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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Transcatheter management of Rasmussen aneurysms in a patient presenting with hemoptysis
Transcatheter management of Rasmussen aneurysms in a patient presenting with hemoptysis
Fritz Valdemar Rasmussen (1837-1877) was a Danish physician who first described Rasmussen's aneurysm in 1868.
Contributed by : Jaitra Desai
Contributed by : Jaitra Desai
Introduction:
Introduction:
A Rasmussen aneurysm is a rare complication of pulmonary tuberculosis (PTB) which was first reported in the literature in 1868 by Fritz Valdemar Rasmussen.He illustrated a detailed pathological description of 11 cases, hence named after him. Rasmussen's aneurysm is a focal dilatation of a branch of a pulmonary artery due to inflammatory erosion of the wall of an artery within a tubercular cavity. It is a rare cause for hemoptysis, reported in only 4% of autopsy series of patients with chronic cavitary tuberculosis [1]. The management is usually by bronchial artery embolization and occasionally by surgical lobectomy.
A Rasmussen aneurysm is a rare complication of pulmonary tuberculosis (PTB) which was first reported in the literature in 1868 by Fritz Valdemar Rasmussen.He illustrated a detailed pathological description of 11 cases, hence named after him. Rasmussen's aneurysm is a focal dilatation of a branch of a pulmonary artery due to inflammatory erosion of the wall of an artery within a tubercular cavity. It is a rare cause for hemoptysis, reported in only 4% of autopsy series of patients with chronic cavitary tuberculosis [1]. The management is usually by bronchial artery embolization and occasionally by surgical lobectomy.
Here we present a case of hemoptysis secondary to Rasmussen aneurysms which were managed with an endovascular approach.
Here we present a case of hemoptysis secondary to Rasmussen aneurysms which were managed with an endovascular approach.
Case presentation:
Case presentation:
A 38-year-old man, known to have multidrug resistant tuberculosis being treated with anti-tubercular therapy, presented with complaints of blood in sputum since four months. These episodes were sporadic, occurring once every 15-20 days. Each episode was associated with loss of 50-100 ml of blood. His Hb: 9.4gm%, TLC: 8900/ cu mm, platelets 2.1 L/cu mm. The chest radiograph showed fibrocavitary changes in the upper, middle and lower zones of left the lung (Fig. 1).
A 38-year-old man, known to have multidrug resistant tuberculosis being treated with anti-tubercular therapy, presented with complaints of blood in sputum since four months. These episodes were sporadic, occurring once every 15-20 days. Each episode was associated with loss of 50-100 ml of blood. His Hb: 9.4gm%, TLC: 8900/ cu mm, platelets 2.1 L/cu mm. The chest radiograph showed fibrocavitary changes in the upper, middle and lower zones of left the lung (Fig. 1).
Figure 1:
Frontal chest radiograph showing fibrocavitary changes in the left lung
CECT scan of the chest showed fibro bronchiectatic and fibrocavitary changes in the left lung. There was a focal outpouching in the left lower lobe, arising from the segmental branch of left pulmonary artery supplying the lateral basal segment of the left lower lobe. It measurd 17.8 x 12.2mm (Figs. 2,3).
CECT scan of the chest showed fibro bronchiectatic and fibrocavitary changes in the left lung. There was a focal outpouching in the left lower lobe, arising from the segmental branch of left pulmonary artery supplying the lateral basal segment of the left lower lobe. It measurd 17.8 x 12.2mm (Figs. 2,3).
Figure 2 , 3
CECT chest showing the rasmussen aneurysm
Interventional technique:
Interventional technique:
Under aseptic precautions and monitored anesthesia care, the right common femoral; vein (CFV) access a pulmonary angiogram was obtained with a Pigtail catheter. The angiogram revealed two Rasmussen aneurysms arising from segmental arteries of left main pulmonary trunk, which were supplying the lateral basal segment (video 1) .
Under aseptic precautions and monitored anesthesia care, the right common femoral; vein (CFV) access a pulmonary angiogram was obtained with a Pigtail catheter. The angiogram revealed two Rasmussen aneurysms arising from segmental arteries of left main pulmonary trunk, which were supplying the lateral basal segment (video 1) .
video 1.mp4Video 1 :
Angiogram showing the inferomedial aneurysm
and inferomedial segment of left lower lobe (Video 2. Fig. 4).
and inferomedial segment of left lower lobe (Video 2. Fig. 4).
video 2.mp4
Video 2 Fig. 4
Angiogrm showing the lateral basal aneurysm
A long sheath was introduced over the wire, with its tip in main pulmonary trunk and selective cannulation of the segmental branch supplying the lateral basal segment was done. Super selective cannulation of the artery was done using a microcatheter and a angiogram was performed. This showed a Rasmussen aneurysm. Embolization of the pseudoaneurysm was done using multiple pushable coils of sizes 18-14-4, 18-14-4,18-14-6, 18-14-6 (video 3). Repeat angiogram was obtained after 72 hours through a left femoral access. It showed complete resolution of the leak with good flow in distal arteries (Video 3)
A long sheath was introduced over the wire, with its tip in main pulmonary trunk and selective cannulation of the segmental branch supplying the lateral basal segment was done. Super selective cannulation of the artery was done using a microcatheter and a angiogram was performed. This showed a Rasmussen aneurysm. Embolization of the pseudoaneurysm was done using multiple pushable coils of sizes 18-14-4, 18-14-4,18-14-6, 18-14-6 (video 3). Repeat angiogram was obtained after 72 hours through a left femoral access. It showed complete resolution of the leak with good flow in distal arteries (Video 3)
video 3.mp4Video 3 : Fig 5
coiling of the pseudoaneurysm using coils
Post embolization angiogram showed complete obliteration of pseudoaneurysm of the lateral basal segment of the left lower lobe of lung (video 4). On follow-up, the patient had no episode of hemoptysis and the Hb was 10 gm%.
Post embolization angiogram showed complete obliteration of pseudoaneurysm of the lateral basal segment of the left lower lobe of lung (video 4). On follow-up, the patient had no episode of hemoptysis and the Hb was 10 gm%.
video 4.mp4Video 4:
post embolisation gram showed no filling in the aneurysm of the lateral basal segment of the left lower lobe
Similarly the inferomedial segmental artery branch was cannulated using a microcatheter, An angiogram showed another Rasmussen aneurysm, that was similarly embolised using two pushable coils of sizes 18-5-3, 18-3-3. Post embolization angiogram revealed complete obliteration of the aneurysm (video 5).
Similarly the inferomedial segmental artery branch was cannulated using a microcatheter, An angiogram showed another Rasmussen aneurysm, that was similarly embolised using two pushable coils of sizes 18-5-3, 18-3-3. Post embolization angiogram revealed complete obliteration of the aneurysm (video 5).
video 5.mp4Video 5.
Complete obliteration of the aneurysm
Discussion:
Discussion:
Intrapulmonary vascular complications of tuberculosis are tuberculous aortitis, Rasmussen aneurysms, involvement of bronchial and non-bronchial systemic arteries, and thromboembolic events. Tuberculosis is the leading cause of massive hemoptysis in the world. In pulmonary tuberculosis, massive hemoptysis is usually due to bronchial artery hypertrophy, whereas in Rasmussen aneurysm the bleeding is of pulmonary artery origin. These aneurysms arise from segmental pulmonary arteries and occur secondary to infiltration of granulation tissue into the adventitia and media. This is replaced in time by fibrin, leading to thinning of the vessel wall and subsequent aneurysm formation and rupture leading to hemoptysis. It commonly presents as massive hemoptysis, thus associated with high mortality rate that exceeds 5–25%.
Intrapulmonary vascular complications of tuberculosis are tuberculous aortitis, Rasmussen aneurysms, involvement of bronchial and non-bronchial systemic arteries, and thromboembolic events. Tuberculosis is the leading cause of massive hemoptysis in the world. In pulmonary tuberculosis, massive hemoptysis is usually due to bronchial artery hypertrophy, whereas in Rasmussen aneurysm the bleeding is of pulmonary artery origin. These aneurysms arise from segmental pulmonary arteries and occur secondary to infiltration of granulation tissue into the adventitia and media. This is replaced in time by fibrin, leading to thinning of the vessel wall and subsequent aneurysm formation and rupture leading to hemoptysis. It commonly presents as massive hemoptysis, thus associated with high mortality rate that exceeds 5–25%.
Extensive clinical, laboratory and imaging evaluation is needed in patients presenting with hemoptysis. Patients’ symptomatology, history of comorbidities and prior ATT are critical when investigating a case of prior pulmonary tuberculosis . Chest radiograph, chest CTA and DSA are the imaging tools. Chest radiograph is predominantly used as an initial screening tool to have an overall gross idea about the disease. Chest X-ray can show cavitations, bronchiectasis, consolidations in such cases of tuberculosis. Contrast enhanced CT (CECT) or chest CTA can further help us in knowing the culprit for hemoptysis in addition to the severity of parenchymal disease. On CTA, a Rasmussen aneurysm is seen as a focal outpouching arising from pulmonary artery branches. Fiber optic bronchoscopy and CT scans together provide a better chance of obtaining a diagnosis. Flexible or rigid bronchoscopy to identify the site of the bleeding should be done[2].
Extensive clinical, laboratory and imaging evaluation is needed in patients presenting with hemoptysis. Patients’ symptomatology, history of comorbidities and prior ATT are critical when investigating a case of prior pulmonary tuberculosis . Chest radiograph, chest CTA and DSA are the imaging tools. Chest radiograph is predominantly used as an initial screening tool to have an overall gross idea about the disease. Chest X-ray can show cavitations, bronchiectasis, consolidations in such cases of tuberculosis. Contrast enhanced CT (CECT) or chest CTA can further help us in knowing the culprit for hemoptysis in addition to the severity of parenchymal disease. On CTA, a Rasmussen aneurysm is seen as a focal outpouching arising from pulmonary artery branches. Fiber optic bronchoscopy and CT scans together provide a better chance of obtaining a diagnosis. Flexible or rigid bronchoscopy to identify the site of the bleeding should be done[2].
DSA serves as both diagnostic and interventional tool for management of rasmussen aneurysm. Surgical lobectomy for patients with massive hemoptysis poses a high risk, due to extensive pulmonary TB causing insufficient respiratory reserve. Surgical lobectomy can be considered as an alternative for patients refractory to endovascular management. Endovascular treatment has become a widespread initial therapy, with a success rate of more than 90%[3]. Several techniques of embolization including coiling, vascular plugs and glue embolization have been evaluated, however no significant advantage was seen in comparison to each other [4]. Vascaular plugs offers several advantages over traditional coil or glue embolisation: the delivery mechanism can achieve exact placement and allows for repositioning; it has minimal risk of migration, even in high flow vessels and short landing zones; and it is possible to occlude a large vessel with a single device (as opposed to multiple coils)[5]. However coils are more costs effective. Thus, all factors must be considered for the desired result. Technical success of endovascular treatment is defined as a lack of residual filling of the aneurysmal sac on immediate post-procedural imaging. Hence, embolization using coils is an effective minimally invasive management for hemoptysis secondary to rasmussen aneurysm.
DSA serves as both diagnostic and interventional tool for management of rasmussen aneurysm. Surgical lobectomy for patients with massive hemoptysis poses a high risk, due to extensive pulmonary TB causing insufficient respiratory reserve. Surgical lobectomy can be considered as an alternative for patients refractory to endovascular management. Endovascular treatment has become a widespread initial therapy, with a success rate of more than 90%[3]. Several techniques of embolization including coiling, vascular plugs and glue embolization have been evaluated, however no significant advantage was seen in comparison to each other [4]. Vascaular plugs offers several advantages over traditional coil or glue embolisation: the delivery mechanism can achieve exact placement and allows for repositioning; it has minimal risk of migration, even in high flow vessels and short landing zones; and it is possible to occlude a large vessel with a single device (as opposed to multiple coils)[5]. However coils are more costs effective. Thus, all factors must be considered for the desired result. Technical success of endovascular treatment is defined as a lack of residual filling of the aneurysmal sac on immediate post-procedural imaging. Hence, embolization using coils is an effective minimally invasive management for hemoptysis secondary to rasmussen aneurysm.
Conclusion:
Conclusion:
Hemoptysis may occur due to multiple Rasmussen aneurysms in a patient with post-primary tuberculosis. Careful evaluation of chest CTA helps to localize multiple aneurysms and is also beneficial for planning of the therapy. Endovascular coiling is a minimally invasive, safe and effective method for treatment of multiple Rasmussen aneurysms.
Hemoptysis may occur due to multiple Rasmussen aneurysms in a patient with post-primary tuberculosis. Careful evaluation of chest CTA helps to localize multiple aneurysms and is also beneficial for planning of the therapy. Endovascular coiling is a minimally invasive, safe and effective method for treatment of multiple Rasmussen aneurysms.
References:
References:
[1] Auerbach O. Pathology and pathogenesis of pulmonary arterial aneurysm in tuberculous cavities. American Review of Tuberculosis. 1939 Jan;39(1):99-115.
[1] Auerbach O. Pathology and pathogenesis of pulmonary arterial aneurysm in tuberculous cavities. American Review of Tuberculosis. 1939 Jan;39(1):99-115.
[2] Syed M, Irby J. Airway management of ruptured pulmonary artery “Rasmussen” aneurysm and massive hemoptysis. BMC Research Notes. 2015 Dec;8:1-4.
[2] Syed M, Irby J. Airway management of ruptured pulmonary artery “Rasmussen” aneurysm and massive hemoptysis. BMC Research Notes. 2015 Dec;8:1-4.
[3] Ugajin A, Fujii H, Nakamura H, Fujita A, Sasaki T, Mato N, Sugimoto H. Transcatheter Proximal Coil Blocking with n‐Butyl‐2‐Cyanoacrylate Injection via the Pulmonary Artery Alone for Rasmussen’s Aneurysm. Case Reports in Radiology. 2019;2019(1):1725238.
[3] Ugajin A, Fujii H, Nakamura H, Fujita A, Sasaki T, Mato N, Sugimoto H. Transcatheter Proximal Coil Blocking with n‐Butyl‐2‐Cyanoacrylate Injection via the Pulmonary Artery Alone for Rasmussen’s Aneurysm. Case Reports in Radiology. 2019;2019(1):1725238.
[4] Marak JR, Kumar T, Gara H, Dwivedi S. Rasmussen aneurysm: Case series of a rare complication of Pulmonary Tuberculosis. Respiratory Medicine Case Reports. 2023 Jan 1;45:101897.
[4] Marak JR, Kumar T, Gara H, Dwivedi S. Rasmussen aneurysm: Case series of a rare complication of Pulmonary Tuberculosis. Respiratory Medicine Case Reports. 2023 Jan 1;45:101897.
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