Endovascular treatment of a ruptured pulmonary artery aneurysm in a patient with Behçet's disease using the Amplatzer Vascular Plug 4

Transcatheter Embolization of Pulmonary Artery Aneurysm With Vascular Plug in Behcet's Disease: A Case Report

Pulmonary artery aneurysm (PAA) is one of the pulmonary manifestations of Behçet's disease, with hemoptysis as the primary symptom, carrying a high mortality risk. Treatment options include medical therapy, transcatheter embolization, and surgery. We report a case of a wide-neck PAA in a patient with Behçet's disease who did not respond to immunosuppressive therapy and was successfully treated with endovascular embolization using a vascular plug. The patient remained asymptomatic, with no recurrence of hemoptysis post-procedure. Treatment selection depends on aneurysm characteristics and institutional expertise. Vascular plugs offer a valuable alternative, particularly for wide-neck aneurysms, ensuring effective and durable occlusion.

Cardiovascular Manifestations in Behçet's Disease

Cardiovascular involvement in Behçet's disease (BD) is considerably related to morbidity and mortality. However, the cardiovascular manifestation is sometimes difficult to distinguish from those of other causes. The suspicion of BD and proper treatment is pivotal in the management of BD. Histology demonstrates perivasculitis. Neutrophil seems to play an important role in the inflammation of BD. It is thought that inflammation causes venous thrombosis and arterial aneurysm. Characteristically, BD involves both arteries and veins of variable size in any region. Venous thrombosis needs immunosuppression, and inferior vena cava thrombosis and Budd-Chiari syndrome require intensive immunosuppressive therapy. Arterial involvement causes aneurysm which usually is treated by surgical or endovascular intervention with immunosuppression. Pulmonary artery aneurysm and cardiac involvement require multimodal managements.

Issues in Medicine

Rasmussen aneurysms are abnormalities of the pulmonary arterial system caused by tuberculosis (TB). They are associated with a highmortality rate when they cause life-threatening haemoptysis. High TB-prevalence regions have a large burden of TB-related haemoptysisbut often limited resources. This series of 25 patients who presented with life-threatening haemoptysis from current and/or previous TBwere found to have abnormal pulmonary arteries on computed tomography pulmonary angiogram (CTPA), which were judged to belikely contributors to their bleeding, either in isolation or with concomitant abnormal bronchial or systemic vasculature. These patientsunderwent transcatheter placement of Amplatzer vascular plugs in the feeder pulmonary artery. Bronchial and systemic lesions wereaddressed separately as needed. Immediate technical success was achieved in all patients, but four of them experienced intraoperativehaemoptysis related to dislodgement of the occluding platelet plug by the high-pressure automatic injector and wire. At 48 hours after theprocedure, 18 (72%) remained haemoptysis-free. Six of these experienced recurrence within 1 year of their procedure. Pulmonary arteryplacement of an Amplatzer vascular plug is a feasible option for treating bleeding Rasmussen aneurysms, but should be part of a combinedapproach to addressing suspected culprit vascular lesions in all intrathoracic vascular systems.

Vascular complications of Behçet disease

Behçet disease is a multi-systemic complex vasculitis with unknown etiology characterized by different clinical involvements, including mucocutaneous, ocular, vascular, articular, neurological, and gastrointestinal manifestations. Growing evidence supports that different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, the vascular phenotype identifies a specific group of patients who suffer from recurrent inflammatory thrombosis and arterial involvement. Vascular disease develops in up to 40% with a definite male preponderance and is usually an early manifestation. Venous involvement is significantly more common than arterial disease, and lower extremity deep vein thrombosis is its most frequent manifestation. Arterial disease involves mostly pulmonary arteries and aorta and manifests mainly in the form of aneurysms. Glucocorticoids and immunosuppressants are the recommended first-line treatments in vasculo-Behçet. Furthermore, controlled trials are still needed to assess the role of adding anticoagulation to the treatment regimen, with an accent on new oral anticoagulants. Treatment with anti-TNF alpha agents seems promising, but the management strategies are not clear yet.

Iatrogenic perforation of a pulmonary artery side branch-a case report

Background

The use of a pulmonary artery catheter (PAC) continues to be important for the diagnosis and therapeutic control of severe heart failure and in the diagnosis of pulmonary arterial hypertension. One of the most feared complications of this examination is perforation of a pulmonary artery with an estimated incidence of 0.031-0.05% and mortality rates of up to 70%.

Case summary

We report on an 80-year-old female patient who experienced a perforation of a pulmonary artery branch during the work-up of pulmonary arterial hypertension by PAC. Immediately after the perforation, haemodynamic shock developed rapidly, necessitating cardiopulmonary resuscitation. Occlusion of the pulmonary artery branch with a semicompliant balloon was applied immediately. After 40 min of occlusion, the bleeding persisted, and endovascular coil implantation was performed. Subsequently, the bleeding stopped, and the haemodynamics stabilized. After treatment, the patient was discharged home without any significant sequelae.

Discussion

Treatment options in pulmonary artery perforation are limited, especially if the patient is inoperable and if balloon occlusion fails. Based on our results, endovascular coil embolization can be considered a therapeutic option.

N-Butyl Cyanoacrylate Embolization of a Peripheral Pulmonary Artery Aneurysm in a Patient with Patent Ductus Arteriosus

N-Butyl cyanoacrylate embolization of peripheral pulmonary artery aneurysms has rarely been performed. This report presents a young woman with a history of patent ductus arteriosus and massive hemoptysis secondary to pulmonary artery aneurysm, successfully managed by embolotherapy using n-Butyl cyanoacrylate. This is the first report of n-Butyl cyanoacrylate embolization treatment of a bleeding pulmonary artery aneurysm in the setting of patent ductus arteriosus. The pertinent literature has been reviewed and the clinical background and the procedure have been explained.

Transcatheter embolization for idiopathic peripheral pulmonary arterial aneurysm: A case report

The natural history of idiopathic peripheral pulmonary arterial aneurysms (PAAs) is unclear; however, they can cause sudden death by rupture. Our case illustrates the utility and low invasiveness of transcatheter embolization using an AMPLATZER™ Vascular Plug 4 and hydrogel-coated metallic coils in patients with idiopathic peripheral PAAs.

Diagnosis and management of hemoptysis

Hemoptysis is the expectoration of blood that originates from the lower respiratory tract. It is usually a self-limiting event but in fewer than 5% of cases it may be massive, representing a life-threatening condition that warrants urgent investigations and treatment. This article aims to provide a comprehensive literature review on hemoptysis, analyzing its causes and pathophysiologic mechanisms, and providing details about anatomy and imaging of systemic bronchial and nonbronchial arteries responsible for hemoptysis. Strengths and limits of chest radiography, bronchoscopy, multidetector computed tomography (MDCT), MDCT angiography and digital subtraction angiography to assess the cause and lead the treatment of hemoptysis were reported, with particular emphasis on MDCT angiography. Treatment options for recurrent or massive hemoptysis were summarized, highlighting the predominant role of bronchial artery embolization. Finally, a guide was proposed for managing massive and nonmassive hemoptysis, according to the most recent medical literature.

Pulmonary artery aneurysms in Behçet disease

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.

Behçet's disease, echocardiographers, and cardiac surgeons: together is better

Behçet's disease is an inflammatory disorder of unknown etiology, characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Many abnormal echocardiographic findings have been previously reported in patients with Behçet's disease. Some of these; namely, aortic root dilation, aortic valve regurgitation, intracardiac thrombi, and pulmonary artery aneurysm may precede other manifestations of the disease and occasionally require surgical intervention for proper management. Compared to patients without Behçet's disease, management of these complications in patients with the disease is challenging and requires different treatment strategies. If diagnosis of Behçet's disease is missed prior to surgical intervention, higher incidence of surgical failure, recurrence, and even higher postoperative mortality may occur. In this review, the author discusses these major cardiac complications of Behçet's disease.

Use of amplatzer vascular plug to treat a biliary cutaneous fistula

Several substances have been used in an attempt to sclerose biliary ducts associated with persistent biliary-cutaneous fistula (BCF). The AMPLATZER Vascular Plug (AVP; AGA Medical, USA) system is a recently developed endovascular occlusion device, introduced as an alternative to permanent embolic materials (metallic coils or acrylic glue), in the occlusion of large and medium-calibre arteries and veins. We report a successful use of the AVP to embolize BCF, developed after the removal of an internal-external biliary drainage.