(Chest. 2002;121:261-263.)
© 2002
American College of Chest Physicians
Rounded Mass in the Middle Lobe After Swan-Ganz Catheterization*
Joey J. Brahim, MD;
David Cheung, MD, PhD, FCCP;
Jesse A. J. Jessurun, MD;
Mariken J. A. Wolters-Geldof, MD and
Klaus F. Rabe, MD, PhD
*
From the Departments of Pulmonology (Drs. Brahim, Cheung, and Rabe), Radiology (Dr. Jessurun), and Cardiology (Dr. Wolters-Geldof), Leiden University Medical Center, Leiden, The Netherlands.
Correspondence to: Joey J. Brahim, MD, Department of Pulmonology, C3-P-18, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands; e-mail: J.J.Brahim{at}LUMC.NL
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Introduction
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A 76
-year-old woman was admitted to the hospital because of episodes of
ventricular tachycardia. She had a history of myocardial infarction in
1973 and underwent coronary artery bypass surgery in 1993.
Transesophageal echocardiography revealed grade 3 mitral valve
regurgitation. A left and right cardiac catheterization was performed
with insertion of a Swan-Ganz catheter via the right femoral vein.
Shortly after inflating the balloon in the wedge position, the patient
experienced an episode of hemoptysis of approximately 50 mL. The
pulmonary artery pressure was 40/20 mm Hg (mean, 21 mm Hg). Because of
oxygen desaturation, she was transferred to the ICU. The chest
radiograph then obtained showed a well-circumscribed rounded mass in
the right middle lung zone (Fig 1
), which was not seen on prior chest radiographs.
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What is the diagnosis?
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Diagnosis:
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False aneurysm of the pulmonary artery induced by a
Swan-Ganz catheter
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Discussion
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Because of suspected intrapulmonary hemorrhage, a CT scan of the
thorax was performed that showed a large mass in the right
mid-zone with slight enhancement after contrast administration (Fig 2
). Because the possibility of a perforation of the pulmonary artery was
also considered clinically, a pulmonary angiogram was performed.
Initial anteroposterior cut film angiography of the right lung was
performed, injecting 30 mL of contrast medium (Iomeron 350; Bracco-Byk;
Byk-Gulden, Germany) at 20 mL/s through a 7.1F Hellman angled pigtail
catheter (Cordis Europe; Roden, The Netherlands). Enhancement of the
lesion was prompt. A selective right interlobar pulmonary artery
injection more clearly demonstrated a persistent collection of contrast
arising from the medial branch of the artery of the middle pulmonary
lobe, compatible with a false aneurysm (Fig 3
). No contrast extravasation into the airways was noticed.
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Figure 2.. CT images (top: mediastinal
setting; bottom: parenchyma setting) through the area of
the mass in the middle lobe with enhancement after contrast
administration with the same attenuation as blood.
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The pigtail catheter subsequently was exchanged over an exchange wire
for a 7F headway guiding catheter with a 5F inner coaxial catheter
(Nycomed; Paris, France). This catheter was advanced over an angled
0.035-inch Radiofocus guidewire (Terumo; Tokyo, Japan) into the medial
branch of the middle lobe pulmonary artery. A 8 x 11-mm detachable
gold valve balloon (GVB 17; Nycomed) was used to occlude the segmental
artery proximal to the pseudoaneurysm. Postembolization digital
pulmonary arteriogram showed successful occlusion of the segmental
artery (Fig 4
).
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Figure 4.. Selective occlusion of the feeding vessel (medial
branch of the middle lobe artery) of the false aneurysm by a detachable
balloon (arrow). Top: cut film. Bottom:
digital subtraction angiography.
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Pulmonary artery rupture is a rare complication of pulmonary artery
Swan-Ganz catheterization (0.05 to 0.2%).1
The most
common presenting symptom is hemoptysis, which can be fatal in 45 to
65% of cases. If the patient survives, a false aneurysm of the
pulmonary artery may be the result, which is located most often in
segmental or subsegmental branches of the right middle or lower lobe
pulmonary artery. This may lead to recurrent life-threatening
hemorrhage.2
Dynamic contrast-enhanced CT and pulmonary
angiography are used to confirm the diagnosis.3
Transcatheter embolotherapy is the treatment of choice with lower
morbidity and mortality than lobectomy. Occlusion of the
pulmonary artery branches is a well-accepted method of treatment by
either selective placement of coils or a detachable balloon in the
feeding artery of the false aneurysm. Both occlusion methods share
similar limitations and complications during the placement of the
embolization device. Advantages of the detachable balloon technique are
the possibility to selectively occlude the feeding vessel just proximal
from the false aneurysm, without the risk of migration that can be the
case with coils.4
A review article by DeLima et
al2
described 92 cases of pulmonary artery rupture induced
by pulmonary catheterization that led to 28 occurrences of false
aneurysm. Of these, only 12 false aneurysms were detected and treated
(11 by transcatheter embolotherapy) before rupture. All patients
treated before rupture of the false aneurysm survived, whereas
mortality was 100% in patients with rupture of false aneurysms before
treatment.
Our patient survived her iatrogenic complication that happened almost 2
years ago, without having recurrent hemoptysis. The mass on her chest
radiograph was no longer visible after 5 months.
In conclusion, a diagnosis of false aneurysm of the pulmonary artery
should be considered in all patients who experience hemoptysis
associated with Swan-Ganz catheterization.
Received for publication September 25, 2000.
Accepted for publication November 21, 2000.
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References
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Boyd, KD, Thomas, SJ, Gold, J, et al (1983) A prospective study of complication of pulmonary artery catheterizations in 500 consecutive patients. Chest 84,243-249
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DeLima, LGR, Wynands, JE, Bourke, ME, et al (1994) Catheter-induced pulmonary artery false aneurysm and rupture: case report and review. J Cardiothorac Vasc Anesth 8,70-75[Medline]
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Ferretti, GR, Thony, F, Link, KM, et al (1996) False aneurysm of the pulmonary artery induced by a Swan-Ganz catheter: clinical presentation and radiologic management. AJR Am J Roentgenol 167,941-945[Abstract/Free Full Text]
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Remy-Jardin, M, Wattinne, L, Remy, J (1991) Transcatheter occlusion of pulmonary artery circulation and collateral supply: failures, incidents, and complications. Radiology 180,699-705[Abstract/Free Full Text]
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Introduction
What is the diagnosis?
