Asian Cardiovasc Thorac Ann 1999;7:78-79
© 1999 Asia Publishing EXchange Pte Ltd
Massive Hemoptysis in Pulmonary Arterial Fistula Masquerading as Aneurysm
Hemant P Pathare, MCh,
Sanjay B Dhaded, MCh,
Jagdish Khandeparkar, MCh,
Ratna A Magotra, MS,
Jaya Deshpande, MD,1,
Ammu Sivaraman, MD,1
Department of Cardiothoracic Surgery India
1 Department of Pathology King Edward VII Memorial Hospital Parel, Mumbai 400012, India
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A 40-year-old male suffering from fibro-cavitary tuberculosis, on 4-drug antituberculous therapy for the previous 4 months, was referred to us after a massive bout of hemoptysis (approximately 500 mL) associated with hemodynamic instability. He required 3 units of packed cells. Chest radiography showed scattered nodular and reticular parenchymal shadows (Figure 1
). An urgent angiogram was carried out for bronchial artery em-bolization. Unfortunately, the bronchial arteries could not be cannulated. Contrast-enhanced computed tomography demonstrated a well-defined 7.3 x 6.1 cm mass involving the right lower lobe (Figure 2), suggestive of a partially thrombosed pulmonary artery aneurysm with impending rupture. The lung parenchyma showed evidence of extensive tuberculosis and bronchiectases especially in the right lower lobe. A hurried suboptimal emergency pulmonary angiogram was performed, which seemed to confirm the diagnosis.
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Figure 1. Chest radiograph showing evidence of extensive tuberculosis and right pulmonary artery prominence.
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Figure 2. Contrast-enhanced computed tomogram suggesting a partially thrombotic aneurysm of the right lower lobar pulmonary artery.
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An emergency right pneumonectomy was carried out. The right lung was extensively adherent to the parietes and a firm mass was palpable in the lower lobe. The operative field was soiled during the resection. Less than 24 hours after an uneventful extubation, the patient developed progressive cardiorespiratory failure. He was subsequently ventilator dependant, required inotropic support, and developed progressive left pneumonitis. Our patient tested positive for sputum acid-fast bacillus. A tracheostomy was carried out on postoperative day 9 to facilitate tracheobronchial toilet. A right bronchopleural fistula was noticed on postoperative day 15, which contributed to subsequent mediastinitis. The patient died of septicemic complications on postoperative day 25. The resected specimen revealed a 7.2 x 6.1 x 4 cm cavity with a thin fibrotic wall surrounded by confluent areas of consolidation. The right lower lobar pulmonary artery was in direct communication with the cavity (Figure 3).
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Figure 3. Specimen of the right lung showing the large tuberculous cavity filled with clots and with a probe passing into the lower right pulmonary artery.
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Tuberculosis is endemic in India. While blood-streaked sputum is common, massive hemoptysis is rare. The bronchial artery is the most common source of bleeding and bronchial artery embolization is the treatment of choice for massive hemoptysis. Advanced tuberculous bronchiectasis may lead to arteriovenous malformation and severe hemoptysis. Other causes of hemoptysis include the microscopic Rasmussen's aneurysms and peripheral pulmonary artery aneurysms fistulizing into the tracheo-bronchial tree. In our case, we presume that chronic infection of the large tuberculous cavity eroded into the right lower lobar pulmonary artery, leading to massive hemoptysis.
Rigid bronchoscopy can help in localizing the site of bleeding to a segmental bronchus that can be occluded with a Fogarty arterial embolectomy catheter. The remaining ipsilateral and contralateral lung is often filled with blood to the extent that acute hypoxia is present. Lavage, suction, and physiotherapy require several days to achieve adequate clearance. Ideally, resection should be attempted only after the remaining lung is adequate to serve the needs of the patient.1 Frequently in primary health centers, antituberculous therapy is started empirically without a prior chest radiograph. Had one been available, the cavity might have been seen. We were misled into believing that this was a pulmonary artery aneurysm with imminent rupture. In view of the patient's poor pulmonary reserve, perhaps a resection of lesser magnitude (a right lower lobectomy) might have saved his life.
Reference
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Shield TW, editor. Congenital vascular lesions of the lungs. In: General thoracic surgery. Vol. 2. Malvern: Williams & Wilkins, 1994:903.
