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Colombian Journal of Anestesiology

Print version ISSN 0120-3347On-line version ISSN 2256-2087

Rev. colomb. anestesiol. vol.49 no.4 Bogotá Oct./Dec. 2021  Epub Aug 25, 2021

https://doi.org/10.5554/22562087.e959 

SPECIAL ARTICLE

Giant pulmonary artery aneurysms

a Department of Cardiothoracic Anesthesiology, Department of General Anesthesiology and Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation. Cleveland, USA.

b Anesthesiology Institute, Cleveland Clinic Foundation. Cleveland, USA.

c Department of Cardiothoracic Anesthesiology and Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation. Cleveland, USA.


The accompanying images demonstrate giant pulmonary artery aneurysms in a patient with idiopathic pulmonary arterial hypertension (Image 1). In addition to the main pulmonary artery, both the left and right pulmonary arteries are aneurysmal and are compressing the lung parenchyma (Image 2).

SOURCE: Authors.

IMAGE 1 Giant pulmonary artery aneurysms in a patient with idiopathic pulmonary arterial hypertension. 

SOURCE: Authors.

IMAGE 2 Left and right pulmonary arteries are aneurysmal and are compressing the lung parenchyma. 

Congenital cardiac heart disease, infection and pulmonary arterial hypertension are leading causes of pulmonary artery aneurysms. Giant aneurysms (diameter >8 centimeters) can compress adjacent structures including the tracheobronchial tree leading to dyspnea, cough, chest pain, wheezing and stridor. Hemoptysis may herald aneurysm rupture. Additionally, tracheobronchomalacia can occur resulting in dynamic airflow obstruction.1,2

Diagnosis is often established with radiological imaging. Ventilation perfusion mismatch from lung collapse in patients with giant aneurysms can worsen cyanosis and hypoxemia related to pre-existing pulmonary arterial hypertension. Alleviation of such collapse and tracheobronchial compression may necessitate airway stenting.

Increases in pulmonary vascular resistance related to increased intrathoracic pressure and excessive sympathetic stimulation can precipitate aneurysm rupture, airway bleeding and exsanguination. Anesthetic management focuses on mitigating such factors. Although spontaneous ventilation minimizes increases in intrathoracic pressure, optimal placement of airway stents necessitates a still deployment field and muscle relaxation to minimize coughing. Awake fiberoptic intubation allows placement of the endotracheal tube beyond the point of tracheal compression safely in most circumstances. Pre-induction establishment of invasive arterial monitoring and large bore intravenous access is important. Induction is best initiated with the patient positioned upright to maximize functional residual capacity. Use of low tidal volume ventilation while avoiding excessive PEEP and recruitment maneuvers is also prudent. Critical airway obstruction, compression at the level of the carina, impending respiratory failure and refractory hypoxemia may warrant institution of pre-induction venovenous extracorporeal circulatory life support. Lastly, topicalization of airway with lidocaine and/or use of intravenous remifentanil infusion during emergence from anesthesia, may help mitigate coughing and stent displacement. 1-3

ACKNOWLEDGEMENTS

Author's contributions

SK: Conception of project, planning and final writing of manuscript.

TO, CC and CT: Conception of project, approval of manuscript.

REFERENCES

1. Kumar B, Munirathinam GK, Mishra AK, Arya VK. Giant Peripheral Pulmonary Artery Aneurysm Rupture Under Anesthesia-A Sequela of Positive-Pressure Ventilation. J Cardiothorac Vasc Anesth. 2017;31(1):279-82. doi: https://doi.org/10.1053/j.jvca.2016.04.011Links ]

2. Greaves SW, Dye L 3rd, Aranda PS, Cain MT, Haasler GB, Almassi GH, Pagel PS, Kreibich M, Beyersdorf F, Elefteriades JA. Perioperative Management of a Large Idiopathic Pulmonary Artery Aneurysm Without Pulmonary Arterial Hypertension. J Cardiothorac Vasc Anesth . 2018;32(5):2402-8. doi: https://doi.org/10.1053/j.jvca.2018.05.003Links ]

3. Malpas G, Hung O, Gilchrist A, Wong C, Kent B, Hirsch GM, Hart RD. The use of extracorporeal membrane oxygenation in the anticipated difficult airway: a case report and systematic review. Can J Anesth. 2018;65:685-97. doi: https://doi.org/10.1007/s12630-018-1099-xLinks ]

Assistance with the study None declared.

Financial support and sponsorship None declared.

Conflicts of interest None declared.

Presentation None declared.

Conflict of interest No external funding and no competing interests declared.

How to cite this article: Khanna S, Thida, Chow C, Trombetta C. Giant pulmonary artery aneurysms. Colombian Journal of Anesthesiology. 2021;49:e959

Received: November 06, 2020; Accepted: November 08, 2020; Accepted: January 21, 2021

Correspondence: Department of Cardiothoracic Anesthesiology, Department of General Anesthesiology and Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation. 9500 Euclid Avenue, E3-108, Cleveland Clinic Foundation, Cleveland, Ohio 44122.

*E-mail:khannas@ccf.org

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