An unusual cause of hemoptysis: costocervical trunk pseudoaneurysm

Abstract

A 40-year-old male patient presented with recurrent bouts of hemoptysis over a period of 4 days amounting to a total quantity of 400 ml. On the evening of presentation to the hospital, he had a massive bout of hemoptysis of approximately 500 ml. He had a history of pulmonary tuberculosis (confirmed on sputum examination and imaging) for which he had not taken the complete course of antitubercular chemotherapy. His initial hemoglobin levels were 11 g/dl, and after the bout of hemoptysis dropped to 7 g/dl. His blood pressure was 100/70 mm Hg with postural hypotension. The result of the bronchoscopic examination was normal. The chest X-ray showed the presence of right upper lobe consolidation. The computed tomography (CT) angiography (using bolus tracking technique with the curser on the descending thoracic aorta) for evaluation of the bronchial vessels showed an abnormal enhancing lesion of approximately 1.3 × 1.4 × 1.2 cm seen on the right upper lobe near the posterior parietal pleura at the lung apex. The lesion was isodense to the surrounding contrast-enhanced subclavian artery branches, and the lesion was seen in relation to one of the branches of the second part of the right subclavian artery which was confirmed on coronal reformatted maximum intensity projections and volumerendered images to be the costocervical trunk (Figs.1, 2, 3). The right bronchial artery, right intercostal arteries, and right internal mammary artery were normal in diameter and course. A decision was taken to approach the lesion through an endovascular approach. The angiography was done via a right transfemoral route. Using a 5F PICARD catheter (Cook, Bloomington, USA), the selective injections of the right subclavian artery showed the presence of an approximately 1.5-cm diameter oval contrast-filled outpouching seen in relation to the highest intercostal branch of the costocervical trunk. Superselective cannulation of this branch was done by using a 2.7F Progreat microcatheter (Terumo, NJ, USA), and the pseudoaneurysm was embolized using n-butyl cyanoacrylate (NBCA) (Endocryl, Samarth Life Sciences Limited, Solan, India) mixed with lipiodol (Lipiodol Ultra-Fluide, Guerbet, Istanbul) (50% mixture, total of about 1 ml). After the embolization, the patient was followed up for 3 months and there was no recurrence of hemoptysis noted. M. Singhal (*) : S. Giragani :A. Lal :N. Khandelwal Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India 160012 e-mail: drmsinghal@yahoo.com