Glue ablation of Rasmussen's aneurysm in a case of epituberculosis

Abstract

A woman in her 40s presented with massive haemoptysis and breathlessness for 1 day. She had been diagnosed with pulmonary tuberculosis based on sputum CBNAAT (Cartridge Based Nucleic Acid Amplification Test) and was on antitubercular treatment for previous 2 weeks. Her chest X-ray showed right middle lobe lateral segment dense consolidation with bilateral nodular infiltrates. CT pulmonary angiography (CTPA) revealed a well-defined homogenously enhancing vascular lesion of size 10×11×13 mm in the right hilar region communicating with the descending branch of right pulmonary artery, suggesting a Rasmussen's aneurysm. It was in close proximity to the segmental bronchus that was almost completely occluded, suggesting epituberculosis. Transvenous pulmonary artery glue embolisation successfully achieved complete ablation of the aneurysm with preserved arterial flow. She has later completed 6 months of antitubercular treatment and is cured with no recurrence of haemoptysis. Her lung infiltrates have resolved with some lung scarring.

Keywords: Interventional radiology; Respiratory system; TB and other respiratory infections; Tuberculosis.

Figure 1

Chest X-ray showing consolidation of the lateral segment of the right middle lobe with bilateral nodular and patchy infiltrates.

Figure 2

CT pulmonary angiogram coronal section showing epituberculosis (yellow arrow showing the aneurysm and red arrow showing grossly narrowed bronchus) and bilateral lung infiltrates.

Figure 3

CT pulmonary angiogram 3D reconstruction, tilted view, showing the Rasmussen’s aneurysm (white arrow) arising from right descending pulmonary artery branch.

Figure 4

Postembolisation right pulmonary angiogram showing complete obliteration of the Rasmussen’s aneurysm with glue cast (red arrow) with preserved patent arteries.

Figure 5

A diagrammatic representation of the pathophysiology of Rasmussen’s aneurysm and how it was treated using glue (jointly created by the authors, Sahasrabudhe Tushar, Mohan Sona and Meshram Shailesh). (A) Normal pulmonary artery branch with normal walls. (B) Tuberculosis (TB) granulation tissue surrounding and invading the vessel wall. (C) Thinned-out and weakened vessel wall due to destruction of adventitia and media causing bulge. (D) Formation of Rasmussen’s aneurysm due to gross bulging of thinned vessel wall. (E) Catheter instilling the glue into the Rasmussen’s aneurysm. (F) Complete obliteration of the Rasmussen’s aneurysm with maintained blood flow in the vessel.