A 68-year-old female experienced four episodes of hemoptysis (more than 400 mL/48 hours). She had a history of pulmonary tuberculosis that was diagnosed about 50 years prior and had underwent embolization of both bronchial arteries and multiple systemic collaterals due to recurrent hemoptysis (seven times) over the five years prior to presentation. Serial chest radiographs and CT showed severe destructive changes with bronchiectasis and cavitary lesions at the left lung.
Because bronchial or systemic arteries causing hemoptysis were not found, right and left coronary angiographies were performed. The coronary angiography revealed two CBFs from both coronary arteries (sinoatrial nodal artery from right coronary artery and distal left circumflex arterial branch) to the left upper and lower lung as well as a massive pulmonary artery shunt (Fig. 3). After careful selection of CBFs as far from the coronary arterial branches as possible with a microcatheter, an embolization was performed with PVA particles and small amounts of Gelfoam particles, resulting in no visible residual hypervascularization or pulmonary artery shunt. The patient was asymptomatic without hemoptysis, but abnormal electrocardiography (EKG) (unusual P axis and short PR, probably junctional tachycardia) and increased cardiac enzyme (serum creatine kinase 375 IU/L, normal range 22-269; creatine kinase-MB 33.0 ng/mL, normal range 0.0-3.4; troponin-I 11.04 ng/mL, normal range 0.0-0.3) were noted the next day. Echocardiography showed normal left ventricular systolic function and EKG was normalized on the sixth day post-embolization. The patient was discharged without any symptoms.
Chest CT and angiographies of both coronary arteries in 68-year-old female, case 3. C, D. Early and late phases of right coronary angiography show enlarged coronary to bronchial artery fistula from proximal right coronary artery and massive pulmonary artery shunt (thick arrows).