CHEST PAIN AND SHORTNESS OF BREATH

Transcription

1 Originally Posted: April 01, 2015 CHEST PAIN AND SHORTNESS OF BREATH Resident(s): Osama Abdul-Rahim Attending(s): Jeffrey Weinstein, Stephen Leschak, Paul Brady Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA

2 CHIEF COMPLAINT & HPI Chief Complaint and/or reason for consultation Acute onset chest pain and shortness of breath History of Present Illness 36 y/o female initially presented with left lower extremity and groin pain after sensing a pop Lower extremity US showed a left thigh mass found to be high grade sarcoma on biopsy with associated DVT extending from the CFV to the popliteal vein Further workup revealed bilateral pulmonary emboli and mediastinal metastases with invasion of the pulmonary artery on the left She is currently 1 week out from her 3 rd cycle of chemotherapy

3 RELEVANT HISTORY Past Medical History Hypertension controlled with medication Past Surgical History C-section Family & Social History DM (grandmother) No tobacco, no EtOH, no other substance use Medications Lisinopril Allergies NKDA

4 DIAGNOSTIC WORKUP Previous chest CT (pre chemotherapy) Current chest CT (post chemotherapy)

5 QUESTION 1 1) Where is the abnormality? (Answer on next slide)

6 ANSWER TO QUESTION 1

7 DIAGNOSIS Left pulmonary artery pseudoaneurysm (PSA) Measures 1 cm across the base and 1 cm in depth No active hemorrhage

8 INTERVENTION Coiling was considered but the neck of the PSA was considered too wide for safe coil placement No covered stent was available with the appropriate length and diameter Therefore, a Wallstent was used as a flow diverter

9 INTERVENTION PE PSA Initial pulmonary angiogram Post Wallstent placement

10 CLINICAL FOLLOW UP Chest CTA three days after stenting showed the PSA had thrombosed After one month the patient reported decreased chest pain and shortness of breath She had no adverse events from stenting

11 SUMMARY & TEACHING POINTS 36 y/o female with left thigh sarcoma and mediastinal metastases which eroded into the left main pulmonary artery Chemotherapy induced regression of the metastasis resulted in a pseudoaneurysm of the left main pulmonary artery Placement of a Wallstent wall stent to exclude the PSA allowed for adequate flow diversion and PSA thrombosis

12 QUESTION 2 2) What are some of the treatment approaches for pseudoaneurysms? A: Coil embolization B: Stent placement C: Thrombin injection D: Ultrasound probe compression E: All of the above

13 CORRECT! 2) What are some of the treatment approaches for pseudoaneurysms? A: Coil embolization (If the neck of the pseudoaneurysm is appropriately narrow then coiling the aneurysm sac is a good option) B: Stent placement (Stent placement, as in this case will help redirect flow away from the aneurysm sac, more so if a covered stent is available) C: Thrombin injection (This can be done with more superficial aneurysms, such as the femoral artery, but care must be taken that the thrombin does not travel systemically) D: Ultrasound probe compression (Manual pressure with an ultrasound probe may be performed with more accessible pseudoaneurysms) E: All of the above Continue with the Case

14 SORRY, THAT S INCORRECT. 2) What are some of the treatment approaches for pseudoaneurysms? A: Coil embolization (If the neck of the pseudoaneurysm is appropriately narrow then coiling the aneurysm sac is a good option) B: Stent placement (Stent placement, as in this case will help redirect flow away from the aneurysm sac, more so if a covered stent is available) C: Thrombin injection (This can be done with more superficial aneurysms, such as the femoral artery, but care must be taken that the thrombin does not travel systemically) D: Ultrasound probe compression (Manual pressure with an ultrasound probe may be performed with more accessible pseudoaneurysms) E: All of the above Continue with the Case

15 QUESTION 3 3) Which of the following is NOT a cause of TRUE pulmonary artery pseudoaneurysms? A: Chronic pulmonary hypertension B: Behçet's disease C: Birt-Hogg Dube syndrome D: Marfan syndrome E: Takayasu arteritis

16 CORRECT! 3) Which of the following is NOT a cause of TRUE pulmonary artery pseudoaneurysms? A: Chronic pulmonary hypertension B: Behcet s disease C: Birt-Hogg Dube syndrome (An autosomal-dominant disorder that causes facial papules, bilateral renal tumors, and pulmonary cysts. Pulmonary pseudoaneurysms are not a characteristic of this syndrome) D: Marfan syndrome E: Takayasu arteritis Continue with the Case

17 SORRY, THAT S INCORRECT. 3) Which of the following is NOT a cause of TRUE pulmonary artery pseudoaneurysms? A: Chronic pulmonary hypertension B: Behcet s disease C: Birt-Hogg Dube syndrome (An autosomal-dominant disorder that causes facial papules, bilateral renal tumors, and pulmonary cysts. Pulmonary pseudoaneurysms are not a characteristic of this syndrome) D: Marfan syndrome E: Takayasu arteritis Continue with the Case

18 REFERENCES & FURTHER READING Lafita V, Borge MA, Demos TC. Pulmonary artery pseudoaneurysm: etiology, presentation, diagnosis, and treatment. Semin Intervent Radiol Mar;24(1): Dallaudière B, Hummel V, Pierre Laissy J. The use of covered stents for treatment of pulmonary artery pseudoaneurysms. J Vasc Interv Radiol Feb;24(2): Kaufman, J. and Lee, M. The Requisites: Vascular and Interventional Radiology, 2 nd Ed. Philadelphia: Elsevier, Print.