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• W2414603146 abstract "Tracheobronchial varices are rare in adults.1 It is reported in association with portal hypertension.1,2 Cyanotic heart disease and pulmonary vein pathology can cause the varices in childhood.3–5 We report a case of endobronchial varices in an adult with hemoptysis and chronic mediastinal granulomatous disease. A 36-year-old white male with past history of massive hemoptysis presents with recurrent nonmassive hemoptysis with no additional symptoms or signs. Previous bronchoscopic examinations revealed mucosal ridges (Fig. 1A) that bled profusely few years back. A computed tomography (CT) scan of the chest reveals 1 calcified nodule in the right lung and a very large mediastinal calcified lymph node in the subcarinal region (Fig. 2A). The right bronchial tree was thickened. A repeat bronchoscopic examination revealed mucosal ridges diffusely spread over the right main stem, right upper lobe, and bronchus intermedius. The “ridges” were nonpulsatile and easily compressible. The mucosal “ridges” were further characterized as submucosal veins using Narrow Band Imaging (NBI; Olympus, EVIS EXERA II system, Tokyo, Japan). CT angiography ruled out pulmonary venous stenosis and revealed a large bronchial artery (Fig. 2B) originating from the descending aorta. Embolization of the artery resulted in control of the hemoptysis and reduction in size of the varices on subsequent bronchoscopic examination. Hemoptysis recurred after few months and a repeat CT scan revealed revascularization to the bronchial arterial network around the inflammatory mediastinal calcification. Coil embolization of the feeding systemic artery resulted in controlling the hemoptysis again. Patient has been hemoptysis free for >1 year now.FIGURE 1: A, Mucosal ridges apparent on white light bronchoscopy, arrow. B, Narrow Band Imaging (NBI) image of a varix protruding into the lumen of the right upper lobe, arrow. C, NBI image of the distal trachea showing the dilated submucosal vessels in cyan green color.FIGURE 2: A, Large calcified subcarinal mediastinal lymph node (red arrow) with thick soft-tissue wrapping around the bronchus intermedius. B, A large bronchial artery arising from the early descending aorta feeding this area was embolized (green arrow).Varices are very rare in the airways. Diagnosis is extremely difficult because of the subtle abnormalities on bronchoscopic examination. Cryptogenic hemoptysis is common.6 It is unknown as how many patients with idiopathic hemoptysis have endobronchial varices. The use of NBI can facilitate the recognition of abnormal superficial and deep mucosal or submucosal vessels due to the different penetration of the used emitted wave lengths. Brown-colored capillaries are superficial (detected by the 415 nm wavelength), whereas the green/cyan color represents the deeper (540 nm wavelength) vessels’ light reflection patterns.7,8 Most of the vessels identified in our patient had a cyan color reflecting the submucosal/deep location of the abnormality (Figs. 1B, C). It is probably a combination of local venous stenosis along with increased supply caused by the chronic mediastinal inflammation evident by the presence of the large calcification that has caused the development of the varices. As the CT scan did not recognize the venous stenosis because it is either localized and involved the small veins or are nonexistent, we decided to decrease the supply to the involved airways hoping to decrease the congestion of the venous circulation by decreasing the flow through it. The patient responded well to the embolization indicating that the increase in flow is the predominant pathology to his hemoptysis and varices. NBI should be considered in idiopathic hemoptysis to detect any mucosal vascular abnormalities that the white light can miss. If pulmonary venous stenosis is not identified as the cause for pulmonary varices, angiographic closure of the bronchial artery might be beneficial." @default.
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• W2414603146 date "2015-10-01" @default.
• W2414603146 modified "2023-10-16" @default.
• W2414603146 title "Pulmonary Varices in an Adult" @default.
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• W2414603146 doi "https://doi.org/10.1097/lbr.0000000000000211" @default.
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