Peripheral pulmonary arterial pseudoaneurysms: therapeutic implications of endovascular treatment and angiographic classifications

To classify peripheral pulmonary arterial pseudoaneurysms (PAPs) associated with infectious lung diseases according to angiographic findings and to determine treatment options for PAPs on the basis of angiographic classifications. The institutional review board approved this study. A total of 24 patients with massive hemoptysis had PAPs that were detected at pulmonary computed tomographic (CT) angiography; underlying diseases were pulmonary tuberculosis (n = 16), a fungus ball (n = 5), lung abscess (n = 2), and pneumonia (n = 1). All patients underwent bronchial and nonbronchial systemic collateral arterial angiography and pulmonary and selective pulmonary angiography. On the basis of the angiographic findings, PAPs were classified into four types: PAPs visualized at nonselective right or left pulmonary angiography were defined as type A (n = 5), PAPs visualized at selective segmental or subsegmental pulmonary angiography were defined as type B (n = 10), PAPs apparent at bronchial and nonbronchial systemic collateral arterial angiography by means of a bronchopulmonary arterial shunt but not at selective pulmonary angiography were classified as type C (n = 5), and PAPs apparent at pulmonary CT angiography alone but not at catheter-directed angiography were classified as type D (n = 4). For type A or B PAPs, bronchial and nonbronchial systemic collateral arteries and pulmonary arteries were successively embolized. Hemoptysis was controlled for all type A and type B PAPs. For type C or type D PAPs, embolization alone of bronchial and nonbronchial systemic collateral arteries and follow-up pulmonary CT angiography were performed. Hemoptysis was not controlled in three of the nine patients: In those patients, percutaneous injection therapy (n = 2) and surgical resection (n = 1) were performed. Classification of PAPs on the basis of angiographic findings and determination of treatment options according to these findings are useful for the endovascular management of PAPs associated with massive hemoptysis.