Scientific letter
Ruptured pulmonary artery aneurysm, a surgical emergency. A case report and literature review
Ruptura de aneurisma de la arteria pulmonar, una emergencia quirúrgica. Reporte de caso y revisión de literatura
Víctor Hugo Contreras-Gutiérrez
, Rodolfo Castaño-Guerra
Corresponding author
victorcontrerasdr@hotmail.es
Corresponding author at: Dr Balmis 102, Colonia doctores, delegación Cuauhtémoc, Ciudad de México, CP 06720, Mexico.
Corresponding author at: Dr Balmis 102, Colonia doctores, delegación Cuauhtémoc, Ciudad de México, CP 06720, Mexico.
Departamento de cardiología del Hospital General de México, Ciudad de México, Mexico
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A case report and literature review" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "239" "paginaFinal" => "241" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Víctor Hugo Contreras-Gutiérrez, Rodolfo Castaño-Guerra" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Víctor Hugo" "apellidos" => "Contreras-Gutiérrez" "email" => array:1 [ 0 => "victorcontrerasdr@hotmail.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Rodolfo" "apellidos" => "Castaño-Guerra" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de cardiología del Hospital General de México, Ciudad de México, Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Dr Balmis 102, Colonia doctores, delegación Cuauhtémoc, Ciudad de México, CP 06720, Mexico." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ruptura de aneurisma de la arteria pulmonar, una emergencia quirúrgica. Reporte de caso y revisión de literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1019 "Ancho" => 1757 "Tamanyo" => 208849 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT angiography 3-D reconstruction (A) and close up image (B) in which the left pulmonary aneurysm and its relationship with other cardiovascular structures are observed. The left pulmonary parenchyma is almost totally collapsed. AAo, ascending aorta; CL, collapsed lung; MPA, main pulmonary artery; PAA, pulmonary arterial aneurysm.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 47-year-old man with no medical history presented to the emergency department complaining of severe sharp chest pain 3<span class="elsevierStyleHsp" style=""></span>h lasting, exacerbated with deep inspiration and accompanied by increasing dyspnea.</p><p id="par0010" class="elsevierStylePara elsevierViewall">At first examination, asymmetric thoracic respiratory movements were observed with a diminished expansion of the left side, where inaudible breath sounds were present.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Blood samples were obtained and arterial gases reported pH 7.41, PaO<span class="elsevierStyleInf">2</span> 63<span class="elsevierStyleHsp" style=""></span>mmHg, PaCO<span class="elsevierStyleInf">2</span> 21.9<span class="elsevierStyleHsp" style=""></span>mmHg, HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">−</span> 16.2<span class="elsevierStyleHsp" style=""></span>mmol/L, oxygen saturation 93%. Red cell count reported hemoglobin of 7.7<span class="elsevierStyleHsp" style=""></span>g/dl and hematocrit of 24%.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A chest X-ray showed an almost fully opacified left hemithorax suggesting a massive left pleural effusion with the ipsilateral lung collapsed and displacement of the trachea toward the right side. Blood was obtained from the thoracentesis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A CT-angiography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) was mandatory for a better assessment of the pulmonary vasculature. It showed an image suggesting an aneurysmatic lesion of the left pulmonary artery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">An invasive approach was decided by means of a posterolateral thoracotomy, where 5000<span class="elsevierStyleHsp" style=""></span>ml of coagulated blood were obtained. A ruptured aneurysmal lesion of 2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm of diameter in the lingular branch of the left pulmonary artery was identified and resected. Lingular lobe resection was also performed.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was admitted to the intensive care unit for further observation, requiring the administration of vasopressors and mechanical ventilatory support. Two weeks after his admission he died because of a nosocomial pulmonary infection.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pulmonary artery aneurysms (PAAs) are rare and infrequently diagnosed,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–4</span></a> the best part we know is derived from autopsy findings.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> They were first described by Bristowe in 1860 at a necropsy<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> and subsequently by Deterling and Claggett in 1947 who reported eight cases in 109,571 necropsies.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,5</span></a> However the true incidence is unknown.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">An aneurysm is defined as a focal dilation of a blood vessel involving all three layers of the wall.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3,7</span></a> Pseudoaneurysms do not involve all layers of the arterial wall but they pose a higher risk of rupture.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In computed tomography (CT) the upper limit of the main pulmonary artery (PA) diameter in adults is 29<span class="elsevierStyleHsp" style=""></span>mm and for interlobar PAs 17<span class="elsevierStyleHsp" style=""></span>mm<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>; PAAs are defined as a dilatation greater than 4<span class="elsevierStyleHsp" style=""></span>cm in the main PA.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">PAAs can be congenital or acquired,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5,8</span></a> in 50% of the postmortem cases were associated with congenital heart disease, in decreasing order, patent ductus arteriosus, ventricular septal defects and atrial septal defects.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is presumed that increased flow caused by left-to-right shunt results in hemodynamic shear stress of the vascular wall and promotes aneurysm formation in the PAs.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">This entity generally affects younger people than aortic aneurysms and there is no sex predilection.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Most of these anomalies affect the main pulmonary artery,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> but when they affect the pulmonary artery PA branches, the left PA affection is more common than the right one.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The most frequent association with the formation of PAAs has been pulmonary arterial hypertension,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> present in 66% of cases, which favors the formation of giant aneurysms.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Low-pressure aneurysms seem to have a better prognosis than hypertensive aneurysms.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Chronic pulmonary embolism is a relatively common cause of PAAs,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> such aneurysms present mural thickening, webs, and intramural thrombi that can calcify.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Pathophysiological mechanisms involved in PAA formation are limited. Structural changes in elastin and collagen secondary to increased PA pressure that leads to PA dilatation has been proposed.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> An abnormal opening of the pulmonary valve or shear stress from a right-to-left shunt may induce apoptosis, remodeling, and aneurysmal transformation of the vessel wall.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Among acquired causes the insertion of Swan-Ganz catheters has been a cause of iatrogenic pseudoaneurysms with a 0.2% incidence of rupture and hemorrhage.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Other iatrogenic causes include chest tube insertion, conventional angiography, surgical resection, biopsy and after penetrating trauma.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Idiopathic PAAs are rare.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The natural history of the PAAs is poorly understood because of the limited number of cases diagnosed ante-mortem; however, not all aneurysms progress to the rupture stage.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Most patients with PAAs are asymptomatic or have non-specific symptoms.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Clinical symptoms include dyspnea, chest pain, hoarseness, palpitations, and syncope. Bronchus compression may produce cyanosis, cough, fever, pneumonia and bronchiectasis. There is an increased risk of pulmonary embolism.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Hemoptysis has been the cause of death in one third of the reported cases and, when present, it should be considered as an indicator of imminent aneurysm rupture,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> massive hemoptysis, considered as a loss of more than 300<span class="elsevierStyleHsp" style=""></span>ml of blood expectorated from the bronchial tree within 24<span class="elsevierStyleHsp" style=""></span>h,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> is an emergency condition that can cause asphyxiation, exsanguination, cardiogenic shock and sudden death.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Pulmonary angiography is the gold standard for establishing the diagnosis of PAAs<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3</span></a> but, owing to its high spatial resolution, contrast-enhanced multi-detector CT is considered the primary technique for diagnosing PAA,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,7</span></a> since it allows the evaluation of the size, shape and exact location of the aneurysm, and concomitant structural cardiovascular abnormalities.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The optimal treatment for PAAs remains unclear since there is limited experience because of the low incidence of the disease.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3</span></a> Due to the lack of guidelines for its management, patients should be managed individually.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Treatment of PAAs used to be predominantly surgical, however nowadays endovascular techniques like coil embolization, balloon embolization or stent graft placement have been increasingly used, since they are less invasive and produce less damage to the lung parenchyma.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">When the main pulmonary trunk is involved, surgical intervention consists of aneurysmectomy or aneurysmorrhaphy.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> With peripheral lesions, embolic therapy has been the treatment of choice, instead of lobectomy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In case of rupture, surgery is the only possible life-saving treatment option. In addition, dissection is an indication for surgery in case of reasonable preoperative morbidity.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,9</span></a> Surgical outcome is unknown.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In the case of our patient, the first ruptured pulmonary aneurysm related massive hemothorax reported in our country as far as we know, no etiology was identified. The management of the patient, as mentioned before, was individually handled, relying on the information provided by the few reported cases in the literature, since apart of being already recognized as a rare disease, the location of the aneurysm at a peripheral branch of the pulmonary artery is even less frequent. Successful resection of the pulmonary aneurysm and drainage of the massive hemothorax, that required multiple transfusions, were life-saving measures in the acute setting and back the indication of an emergency surgical approach in such patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1267 "Ancho" => 982 "Tamanyo" => 143376 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT angiography in which a left massive hemothorax displaces the mediastinal structures to the contralateral side. An aneurysmal image and extravasation of the contrast media are observed in the left hemithorax. CM, contrast media; PAA, pulmonary artery aneurysm.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1019 "Ancho" => 1757 "Tamanyo" => 208849 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT angiography 3-D reconstruction (A) and close up image (B) in which the left pulmonary aneurysm and its relationship with other cardiovascular structures are observed. The left pulmonary parenchyma is almost totally collapsed. AAo, ascending aorta; CL, collapsed lung; MPA, main pulmonary artery; PAA, pulmonary arterial aneurysm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aneurysms of the pulmonary artery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Kreibich" 1 => "M. Siepe" 2 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 0 | 4 |
| 2024 October | 57 | 4 | 61 |
| 2024 September | 90 | 13 | 103 |
| 2024 August | 82 | 25 | 107 |
| 2024 July | 74 | 15 | 89 |
| 2024 June | 79 | 7 | 86 |
| 2024 May | 44 | 9 | 53 |
| 2024 April | 66 | 10 | 76 |
| 2024 March | 99 | 8 | 107 |
| 2024 February | 91 | 0 | 91 |
| 2024 January | 111 | 11 | 122 |
| 2023 December | 104 | 21 | 125 |
| 2023 November | 87 | 11 | 98 |
| 2023 October | 116 | 10 | 126 |
| 2023 September | 77 | 9 | 86 |
| 2023 August | 75 | 8 | 83 |
| 2023 July | 65 | 6 | 71 |
| 2023 June | 73 | 6 | 79 |
| 2023 May | 78 | 9 | 87 |
| 2023 April | 94 | 5 | 99 |
| 2023 March | 96 | 2 | 98 |
| 2023 February | 57 | 1 | 58 |
| 2023 January | 90 | 12 | 102 |
| 2022 December | 80 | 11 | 91 |
| 2022 November | 84 | 8 | 92 |
| 2022 October | 89 | 8 | 97 |
| 2022 September | 71 | 18 | 89 |
| 2022 August | 104 | 11 | 115 |
| 2022 July | 47 | 9 | 56 |
| 2022 June | 71 | 15 | 86 |
| 2022 May | 65 | 8 | 73 |
| 2022 April | 80 | 10 | 90 |
| 2022 March | 135 | 9 | 144 |
| 2022 February | 121 | 8 | 129 |
| 2022 January | 100 | 15 | 115 |
| 2021 December | 87 | 9 | 96 |
| 2021 November | 105 | 14 | 119 |
| 2021 October | 102 | 13 | 115 |
| 2021 September | 101 | 17 | 118 |
| 2021 August | 112 | 9 | 121 |
| 2021 July | 103 | 8 | 111 |
| 2021 June | 111 | 13 | 124 |
| 2021 May | 109 | 5 | 114 |
| 2021 April | 325 | 14 | 339 |
| 2021 March | 166 | 7 | 173 |
| 2021 February | 108 | 6 | 114 |
| 2021 January | 163 | 17 | 180 |
| 2020 December | 151 | 14 | 165 |
| 2020 November | 131 | 9 | 140 |
| 2020 October | 165 | 5 | 170 |
| 2020 September | 166 | 16 | 182 |
| 2020 August | 126 | 16 | 142 |
| 2020 July | 135 | 11 | 146 |
| 2020 June | 89 | 21 | 110 |
| 2020 May | 82 | 10 | 92 |
| 2020 April | 81 | 9 | 90 |
| 2020 March | 148 | 15 | 163 |
| 2020 February | 192 | 10 | 202 |
| 2020 January | 168 | 7 | 175 |
| 2019 December | 174 | 10 | 184 |
| 2019 November | 135 | 20 | 155 |
| 2019 October | 150 | 17 | 167 |
| 2019 September | 134 | 16 | 150 |
| 2019 August | 140 | 43 | 183 |
| 2019 July | 121 | 33 | 154 |
| 2019 June | 164 | 58 | 222 |
| 2019 May | 164 | 50 | 214 |
| 2019 April | 140 | 50 | 190 |
| 2019 March | 77 | 23 | 100 |
| 2019 February | 81 | 17 | 98 |
| 2019 January | 92 | 14 | 106 |
| 2018 December | 72 | 12 | 84 |
| 2018 November | 55 | 6 | 61 |
| 2018 October | 45 | 14 | 59 |
| 2018 September | 52 | 21 | 73 |
| 2018 August | 39 | 27 | 66 |
| 2018 July | 49 | 17 | 66 |
| 2018 June | 35 | 13 | 48 |
| 2018 May | 47 | 9 | 56 |
| 2018 April | 11 | 10 | 21 |
| 2018 March | 19 | 4 | 23 |
| 2018 February | 29 | 10 | 39 |
| 2018 January | 23 | 3 | 26 |
| 2017 December | 41 | 6 | 47 |
| 2017 November | 23 | 10 | 33 |
| 2017 October | 41 | 11 | 52 |
| 2017 September | 54 | 19 | 73 |
| 2017 August | 221 | 11 | 232 |
| 2017 July | 9 | 6 | 15 |
| 2017 June | 6 | 4 | 10 |
| 2017 May | 4 | 10 | 14 |
| 2017 April | 10 | 15 | 25 |
| 2017 March | 11 | 20 | 31 |
| 2017 February | 0 | 9 | 9 |
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