pulmonary artery aneurysms and pseudoaneurysms are uncommon ; most are caused by infections , like tuberculosis , vasculitis ( behet 's syndrome ) or trauma , often iatrogenic ; less common causes include pulmonary hypertension , congenital heart disease , lung carcinoma , and connective tissue disease ( 1 - 3 ) . because of potential risk of high mortality , secondary to pseudoaneurysm enlargement and rupture , prompt
we , hereby , describe a case of ascending branch of the left pulmonary artery pseudoaneurysm , following a left upper lobectomy , for which a transcatheter endovascular embolisation of the aneurysm with intra - aneurysmal n - butyl 2-cyanoacrylate ( glue ) injection was performed .
a 30-year - lady had been presented to us 3 months ago with multiple episodes of hemoptysis and one major episode of 400 cc , and gave us a history of intermittent fever , cough , breathlessness and chest pain for a period of 2 - 3 months .
she was a known case of pulmonary tuberculosis with left upper lobe fungal ball ( pulmonary aspergillosis ) for the past 7 years .
she had had complete a course of anti - tuberculosis therapy and was asymptomatic until this period when she was presented to us with hemoptysis . at this time
the patient visited an emergency department again a month ago for exacerbation of the above symptoms .
because of the recurrent symptoms and deteriorating pulmonary function test results , the left upper lobectomy for pulmonary aspergilloma was performed .
the inferior pulmonary ligament was excised in order to enable the lower lobe to occupy the entire left thoracic cavity .
the early postoperative period was uneventful . in the third post - operative week , she started having streaky hemoptysis .
fibre optic bronchoscopy detected a normal tracheobronchial tree , however , the left upper lobe surgical closure site was congested and inflamed .
though the white blood cell count was normal , the patient was treated for a presumed chest infection .
the patient had spotty hemoptysis for the next two weeks , until she developed 2 - 3 episodes of massive hemoptysis of about 400 - 500 cc of blood .
patient was intubated and emergency computed tomography ( ct ) pulmonary angiography was done , which revealed a large pseudoaneurysm of the ascending branch of the left pulmonary artery ( fig .
because of the patient 's severe pulmonary insufficiency , she was not a surgical candidate and was referred to us for endovascular embolisation . under local anesthesia , with anesthetists standing by for emergency resuscitation if need arise , pulmonary angiography with 5 fr , 110-cm pigtail catheter ( cordis , johnson & johnson , new jersey ) was introduced via the right femoral venous approach , which showed approximately 3.5 cm aneurysm arising from the ascending branch of the left pulmonary artery , shortly after its origin ( fig .
then , a 5 fr , 100-cm head hunter catheter ( cordis , johnson & johnson , new jersey ) was introduced into the feeding artery of the aneurysm , just short of the aneurysm sac .
initially , we tried to occlude the feeding vessel with 35 - 5 - 5 and 35 - 8 - 8 coils ( cook , bloomington , in , usa ) , but both of these coils got misplaced proximally in the lateral basal and lower lobe trunk arteries , respectively .
because of larger diameter of the coils than the caliber of these arteries , the misplaced coils got stuck in a proximal part of the arteries . on an angiogram , we could see the uninterrupted rapid blood flow through the coils to the lower branches .
further , with digital road mapping , 5 fr head hunter catheter in the feeding artery , and acting as a guiding catheter , the aneurysm sac was catheterized with a 2.7 fr microcatheter ( terumo progreat ; terumo deutschland gmbh , germary ) .
now we decided to occlude the aneurismal sac by completely filling the sac with n - butyl 2-cyanoacrylate ( glue ) injection .
we calculated the volume of the glue mixture required in order to fill the aneurysm cavity by slowly calculating the volume of contrast injected , without causing the reflux of the contrast into the normal pulmonary circulation proximally .
the volume required was approximately 4 cc . to prevent a reflux , 5 cc of higher concentration i.e. 75% glue mixture of histoacryl ( braun , melsungen , germany ) and iodized oil ( lipiodol , andre guerbert , aulnay sous bois , france ) was taken in a 5-ml luer - lock syringe
, however we could only inject approximately 1.5 cc of the glue , as the microcatheter got blocked .
catheter sticking or breakage did not occur during the process of catheter retrieval and was immediately flushed vigorously with 5% dextrose to reopen the lumen .
check angiogram showed the glue cast in the central part of the aneurysm sac with aneurysm still filling in the periphery ( fig .
we now attempted to occlude the feeding artery with coil , but this time , the coil got dislodged in the aneurysmal sac .
now , the angiographic picture was much clearer , and on correlating with ct saggital reconstructed images , we got to know that the length of the feeding artery to the pulmonary artery aneurysm ( pap ) sac was very short .
so now , not to compromise the pulmonary circulation , we did not have any other option except to fill the sac either with coils or liquid materials .
in order to be economical on the cost , as well as our past experience with the glue , we decided to occlude pap with intra - aneurysmal injection of the glue .
we introduced the previously used microcatheter into the sac , and this time , we used 50% glue mixture and were able to fill the sac completely with calculated volume of 3 cc of liquid mixture without spillage into the proximal normal circulation .
post embolisation check angiogram showed a complete obliteration of the aneurysm sac with anterior ascending branch , and other branches of the left pulmonary artery being patent ( fig .
there was no alteration in the blood flow through the coils into the lower lobe branches , and therefore , we did not try to retrieve the coils .
ct performed on the 6th day showed glue cast with no filling of the aneurysm .
however , after being asymptomatic for 2 months , she presented again to our hospital with a single episode of 300 cc of hemoptysis .
emergency ct was performed , which did not show the new aneurysm or refilling of the previously embolised aneurysm ( fig .
1 g ) ; however , at this time , we could see a new aspergilloma in lateral basal segment of the lower lobe , and rib osteomyelitis ( fig .
at present , she is still admitted and is on a conservative management and being further investigated for these new ct findings .
pulmonary artery aneurysms and pseudoaneurysms ( paps ) are rare ; most are caused by infections , like tuberculosis , vasculitis ( behet 's syndrome ) or trauma , often iatrogenic , especially after swan ganz catheter insertion ; and less common causes include pulmonary hypertension , congenital heart disease , lung carcinoma , and connective tissue disease ( 1 - 3 ) .
thus , any destructive process of the lung , whatever its pathogenesis , can erode the vessels in its vicinity , be it a pulmonary or systemic vessel .
the etiology in this case can be attributed to inadvertent insult to the pulmonary artery during surgery for pulmonary aspergilloma .
also , after lobectomy , significant increase in the pulmonary vascular resistance index has been described in the literature ( 4 ) , and this could have had a possible contributory role for the development of the pseudoaneurysm .
another cause could be a low grade infection of the already weakened upper lobe pulmonary arterial wall , though the blood investigations were normal in our patient .
the most common cause for intrapulmonary bleedings is the hemoptysis , due to bronchial artery erosion seen in as many as 95% of all cases . in contrast , bleeding from the pulmonary arteries is very rare , usually massive , accounting for less than 5% of all cases ( 5 ) , and is usually due to pseudoaneurysm rupture . because of the risk of pap enlargement and rupture , which leads to death in approximately 50% of patients , prompt therapy is required .
the available treatment modalities for pap are medical therapy , surgery and percutaneous catheter embolisation of the pseudoaneurysm .
medical treatment by the means of immunosuppressive drugs and steroids has been found to cure or decrease the size of aneurysms in behcets disease ( 6 , 7 ) .
several surgical techniques , such as lobectomy , pneumonectomy , hilar clamping with direct arterial repair and ligation , have been used . however ,
in our case , due to the patient 's severe pulmonary insufficiency , she was not a surgical candidate .
there are number of reports in the literature addressing the treatment of paps - most of them using metallic coils ( 8) or silicon balloon ( 9 ) to occlude the arterial feeders .
these placements can also occlude the perfusion to aerated lung , distal to the embolisation site , and are associated with complications , like coil migration and damage to vessel wall .
other authors have occluded the pap by intraneurysmal placement of coils ( 10 ) ; however it carries a potential risk of mass effect and aneurysm rupture .
still , other authors have described the use of covered stents ( 11 ) , and recently , hovis and zeni ( 12 ) have used thrombin percutaneously for the paa refractory to coil the embolisation . in our case , initially , we attempted unsuccessfully to occlude the feeding artery with the coils .
however , the coils migrated proximally to enter into the lower lobe circulation without compromising the blood circulation to these segments .
we later realized that this was due to a short length and wide neck of the feeding artery , that we were not able to keep the catheter stable in this branch .
we did not want to occlude the aneurysmal sac with coils , firstly because of the large size of the lesion , use of multiple coils could result in a mass effect after embolisation , and secondly it would have been very expensive ; also it might be further complicated by coil migration , resulting from the wide neck of the aneurysm . in our case , because of regular and comfortable experience at tackling abdominal visceral aneurysms with glue embolization , we decided to use this liquid material as embolic material .
( 7 ) embolised the feeding branch to paa , using the glue with a " bubble technique " ; however , this was not possible in our case because of the short length in the feeding artery .
therefore , we considered the alternative option of intraaneurysmal injection of liquid embolic ( glue ) .
glue ( n - butyl 2-cyanoacrylate ) is a rapidly hardening liquid adhesive , and has been used as an effective embolic agent for brain vascular malformations ; however , necessity of operator experience with the use of liquid embolic material is a major limitation in its application to aneurysms .
there are some studies showing the feasibility of intraaneurysmal injection of the glue in intracranial aneurysms ( 13 ) , thereby keeping the antegrade flow in the aneurysm bearing artery patent .
we report the first case , in which the n - butyl 2-cyanoacrylate was successfully injected , intraaneurysmally , through the transcatheter route for the occlusion of a pulmonary artery pseudoaneurysm , after an upper lobe lobectomy for aspergillosis .
glue offers the advantage of permanent occlusion of the vessel , and because of its low viscosity , it can be injected through a microcatheter into small and tortuous arteries .
it is admixed with ethiodized oil in various ratios to achieve radiopacity and to adjust the polymerization time allowing for more controlled embolisation . the use of higher concentrations of glue results in quicker solidification ; however , on the contrary , the longer the polymerization time , the greater the risk of non - target embolisation because there is the possibility of embolic material being washed away before it solidifies . in our case
we initially used 75% glue to prevent the reflux into the parent artery ; however there was early polymerisation of the glue with the sac preventing an evenly distribution .
therefore , we had to dilute the glue to make it 50% concentration , and this time , there was complete filling of the aneurysm . in conclusion
intraaneurysmal injection of the liquid embolic materials is feasible , safe , and effective trancatheter treatment option for pulmonary artery aneurysms and is possibly not associated with the risk of rupture seen with packing of aneurysms with coils .
however , appropriate concentration of the glue , long term results , and etc . will require further experience to confirm its safety and efficacy in pulmonary circulation .
 we report a case of pseudoaneurysm of the anterior ascending branch of the left pulmonary artery , following a left upper lobectomy for pulmonary aspergillosis , for which we have done an endovascular treatment . 
 this is the first case where complete pseudoaneurysm occlusion was accomplished after a transcatheter intra - aneurysmal n - butyl 2-cyanoacrylate ( glue ) injection . 