Catheter Interventional Treatment with Simultaneous Bronchoscopic Guidance for the Acute Pulmonary Hemorrhage Induced by Ruptures of Major Aortopulmonary Collateral Arteries

Objectives: Major aortopulmonary collateral arteries (MAPCA) are often developed by patients with congenital heart disease. MAPCA supply blood to the lungs and may develop complications such as ruptures with consecutive pulmonary hemorrhage.

Methods: A 24-year-old female patient after total cavopulmonary connection operation in 2003 due to unbalanced atrioventricular septal defect was admitted with hemoptysis to a pulmonology clinic. During the bronchoscopy, the patient developed acute pulmonary hemorrhage and was transferred to our clinic. Our invasive diagnostic showed satisfactory Fontan's circulation with numerous MAPCA. In the cath laboratory, three collateral vessels were occluded with two 5-mm and one 8-mm vascular plugs (AVP4) which stopped the pulmonary bleeding. Four days later the patient again developed acute pulmonary hemorrhage and was urgently admitted to the cath laboratory. In the cath laboratory, simultaneous bronchoscopy was used as guidance to the locations of the bleeding MAPCA. During angiography, the advancement of the bronchoscope to the endobronchial bleeding sites was followed by occlusion of the ruptured MAPCA. Two MAPCA were occluded with 6- and 7-mm AVP4. The MAPCA causing the major pulmonary bleeding arose from a convolute of small vessels out of the aorta descending. These small vessels were impossible to occlude with standard vascular plugs or spirals. The pulmonary hemorrhage worsened the decision was made to occlude the source of the bleeding with a covered stent. After implantation of a 45-mm covered CP stent, the bleeding eventually stopped.

Conclusion: Numerous patients with Fontan's circulation tend to develop life-threatening pulmonary hemorrhages due to ruptures of MAPCA. Whereas bronchoscopic stopping the bleeding might be impossible, in catheter interventional treatment of the MAPCA-caused pulmonary bleeding a simultaneous bronchoscopy appears to be a useful guiding method. The present case illustrates the advantages of catheter interventional treatment with simultaneous bronchoscopic guidance to provide optimal management of ongoing pulmonary hemorrhage secondary to MAPCA rupture. Due to morphological features or anatomical localization, interventional MAPCA occlusion via vascular plugs or spirals might be difficult or impossible. As our case illustrates, overstenting the vessel's origin with a covered stent can be successfully applied for MAPCA occlusion respectively management of active MAPCA induced bleeding.

Publication History

Article published online:
21 February 2021