Video-Assisted Thoracic Resection of a Rare Ectopic Mediastinal Bronchial Artery Aneurysm
Bronchial artery aneurysm (BAA) is an exceptionally rare but potentially life-threatening condition. It is reported in less than 1% of all selective bronchial arteriographies. The primary treatment for BAA is endovascular therapy, which includes transcatheter arterial embolization or aortic stent-graft placement. However, surgical intervention becomes necessary in cases of treatment failure, recurrence, or contraindications to endovascular therapy. This article presents a detailed account of a rare case of an ectopic mediastinal bronchial artery aneurysm successfully resected via video-assisted thoracic surgery (VATS).
Case Presentation
A 54-year-old asymptomatic male patient was found to have an abnormal hilar shadow in the right lung during a routine computed tomography (CT) examination. His past medical history and laboratory data were unremarkable. Further evaluation with three-dimensional CT and angiography revealed a mediastinal bronchial artery aneurysm measuring 29 mm in diameter. The aneurysm was associated with a dilated and tortuous bronchial artery originating from the right subclavian artery.
Diagnostic Imaging
The three-dimensional CT and angiography provided a clear visualization of the aneurysm’s location and the tortuous afferent bronchial artery. The imaging confirmed that the afferent artery originated from the right subclavian artery, coursed downward along the mediastinum, and entered the right pulmonary artery. This anatomical complexity made endovascular artery embolization impractical, thus necessitating surgical intervention.
Surgical Procedure
The patient was positioned in a left lateral decubitus position, and a three-port VATS approach was employed. The bronchial artery aneurysm was located between the right bronchus and the inferior pulmonary vein. The surgical team meticulously ligated the afferent and efferent branches of the aneurysm and proceeded to completely resect it from the adjacent connective tissues. Additionally, the origin of the bronchial artery from the right subclavian artery was severed. The entire procedure was completed in 80 minutes.
Postoperative Outcome
The patient experienced an uneventful recovery and was discharged on the second postoperative day. Follow-up examinations conducted three months after the surgery showed no signs of recurrence.
Discussion
Bronchial artery aneurysms are exceedingly rare, with approximately 110 cases reported in the medical literature. The etiology of BAA remains unclear, with many cases being idiopathic. Some patients have associated conditions such as bronchiectasis, chronic obstructive pulmonary disease, infectious diseases, or tuberculosis. However, a significant number of patients present with an unremarkable medical history.
The clinical manifestations of BAA vary widely, ranging from asymptomatic cases to severe presentations such as hemoptysis, chest pain, hemomediastinum, and shock. The severity of symptoms often depends on the size and location of the aneurysm and whether it has ruptured. Enhanced three-dimensional CT and angiography are essential diagnostic tools for evaluating the aneurysm’s characteristics and planning the appropriate treatment.
Treatment Strategies
Given the potential risk of fatal rupture, bronchial artery aneurysms should be treated immediately upon diagnosis. Endovascular intervention has emerged as the first-line treatment for BAA. However, this approach has limitations, including treatment failure, air emboli resulting from artery embolization, and spinal cord ischemia in cases involving aortic stent-grafts. In patients with aneurysms in multiple branches of the bronchial artery, missed vessel embolization can lead to recurrence. Consequently, surgical treatment is considered for patients who experience treatment failure, recurrence, or have contraindications to endovascular therapy.
Advantages of VATS
Video-assisted thoracic surgery offers several advantages for the treatment of bronchial artery aneurysms. VATS is less invasive compared to traditional thoracotomy, and advancements in surgical instruments have further reduced its invasiveness. The morbidity rate associated with VATS is particularly low in patients with a clean medical history. Surgeons can achieve complete resection of the aneurysm along with its branches, thereby minimizing the risk of recurrence. Preoperative three-dimensional CT and angiography play a crucial role in delineating the aneurysm’s location and branches, facilitating a safe and thorough resection.
Surgical Considerations
During the surgery, it is imperative to carefully distinguish between the afferent and efferent vessels of the aneurysm to avoid hemorrhage. The ligation of these vessels must be performed meticulously to ensure complete resection of the aneurysm. The VATS procedure allows for precise visualization and manipulation of the surgical field, enhancing the safety and efficacy of the operation.
Conclusion
The case presented here highlights the successful resection of an extremely rare ectopic mediastinal bronchial artery aneurysm using video-assisted thoracic surgery. The tortuous and ectopic nature of the afferent artery made endovascular therapy unfeasible, underscoring the importance of surgical intervention in such complex cases. VATS offers a minimally invasive and effective treatment option for bronchial artery aneurysms, particularly in asymptomatic patients or those with contraindications to endovascular therapy. Preoperative imaging with three-dimensional CT and angiography is essential for accurate diagnosis and surgical planning.
doi.org/10.1097/CM9.0000000000001157
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