Medical Image of the Week: Bronchial Artery Embolization

Figure 1. Thoracic CT with contrast demonstrating right upper and lower lobe tree-in-bud and ground glass opacities (arrows) consistent with progressing pulmonary coccidioidomycosis.

Figure 2. Chest radiograph demonstrates the ethylene vinyl alcohol polymer retained in the bronchial arteries after the embolization procedure (arrows).

A 25-year-old woman with a past medical history significant for pulmonary coccidioidomycosis and poorly controlled type I diabetes mellitus presented to the emergency department with a chief complaint of 4 days of progressively worsening shortness of breath and 3-4 days of intermittent hemoptysis. Initial CT scan demonstrated progressive tree-in-bud and ground glass opacities in the right upper and lower lung lobes suggesting worsening of her ongoing coccidiomycosis (Figure 1). On hospital day 3 she began to have worsening hypoxemia and hemoptysis requiring transfer to the intensive care unit. Interventional radiology was consulted who performed an emergent right sided bronchial artery embolization with the ethylene vinyl alcohol polymer, Onyx^tm. After embolization her chest radiographs demonstrated evidence of the embolization material in the pulmonary vasculature (Figure 2).

Ethylene vinyl alcohol polymer, Onyx^tm is a liquid embolic substance which solidifies after contact with ionic materials (1). This results in a rapid, irreversible and permanent embolization of the bleeding target vessel (2). It was initially approved for use in the embolization of cerebral arteriovenous malformations, however has been used for rapid embolization of other hemorrhagic conditions such has hemoptysis from bleeding bronchial arteries (3). The most common complication after embolization is chest pain that is self-limiting. Transverse myelitis from spinal cord ischemia is the most serious complication associated with bronchial artery embolization however the occurrence is significantly decreased by spinal arterial identification during initial angiography (4). This patient’s embolization was without complications. She was successfully extubated on hospital day 15 without evidence of ongoing hemoptysis and will continue to follow up in the pulmonary and infectious disease clinics for ongoing treatment of her Coccidiodes pulmonary disease.

Benjamin J. Jarrett MD, MPH and Sachin Chaudhary, MD

Department of Medicine

University of Arizona

Tucson, AZ USA

References

1. Lubarsky M, Ray C, Funaki B. Embolization agents-which one should be used when? Part 2: small-vessel embolization. Semin Intervent Radiol. 2010 Mar;27(1):99-104. [CrossRef] [PubMed]
2. Yamashita K, Taki W, Iwata H, Nakahara I, Nishi S, Sadato A, Matsumoto K, Kikuchi H. Characteristics of ethylene vinyl alcohol copolymer (EVAL) mixtures. AJNR Am J Neuroradiol. 1994 Jun;15(6):1103-5. [PubMed]
3. Guimaraes M, Wooster M. Onyx (Ethylene-vinyl Alcohol Copolymer) in Peripheral Applications. Semin Intervent Radiol. 2011 Sep;28(3):350-6. [CrossRef] [PubMed]
4. Sopko DR, Smith TP. Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 2011 Mar;28(1):48-62. [CrossRef] [PubMed]

Cite as: Jarrett BJ, Chaudhary S. Medical image of the week: bronchial artery embolization. Southwest J Pulm Crit Care. 2016;13(1):32-3. doi: http://dx.doi.org/10.13175/swjpcc053-16 PDF

Medical Image of the Week: Massive Abdominal Aortic Aneurysm

Figure 1. Non-contrast CT A) axial, B) sagittal, and C) coronal views demonstrate a massive abdominal aortic aneurysm measuring 12.5 cm wide at maximal diameter.

Figure 2. Representative images from a CT-angiogram shows A) upper and B) lower abdominal axial sections showing renal artery involvement (red arrow) and substantial intramural thrombus (light blue brace). C) Coronal view demonstrates fusiform dilation of the iliacs (green arrow) and D) sagittal view demonstrates involvement of the thoracoabdominal aorta (pink arrow) and all major arterial branches of the abdominal aorta (celiac trunk, superior and inferior mesenteric arteries; dark blue arrows).

An 88 year-old presented to the emergency department with left flank and lower back pain as well as lower abdominal fullness. The fullness had started 2 days prior, but the left flank pain acutely started in the early morning before presenting. He had a history of unmedicated hypertension, hyperlipidemia, and mild vertigo. His review of systems was positive for chills and difficulty urinating but no hematuria. He was a non-smoker, and had undergone orthopedic surgeries but had otherwise avoided emergent hospitalizations.

On exam, vitals were unremarkable; there was no flank nor costovertebral angle tenderness; however, a midline pulsatile mass was present. An initial non-contrast CT abdomen/pelvis revealed a massive abdominal aortic aneurysm (AAA, Figure 1). Follow-up CT angiogram of the AAA can be seen in Figure 2. Upon further questioning, he had undergone a research study some 30 years earlier involving ultrasound to screen for AAA and was told he did not have one at the time.

AAA’s occur in 4-9% of the population (1-3) because of the diminished elastin in the infrarenal aorta. Inciting or etiologic factors include inflammatory, genetic and biochemical mediators, with positive risk factors including white race, atherosclerosis, smoking, male gender, hypertension, personal history of other arterial aneurysms, family history of AAA’s, and advancing age. Screening all men aged 65-79 has been shown to reduce mortality (2) despite the non-trivial mortality associated with elective AAA repair (3). Only 1% of 65 year-old men with a negative ultrasound will go on to develop an AAA (2).

The feared and fatal complication of AAA is rupture, and occurs in 10,500 ± 1,500 patients yearly in the U.S.A., with larger AAA’s posing higher annual risk of rupture (1-3). Emergent surgical repair mortality in the 30-50% that survive a rupture long enough to go to the operating room is roughly 50%.

The extensive nature of this patient’s aneurysm would have made for a nearly-impossible surgery, with operative mortality estimates between 15% using the British Aneurysm Repair Score (3) to 50% based on clinical opinion. This dissuaded the patient, his family, and vascular surgery team from pursuing elective repair. The patient desired discharge with pain medications and stricter blood pressure control with outpatient follow-up.

Michael Larson, M.D., Ph.D.

Tucson Hospitals Medical Education Program

Tucson, AZ, USA

References

1. Lederle FA. Ultrasonographic screening for abdominal aortic aneurysms. Ann Intern Med. 2003 Sep 16;139(6):516-22. [CrossRef] [PubMed]
2. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD002945. [CrossRef] [PubMed]
3. Grant SW, Hickey GL, Grayson AD, Mitchell DC, McCollum CN. National risk prediction model for elective abdominal aortic aneurysm repair. Br J Surg. 2013 Apr;100(5):645-53. [CrossRef] [PubMed]

Cite as: Larson M. Medical image of the week: massive abdominal aortic aneurysm. Southwest J Pulm Crit Care. 2016:13(1):30-1. doi: http://dx.doi.org/10.13175/swjpcc052-16 PDF