Immediate Diagnosis and Nonoperative Treatment of a Pulmonary Artery Pseudoaneurysm after Blunt Traumatic Injury

Abstract

P ulmonary artery pseudoaneurysms after traumatic injury are a very rare occurrence; only 14 cases have been reported in the literature. Blunt traumatic pulmonary artery pseudoaneurysms constitute a small number of these cases; only three cases have been reported to date. In every reported case of traumatic pulmonary artery pseudoaneurysm since 1920, the pseudoaneurysm was repaired operatively using local resection (aneurysectomy), ligation of vessels, lobectomy, or embolization. 1,2 We report a case of blunt traumatic main pulmonary artery pseudoaneurysm detected on initial computed tomography (CT) that was treated nonoperatively. To our knowledge, this is the first reported pulmonary artery pseudoaneurysm detected immediately on trauma assessment and also the first reported patient with traumatic pulmonary artery pseudoaneurysm treated nonoperatively that survived. CASE REPORTA 57-year-old man who was involved in a head-on motor vehicle collision as the unrestrained passenger presented awake and alert with multiple facial lacerations and unknown loss of consciousness. The patient denied any known drug allergies and took no medications. Medical history was significant for hypertension and diabetes mellitus and there was no surgical history. The patient did admit to regular alcohol and marijuana use but denied any significant family medical history. The primary survey was unremarkable. The airway was patent, Glasgow Coma Scale score was 15, and the patient seemed in no apparent distress. No additional injuries were noted and motor and sensory exams were normal. The usual resuscitation maneuvers were employed.Routine pelvis and chest x-rays were obtained. The chest film revealed minimal widening of the superior mediastinum (measured as 10 cm of 38.5 cm chest width) and tortuosity of the thoracic aorta. The pelvic film was negative. The patient had helical multidetector CT imaging without contrast of the head, face, and c-spine. The head CT was negative for intracranial injury, whereas the CT scan of the face showed minimal medial displacement of the left zygoma. In addition, helical multidetector CT imaging of the chest with intravenous contrast was obtained in addition to the usual abdomen/ pelvis CT with oral and intravenous contrast. The chest CT was added because of widened mediastinum and loss of aortic knob. The chest CT revealed a lobulated contour of the main pulmonary artery with an 18-mm probable pseudoaneurysm along the left superior margin of the main pulmonary artery (Fig. 1). A small amount of mediastinal hematoma was seen although the aorta and great vessels of the arch were intact. There was no evidence of pericardial effusion, pleural effusion, or pneumothorax. The abdomen/pelvis CT scan revealed minimal free fluid in the left upper quadrant inferior to the spleen and in the left paracolic gutter with the absence of identifiable solid organ injury.The patient was then taken for pulmonary angiography, which also revealed a lobulated appearance with a focal contour abnormality along the left anterio...

Pulmonary vessel pseudo-aneurysm after blunt traumatic injury: A report of two cases

“…The results of the conservative (non-surgical) management employed in the two cases of PAPA resulting from blunt trauma reported herein are consistent with the reports of other asymptomatic pseudoaneurysm that were diagnosed during the initial assessment [14]. Thus, while the potential morbidity and mortality of asymptomatic traumatic PAPAs remain unknown, the limited information from the literature is not sufficient to mandate surgical management.…”

“…In 2006, Reade et al first described the case of blunt traumatic main PAPA, detected on initial computed tomography (CT) scan, that was treated non-operatively [14]. In every reported case, the traumatic PAPA was repaired operatively by means of local resection (aneurysectomy), ligation of vessels, lobectomy or embolisation [5,15].…”

“…Seventeen cases have been described in the literature [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17]: 12 of these resulted from penetrating injuries [1,2,4,5,7,8,12,13,[15][16][17], 4 from blunt injuries [3,9,11,14], and 1 case that involved penetrating chest trauma with simultaneous pulmonary artery and pulmonary vein pseudo-aneurysm [10].In 2006, Reade et al first described the case of blunt traumatic main PAPA, detected on initial computed tomography (CT) scan, that was treated non-operatively [14]. In every reported case, the traumatic PAPA was repaired operatively by means of local resection (aneurysectomy), ligation of vessels, lobectomy or embolisation [5,15].…”

An Unusual Case of Blunt Traumatic Pulmonary Artery Pseudoaneurysm Detected within a Day

“…In literature, two cases of spontaneous resolution of a PAP had also been reported. 3,4 Operative management has traditionally been recommended because of the risk of rupture leading to massive haemoptysis if a PAP is left untreated. Recently, less invasive treatments such as coil embolization and percutaneous injection therapy have been attempted to avoid surgery.…”

Non-operative treatment of a striking post-traumatic pulmonary artery intimal dissection

“…Although spontaneous resolution of some pulmonary artery pseudoaneuryms has been reported these lesions should not be left untreated because of the risk of rupture leading to massive haemoptysis and subsequent death in almost 50% of the cases. 3,11,12 We present a case of posttraumatic pulmonary artery intimal injury evolved in pulmonary artery pseudoaneurysm underwent non-operative treatment and survived after ICU discharge.…”