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DOI:10.2214/AJR.06.0291
AJR 2006; 187:W544-W545
© American Roentgen Ray Society

CT Visualization of Mediastinal Bronchial Artery Aneurysm

Sean R. Wilson, David I. Winger and Douglas S. Katz

Winthrop University Hospital Mineola, NY 11501



 
WEB—This is a Web exclusive article.

Keywords: aneurysm • aorta • cardiopulmonary imaging

Bronchial artery aneurysms have been observed on fewer than 1% of all selective bronchial arteriograms [1]. Jacob described the first case of bronchial artery aneurysm in 1930 in a patient with syphilis, and since then approximately 50 cases have been reported [2]. CT reports of mediastinal bronchial artery aneurysms are rare.

A 72-year-old man with a medical history significant for chronic bronchitis, hypertension, and bronchiectasis with episodes of hemoptysis presented to our emergency department with fever, pleuritic chest pain, productive cough, and an elevated WBC.

For further evaluation after chest radiography, a CT examination of the chest performed with IV contrast material showed a 12 x 14 x 16 cm left empyema with associated collapse of the left wlower lobe. Bronchiectasis was present in the right lower and middle lobes. Large bronchial artery collaterals and a 4-cm left pulmonary artery were identified. Bronchial arteries on CT that are larger than 0.2 cm are usually abnormal [3]. A 3.1 x 2.8 cm bronchial artery aneurysm was found that was contiguous with a large collateral artery that originated from the aortic arch and extended into the middle mediastinum (Fig. 1A). The average size of mediastinal bronchial artery aneurysms is 2.3 x 2.1 cm [4]. The patient's aneurysm was found to contain a 1.9 x 1.8 x 2.0 cm thrombus and abutted the esophagus wall and the trachea. Because of the patient's preexisting medical conditions, no surgical or interventional procedure was performed. A repeat CT scan obtained 17 months later showed no change in the aneurysm (Figs. 1B, 1C, and 1D; and Figs. S1E-S1G, which are movies that are available online at www.ajronline.org).


Figure 1
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  		Fig. 1A —72-year-old man with fever, cough, left empyema, and incidental bronchial artery aneurysm. Please note that Figures S1E-S1G are movies available online as supplemental data at www.ajronline.org. Initial transverse CT image shows bronchial artery aneurysm (arrow) adjacent to aortic arch and posterior to trachea.

 

Figure 2
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  		Fig. 1B —72-year-old man with fever, cough, left empyema, and incidental bronchial artery aneurysm. Please note that Figures S1E-S1G are movies available online as supplemental data at www.ajronline.org. Coronal reformation image from follow-up CT performed 17 months after A shows no change in appearance of aneurysm (arrows).

 

Figure 3
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  		Fig. 1C —72-year-old man with fever, cough, left empyema, and incidental bronchial artery aneurysm. Please note that Figures S1E-S1G are movies available online as supplemental data at www.ajronline.org. Sagittal reformation from follow-up CT reveals relation of aneurysm (arrows) to large feeding bronchial artery originating from aorta (black arrowhead) and draining portion of artery (white arrowhead).

 

Figure 4
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  		Fig. 1D —72-year-old man with fever, cough, left empyema, and incidental bronchial artery aneurysm. Please note that Figures S1E-S1G are movies available online as supplemental data at www.ajronline.org. Volumetric rendering in sagittal orientation shows feeding bronchial artery originating from aortic arch (arrowhead) and aneurysm (arrow). See Fig. S1E, video, in supplemental data at www.ajronline.org. Movie of transverse images from follow-up CT shows bronchial artery and aneurysm originating from aortic arch and posterior to trachea. See Fig. S1F, video, in supplemental data at www.ajronline.org. Movie of coronal reformatted images from follow-up CT shows bronchial artery and aneurysm originating from aortic arch and posterior to trachea. See Fig. S1G, video, in supplemental data at www.ajronline.org. Movie of sagittal reformatted images from follow-up CT shows bronchial artery and aneurysm originating from aortic arch and posterior to trachea.

 
In patients without predisposing pulmonary or systemic disease, bronchial artery aneurysms are extremely rare. Most cases have been reported in patients with silicosis, bronchiectasis, lung cancer, or recurrent infection [4]. Bronchial artery aneurysms have also been found in individuals with predisposing congenital conditions and systemic vascular diseases such as cystic fibrosis and atherosclerosis, respectively.

The cause of bronchial artery aneurysms has not been established. Four factors are believed to be involved: increased blood flow, pressure in the bronchial arteries, focal vessel weakening, and injury to the vessel wall [5]. Diameter has not been reported to be a risk factor that leads to bronchial artery aneurysm rupture. Early diagnosis and treatment of bronchial artery aneurysms are crucial, however, because of the possibility of life-threatening rupture and hemorrhage. Typically, patients are asymptomatic until the aneurysm ruptures [5].

Bronchial artery aneurysms are typically classified anatomically, either as mediastinal or intrapulmonary, because of their different associated clinical symptoms. Intrapulmonary aneurysms often present with massive or intermittent hemoptysis. Although mediastinal aneurysms may manifest as a mediastinal mass, acute superior vena cava obstruction, dysphagia, hemothorax, hemomediastinum, and hematemesis can occur [4, 5]. Bronchial artery aneurysms have also been found to mimic endobronchial tumors or, alternatively, may acutely hemorrhage and simulate the severe pain of aortic dissection or an aortic rupture [2].

Until the past decade, bronchial artery aneurysms were treated surgically. Surgical procedures such as resection or ligation of the aneurysm have been associated with high morbidity and mortality. Since then, endovascular techniques such as transcatheter embolization have been increasingly applied [4]. Studies of patients with acute massive hemoptysis have shown that bronchial artery embolization is effective in controlling bleeding initially [3]. Collateral vessels, incomplete embolization, and arterial re-canalization may cause a recurrent aneurysm; this accounts for the reported unfavorable long-term recurrence rates [2, 3].


References
Top
 References
 

  1. Fujita J, Akashi K, Kunikane H, et al. A case of bronchial artery aneurysm demonstrating a mass shadow on chest X-ray film [in Japanese]. Nihon Kyobu Shikkan Gakkai Zasshi 1991;29 : 1591-1595[Medline]
  2. Tanaka K, Ihaya A, Horiuci T, et al. Giant mediastinal bronchial artery aneurysm mimicking benign esophageal tumor: a case report and review of 26 cases from literature. J Vasc Surg2003; 38:1125 -1129[CrossRef][Medline]
  3. Yoon W, Kim JK, Kim YH, et al. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. RadioGraphics 2002;22 : 1395-1409[Abstract/Free Full Text]
  4. Kasashima F, Endo M, Kosugi I, et al. Mediastinal bronchial artery aneurysm treated with a stent-graft. J Endovasc Ther2003; 10:381 -385[CrossRef][Medline]
  5. Sancho C, Dominguez J, Escalante E, et al. Embolization of an anomalous bronchial artery aneurysm in a patient with agenesis of the left pulmonary artery. J Vasc Interv Radiol1999; 10:1122 -1126[Medline]

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