Successful conservative repair of the traumatic left main pulmonary artery pseudoaneurysm.

Dear Editor,

Traumatic pulmonary pseudoaneurysm is a rare but lethal condition. Traditional treatment includes surgery or embolization. Another treatment option is conservative therapy. Only three cases of conservative repair have been reported to date, and two of these patients died.[1] We report a case of successful conservative repair of a blunt traumatic pseudoaneurysm of the main pulmonary artery.

A 48-year-old man was admitted to our hospital for multiple traffic traumas. Computed tomography revealed a left main pulmonary artery pseudoaneurysm 20 mm in diameter and mediastinal hematoma [Figure 1a]. Other injuries were subarachnoid hemorrhage and multiple fractures. We selected conservative therapy for the pseudoaneurysm because the contrast medium did not leak to outside the artery and the follow-up computed tomography of the next day and after 1 week revealed that pseudoaneurysm did not differ in size. After 1 and 2 months later, the pseudoaneurysm regained normal diameter, and mediastinal hematoma was disappeared [Figure 1b and c]. He was discharged after therapies of other injuries.

Figure 1

A left main pulmonary artery pseudoaneurysm (a) (arrow). 1 month (b) and 2 months after conservative therapy (c), the left main pulmonary artery regained normal diameter and mediastinal hematoma resolved

Pulmonary pseudoaneurysms are a rare but lethal condition. Common causes include often iatrogenic, infection, neoplasm, trauma, vasculitis, and pulmonary hypertension.[12] Contrast-enhanced computed tomography and angiography are valuable modalities demonstrating the location, size, and rupture. However, the timing of detection was varied from hours to years from the causal event. Traditional therapy was surgery (aneurysmectomy, ligation of vessels, lobectomy, pneumonectomy) or embolization.[1234] When it is difficult to encircle the proximal left main pulmonary artery and repair the vascular wall through surgery, pneumonectomy is the viable option. Intraluminal embolization is associated with a high risk of embolus migration to the peripheral lung.

An indication of conservative treatment was still controversial. Previous nonoperative cases presented delayed and fatal massive hemoptysis. Peripheral location, small size, lack of symptom, and reduction in size were acceptable for nonoperative treatment.[1] In our case, although an aneurysm was proximal in origin and not small, conservative treatment was successful. The presence of anatomical structures around the left main pulmonary artery such as the pericardium, mediastinal pleura, and Botallo ligament can reinforce the vascular wall and help avoid pseudoaneurysm rupture.

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