A 34-year-old female presented to the emergency department of our institute with massive hemoptysis. Initially, the patient had streaky hemoptysis for 1 week, followed by a bout of massive hemoptysis (~300 ml in 24 h). The patient had a past history of sputum positive pulmonary TB for the past 2 years, for which she had received antitubercular therapy. On examination, the patient had tachycardia (pulse 110/min), hypotension (blood pressure: 90/58 mmHg), and respiratory rate was 18/min with oxygen saturation of 92% on room air. Local examination revealed crepitation in the left upper zone. Laboratory investigations revealed leukocytosis (18 x 103/dl), elevated erythrocyte sedimentation rate was 60 mm/h, and anemia (hemoglobin was 9 g/dl). Liver and renal function tests and coagulation profile were within normal limits.
Chest radiograph showed fibrocavitary changes in bilateral upper zones (not shown here). Computed tomography bronchial angiography (CTBA) was performed with bolus tracking technique with the preset trigger of 100 HU at descending thoracic aorta at the level of T4, on a 64 slice CT (Lightspeed VCT, GE Healthcare, USA) with detector collimation of 64 mm x 0.625 mm. 80 ml of iodinated nonionic contrast medium (omnipaque, GE Healthcare, USA) was administered during the study at a rate of 3.8 ml/s. CTBA revealed fibrocavitary changes with surrounding consolidation in bilateral upper lobes with centrilobular nodules in left upper lobe consistent with reactivation of disease. A small contrast-filled outpouching was seen within the cavity in left upper lobe [Figure 1a and b]. However, a vessel of origin could not be traced and was presumed to be arising from one of the pulmonary artery branches. (Rasmussen's aneurysm); no evidence of bronchial artery hypertrophy was seen, however intercostal arteries on the left side were prominent.
The patient was subsequently considered for endovascular management. Diagnostic angiogram of bronchial arteries using 5F SIM 1 catheter (Cook, Bloomington, USA) using the right transfemoral approach showed normal bronchial arteries on both sides with no abnormal parenchymal blush. A pseudoaneurysm was seen arising from the left 3rd posterior intercostal artery with abnormal parenchymal blush and systemic pulmonary shunting [Figure 2a]. Selective cannulation of the intercostal artery was done with progreat microcatheter (Terumo, NJ, Japan) [Figure 2b] and embolized using polyvinyl alcohol particles (PVA) 500 mm-700 um and gelfoam slurry. Postembolization check angiograms did not show opacification of pseudoaneurysm [Figure 2c]. The procedure was uneventful with improved hemodynamic status postprocedure. There was no further episode of hemoptysis on follow-up for 3 months.