Eur J Cardiothorac Surg 2000;18:366-369
© 2000 Elsevier Science NL
Operative aneurysmectomy and middle lobectomy for asymptomatic bronchial artery aneurysm in young patient
Yukihito Saito,
Yoshiaki Ueda,
Hiroji Imamura,
Akiharu Okamura
Department of Thoracic and Cardiovascular Surgery, Surgical Pathology, Kansai Medical University, 10–15 Fumizonocho, Moriguchi 570-8507, Japan
Received 26 November 1999;
received in revised form 15 March 2000;
accepted 18 April 2000.
Corresponding author. Fax: +81-6-6994-7022
e-mail: saitoy{at}takii.kmu.ac.jp
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Abstract
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A 33-year-old woman was admitted for investigation of a round right hilar shadow on chest X-ray. A bronchial arteriogram revealed it was a bronchial artery aneurysm. She had no symptoms such as bloody sputum or hemoptysis. Although bronchial arterial embolization (BAE) is a good procedure for controlling hemoptysis, sometimes hemostasis is unsuccessful or bleeding recurs after BAE. Our patient underwent an operative aneurysmectomy and middle lobectomy to eliminate aneurysmal rupture instead of BAE.
Key Words: Bronchial artery • Aneurysm
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1. Introduction
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Rupture of a bronchial artery aneurysm into the bronchus or mediastinum can be life-threating. Transcatheter procedures have been applied to patients with various pulmonary vascular diseases such as pulmonary arterio-venous malformation or bronchial artery aneurysm (BAA). Recently many reports have advocated that transcatheter arterial embolization is the treatment of choice for BAA instead of thoracotomy [1–3]. In general, bronchial artery transcatheter embolization (BAE) is chosen as a procedure to obliterate the blood flow to aneurysms in hemodynamically stable patients with no evidence of rupture. However, embolization of BAA can cause iatrogenic complications that render the procedure inefficient [4]. Also, some cases of rebleeding after establishment of temporary hemostasis by BAE have been reported [5]. Therefore operative aneurysmectomy, a procedure with greater certainty of preventing recurrence, should be considered.
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2. Case report
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A 33-year-old woman was admitted on February 15 1999, because of a round right hilar shadow on chest X-ray. Bronchoscopy revealed no intrabronchial abnormality. A sputum cytology/bacteriology examination showed no evidence of neoplasia or infection, and serum tumor markers such as CEA, SLX and SCC were in the normal range. On chest CT, the hilar mass showed clear enhancement by contrast medium, similar to pulmonary vessels. We suspected a pulmonary vessel anomaly such as an arterio-venous malformation or a varix. A bronchial arteriogram revealed it was a bronchial artery aneurysm (Fig. 1C)
. She had no symptoms such as bloody sputum or hemoptysis. After discussing whether BAE or thoracotomy would be the better choice for her treatment, we decided to perform a thoracotomy, because of its greater certainty of preventing a fatal hemorrhage which might have resulted from aneurysmal rupture.
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Fig. 1. Operative photograph (A) of the bronchial artery aneurysm (arrow) which did not diminish the tension after ligation of the major feeding bronchial artery. Schema (B). Dashed line in B indicates the location of middle lobe artery which was adherent to BAA. Selective bronchial arteriogram (C) showing a bronchial artery aneurysm (arrow). Pulmonary artery of the middle lobe (small arrows) is demonstrated caused by broncho-pulmonary arterial shunt.
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3. Operation
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She underwent thoracotomy via standard postero-lateral approach. A BAA 20 mm in diameter with an arterial pulsation and thrill was located in the horizontal fissure of the right lung. The BAA compressed the middle lobe artery, such that safe separation was impossible. It would likely be necessary to resect the middle lobe along with the BAA, because BAA was partially buried in the middle lobe. First, we ligated and cut a thick and winding bronchial artery covered with mediastinal pleura at the level of the carina. However, the pulsation of the BAA did not diminish and a thrill was still palpable (Fig. 1A,B). Middle lobe veins and the central part of the right pulmonary artery were clamped simultaneously, but the BAA retained its tension. Next, we clamped pulmonary artery above and below the BAA. A small incision was made in the pulmonary arterial wall close to the BAA. Continuous bleeding from the incision was observed, but the tension of the BAA still did not reduce. We realized that the BAA had many collateral connections to arteries in the peribronchial tissue and mediastinum. Therefore, we dissected the peribronchial sheath around the middle bronchus and ligated the peribronchial tissue including collateral arteries feeding into the BAA. As dissection of the peribronchial tissue proceeded, tension in the BAA gradually subsided. Then a side wall of the mid-pulmonary artery trunk including the BAA, which was densely adherent to the middle lobe artery was resected. No further bleeding was observed from the cut surface of the aneurysm. The cut surface of the pulmonary artery was repaired by suturing with 5-0 Prolene. The middle lobe vein was resected, the middle bronchus was cut and closed by suturing with 4-0 Prolene. Resection of middle lobe including BAA was then complete.
Histopathologically, the resected aneurysm was identified to be a saccular aneurysm (Fig. 2A)
.. Peculiarly, numerous muscular arterioles and capillaries were demonstrated around the root of the aneurysm, and an arrow indicated a portion of arteriolar communication with the aneurysmal wall (Fig. 2B).
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Fig. 2. Saccular aneurysm (A; Elastica Masson trichrome, x2.5). Numerous blood vessels were observed around the root of the aneurysm in (B). An arrow indicated a communicating portion between the muscular arteriole and the aneurysmal wall (Elastica Masson trichrome, x10). Asterisk, root of the aneurysm
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We speculate that these vessels connected with patent peripheral collateral arteries to provide blood flow to the BAA after the major feeding bronchial artery was ligated.
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4. Comment
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BAE is a good procedure to control patients with hemoptysis. However, in some patients hemostasis is unsuccessful or bleeding recurs after BAE, because of several reason, such as arterial re-canalization after embolization or aortic dissection of the origin of bronchial artery during an endovascular procedure [4–8]. These mean that the hemoptysis is not radically controlled by BAE alone, because of subsequent revascularization by collateral arteries surrounding the lesion that connect with patent peripheral bronchial arteries. We should understand that patients are not completely cured of a BAA by BAE. Elimination of the image of a BAA on the post-BAE bronchial arteriogram should not be equated with elimination of the lesion itself. Blood flow into an aneurysm may not necessarily be cut off completely even if major bronchial arterial occlusion has been established by BAE.
Our patient's BAA did not collapse after we ligated the major bronchial artery feeding into the BAA. The risk of rupture of the thin-walled BAA was not resolved because tension in the BAA was maintained by blood supplied by collateral vessels. For this reason, embolization of the bronchial artery supplying an aneurysm may fail to eliminate the lesion.
We understand BAE is a good treatment choice for patients with hemoptysis who have poor lung function or cannot undergo a thoracotomy because of high risk status. Although definite conclusions cannot be drawn from this case report, we recommend that in young patients who can tolerate the procedure and have long life expectancy, thoracotomy and operative aneurysmectomy with or without lobectomy should be considered to prevent lethal hemorrhage caused by aneurysmal rupture even if it is not symptomatic.
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References
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Abstract
1. Introduction
