Pulmonary artery-bronchus fistula treated with coil embolization

Abstract

Bronchopulmonary arterial fistula consists of an abnormal connection between the bronchus and the vascular tree and is a rare but serious complication associated with a variety of lung interventions. We present a case of a 61-year-old female with a history of metastatic breast cancer treated with lumpectomy and radiation 20 years prior, who was found to have a fistula between the right pulmonary artery and the right mainstem bronchus. Our patient was treated endovascularly with coil embolization in the setting of massive hemoptysis flooding the trachea, which was successful in controlling the acute bleed, although care was withdrawn in the following days following a discussion with the family given the presence of advanced metastatic disease. This case illustrates the use of endovascular techniques to treat an actively bleeding bronchopulmonary arterial fistulae, including a review of the existing literature regarding the optimal endovascular management strategy. Although our patient did not achieve the best outcome, endovascular intervention with stent-placement or embolization can serve to temporarily halt blood flow through the fistula, stabilizing the patient and allowing for more radical therapy after improvement.

Keywords: BPAF, bronchopulmonary arterial fistula; Bronchopulmonary arterial fistula; Bronchovascular fistula; Coil embolization; DSA, digital subtraction angiogram; Endobronchial stent; IP, interventional pulmonologist; RMB, right mainstem bronchus; RPA, right pulmonary artery; RPA-TA, right pulmonary artery-truncus anterior; RUL, right upper lobe; SEMS, self-expanding metallic stent.

Fig. 1

(a-b). Coronal oblique multiplanar reconstructed (a), and axial images of the patient CT pulmonary angiogram showing the right upper lobe para-hilar cavitary mass (star) with close proximity to the right pulmonary artery truncus anterior (arrow). On the thin-slice image (not shown), there was subtle wall irregularity of this vessel suggesting the possibility of a pseudoaneurysm or a fistula.

Fig. 2

Right pulmonary digital subtraction angiogram showing a fistula (arrow) between the right pulmonary artery truncus anterior, the cavitary lesion and the right main stem bronchus with blood flooding the trachea (circle).

Fig. 3

Repeat pulmonary digital subtraction angiography post coil (circle) embolization showed complete occlusion of the truncus anterior artery and the fistula.

Fig. 4

The angiogram annotation summarizes prior case reports of endovascular treatments of the BPAF. Straight blue line: A covered stent was placed to treat RPA fistula. The stent excluded the right upper and middle lobe pulmonary artery branches. Green line: a covered stent was placed within the right interlobar pulmonary artery, area of the fistula, only some segmental pulmonary artery branches were excluded. Blue cylinders: Amplatzer plugs and coils were used to embolize the right interlobar pulmonary artery and main pulmonary artery in two different cases of BPAF. Orange line: Ideal coil embolization or covered stent placement in our case.