Summary: An 84-year–old woman presented with hemoptysis during an elective right-heart catheterization when a pulmonary capillary wedge pressure
measurement was performed. Her history was significant for hypertension,
atrial fibrillation, pulmonary hypertension, and atrial septal defect
repaired 40 years prior. She presented with diffuse expiratory wheezing
and was admitted to the ICU and intubated. Bronchoscopy was performed
and showed blood clots in the right mainstem bronchus, but there was no
active bleeding. A chest radiograph at ICU admission revealed a right
upper-lobe ill-defined airspace opacity (Figure 1).
Summary: On day 2 of
admission, the patient was extubated and transferred to a medical floor.
She developed a cough and a repeat CXR was performed, which showed
persistence of the right upper lobe (RUL) opacity, which was further
studied with a computed tomography angiography (CTA) scan. The patient
declined any intervention and is being followed clinically.
Iatrogenic pulmonary artery pseudoaneurysm (IPAP)
Upon admission to the ICU, after catheterization, a chest radiograph
showed a RUL opacity. A repeat chest radiograph on day 2 in the hospital
showed further increase in density of the RUL airspace opacity (Figure
2). Subsequent follow-up imaging studies at days 3 and 9 after
catheterization showed the RUL opacity to develop into a well-marginated
ovoid opacity (Figures 3 and 4).
CTA showed a large, ovoid,
enhancing mass with crescent-shaped low attenuation in the RUL and with
extensive surrounding ground-glass opacity compatible with a large
partially thrombosed pseudoaneurysm with peripheral hemorrhage (Figure
5). Axial and oblique coronal MPR reformations of the contrast-enhanced
CT revealed the RUL mass to be tubular in shape arising adjacent to a
right hilar-pulmonary vessel (Figure 6 and 7).
In 1985, 500,000 right-heart catheters were placed in the United States, and approximately 1 million were used worldwide.1
During the last 2 decades, the trend indicates that pulmonary artery
(PA) catheterization use decreased by 65% from 5.66 to 1.99 per 1000
medical admissions in the U.S.,2 probably due to growing
evidence that this invasive procedure does not reduce mortality, but
increases the chances of transient arrhythmias, catheter-related sepsis,
and pulmonary-artery injury.3,4 Rarely, injuries to the
pulmonary arteries lead to vessel rupture with focal bleeding into the
surrounding lung parenchyma that may be limited by thrombus formation,
extravascular tissue compression, or both, leading to the formation of a
The incidence of post right-heart catheterization IPAP formation has been reported to be well below 1%.5The reported occurrence of pulmonary artery rupture is 0.02% to 0.4%,6,7
and these events occur more commonly in segmental pulmonary arteries to
the right lower lobe and right middle lobe, carrying up to 50%
mortality secondary to aspiration and asphyxia due to uncontrolled
The most common clinical
manifestations of pulmonary artery rupture are cough, hemoptysis,
hypoxemia, and exsanguination. Most cases present shortly after catheter
manipulations, and the diagnosis is based on the temporal association
between the intervention and the immediate onset of symptoms. IPAP has
also been reported as late as
6 months following PA catheterization, due to rebleeding or, more
frequently, as an incidental finding in subsequent imaging studies.9,10
reported risk factors for IPAP formation include advanced age (>
60), female gender, long-term steroid use, and surgically induced
hypothermia.11 It is alleged that atherosclerotic changes of
the pulmonary vessels in these patients makes them less compliant and
more fragile than normal vessels.7
In most cases, the
right pulmonary artery is affected, as the inferior right pulmonary
artery is the most common location for catheter-tip placement. It has
been stipulated that this results from the inherent curvature of the
catheter that favors insertion into the inferior right pulmonary artery.12
The formation of pseudoaneurysms has been associated with technical
challenges during catheter placement. Shear stress is related to
catheter stiffness, prolonged balloon inflation, multiple manipulations
of the catheter, and peripheral placement of the catheter.13
radiography is the initial modality in the evaluation of a patient with
cough or most thoracic symptoms. A pulmonary artery pseudoaneurysm
should be suspected in patients presenting with radiographic changes,
usually hilar enlargement, commonly early within the first week after PA
catheterization.14 In the course of 1 to 3 weeks after
catheterization, the appearance of an organized opacity with diameter
ranging between 2 cm and 8 cm has been described.1 However, many times the chest radiograph may be unremarkable despite development of an IPAP.14
CT examination allows accurate evaluation of the size, location, and
origin of the IPAP. A pseudoaneurysm is observed as a saccular or
fussiform mass in continuity with an adjacent vessel,13
occasionally with a partially thrombosed lumen. A thickened wall in the
vessel with pseudoaneurysm could also be seen with a connective tissue
disorder, such as vasculitis implicated in the formation of
pseudoaneurysm. A lung tumor invading the pulmonary vessel wall,
tuberculosis reactivation, and pyogenic infection can be distinct causes
of a weakened pulmonary artery, leading to the pseudoaneurysm
A halo of ground-glass attenuation
surrounding a well-circumscribed nodule has been described as likely
representing an intermediate stage of clearance of extravasated blood,
in which the air spaces have nearly cleared, but interstitial thickening
persists. The surrounding halo of ground-glass density may resemble the
appearance of acute invasive Aspergillus infection, but IPAP tends to
be a single lesion in a noninmunocompromised patient.15
with multiplanar reconstruction (MPR) has been advocated as the
noninvasive modality of choice for diagnostic and therapy planning
purposes. The bleeding vessel and its origin can be easily identified.
The contrast-enhanced CT evaluation of a pulmonary mass after Swan-Ganz
catheter placement helps differentiate IPAP from pulmonary infarct and
limited parenchymal hemorrhages of other origins.8
Pulmonary angiography is the historical reference test providing accurate assessment of size and anatomical localization.6
Pulmonary artery pseudoaneurysms are seen as an extravascular
collection of contrast material in continuity with a branch of the
pulmonary artery. One of the benefits of the procedure is that it allows
simultaneous transcatheter embolization.
When conventional or CT
pulmonary angiography cannot be performed, magnetic resonance
angiography (MRA) becomes a valuable option. T1-weighted images
adequately demonstrate the pseudoaneurysms. Fast spin echo (FSE) and
gradient echo imaging are useful in the morphologic evaluation of
pulmonary vasculature from main trunk to subsegmental branches.16 When possible, gadolinium-enhanced MRA improves the evaluation of subsegmental arterial branches.
treatment, IPAP may enlarge or rehemorrhage with a fatal outcome. In a
review article of 28 cases of pseudoaneurysms after pulmonary
catheterization, all patients treated before rupture of the false
aneurysm survived (12 patients), whereas mortality reached 100% in those
whose aneurysm ruptured before treatment.17 However, some
authors still propose conservative management and close follow up with
imaging for smaller pseudoaneurysms measuring < 2.2 cm.18,19
the acute setting of aneurysm rupture, immediate management comprises
lateral decubitus positioning, intubation with a double-lumen
endotracheal tube, and ventilation with positive end-expiratory
pressure. Occasionally, IPAP perforation due to Swan-Ganz catheter can
occur during cardiac surgery, in these cases parenchymal resection and
pulmonary artery repair is crucial.20 It is the larger
pseudoaneurysms that have the higher risk of rupture making surgery
hazardous. Pulmonary resection or lobectomy can be considered for severe
cases in which previous nonsurgical treatment attempts failed, but it
confers high mortality as well.
endovascular embolization is considered the treatment of choice. It has
proven to be safe, minimally invasive, fast, and a cost-effective
alternative to surgery.21 The procedure can be performed by
selectively placing coils or plugs in or adjacent to the pseudoaneurysm.
Alternatively, percutaneous embolization methods used are sclerosing
agents (sobutyl-2-cyanoacrylate), absorbable gelatin sponges, or
detachable balloons in the artery feeding the false aneurysm.10
Although the choice of the most appropriate procedure is generally
based on experience and skills of the performing interventional
radiologist, coil embolization is advocated as the first approach for
the management of PAPs by many authors in interventional radiology
Swan-Ganz catheterization, which provides very important hemodynamic
information, is a very useful invasive procedure in evaluating and
managing critically ill patients. Prompt recognition of its
complications, in particular iatrogenic pulmonary artery rupture, is
mandatory due to its high morbidity and mortality.
the imaging manifestations is critical. When chest radiographs are
unremarkable and the clinical suspicion is present, further imaging with
a contrast-enhanced multidetector CT scan or pulmonary angiography is
Percutaneous-catheter coil embolization is the
typical first-line management, as it relatively quickly and safely
treats the injury with stable long-term results.
- Robin ED. Overuse and abuse of Swan-Ganz catheters. Int J Clin Monit Comput. 1987;4:5-9.
- Wiener RS, Welch HG. Trends in the use of the pulmonary artery catheter in the United States, 1993-2004. JAMA. 2007; 298:423-429.
- Rubenfeld, GD, McNamara-Aslin E, Rubinson L. The pulmonary artery catheter, 1967-2007: Rest in peace? JAMA. 2007;298:458-461.
- Slung HB, Scher KS. Complications of the Swan-Ganz catheter. World J Surg. 1984;8:76-81.
- Boyd KD, Thomas SJ, Gold J, et al. A prospective study of
complications of pulmonary artery catheterizations in 500 consecutive
patients. Chest. 1983;84:245-249.
- Poplausky MR, Rozenblit G, Rundback JH, Swan-Ganz. Catheter-induced
pulmonary artery pseudoaneurysm formation: Three case reports and a
review of the literature. Chest. 2001;120:2105-2111.
- Kearney TJ, Shabot MM. Pulmonary artery rupture associated with the Swan-Ganz catheter. Chest. 1995;108:1349-1352.
- Ferretti GR, Thony F, Link KM, et al., False aneurysm of the
pulmonary artery induced by a Swan-Ganz catheter: Clinical presentation
and radiologic management. AJR Am J Roentgenol. 1996;167:941-945.
- Sam A, Sandur S. An iatrogenic lung nodule. Chest 2009;136:314-317.
- Abreu AR, Campos MA, Krieger BP. Pulmonary artery rupture induced by
a pulmonary artery catheter: A case report and review of the
literature. J Intensive Care Med. 2004;19:291-296.
- Dieden JD, Friloux LA, 3rd, and JW Renner. Pulmonary artery false aneurysms secondary to Swan-Ganz pulmonary artery catheters. AJR Am J Roentgenol. 1987;149:901-906.
- Burrel M, Real MI, Barrufet M, et al. Pulmonary artery
pseudoaneurysm after Swan-Ganz catheter placement: Embolization with
vascular plugs. J Vasc Interv Radiol. 2010;21:577-581.
- Castaner E, Gallardo X, Rimola J, et al. Congenital and acquired pulmonary artery anomalies in the adult: Radiologic overview. Radiographics. 2006;26:349-371.
- Nguyen ET, Silva CI, Seely JM, et al. Pulmonary artery aneurysms and pseudoaneurysms in adults: Findings at CT and radiography. AJR Am J Roentgenol. 2007;188:W126-134.
- Guttentag AR, Shepard JA, McLoud TC. Catheter-induced pulmonary artery pseudoaneurysm: The halo sign on CT. AJR Am J Roentgenol. 1992;158:637-639.
- Ugolini P, Mousseaux E, Sadou Y, et al. Idiopathic dilatation of the pulmonary artery: Report of four cases. Magn Reson Imaging. 1999;17:933-937.
- DeLima LG, Wynands JE, Bourke ME, et al. Catheter-induced pulmonary artery false aneurysm and rupture: Case report and review. J Cardiothorac Vasc Anesth. 1994;8:70-75.
- You CK, Whatley GS. Catheter-induced pulmonary artery pseudoaneurysm: a case of complete resolution without intervention. Can J Surg. 1994;37:420-424.
- Rouquier J, Arrivé L, Masini JP, et al. Spontaneous resolution of
asymptomatic false aneurysm of the pulmonary artery induced by Swan-Ganz
catheter. J Radiol. 2001;82:1732-1734.
- Choh JH, Khazei AH, Ihm HJ, et al. Catheter induced pulmonary arterial perforation during open heart surgery. J Cardiovasc Surg (Torino). 1994;35:61-64.
- Karak P, Dimick R, Hamrick KM, et al. Immediate transcatheter
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