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• W2004598174 abstract "We present a rare case of massive hemoptysis in a patient with congenital absence of the left pulmonary artery that was treated with particle embolization. After the procedure, the patient's hemoptysis stopped, and the patient has been asymptomatic since the embolization 10 months ago. Review board approval is not needed for retrospective review of case material at our institution.A 31-year-old man was transferred from an outside hospital to our institution with a history of several episodes of massive hemoptysis. The patient had a history of DiGeorge syndrome, congenital agenesis of the left pulmonary artery, and a right-sided aortic arch. The patient's massive hemoptysis was due to systemic collateralization of his left lung with probable pulmonary hypertension.Echocardiography showed an unobstructed right-sided aortic arch with an absent left pulmonary artery and an unobstructed large main pulmonary artery. Left ventricular function was normal, but echocardiography showed right ventricular hypertrophy. The estimated right ventricular end-diastolic pressure was 23 mm Hg (average 4 mm Hg, normal range 0–8 mm Hg) (1Albert R.K. The Merck Manual Online. Section 6, Chapter 63. Table 2: Normal Pressures in the Heart and Great Vessels. Merck Sharpe & Dohme, Whitehouse Station, NJ2010http://www.merckmanuals.com/professional/sec06/ch063/ch063b.htmlGoogle Scholar). Computed tomography (CT) angiogram of the thorax confirmed a right-sided aortic arch with an aberrant left subclavian artery, absence of the left main pulmonary artery, a dilated main pulmonary artery, and a persistent ductus arteriosus. CT also showed numerous hypertrophied systemic collateral arteries supplying the left lung, including two left bronchial arteries, branches of the descending thoracic aorta, and branches of the left internal mammary artery and the left inferior phrenic artery. The pulmonary veins showed a normal drainage pattern, and the central tracheobronchial tree anatomy was normal.Selective arteriography was performed with a 5-F Cobra 2 catheter (Cook, Inc, Bloomington, Indiana) and 5-F Simmons 1 catheter (Cook, Inc). There were two dilated left bronchial arteries supplying the left lower lobe, which originated from the thoracic aorta between the T6-9 levels; three systemic collaterals arose from the distal aorta supplying the left upper and lower lobes (Figs 1 and 2). The caudalmost vessels supplying the posteromedial segment of the left lower lobe were believed to be the source of hemorrhage. These vessels were enlarged and tortuous and showed abnormal parenchymal staining (Fig 3a). One bronchial artery and the two largest nonbronchial systemic collaterals were selected for embolization. No extravasation or shunting to pulmonary artery or vein was shown. No spinal arteries were visualized from any of the selected vessels. A 2.8-F Progreat (Terumo, Tokyo, Japan) microcatheter was used coaxially through the 5-French diagnostic catheter to select the distal aspect of these three branches. Embolization of these vessels was performed to complete stasis with 355- to 500-μ nonspherical polyvinyl alcohol particles (Contour, Boston Scientific, Natick, Massachusetts). Embolization of the largest bronchial artery was performed with a combination of 355- to 500-μ and 500- to 710-μ polyvinyl alcohol (Fig 3b). There were no immediate complications, and the patient was discharged 2 days after embolization. The patient remained asymptomatic with no recurrence of hemoptysis 10 months after embolization.Figure 2Sagittal image from CT angiogram showing hypertrophied systemic collateral arteries arising from left internal mammary artery (arrow) and from dilated left inferior phrenic artery (asterisk).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3(a) Selective arteriogram of dominant left bronchial artery via a microcatheter shows marked dilatation and tortuosity of vessel with abnormal parenchymal stain (arrow). (b) Selective arteriogram after embolization shows occlusion of distal left bronchial artery and no further parenchymal stain (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Our literature review did not reveal published reports of successful primary particle embolization in patients with unilateral pulmonary artery agenesis. There is one report discussing primary management using coil embolization in two patients with isolated unilateral absence of a pulmonary artery by Rene et al (2Rene M. Sans J. Dominguez J. Sancho C. Valldeperas J. Unilateral pulmonary artery agenesis presenting with hemoptysis: treatment by embolization of systemic collaterals.Cardiovasc Intervent Radiol. 1995; 18: 251-254Crossref PubMed Scopus (45) Google Scholar). These authors describe a case of a 37-year-old man with right pulmonary artery agenesis and hemoptysis that was controlled by coil embolization. The second patient was a 40-year-old man who was admitted with hemoptysis secondary to collaterals from left pulmonary artery agenesis that was controlled by repeat absorbable gelatin sponge (Gelfoam, Pfizer, New York, New York) and coil embolization. Rene et al (2Rene M. Sans J. Dominguez J. Sancho C. Valldeperas J. Unilateral pulmonary artery agenesis presenting with hemoptysis: treatment by embolization of systemic collaterals.Cardiovasc Intervent Radiol. 1995; 18: 251-254Crossref PubMed Scopus (45) Google Scholar) did not discuss the limitations of coil embolization, which include the inability to perform repeat embolization of vessels distal to the coil in cases of recurrent hemoptysis. As with management of hemoptysis from other causes, such as bronchiectasis, neoplasia, tuberculosis, and aspergillosis, particle embolization can be used instead of coil embolization. The main advantages to particle embolization are the ability to perform a distal embolization of abnormal parenchymal vessels and the ability to access areas of neocollateralization in the setting of recurrent hemoptysis for reembolization.Sometimes patients may undergo multiple sessions of embolization, which may be due to too many hypertrophied vessels to address in one session and recurrent hemoptysis after a variable hemoptysis-free period. Recurrent hemoptysis after embolization is thought to be due to recanalization of vessels after embolization or hypertrophy of collateral nonbronchial systemic arteries (3Yu-Tang Goh P. Lin M. Teo N. En Shen Wong D. Embolization for hemoptysis: a six-year review.Cardiovasc Intervent Radiol. 2002; 25: 17-25Crossref PubMed Scopus (111) Google Scholar).In summary, our experience with this patient provides support that primary particle embolization can be used as an alternative to other forms of embolization and surgery. Primary particle embolization can be considered as first-line treatment for moderate to massive hemoptysis and is lifesaving. We present a rare case of massive hemoptysis in a patient with congenital absence of the left pulmonary artery that was treated with particle embolization. After the procedure, the patient's hemoptysis stopped, and the patient has been asymptomatic since the embolization 10 months ago. Review board approval is not needed for retrospective review of case material at our institution. A 31-year-old man was transferred from an outside hospital to our institution with a history of several episodes of massive hemoptysis. The patient had a history of DiGeorge syndrome, congenital agenesis of the left pulmonary artery, and a right-sided aortic arch. The patient's massive hemoptysis was due to systemic collateralization of his left lung with probable pulmonary hypertension. Echocardiography showed an unobstructed right-sided aortic arch with an absent left pulmonary artery and an unobstructed large main pulmonary artery. Left ventricular function was normal, but echocardiography showed right ventricular hypertrophy. The estimated right ventricular end-diastolic pressure was 23 mm Hg (average 4 mm Hg, normal range 0–8 mm Hg) (1Albert R.K. The Merck Manual Online. Section 6, Chapter 63. Table 2: Normal Pressures in the Heart and Great Vessels. Merck Sharpe & Dohme, Whitehouse Station, NJ2010http://www.merckmanuals.com/professional/sec06/ch063/ch063b.htmlGoogle Scholar). Computed tomography (CT) angiogram of the thorax confirmed a right-sided aortic arch with an aberrant left subclavian artery, absence of the left main pulmonary artery, a dilated main pulmonary artery, and a persistent ductus arteriosus. CT also showed numerous hypertrophied systemic collateral arteries supplying the left lung, including two left bronchial arteries, branches of the descending thoracic aorta, and branches of the left internal mammary artery and the left inferior phrenic artery. The pulmonary veins showed a normal drainage pattern, and the central tracheobronchial tree anatomy was normal. Selective arteriography was performed with a 5-F Cobra 2 catheter (Cook, Inc, Bloomington, Indiana) and 5-F Simmons 1 catheter (Cook, Inc). There were two dilated left bronchial arteries supplying the left lower lobe, which originated from the thoracic aorta between the T6-9 levels; three systemic collaterals arose from the distal aorta supplying the left upper and lower lobes (Figs 1 and 2). The caudalmost vessels supplying the posteromedial segment of the left lower lobe were believed to be the source of hemorrhage. These vessels were enlarged and tortuous and showed abnormal parenchymal staining (Fig 3a). One bronchial artery and the two largest nonbronchial systemic collaterals were selected for embolization. No extravasation or shunting to pulmonary artery or vein was shown. No spinal arteries were visualized from any of the selected vessels. A 2.8-F Progreat (Terumo, Tokyo, Japan) microcatheter was used coaxially through the 5-French diagnostic catheter to select the distal aspect of these three branches. Embolization of these vessels was performed to complete stasis with 355- to 500-μ nonspherical polyvinyl alcohol particles (Contour, Boston Scientific, Natick, Massachusetts). Embolization of the largest bronchial artery was performed with a combination of 355- to 500-μ and 500- to 710-μ polyvinyl alcohol (Fig 3b). There were no immediate complications, and the patient was discharged 2 days after embolization. The patient remained asymptomatic with no recurrence of hemoptysis 10 months after embolization. Our literature review did not reveal published reports of successful primary particle embolization in patients with unilateral pulmonary artery agenesis. There is one report discussing primary management using coil embolization in two patients with isolated unilateral absence of a pulmonary artery by Rene et al (2Rene M. Sans J. Dominguez J. Sancho C. Valldeperas J. Unilateral pulmonary artery agenesis presenting with hemoptysis: treatment by embolization of systemic collaterals.Cardiovasc Intervent Radiol. 1995; 18: 251-254Crossref PubMed Scopus (45) Google Scholar). These authors describe a case of a 37-year-old man with right pulmonary artery agenesis and hemoptysis that was controlled by coil embolization. The second patient was a 40-year-old man who was admitted with hemoptysis secondary to collaterals from left pulmonary artery agenesis that was controlled by repeat absorbable gelatin sponge (Gelfoam, Pfizer, New York, New York) and coil embolization. Rene et al (2Rene M. Sans J. Dominguez J. Sancho C. Valldeperas J. Unilateral pulmonary artery agenesis presenting with hemoptysis: treatment by embolization of systemic collaterals.Cardiovasc Intervent Radiol. 1995; 18: 251-254Crossref PubMed Scopus (45) Google Scholar) did not discuss the limitations of coil embolization, which include the inability to perform repeat embolization of vessels distal to the coil in cases of recurrent hemoptysis. As with management of hemoptysis from other causes, such as bronchiectasis, neoplasia, tuberculosis, and aspergillosis, particle embolization can be used instead of coil embolization. The main advantages to particle embolization are the ability to perform a distal embolization of abnormal parenchymal vessels and the ability to access areas of neocollateralization in the setting of recurrent hemoptysis for reembolization. Sometimes patients may undergo multiple sessions of embolization, which may be due to too many hypertrophied vessels to address in one session and recurrent hemoptysis after a variable hemoptysis-free period. Recurrent hemoptysis after embolization is thought to be due to recanalization of vessels after embolization or hypertrophy of collateral nonbronchial systemic arteries (3Yu-Tang Goh P. Lin M. Teo N. En Shen Wong D. Embolization for hemoptysis: a six-year review.Cardiovasc Intervent Radiol. 2002; 25: 17-25Crossref PubMed Scopus (111) Google Scholar). In summary, our experience with this patient provides support that primary particle embolization can be used as an alternative to other forms of embolization and surgery. Primary particle embolization can be considered as first-line treatment for moderate to massive hemoptysis and is lifesaving." @default.
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• W2004598174 title "Particle Embolization as Primary Endovascular Management of a Patient with Massive Hemoptysis and Isolated Unilateral Absence of the Left Pulmonary Artery" @default.
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