Pulmonary artery pseudoaneurysm embolisation to treat massive haemoptysis due to metastatic oropharyngeal squamous cell carcinoma

摘要

A 57-year-old woman with metastatic oral squamous cell carcinoma presented to the emergency department with massive haemoptysis. Her blood pressure was 96/69 mm Hg with a heart rate of 65 beats per minute. Laboratory tests showed a mild coagulopathy (INR 1.3) for which vitamin K and tranexemic acid were administered. CT angiography revealed a metastatic pulmonary cavity, with an adjacent 10 mm pseudoaneurysm arising from a posterior basal segmental branch of the left pulmonary artery (figure 1). No other pulmonary, bronchial or systemic arterial anomaly was identified. Under general anaesthesia, the left pulmonary artery was selectively catheterised using a steerable 0.035′ guidewire (Storq, Cordis, Baar, Switzerland), a 7F hydrophilic sheath (Ansel, Cook Medical, Indiana, USA) and a 5F multipurpose catheter (Cook Medical, Bloomington, Indiana, USA). Pulmonary artery angiography was performed with arrested respiration and selective pulmonary artery catheterisation carried out with a 130 cm microcatheter (Progreat, Terumo, Tokyo, Japan). The pulmonary artery proximal and distal to the pseudoaneurysm was embolised with one 7×300 mm and five 10×500 mm helix ev3 concerto detachable coils (Medtronic, Minneapolis, Minnesota, USA). The pseudoaneurysm was embolised with a single 7×10 mm complex helical-18 microcoil and nine 4×7 mm multiloop-18 microcoils (Boston Scientific, Marlborough, Massachusetts, USA) with satisfactory angiographic result and no filling of the pseudoaneurysm (figure 2). This is also called a sandwich technique.1 The patient’s haemoptysis resolved, and her vital signs stabilised following the procedure with a short postprocedural stay in intensive care. No further haemoptysis occurred over the next 2 weeks, although she died following a further episode on day 24 postprocedure. Interim investigations with MRI neck and Positron Emission Tomography (PET)-CT demonstrated locoregional recurrence of squamous cell carcinoma and uptake within the pulmonary cavity attributed to metastases. Serial chest radiographs revealed a pleural effusion thought to be infective, in view of an elevated white cell count, which resolved after treatment with piperacillin. No angiographic follow-up was performed. The cause of recurrent massive haemoptysis was not confirmed and a postmortem was not performed.