Successful embolization of Rasmussen’s aneurysm for severe haemoptysis

A 56 year old man with a history of smoking related COPD was admitted to our hospital with a one week history of worsening chronic cough with the recent development of haemorrhagic phlegm and a subfebrile state. Chest x-rays showed a cavitary infiltrate in the left upper lobe, a right pleural effusion and bilateral mediastinal partially calcified enlarged lymph nodes. Direct sputum examination was positive for M. tuberculosis and was confirmed by culture. Eight days after initiation of a standard four drug antituberculosis treatment regime the patient presented with repeated and major haemoptysis of up to 200 ml/event. Chest x-ray showed a new air fluid level in the left superior cavity. A CTscan of the thorax disclosed a voluminous Rasmussen’s pseudoaneurysm (figure 1). Selective catheterization using a femoral approach to the left apical superior pulmonary artery showed the pseudoaneurysm arising from a subsegmental branch (figure 2). The branch was selectively embolized with 3 coils (0.035 inches 5–3 mm in diameter [COOK, Bloomington, Indiana, USA]) resulting in occlusion of this segmental branch and no filling of the pseudoaneurysm (figure 2). Haemoptysis stopped and over the next few days sputum became negative for acid fast bacilli. No further surgical intervention was performed. Chest x-ray after one year follow-up showed resolution of the cavitary lesion and no recurrence of haemoptysis. Standardized tuberculosis treatment with a four drug regime (isoniazid – rifampicin – pyrazinamide – ethambutol) over two months followed by four months of a two drug regime (isoniazid – rifampicin) was successfully completed and the patient was declared cured at the end of the treatment (1 direct exam and 2 negative cultures before the end of the treatment) [1].