A Rare Case of Ruptured Bronchial Artery Pseudoaneurysm and Its Nonsurgical Management With Interventional Techniques

Abstract

Ruptured bronchial artery pseudoaneurysms with mediastinal hematoma are rare entities with a very limited number of published cases to date. The diagnosis of such cases can be difficult as the patient may present with symptoms mimicking other diseases, mainly mediastinal malignancy. A high degree of clinical suspicion and imaging techniques like contrast-enhanced computed tomography (CECT) chest and computed tomography angiography (CTA) aids in the diagnosis. Under the lights of an interventional radiologist, an urgent endovascular approach is most commonly preferred for its nonsurgical management. We present a rare case of a 47-year-old male with no previous lung disease or trauma with dyspnea and sudden onset chest pain. A massive effusion was suspected on the right side. CECT chest and digital subtraction angiography (DSA) revealed a pseudoaneurysm of a bronchial vessel with associated mediastinal hematoma, collapse of basal right lower lobe, and collection in right pleural space. This patient was later successfully treated by endovascular embolization techniques. Bronchial artery pseudoaneurysm may be considered a remote possibility in the absence of trauma or other lung diseases that may present with a massive hemothorax or mediastinal hematoma. Although CECT can be useful, digital angiography is considered the gold standard. Early intervention with the endovascular approach is a commonly recommended technique.

Keywords: bronchial artery aneurysm; bronchial artery pseudoaneurysm; digital subtraction angiography; embolization; mediastinal hematoma.

Figure 1. Coronal computed tomography (CT) section showing mediastinal hematoma with contrast-filled pseudoaneurysm adjacent to bronchus intermedius and chest tube in right pleural space.

A: mediastinal hematoma B: contrast-filled pseudoaneurysm C: chest tube in right pleural space

Figure 2. Digital subtraction angiography of right bronchial artery via microcatheter injection showing pseudoaneurysm sac with patent distal flow.

A: microcatheter injection B: pseudoaneurysm sac

Figure 3. Post coil embolization showing trapped pseudoaneurysm sac, which is reduced in size.

A, B: coil embolization C: pseudoaneurysm sac

Figure 4. Final fluoroscopic image after glue embolization of remaining sac, showing glue cast within the pseudoaneurysm sac in the right bronchial artery. Coil embolization is also visualized.

A: pseudoaneurysm sac B,C: coil embolization

Figure 5. Follow-up coronal CT section after three weeks showing significant interval decrement of mediastinal hematoma with intact mediastinal coils in middle mediastinum.

A: mediastinal hematoma B, C: mediastinal coils