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Pulmonary artery aneurysm in a patient with interatrial communication type ostium secundum

Urbano Galvez J.M

Hospital Regional Universitario Infanta Cristina
Badajoz, Spain

Introduction
Case
Discussion


Introduction:
The lung artery aneurysm is the pathological dilation of the trunk of this artery or of one or both main branches. It is a pathology rarely diagnosed by their low prevalence and because it can sometimes go unknown by their clinical evolution. The most frequent thing is that it made mistakes with adenopathies or masses in mediastinum or in lung in the radiological studies. They sometimes pass unknown during a lifetime and its are discovered accidentally in necropsy studies. Their etiology is variable as well as its presage for that that once discovered it is necessary to investigate since on the cause that produced them, although they are sometimes benign in other occasions according to the cause can have a fatal evolution as for example in the: illness of Behçet, syndrome of Hughes Stovin and postendocarditis mycotic aneurysms. These last etiologies require an aggressive attitude regarding their treatment (surgery).

Case: A 66 year-old woman with antecedents of arterial hypertension and IAC. ostium secundum that she went for throbs and disnea of several hours of evolution. So much in the physical exploration as in the EKG you objective a quick atrial fibrillation that is reverted after braking with digoxina. In the thorax Rx a mass of about 4x3 cm. is observed in right parahiliar zone (figure 1). The biochemical and gasometric studies were normal. Bronchofibroscopic study was normal. She was carried out tomografia axial computerized that demonstrated the existence of aneurysmal dilation in the main branch of the right lung artery and another of smaller size in the main branch of the left lung artery (figure 2 and figure 3). Before the symptoms lack the surgical solution was underrated being opted by the periodic observation. During six years of pursuit the patient has not presented attributable breathing clinic to the aneurysm neither you seed clear etiology of the aneurysm for that that this it was classified as idiopathic. Several episodes of paroxysmal atrial fibrillation that required permanent oral anticoagulation were observed.

 

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Fig. 1

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Fig. 2

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Fig. 3

Discussion: The aneurysm of the lung artery is a strange entity. They are described in the literature like isolated cases or small series in those that the most diverse causes are included. They are more frequent in the masculine sex. It is frequent that the congenital or idiopathic aneurysms pass unknown or its were detected accidentally. The associate symptoms are not very specific: cough, palpitates, etc. Sometimes a massive hemoptysis for vascular rupture is first manifestation.

To exception of the idiopathic or congenital aneurysms, it would be forced the presence of some their previous clinical positions so that the aneurysm takes place: hiperafflux with lung hypertension, and the coexistence of a pathology that affects the vessel wall.

The characteristic commitment morphologic of arterial wall and the secular aspect of the lesion, they differ to the genuine aneurysm of the simple dilation artery that can happen with the increase of lung vascular pressure. Among the affections of the vascular wall, they have been described in the illness of Behçet, vasculitis of uncommon appearance and that it affects several vascular territories, in the illness of Erdheim (cystic degeneration of the arterial half layer) of unknown cause and in Hughes Stovin's syndrome that consists on the association of pulmonary aneurysms with thrombosis or pulmonary emboli and systemic thrombosis. It can see different phases: a phase asymptomatic, later on symptoms of hypertension endocraneal for jugular thrombosis or of breasts you last them, recurrent systemic veined thrombosis and finally breathing symptoms with semiology similar to pulmonary thromboembolism and hemoptysis.

Less frequent they are the aneurysms that associate to Weber Rendu Osler illness, a dominant autosomal hereditary process that one manifests for telangiectasias in face, hands and mucous, with tendency to the hemorrhage (hemorrhagical hereditary telangiectasia). The lung aneurysms generally affects to the trunk and main branches, and they can be multiple, multiple-lobed and occupied by thrombus inside their. They can associate, although not necessarily, with cardiac valvular affectation (stenosis or insufficient) and lung blows.

Aneurysm diagnose is facilitated by bloodless methods. Before the radiological clinical suspicion, it should be carried out an echocardiogram with registry Doppler that allows discarding affectation valvular and a TAC and/or thoracic IRM that confirms the diagnosis of lung aneurysm. The angiography study should be reserved since for those cases that require surgery, it doesn't contribute more precise data presumably in the evolution aneurysms benign. Medical treatment is limited and it should be reserved for evolution aneurysm "benign" (idiopathic, hypertension pulmonary). The surgical indication will be used those unstable aneurysms, with hemoptysis in those that there are a high break risk and bigger mortality (mycotics, illness of Behçet, syndrome of Hughes Stovin and illness of Osler-Weber Rendu). The surgical technique will vary in function of the localization and aneurysm etiologic and it goes from the embolización, until the lobed resection in those more outlying aneurysms.


Questions, contributions and commentaries to the Authors: send an e-mail message (up to 15 lines, without attachments) to image-pcvc@pcvc.sminter.com.ar , written either in English, Spanish, or Portuguese.

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Update
Dic/03/1999