8/10/2019 SIR RFS Case Series: Chest Pain and Shortness of Breath

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CHEST PAIN AND SHORTNOF BREATH

Originally Posted:

Resident(s): Osama Abdul-RahimAttending(s): Jeffrey Weinstein, Stephen Leschak, Paul Brady

Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA

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CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation Acute onset chest pain and shortness of breath

History of Present Illness

36 y/o female initially presented with left lower extremity and groin psensing a pop

Lower extremity US showed a left thigh mass found to be high gradeon biopsy with associated DVT extending from the CFV to the poplit

Further workup revealed bilateral pulmonary emboli and mediastinametastases with invasion of the pulmonary artery on the left

She is currently 1 week out from her 3rdcycle of chemotherapy

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RELEVANT HISTORY

Past Medical History Hypertension controlled with medication

Past Surgical History C-section

Family & Social History DM (grandmother)

No tobacco, no EtOH, no other substance use

Medications Lisinopril

Allergies NKDA

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DIAGNOSTIC WORKUP

Previous chest CT (pre chemotherapy) Current chest CT (post ch

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QUESTION 1

1) Where is the abnormality?(Answer on next slide)

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ANSWER TO QUESTION 1

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DIAGNOSIS

Left pulmonary artery pseudoaneurysm (PSA) Measures 1 cm across the base and 1 cm in depth

No active hemorrhage

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INTERVENTION

Coiling was considered but the neck of the PSA was considered toofor safe coil placement

No covered stent was available with the appropriate length and dia

Therefore, a Wallstent was used as a flow diverter

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INTERVENTION

PSA

PE

Initial pulmonary angiogram Post Wallstent plac

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CLINICAL FOLLOW UP

Chest CTA three days after stentingshowed the PSA had thrombosed

After one month the patientreported decreased chest pain andshortness of breath

She had no adverse events fromstenting

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QUESTION 2

2) What are some of the treatment approaches for pseudoaneurysms?

A: Coil embolization

B: Stent placement

C: Thrombin injection

D: Ultrasound probe compression

E: All of the above

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CORRECT!

2) What are some of the treatment approaches for pseudoaneurysms?

A: Coil embolization (If the neck of the pseudoaneurysm is appropriately nthen coiling the aneurysm sac is a good option)

B: Stent placement (Stent placement, as in this case will help redirect flowfrom the aneurysm sac, more so if a covered stent is available)

C: Thrombin injection (This can be done with more superficial aneurysms, the femoral artery, but care must be taken that the thrombin does not travsystemically)

D: Ultrasound probe compression (Manual pressure with an ultrasound probe performed with more accessible pseudoaneurysms)

E: All of the aboveContinue with the Case

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SORRY, THATS INCORRECT.

2) What are some of the treatment approaches for pseudoaneurysms?A: Coil embolization (If the neck of the pseudoaneurysm is appropriately n

then coiling the aneurysm sac is a good option)

B: Stent placement (Stent placement, as in this case will help redirect flowfrom the aneurysm sac, more so if a covered stent is available)

C: Thrombin injection (This can be done with more superficial aneurysms,

the femoral artery, but care must be taken that the thrombin does not travsystemically)

D: Ultrasound probe compression (Manual pressure with an ultrasound probe performed with more accessible pseudoaneurysms)

E: All of the above

Continue with the Case

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QUESTION 3

3) Which of the following is NOT a cause of TRUE pulmonary artery pseudo

A: Chronic pulmonary hypertension

B: Behet's disease

C: Birt-Hogg Dube syndrome

D: Marfan syndrome

E: Takayasu arteritis

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CORRECT!

3) Which of the following is NOT a cause of TRUE pulmonary artery pseudo

A: Chronic pulmonary hypertension

B: Behcets disease

C: Birt-Hogg Dube syndrome (An autosomal-dominant disorder that capapules, bilateral renal tumors, and pulmonary cysts. Pulmonary

pseudoaneurysms are not a characteristic of this syndrome)D: Marfan syndrome

E: Takayasu arteritis

Continue with the Case

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SORRY, THATS INCORRECT.

3) Which of the following is NOT a cause of TRUE pulmonary artery pseudoA: Chronic pulmonary hypertension

B: Behcets disease

C: Birt-Hogg Dube syndrome (An autosomal-dominant disorder that capapules, bilateral renal tumors, and pulmonary cysts. Pulmonary

pseudoaneurysms are not a characteristic of this syndrome)D: Marfan syndrome

E: Takayasu arteritis

Continue with the Case

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REFERENCES & FURTHER READING

Lafita V, Borge MA, Demos TC. Pulmonary artery pseudoaneurysm: etiolog

presentation, diagnosis, and treatment. Semin Intervent Radiol. 2007Mar;24(1):119-23.

Dallaudire B, Hummel V, Pierre Laissy J. The use of covered stents for treof pulmonary artery pseudoaneurysms. J Vasc Interv Radiol. 2013 Feb;248.

Kaufman, J. and Lee, M. The Requisites: Vascular and Interventional RadEd. Philadelphia: Elsevier, 2014. Print.