–20). Intrasaccular embolization with coils is reported to be an effective technique for preservation of distal segments of the pulmonary artery and sparing of pulmonary function distal to the pseudoaneurysm (26).
Pseudoaneurysm in Behçet Disease
Behçet disease is a chronic, systemic collagen-vascular disorder of unknown origin that mainly affects young men from Mediterranean countries, the Middle East, or Japan (10). Current diagnostic criteria for Behçet disease consist of the presence of recurrent oral ulcerations plus two additional criteria including recurrent genital ulcerations, eye lesions, skin lesions, and positive pathergy tests (10). Pulmonary involvement, which is present in 5% of affected patients, occurs in a late stage of the disease (10,14,27). The presence of a pulmonary artery pseudoaneurysm suggests a poor prognosis, with massive hemoptysis being associated with a high mortality rate (Figs 6, 7) (10). The apparent pulmonary artery aneurysms in patients with Behçet disease are pseudoaneurysms that arise as complications of vasculitis and transmural necrosis (10,14). In most patients, the pseudoaneurysms are multiple, bilateral, saccular, and partially or completely thrombosed; the pulmonary arteries distal to the pseudoaneurysms also are thrombosed (Fig 6) (14,27). Although medical treatment with cytostatic agents and corticosteroids may cause regression of pseudoaneurysms, recurrent hemoptysis or progression in size of pseudoaneurysms is common (1,10,14). Selective transcatheter embolization is a valuable alternative to surgery (1,14, 28,29). The technique of embolization varies from one center to another, with some interventional radiologists using coils while others favor acrylic glue (Figs 6, 7) (1,14,28,29). In cases of recurrent hemoptysis after embolization of pseudoaneurysms, bronchial artery opacification and embolization should be discussed (Fig 8) (29).
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Figure 6a. Large pulmonary artery pseudoaneurysm in a 28-year-old man with Behçet disease. (a) Contrast-enhanced CT scan depicts a large left pulmonary artery pseudoaneurysm (arrow). (b) Angiogram shows successful selective embolization of the pseudoaneurysm with multiple coils.
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Figure 6b. Large pulmonary artery pseudoaneurysm in a 28-year-old man with Behçet disease. (a) Contrast-enhanced CT scan depicts a large left pulmonary artery pseudoaneurysm (arrow). (b) Angiogram shows successful selective embolization of the pseudoaneurysm with multiple coils.
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Figure 7a. Bilateral pulmonary artery pseudoaneurysms in a 34-year-old man with Behçet disease. (a, b) Angiograms obtained with selective injection in the right (a) and left (b) pulmonary arteries depict bilateral pseudoaneurysms (arrow) and the occlusion of distal pulmonary artery branches (*). Selective embolization of the two right pulmonary artery pseudoaneurysms in a was successfully performed by using coils. (c) The balloon-assisted technique (arrow) was used for embolization in the left pulmonary artery. (d) Follow-up CT scan demonstrates the complete occlusion of the pseudoaneurysms.
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Figure 7b. Bilateral pulmonary artery pseudoaneurysms in a 34-year-old man with Behçet disease. (a, b) Angiograms obtained with selective injection in the right (a) and left (b) pulmonary arteries depict bilateral pseudoaneurysms (arrow) and the occlusion of distal pulmonary artery branches (*). Selective embolization of the two right pulmonary artery pseudoaneurysms in a was successfully performed by using coils. (c) The balloon-assisted technique (arrow) was used for embolization in the left pulmonary artery. (d) Follow-up CT scan demonstrates the complete occlusion of the pseudoaneurysms.
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Figure 7c. Bilateral pulmonary artery pseudoaneurysms in a 34-year-old man with Behçet disease. (a, b) Angiograms obtained with selective injection in the right (a) and left (b) pulmonary arteries depict bilateral pseudoaneurysms (arrow) and the occlusion of distal pulmonary artery branches (*). Selective embolization of the two right pulmonary artery pseudoaneurysms in a was successfully performed by using coils. (c) The balloon-assisted technique (arrow) was used for embolization in the left pulmonary artery. (d) Follow-up CT scan demonstrates the complete occlusion of the pseudoaneurysms.
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Figure 7d. Bilateral pulmonary artery pseudoaneurysms in a 34-year-old man with Behçet disease. (a, b) Angiograms obtained with selective injection in the right (a) and left (b) pulmonary arteries depict bilateral pseudoaneurysms (arrow) and the occlusion of distal pulmonary artery branches (*). Selective embolization of the two right pulmonary artery pseudoaneurysms in a was successfully performed by using coils. (c) The balloon-assisted technique (arrow) was used for embolization in the left pulmonary artery. (d) Follow-up CT scan demonstrates the complete occlusion of the pseudoaneurysms.
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Figure 8. Recurrent hemoptysis 1 week after embolization of two pulmonary artery pseudoaneurysms in a 43-year-old man with Behçet disease. Angiogram obtained with selective injection in a common right-left bronchial artery (BA) depicts diffuse pulmonary hypervascularization, with opacification of pulmonary artery branches (arrowheads) distal to the embolized pseudoaneurysms (arrows). Bleeding ceased completely after bronchial artery embolization.
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Pulmonary Artery Aneurysms
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Pulmonary artery aneurysms are rare, and most reported cases were found at autopsy (1,30). The causes of these lesions are not well known, but pulmonary artery aneurysms may be congenital or acquired in origin. Pulmonary hypertension is reputed to be an important factor in the pathogenesis of pulmonary artery aneurysms. Idiopathic aneurysms are extremely rare (30). The major complication of pulmonary artery aneurysm is hemoptysis, which results from rupture and which is frequently fatal. Clear guidelines for treatment do not exist, but treatment is recommended in the presence of a progressive increase in size (30). Transcatheter embolization with steel coils is an effective and safe method of preventing aneurysm rupture (Fig 9).
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Figure 9a. Pulmonary artery aneurysm in a 78-year-old woman with a chronic cough. (a) Chest radiograph, obtained 6 years after an initial radiographic finding of a pulmonary nodule in the left lung, shows an increase in the size of the nodule (arrow). (b) Maximum intensity projection obtained at contrast-enhanced multisection CT depicts a 3-cm-diameter aneurysm in the apical pulmonary artery of the culmen. (c) Pulmonary angiogram demonstrates the presence and location of the aneurysm (arrow). (d) Angiogram shows selective embolization of the arterial supply to the aneurysm with the use of detachable microcoils (arrow). (e) Postembolization CT scan shows complete exclusion of the aneurysm, with patency maintained in the distal pulmonary artery branches (arrow). (f) Chest radiograph shows the occluded aneurysm.
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Figure 9b. Pulmonary artery aneurysm in a 78-year-old woman with a chronic cough. (a) Chest radiograph, obtained 6 years after an initial radiographic finding of a pulmonary nodule in the left lung, shows an increase in the size of the nodule (arrow). (b) Maximum intensity projection obtained at contrast-enhanced multisection CT depicts a 3-cm-diameter aneurysm in the apical pulmonary artery of the culmen. (c) Pulmonary angiogram demonstrates the presence and location of the aneurysm (arrow). (d) Angiogram shows selective embolization of the arterial supply to the aneurysm with the use of detachable microcoils (arrow). (e) Postembolization CT scan shows complete exclusion of the aneurysm, with patency maintained in the distal pulmonary artery branches (arrow). (f) Chest radiograph shows the occluded aneurysm.
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Figure 9c. Pulmonary artery aneurysm in a 78-year-old woman with a chronic cough. (a) Chest radiograph, obtained 6 years after an initial radiographic finding of a pulmonary nodule in the left lung, shows an increase in the size of the nodule (arrow). (b) Maximum intensity projection obtained at contrast-enhanced multisection CT depicts a 3-cm-diameter aneurysm in the apical pulmonary artery of the culmen. (c) Pulmonary angiogram demonstrates the presence and location of the aneurysm (arrow). (d) Angiogram shows selective embolization of the arterial supply to the aneurysm with the use of detachable microcoils (arrow). (e) Postembolization CT scan shows complete exclusion of the aneurysm, with patency maintained in the distal pulmonary artery branches (arrow). (f) Chest radiograph shows the occluded aneurysm.
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Figure 9d. Pulmonary artery aneurysm in a 78-year-old woman with a chronic cough. (a) Chest radiograph, obtained 6 years after an initial radiographic finding of a pulmonary nodule in the left lung, shows an increase in the size of the nodule (arrow). (b) Maximum intensity projection obtained at contrast-enhanced multisection CT depicts a 3-cm-diameter aneurysm in the apical pulmonary artery of the culmen. (c) Pulmonary angiogram demonstrates the presence and location of the aneurysm (arrow). (d) Angiogram shows selective embolization of the arterial supply to the aneurysm with the use of detachable microcoils (arrow). (e) Postembolization CT scan shows complete exclusion of the aneurysm, with patency maintained in the distal pulmonary artery branches (arrow). (f) Chest radiograph shows the occluded aneurysm.
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Figure 9e. Pulmonary artery aneurysm in a 78-year-old woman with a chronic cough. (a) Chest radiograph, obtained 6 years after an initial radiographic finding of a pulmonary nodule in the left lung, shows an increase in the size of the nodule (arrow). (b) Maximum intensity projection obtained at contrast-enhanced multisection CT depicts a 3-cm-diameter aneurysm in the apical pulmonary artery of the culmen. (c) Pulmonary angiogram demonstrates the presence and location of the aneurysm (arrow). (d) Angiogram shows selective embolization of the arterial supply to the aneurysm with the use of detachable microcoils (arrow). (e) Postembolization CT scan shows complete exclusion of the aneurysm, with patency maintained in the distal pulmonary artery branches (arrow). (f) Chest radiograph shows the occluded aneurysm.
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Figure 9f. Pulmonary artery aneurysm in a 78-year-old woman with a chronic cough. (a) Chest radiograph, obtained 6 years after an initial radiographic finding of a pulmonary nodule in the left lung, shows an increase in the size of the nodule (arrow). (b) Maximum intensity projection obtained at contrast-enhanced multisection CT depicts a 3-cm-diameter aneurysm in the apical pulmonary artery of the culmen. (c) Pulmonary angiogram demonstrates the presence and location of the aneurysm (arrow). (d) Angiogram shows selective embolization of the arterial supply to the aneurysm with the use of detachable microcoils (arrow). (e) Postembolization CT scan shows complete exclusion of the aneurysm, with patency maintained in the distal pulmonary artery branches (arrow). (f) Chest radiograph shows the occluded aneurysm.
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Pulmonary Arteriovenous Malformations
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Pulmonary arteriovenous malformations, which are most commonly congenital in origin, produce abnormal communication between pulmonary arteries and pulmonary veins (31). From 60% to 90% of patients with pulmonary arteriovenous malformations have hereditary hemorrhagic telangiectasia, which is also known as Rendu-Osler-Weber syndrome; however, abnormal communication between blood vessels of the lung also may be found in a variety of acquired conditions (31). Pulmonary arteriovenous malformations provide direct capillary-free communications between the pulmonary and the systemic circulation, with three main clinical consequences: (a) Pulmonary arterial blood passing through these right-to-left shunts cannot be oxygenated, a situation that may lead to hypoxemia. (b) The absence of a normal filtering capillary bed allows particulate material (air bubbles or clots) to reach the systemic circulation directly (paradoxical embolism), with potential clinical sequelae in the cerebral circulation (transient ischemic attack, stroke, brain abscess). (c) These abnormal vessels, particularly in pregnant women, may rupture into the bronchus (hemoptysis) or the pleural cavity (hemothorax) (31). There are various types of pulmonary arteriovenous malformation. A simple malformation consists of single or multiple feeding arteries that originate from a single segmental artery (Fig 10), whereas in a complex pulmonary arteriovenous malformation, feeding arteries always originate from two or more segmental arteries (32). In some patients with simple and/or complex pulmonary arteriovenous malformations, a diffuse pattern of malformations may be present (Fig 11) (32).
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Figure 10a. Simple arteriovenous malformation in a 43-year-old man with hereditary hemorrhagic telangiectasia. (a) Coronal maximum intensity projection obtained at multisection CT depicts a simple arteriovenous malformation of the pulmonary lingula (arrow). (b) Selective pulmonary angiogram demonstrates the type of malformation. A feeding artery (A), sac (S), and draining vein (V) are well depicted. (c) Angiogram obtained during the same session as b shows complete occlusion of the malformation with coils (arrow).
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Figure 10b. Simple arteriovenous malformation in a 43-year-old man with hereditary hemorrhagic telangiectasia. (a) Coronal maximum intensity projection obtained at multisection CT depicts a simple arteriovenous malformation of the pulmonary lingula (arrow). (b) Selective pulmonary angiogram demonstrates the type of malformation. A feeding artery (A), sac (S), and draining vein (V) are well depicted. (c) Angiogram obtained during the same session as b shows complete occlusion of the malformation with coils (arrow).
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Figure 10c. Simple arteriovenous malformation in a 43-year-old man with hereditary hemorrhagic telangiectasia. (a) Coronal maximum intensity projection obtained at multisection CT depicts a simple arteriovenous malformation of the pulmonary lingula (arrow). (b) Selective pulmonary angiogram demonstrates the type of malformation. A feeding artery (A), sac (S), and draining vein (V) are well depicted. (c) Angiogram obtained during the same session as b shows complete occlusion of the malformation with coils (arrow).
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Figure 11a. Diffuse arteriovenous malformations in a 28-year-old woman with hereditary hemorrhagic telangiectasia and severe hypoxemia. (a) CT scan shows small malformations in subsegmental branches (arrows) of all the segmental pulmonary arteries. (b) Angiogram obtained with selective injection in the right pulmonary artery after four embolization sessions shows occlusion of the feeding vessels of the multiple malformations.
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Figure 11b. Diffuse arteriovenous malformations in a 28-year-old woman with hereditary hemorrhagic telangiectasia and severe hypoxemia. (a) CT scan shows small malformations in subsegmental branches (arrows) of all the segmental pulmonary arteries. (b) Angiogram obtained with selective injection in the right pulmonary artery after four embolization sessions shows occlusion of the feeding vessels of the multiple malformations.
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Percutaneous transcatheter embolotherapy with the use of coils is currently the treatment of choice for avoidance of neurologic complications (Fig 12) and pulmonary hemorrhage in patients with pulmonary arteriovenous malformation (31,33,34). Embolization also may be offered to improve hypoxemia in patients with diffuse malformations (Fig 11) (33,34).
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Figure 12a. Neurologic complication of hereditary hemorrhagic telangiectasia in a 47-year-old woman. (a) Brain MR image depicts an abscess (arrow). (b) CT scan shows a small pulmonary arteriovenous malformation in the right upper lobe (arrow). (c) Angiogram obtained with selective injection in a segmental branch of the apical right pulmonary artery depicts a simple malformation with a single 2.5-mm-diameter feeding artery (A) and draining vein (V). (d) Angiogram shows complete embolization of the malformation (arrow).
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Figure 12b. Neurologic complication of hereditary hemorrhagic telangiectasia in a 47-year-old woman. (a) Brain MR image depicts an abscess (arrow). (b) CT scan shows a small pulmonary arteriovenous malformation in the right upper lobe (arrow). (c) Angiogram obtained with selective injection in a segmental branch of the apical right pulmonary artery depicts a simple malformation with a single 2.5-mm-diameter feeding artery (A) and draining vein (V). (d) Angiogram shows complete embolization of the malformation (arrow).
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Figure 12c. Neurologic complication of hereditary hemorrhagic telangiectasia in a 47-year-old woman. (a) Brain MR image depicts an abscess (arrow). (b) CT scan shows a small pulmonary arteriovenous malformation in the right upper lobe (arrow). (c) Angiogram obtained with selective injection in a segmental branch of the apical right pulmonary artery depicts a simple malformation with a single 2.5-mm-diameter feeding artery (A) and draining vein (V). (d) Angiogram shows complete embolization of the malformation (arrow).
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Figure 12d. Neurologic complication of hereditary hemorrhagic telangiectasia in a 47-year-old woman. (a) Brain MR image depicts an abscess (arrow). (b) CT scan shows a small pulmonary arteriovenous malformation in the right upper lobe (arrow). (c) Angiogram obtained with selective injection in a segmental branch of the apical right pulmonary artery depicts a simple malformation with a single 2.5-mm-diameter feeding artery (A) and draining vein (V). (d) Angiogram shows complete embolization of the malformation (arrow).
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Endovascular Catheter-based Biopsy
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Filling defects in the main pulmonary artery or branches are usually associated with thromboembolic disease (35,36). When no symptomatic improvement is obtained despite anticoagulation therapy, or when the thrombus enhances at CT after the administration of iodinated contrast material or produces enlargement of the artery, evidence for another diagnosis (eg, that of angiosarcoma) may be sought a
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Abstract
Introduction
