Presentations

Abstract

Introduction:

A pseudoaneurysm is an area of focal arterial dilation involving two or less layers of the arterial wall and is often associated with a perivascular hematoma. Pulmonary artery pseudoaneurysms (PAPs) are frequently iatrogenic conditions, but can also arise secondary to trauma, neoplasm, infection, or vasculitis. Non-iatrogenic traumatic PAPs are rare and primarily caused by penetrating injuries, such as gunshot wounds. There are few reported cases of PAPs due to blunt force trauma. We present a case of a 49-year-old male with a right pulmonary artery pseudoaneurysm (PAP) due to a blunt force injury caused by a high- speed motor vehicle collision.

Case Information:

Our patient, a 49-year-old male, presented to the emergency department immediately following a high-speed motor vehicle collision with a blunt force injury. He was asymptomatic at the time of presentation. A chest x-ray and chest computed tomography angiogram (CTA) were performed. Based on the imaging obtained, the following diagnoses were made: right PAP, sternal manubrium fracture with retrosternal hematoma, small right pneumothorax, and right middle lobe pulmonary contusions. The patient was admitted to the hospital and received a follow-up CTA. The pseudoaneurysm was unchanged and the injury was central in an area deemed low risk for uncontained rupture. After seven days of observation without medical or invasive intervention, the patient remained clinically stable. He was discharged from the hospital without additional intervention. The patient was instructed to follow up, but at six months post-injury there was no available record of follow up.

Discussion/Clinical Findings:

Pulmonary artery pseudoaneurysms are difficult to identify as they can be asymptomatic, or mimic other causes of chest pain such as pneumothorax, pulmonary embolism, and pericarditis. While identification of PAPs can be challenging, early identification is important, as PAPs can cause fatal hemoptysis, especially when peripheral (i.e., in the lung). Patients with traumatic PAPs typically present with a complaint of chest pain and may develop hemoptysis as well as shortness of breath. In addition, multiple treatments for PAPs exist, including trans-catheter embolization, surgical ligation, lobectomy, and endovascular graft placement. This case is unique in that our patient sustained a PAP due to blunt force trauma, was asymptomatic, and received no treatment for the PAP. No patients in the existing documented cases of PAPs sustained due to blunt force trauma remained asymptomatic and did not require intervention. Our take home message from this case is to have a high suspicion for PAPs, even in the context of blunt force trauma. Furthermore, patients with PAPs who remain asymptomatic can do well without intervention.

Conclusion:

A pulmonary artery pseudoaneurysm is a very uncommon injury due to blunt force trauma to the chest. Pulmonary artery pseudoaneurysms may present with chest pain, hemoptysis, and shortness of breath. A minority of patients with a PAP are asymptomatic, which contributes to the under recognition of PAPs. The diagnostic standard for identification of a pulmonary artery pseudoaneurysm is a chest CTA, where PAPs appear as focal dilation of the pulmonary artery. PAPs can be treated with trans-catheter embolization, surgical ligation, lobectomy, endovascular graft placement, or continued observation.