Lung Bleeding Caused by Tumoral Infiltration into the Pulmonary Artery—Minimally Invasive Repair Using Microcoils

Abstract

A 45-year-old male was admitted to our hospital, having experienced a sudden life-threatening hemoptysis. The patient’s history was without any pathological findings except for a history of 25 pack years of smoking. For 2 months he had suffered from dyspnea and weight loss of about 5 kg. The life-threatening situation was caused not only by blood loss (hemoglobin dropped to 8.5 mg/dl) but by a significant deterioration of respiration due to coughing and the resulting massive agitation of the patient. Therefore, it was decided to keep the patient under general anesthesia for further treatment to better control the respiration situation and to stabilize him, after which bronchoscopy was performed. This examination showed active bleeding arising from a bronchus of the right upper lobe, however, exact localization of the origin of the bleeding was not possible and therefore adrenaline was successfully administered intrabronchially to stop the hemoptysis. After this tentative therapy the patient was sent to our institution for a CT examination to diagnose the exact reason for the bleeding and to make planning of further therapy possible. Due to the policy of our hospital to immediately perform CT examinations in patients suffering from any lifethreatening condition (for example, bleedings of unknown origin or after serious accidents), no conventional lung xrays were taken. A biphasic CT examination was performed using a 64row scanner (Siemens Sensation 64; Forchheim, Germany). The scan was performed using a fixed protocol (detector collimation, 32 · 2 · 0.6 mm; spatial resolution, 0.4 · 0.4 · 0.4 mm; gantry rotation time, 330 ms; pitch, 1 mm/gantry rotation; tube voltage, 120 kV; tube current, 120 mAs), and a volume of 80 ml of contrast (Iomeprol 300; Altana Pharma, Konstanz, Germany) at a flow rate of 4.5 ml/s was given using bolus triggering. This arterial phase was followed by a venous phase after an additional delay of 45 s using the same scan parameters. For display purposes, maximum-intensity projections (MIPs) and multiplanar reformations (MPRs) were used. An advanced-stage lung cancer had to be diagnosed, located centrally adjacent to the right hilum with invasion of the mediastinum. On the coronal reformats a pseudoaneurysm of a pulmonary artery was found, which was due to an erosion by the tumor (Fig. 1). Further proceedings were discussed among the thoracic surgeons, anesthesiologists, and interventional radiologists and it was decided to make a minimally invasive attempt to treat the pseudoaneurysm in this highly palliative situation. The patient was still under general anesthesia on demand of the anesthiologists to avoid difficulties in treatment due to coughing or due to agitation of the patient. He was positioned on the table of the angio suite and an approach via the right femoral vein was employed in order to probe the pathologic pulmonary artery. For the transcardiac pathway a combination of a 0.035-in. hydrophilic guide wire (Terumo; Terumo Deutschland GmbH, Eschborn, Germany) and a 4-Fr pigtail catheter (Optimed; Ettlingen, Germany) was used. After successfully reaching the central pulmonary artery an overview angiography was performed using 35 ml of contrast at a flow rate of 18 ml/s. The R. T. Hoffmann (&) M. F. Reiser Institute of Clinical Radiology, Ludwig-Maximilians University, Grosshadern Campus, Marchioninistrasse 15, Munich 81377, Germany e-mail: ralf-thorsten.hoffmann@med.uni-muenchen.de