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Non-bronchial causes of haemoptysis: imaging and interventions. Pol J Radiol 2020; 85:e328-e339. [PMID: 32685069 PMCID: PMC7361373 DOI: 10.5114/pjr.2020.97014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/16/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose To describe non-bronchial causes of haemoptysis on imaging and the role of interventional radiology in their management from cases of haemoptysis archived from our database at a tertiary care, federally funded institution. Material and methods Retrospective analysis of cases that presented with haemoptysis in our institution from 2008 to 2013 was done, and details of cases in which the bleeding was from a non-bronchial source were archived and details of imaging and treatment were recorded. Results Retrospective analysis of patients presenting with haemoptysis yielded 24 (n = 24) patients having haemoptysis from non-bronchial sources. Causes of haemoptysis were: Rasmussen aneurysms (n = 12/24), costocervical trunk pseudoaneurysm (n = 1/24), left internal mammillary artery pseudoaneurysm (n = 1/24), left ventricular aneurysms (n = 3/24), pulmonary arteriovenous malformations (AVMs) (n = 5/24), and proximal interruption of pulmonary artery (n = 2/24). Imaging and interventional radiology management are described in detail. Conclusions Haemoptysis can be from non-bronchial sources, which may be either from systemic or pulmonary arteries or cardio-pulmonary fistulas. Bronchial computed tomography angiography (CTBA), if feasible, must always be considered before bronchial artery embolisation because it precisely identifies the source of haemorrhage and vascular anatomy that helps the interventional radiologist in pre-procedural planning. This circumvents chances of re-bleed if standard bronchial artery embolisation is done without CTBA.
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2
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Voiriot G, Parrot A, Antoine M, Gibelin A, Haddad S, Carette MF, Fartoukh M, Khalil A. Transcatheter embolotherapy of pulmonary artery aneurysms as emergency treatment of hemoptysis in Behcet patients: experience of a referral center and a review of the literature. Intern Emerg Med 2018. [PMID: 29516432 DOI: 10.1007/s11739-018-1817-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Hemoptysis is a life-threatening complication of Behcet's disease that is likely related to pulmonary artery aneurysm (PAA). Vascular interventional radiology may offer effective emergency therapeutic option, but has not been thoroughly investigated in this setting. A case series of a French referral center for hemoptysis combined with a literature review of case reports was conducted. Between 1995 and 2016, 12 patients were referred to our center for hemoptysis revealing or complicating the course of Behcet's disease. Pulmonary artery aneurysm (PAA) was the mechanism of hemoptysis in ten patients, nine of whom were treated by a transcatheter embolotherapy. Combining an additional 8 case reports from the literature, 17 patients treated by transcatheter embolotherapy for PAA were analyzed. The duration of the course of Behcet's disease was 22 months [IQR 3-45] at the time of PAA diagnosis. Transcatheter embolotherapy of PAA was successful for immediately controlling hemoptysis in all patients, without major complication except for one. Hemoptysis recurred in seven patients (41%) within 5 months [IQR 1-12]. The use of coils for transcatheter embolotherapy was associated with hemoptysis recurrence. A bronchosystemic hypervascularization related to the previously occluded PAA was the main mechanism of bleeding recurrence, leading to bronchosystemic artery embolization in four patients and surgery in two patients. Behcet's disease-related hemoptysis is mainly due to PAA. Transcatheter embolotherapy should be considered as the first-line emergency treatment for PAA-related hemoptysis, in association with the immunosuppressive regimen. Hemoptysis may recur in half of the cases, involving preferentially a bronchosystemic arterial mechanism.
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Affiliation(s)
- Guillaume Voiriot
- Service de Réanimation Médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020, Paris, France.
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est, Créteil, France.
| | - Antoine Parrot
- Service de Réanimation Médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020, Paris, France
| | - Martine Antoine
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Aude Gibelin
- Service de Réanimation Médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020, Paris, France
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est, Créteil, France
- Faculté de Médecine, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Samuel Haddad
- Service de Radiologie, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie-France Carette
- Faculté de Médecine, Université Pierre et Marie Curie Paris VI, Paris, France
- Service de Radiologie, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Muriel Fartoukh
- Service de Réanimation Médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020, Paris, France
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est, Créteil, France
- Faculté de Médecine, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Antoine Khalil
- Service de Radiologie, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, Paris, France
- Service de Radiologie, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique-Hôpitaux de Paris, Paris, France
- Faculté de Médecine, Université Paris Diderot Paris VII, Paris, France
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3
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Rossi GM, Emmi G, Vaglio A. Hemoptysis in Behçet's syndrome: from bedside to bench? Intern Emerg Med 2018; 13:467-469. [PMID: 29736629 DOI: 10.1007/s11739-018-1863-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/21/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Giovanni Maria Rossi
- Renal Unit, Clinical and Experimental Medicine Department, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
- Medicina Interna Interdisciplinare, Department of Clinical and Experimental Medicine, Careggi University Hospital of Florence, Florence, Italy
| | - Giacomo Emmi
- Medicina Interna Interdisciplinare, Department of Clinical and Experimental Medicine, Careggi University Hospital of Florence, Florence, Italy
| | - Augusto Vaglio
- Renal Unit, Clinical and Experimental Medicine Department, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy.
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4
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Abstract
Pulmonary artery aneurysms (PAAs) are the most common type of pulmonary involvement in Behçet's disease. However, the relationships between clinical features and prognosis have not been sufficiently evaluated. This article describes the results of a comprehensive review, revealing that PAAs have a predilection for hemoptysis manifestations, increased dimensions, right lower lobar location, multiplicity and concurrent intramural thrombus formation. Surgical intervention was needed in one third of patients. Patients with massive hemoptysis and PAA rupture warranted emergency operations. Conservatively treated patients were prone to PAA progression; interventional embolization was associated with higher risks of recurrence and reintervention for PAAs; and surgically treated patients exhibited the highest mortality rates. In conclusion, PAAs in Behçet's disease are characterized by a predilection for hemoptysis manifestations, right lower lobar location, multiplicity, and concurrent intramural thrombus formation. Both the condition itself and the surgical operations it warrants are linked with high mortality due to PAA hemorrhage.
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Affiliation(s)
- Shi-Min Yuan
- Fujian Medical University, People's Republic of China
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5
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Ianniello A, Carrafiello G, Nicotera P, Vaghi A, Cazzulani A. Endovascular treatment of a ruptured pulmonary artery aneurysm in a patient with Behçet's disease using the Amplatzer Vascular Plug 4. Korean J Radiol 2013; 14:283-6. [PMID: 23482415 PMCID: PMC3590341 DOI: 10.3348/kjr.2013.14.2.283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 04/03/2012] [Indexed: 11/15/2022] Open
Abstract
A pulmonary artery aneurysm is a common manifestation and the leading cause of mortality in Behçet's disease. We describe a case of spontaneous rupture of a pulmonary artery aneurysm that, due to the inadequacy of medical therapy and the disadvantages of surgery, became the ideal candidate for endovascular management and was successfully performed by using the Amplatzer Vascular Plug 4.
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Affiliation(s)
- Andrea Ianniello
- Department of Radiology, G. Salvini Hospital, Garbagnate Milanese (MI) 20024, Italy.
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Seyahi E, Melikoglu M, Akman C, Hamuryudan V, Ozer H, Hatemi G, Yurdakul S, Tuzun H, Oz B, Yazici H. Pulmonary artery involvement and associated lung disease in Behçet disease: a series of 47 patients. Medicine (Baltimore) 2012; 91:35-48. [PMID: 22210555 DOI: 10.1097/md.0b013e318242ff37] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Pulmonary artery aneurysms (PAAs) are well known causes of mortality and morbidity in Behçet disease (BD). However, pulmonary artery involvement in BD is not limited to PAA; the other main type of pulmonary artery involvement is pulmonary artery thrombus (PAT), with or without associated PAA. In addition, other types of lung disease like nodules and cavities in the lung parenchyma are frequently associated with pulmonary artery involvement, and can be misinterpreted as being due to infection. We surveyed the clinical, radiologic, and laboratory characteristics and outcome of 47 BD patients with pulmonary artery involvement and the associated findings, all seen and followed at a single dedicated tertiary care center.We identified 47 (41 male, 6 female) patients in whom pulmonary artery involvement was diagnosed, who were registered in the multidisciplinary clinic at Cerrahpasa Medical Faculty between January 2000 and December 2007. Mean age at diagnosis was 29 ± 8 years, and mean disease duration to the onset of pulmonary artery involvement was 3.6 ± 4.8 years. Hemoptysis was the most common presenting symptom (79%) followed by cough, fever, dyspnea, and pleuritic chest pain. Thirty-four of 47 patients (72%) presented with PAA, including 8 with associated PAT. The remaining 13 patients (28%) had isolated PAT. Patients with isolated PAT in general have clinical features similar to patients with PAA. However, hemoptysis was less frequent and voluminous in patients with isolated PAT. Most (91%) of the patients had active disease outside the lungs when they presented with pulmonary artery involvement.Forty (85%) patients had nodules and 6 (13%) had cavities when first seen. Peripheral venous thrombosis was present in 36 of 47 (77%) patients, and intracardiac thrombi in 12 of the 36 (33%) patients. Nodules, cavities, and intracardiac thrombi were mainly present in the acute stages of pulmonary artery involvement.Pulmonary artery involvement is usually multiple, and involves mostly descending branches of the pulmonary artery. Pulmonary artery involvement may disappear, but arterial stenosis or occlusions usually develop at the same location. After a mean follow-up of 7 years, 12 of 47 (26%) patients were dead; patients with larger aneurysms were more likely to die. Sixteen of 47 (34%) patients were symptom free, and the remaining 40% had mild dyspnea (13/47) and/or small bouts of hemoptysis (8/47).Pulmonary artery pressure may be elevated, and may indicate a poor prognosis. Mediastinal lymphadenopathy and mild pleural and pericardial effusions may also be observed. Corticosteroids and immunosuppressive agents are the mainstays of treatment; however, refractory cases may require embolization, lobectomy, cavitectomy, and decortication.
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Affiliation(s)
- Emire Seyahi
- From Division of Rheumatology (ES, MM, VH, GH, SY, HY); Department of Radiology (CA, HO); Department of Cardiovascular Surgery (HT); and Department of Pathology (BO); Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
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7
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The estimated pulmonary artery pressure can be elevated in Behçet’s syndrome. Respir Med 2011; 105:1739-47. [DOI: 10.1016/j.rmed.2011.07.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Revised: 07/26/2011] [Accepted: 07/27/2011] [Indexed: 11/22/2022]
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8
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Sueyoshi E, Matsuoka Y, Sakamoto I, Uetani M. CT and clinical features of hemorrhage extending along the pulmonary artery due to ruptured aortic dissection. Eur Radiol 2009; 19:1166-74. [DOI: 10.1007/s00330-008-1272-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 11/07/2008] [Accepted: 11/12/2008] [Indexed: 02/07/2023]
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Cil BE, Turkbey B, Canyiğit M, Kumbasar OO, Celik G, Demirkazik FB. Transformation of a ruptured giant pulmonary artery aneurysm into an air cavity after transcatheter embolization in a Behçet's patient. Cardiovasc Intervent Radiol 2006; 29:151-4. [PMID: 16328688 DOI: 10.1007/s00270-005-0225-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pulmonary artery aneurysms due to Behçet's disease are mainly seen in young males and very rarely in females. To our knowledge there are only 10 cases reported in the related literature. Emergent transcatheter embolization was performed in a female patient with a known history of Behçet's disease in whom massive hemoptysis developed because of rupture of a giant pulmonary artery aneurysm. At 6-month follow-up, transformation of the aneurysm sac into an air cavity was detected. To our knowledge, such a transformation has never been reported in the literature before. Embolization of the pulmonary artery aneurysm and the mechanism of cavity transformation are reviewed and discussed.
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Affiliation(s)
- Barbaros E Cil
- Department of Radiology, Hacettepe University School of Medicine, Sihhiye, Ankara 06100, Turkey.
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Bruzzi JF, Rémy-Jardin M, Delhaye D, Teisseire A, Khalil C, Rémy J. Multi-detector row CT of hemoptysis. Radiographics 2006; 26:3-22. [PMID: 16418239 DOI: 10.1148/rg.261045726] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hemoptysis is symptomatic of a potentially life-threatening condition and warrants urgent and comprehensive evaluation of the lung parenchyma, airways, and thoracic vasculature. Multi-detector row computed tomographic (CT) angiography is a very useful noninvasive imaging modality for initial assessment of hemoptysis. The combined use of thin-section axial scans and more complex reformatted images allows clear depiction of the origins and trajectories of abnormally dilated systemic arteries that may be the source of hemorrhage and that may require embolization. Conditions such as bronchiectasis, chronic bronchitis, lung malignancy, tuberculosis, and chronic fungal infection are some of the most common underlying causes of hemoptysis and are easily detected with CT. "Cryptogenic" hemoptysis is common among smokers and warrants subsequent follow-up imaging to exclude possible underlying malignancy. The bronchial arteries are the source of bleeding in most cases of hemoptysis. Contributions from the non-bronchial systemic arterial system represent an important cause of recurrent hemoptysis following apparently successful bronchial artery embolization. Vascular anomalies such as pulmonary arteriovenous malformations and bronchial artery aneurysms are other important causes of hemoptysis. Multi-detector row CT angiography permits noninvasive, rapid, and accurate assessment of the cause and consequences of hemorrhage into the airways and helps guide subsequent management.
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Affiliation(s)
- John F Bruzzi
- Department of Radiology, Hospital Calmette, University Center of Lille, Blvd Jules Leclercq, 59037 Lille, France
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11
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Pelage JP, El Hajjam M, Lagrange C, Chinet T, Vieillard-Baron A, Chagnon S, Lacombe P. Pulmonary Artery Interventions: An Overview. Radiographics 2005; 25:1653-67. [PMID: 16284141 DOI: 10.1148/rg.256055516] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Interventional radiologists should be familiar with minimally invasive procedures used to treat various abnormalities of the pulmonary arteries. These well-established techniques, which obviate open surgery, are safe and effective when performed by an experienced interventionalist. Catheter-based thrombolysis with intrapulmonary arterial infusion of thrombolytic drugs, percutaneous thrombectomy, or embolus fragmentation can be performed in patients with life-threatening pulmonary embolism. Pulmonary artery stenoses, mainly encountered in patients with pulmonary vasculitis (as in Behçet disease or Takayasu arteritis), may be treated with balloon angioplasty and stent placement. Transcatheter embolization of pulmonary arteriovenous malformation is the standard treatment for hereditary hemorrhagic telangiectasia and is a very effective alternative to surgery to correct an aneurysm or pseudoaneurysm. In cases of hemoptysis that originates in the pulmonary artery, early diagnosis is mandatory for treatment with embolization. Percutaneous retrieval of foreign bodies from the heart or the pulmonary arteries and endovascular biopsy should also be part of the armamentarium of interventional radiologists.
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Affiliation(s)
- Jean-Pierre Pelage
- Department of Radiology, Hôpital Ambroise Paré, 9 ave Charles-de-Gaulle, 92104 Boulogne Cedex, France.
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12
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Abstract
STUDY OBJECTIVES The aims of this study were to investigate the frequency of pulmonary problems in Behçet disease (BD), and to discuss lesser-known features of pulmonary BD such as clinical characteristics, analysis of prognosis, and evaluation of treatment options with respect to the previously published cases. DESIGN We conducted a comprehensive review of the literature to analyze cumulated data about pulmonary involvement in BD. SETTING We found 159 articles regarding pulmonary disease associated with BD in May 2003. PATIENTS The evaluation of these articles demonstrated 598 pulmonary problems in 585 cases. RESULTS Pulmonary artery aneurysms (PAAs) are the most common pulmonary lesion in BD, and these are almost always associated with hemoptysis. Seventy-eight percent of patients with aneurysms have concomitant extrapulmonary venous thrombi or thrombophlebitis. Other pulmonary problems are reported in BD, and these are principally related to vascular lesions and radiologic abnormalities. CONCLUSIONS Pulmonary vascular problems, either PAA or involvement of small-sized vessels, are the main pulmonary disorders in BD. Immunopathologic findings indicate that the underlying pathogenesis is pulmonary vasculitis, which may result in thrombosis, infarction, hemorrhage, and PAA formation. Patients with small nonspecific radiologic abnormalities should be followed up closely since early diagnosis of vascular lesions may be life-saving. Immunosuppression is the main therapy for the treatment of a vasculitis. It is important that pulmonary angiitis is not mistaken for pulmonary thromboembolic disease since fatalities have occurred in BD shortly after initiation of anticoagulation/thrombolytic treatment.
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Affiliation(s)
- Oguz Uzun
- Department of Pilmonary Medicine, Faculty of Medicine, Ondokuz Mayis University, Tip Fak, Göğüs Hst. ABD 55139, Kurupelit-Samsun, Turkey.
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Hamuryudan V, Er T, Seyahi E, Akman C, Tüzün H, Fresko I, Yurdakul S, Numan F, Yazici H. Pulmonary artery aneurysms in Behçet syndrome. Am J Med 2004; 117:867-70. [PMID: 15589493 DOI: 10.1016/j.amjmed.2004.05.027] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2004] [Accepted: 05/20/2004] [Indexed: 11/21/2022]
Affiliation(s)
- Vedat Hamuryudan
- Behçet's Syndrome Research Center, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey.
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Interventionen. Thorax 2003. [DOI: 10.1007/978-3-642-55830-6_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
Pulmonary artery aneurysms varying in size and number continue to be the principal feature of pulmonary involvement in Behçet disease (BD). Pulmonary aneurysms have been reported to be associated with cardiac thromboses, mainly in the right heart. Bronchiolitis obliterans organizing pneumonia has also been seen in the setting of pulmonary artery aneurysms. Aneurysms of the aortic arch and subclavian artery are rarely recognized thoracic manifestations of BD. Noninvasive imaging techniques, such as helical computed tomography and magnetic resonance angiography, are the safer and preferred methods for identifying aneurysms and thrombi. Digital substraction angiography has been found to be inadequate in showing thrombosed vessels. Follow-up computed tomography was performed in the documentation of the aneurysmal healing process. In patients receiving immunosuppressive treatment, intramural thrombus formation occurred and was followed by aneurysmal regression and disappearance. General principles for the treatment of systemic vasculitis are used in the treatment of BD.
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Affiliation(s)
- F Erkan
- Division of Pneumology, Istanbul Medical Faculty, University of Istanbul, Capa/Istanbul, Turkey
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