http://informahealthcare.com/hth ISSN: 0265-6736 (print), 1464-5157 (electronic) Int J Hyperthermia, 2015; 31(1): 1–4 ! 2015 Informa UK Ltd. DOI: 10.3109/02656736.2014.995239
RESEARCH ARTICLE – CASE HISTORY
Pulmonary artery pseudoaneurysm after radiofrequency ablation: Report of two cases
Int J Hyperthermia Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
Sophie Borghol1, Nicolas Alberti1, Nora Frulio1, Amandine Crombe1, Marion Marty2, Alain Rolland1,3 & Herve Trillaud1 1
Department of Radiology, Saint Andre´ Hospital, Bordeaux, France, 2Department of Pathology, Haut-Le´veˆque Hospital, Pessac, France, and Department of Radiology, La Rochelle Hospital, La Rochelle, France
3
Abstract
Keywords
We report two cases of pulmonary arterial pseudoaneurysms (PAs) following percutaneous radiofrequency ablation (PRFA). The first patient was a 74-year-old Caucasian man who was treated for a secondary location of an advanced melanoma. A computed tomography scan at 72 h after the procedure, performed for basithoracic pain, hyperthermia and haemoptysis, revealed a 17-mm PA within the ablative zone. A lobectomy was performed. The second patient was an 80-year-old white man followed up for a right apical lung adenocarcinoma. Massive haemoptysis occurred 24 h after PRFA; emergent contrast-enhanced CT and pulmonary arteriography revealed a pulmonary artery PA (20 mm diameter), which was embolised with coils. The initial clinical course was satisfactory; however, 15 days after the procedure, the patient unfortunately presented a new massive haemoptysis and died a few hours later. The long ablation duration and the multiple repositioning of the electrodes might have been risk factors for this rare and potentially lethal complication.
Complication, lung, metastasis, pseudoaneurysm, pulmonary artery, radiofrequency ablation
Introduction Tumour destruction by percutaneous radiofrequency ablation (PRFA) is a minimally invasive procedure to treat lung tumours, primary or secondary, especially in inoperable patients. At high temperatures, it results in immediate coagulative necrosis adjacent to the electrode [1–9]. Haemorrhagic complications are rare but potentially lethal [10–15]. We report two cases of pulmonary arterial pseudoaneurysms (PAs) following PRFA. This work has no disclosure of funding and was approved by the Institutional Review Board of our institution.
Case 1 The first patient was a 74-year-old Caucasian man, referred to us 9 years ago for advanced melanoma and treated by systemic chemotherapy. In 2011, one unique metastasis was diagnosed in the right basal pyramid of the lung (17 mm) (Figure 1A). Coagulability was within the normal range. No thrombocythemia was found. The patient did not receive any anticoagulant therapy. As the patient was frail, with many comorbidities, PRFA was preferred over lung surgery and was performed 15 days later using a multi-tined expandable electrode with 3-cm diameter arrays (LeVeen, Boston Scientific, Natick, MA, USA) under general anaesthesia. Correspondence: Sophie Borghol, Department of Radiology, Saint Andre´ Hospital, 1 Rue Jean Burguet, 33000 Bordeaux, France. Tel: +33 (0) 5 56 795679. Fax: +33 (0) 5 56 795899. E-mail: [email protected]
History Received 16 November 2014 Revised 1 December 2014 Accepted 2 December 2014 Published online 20 January 2015
The nodule, located in the right costophrenic angle, was barely accessible; therefore the needle was repeatedly repositioned. Although parenchymal haemorrhage followed the lung RF ablation immediately, the patient remained asymptomatic. The ablation lasted 42 min. The maximum energy used was 60 W. By 72 h after the treatment; the patient was febrile and complained of chest pain associated with the expectoration of small quantities of blood. Emergent contrastenhanced CT revealed a 17-mm PA inside the ablation zone (Figures 1B and C). Subsequently the patient was moved to the angiographic suite. Interestingly, the angiography did not show any PA. However, surgery was decided because of the risk of rebleeding and 13 days after the PRFA, a right inferior lobectomy was performed. The histological analysis of the specimen did not reveal vascular malformation, or tumour tissue. The patient is alive 3 years after the initial lung RF ablation. No recurrence of the melanoma has been observed.
Case 2 The second patient was an 80-year-old white man with a history of tuberculosis and chronic obstructive pulmonary disease. Computed tomography (CT) scan showed a nodular lesion 26 mm in diameter in the right apical lobe (Figure 2A). Histological analysis after CT-guided lung needle biopsy confirmed the presence of lung adenocarcinoma. The patient did not receive any anticoagulant therapy. Coagulability was within the normal range. PRFA was decided on and performed 1 month later using a multi-tined expandable electrode with 3-cm diameter arrays (LeVeen) under general anaesthesia.
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S. Borghol et al.
Int J Hyperthermia, 2015; 31(1): 1–4
Figure 1. Chest CT. A 74-year-old man received lung PRFA for lung metastases from melanoma. (A) Axial slice (parenchymal window) showing a right basal nodule, 15 mm in diameter (arrow). Low haemoptysis occurred 72 h after the procedure. (B) and (C), axial and coronal (minimum intensity projection) slices (mediastinal window) performed 72 h after the procedure, showing the occurrence of a 17-mm PA in the ablation zone (arrows).
The electrode was repeatedly repositioned. The ablation lasted 90 min. The maximum energy used was 180 W. A small alveolar haemorrhage was noticed during deployment of the needle, and there was also a minor antero-inferior pneumothorax. Massive haemoptysis developed 24 h after PRFA; emergent contrast-enhanced CT and pulmonary arteriography revealed a pulmonary artery PA (20 mm in diameter) inside the ablation zone (Figures 2B and C), which was embolised with five microcoils (Interlock-18 Fibered IDC Occlusion System; Boston Scientific, Natick). The final arteriography did not reveal further filling of the PA (Figure 2D). The patient’s clinical course was uneventful after the pulmonary arterial embolisation. Indeed, while no complications associated with embolisation (such as pulmonary infarction, pleural effusion or haemoptysis) were observed during the immediate follow-up period, the patient unfortunately presented a new massive haemoptysis 15 days after the procedure and died a few hours later.
Discussion PRFA is very well tolerated in the lung, and most of the complications, which occur in 50% of cases, are minor. In a series of 1000 lung PRFA, major complications included aseptic pleuritis (2.3%), pneumonia (1.8%), lung abscess (1.6%), bleeding requiring blood transfusion (1.6%), pneumothorax requiring pleural sclerosis (1.6%), bronchopleural fistula (0.4%), brachial nerve injury (0.3%). and tumour seeding (0.1%)[16]. Little is known about potential rare
complications after PRFA. It is difficult to estimate the prevalence of haemorrhagic complications after PRFA because only few cases have been described in the literature published in English [10–15]. However, spontaneous resolution of PAs has also been reported; and the incidence of pulmonary artery rupture is probably underestimated [11]. Pulmonary arterial PAs develop after pulmonary artery rupture and result from the accumulation of self-contained blood in an aneurysmal sac compressed by the lung parenchyma. A PA is a contained rupture; there is a disruption in all three layers of the arterial wall. The causes of PAs include vasculitis, infection, direct tumour invasion, and trauma [17] (often iatrogenic, with Swan-Ganz catheterisation as the most common cause [18,19]). During the PRFA, PAs may result from thermal (indirect) and/or mechanical (direct) injury to the vessels. We speculate that these were associated in our two cases but the exact causes could not be determined. However, our report also suggests that a long ablation time as well as multiple repositioning of the electrode might be risk factors involved in this rare complication. These two factors were indeed present in our cases. The underlying mechanism could be an increased risk for vessel wall injuries because of the length of the procedure and the repositioning of the electrodes several times. Further reports are necessary to validate or invalidate this hypothesis. Thus, the treatment strategy for lung neoplasms located adjacent to vessels should be decided after thorough discussion. We believe that surgical management should be preferred over PRFA for the local treatment of tumours
Int J Hyperthermia Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
DOI: 10.3109/02656736.2014.995239
Pulmonary pseudoaneurysm after radiofrequency
3
Figure 2. Occurrence of a lung adenocarcinoma in an 80-year-old patient. (A) CT, axial slice (parenchymal window) showing the right apical 26-mm lesion before PRFA (arrow). Massive haemoptysis occurred 24 h after lung PRFA. (B) CT axial slice (mediastinal window). Contrast-enhanced CT scan showed a haematoma adjacent to the ablative zone. A pulmonary artery P was observed in the haematoma (arrow). (C) Pulmonary arteriography confirmed the apparition of a PA in the lower right lobe pulmonary artery (black arrow) associated with an active extravasation of contrast (white arrow). (D) Angiography: pulmonary arteriography immediately after coil embolisation. Coils were placed into and proximal to the PA. The PA was excluded.
located adjacent to large vessels because of the bleeding risk and also the so-called ‘heat-sink effect’, which can result in sub-lethal temperatures in target tissues and explains why the tumours located adjacent to vessels 3 mm or greater in diameter are difficult to completely ablate [20]. Rupture occurs in 0.01–0.47% of cases with a mortality rate as high as 33–80%. Rupture is often associated with tuberculosis (case 2) and advanced age (cases 1 and 2), as well as with bronchiectasis, aspergillomas, penetrating trauma or pulmonary hypertension [17]. In our two cases, haemoptysis occurred 72 and 24 h respectively after PRFA. However, delayed haemoptysis has already been reported [13,14,21]. Prompt intervention is necessary because rebleeding occurs in 30–40% of cases, nearly always leading to death [13,14]. When a significant or prolonged haemoptysis is observed after PRFA, contrast-enhanced CT could be recommended for the diagnosis of PA. Protective measures are necessary to avoid this complication. Taking care not to penetrate the vessel wall with the electrode tines is essential. Moreover, different devices are available in PRFA; among unipolar devices, electrodes are
mainly expandable or straight. The use of straight electrodes might decrease the risk of PA (low-risk of trauma). And lastly, cold-based treatments, such as cryotherapy, have been reported to preserve the collagenous architecture of central vasculature [22–26]. Several therapeutic options are available for the treatment of pulmonary artery PAs. Transcatheter embolisation is now the first choice among treatments for haemorrhagic PAs because it causes less morbidity and mortality than surgical intervention [13]. In patient 2, the pulmonary arteriography clearly exhibited the PA that we then occluded with five microcoils. Immediately after coil embolisation, the PA was successfully excluded. Nevertheless, rebleeding occurred 15 days later and the patient died a few hours later. Asphyxia, rather than hypovolemia, is the cause of death in most patients [27]. In patient 1, it was not possible to visualise the PA from the pulmonary arteriography performed on day 3. Hence, the PA could not be embolised and we decided to perform surgery because of the rebleeding risk. The combination with a temporary balloon occlusion of a large pulmonary artery adjacent to the metastatic lung tumour treated with PRFA,
4
S. Borghol et al.
might reduce the risk of bleeding. However, this technique seems to induce atelectasis and long-lasting vascular occlusion responsible for a high rate of readmission [28].
Int J Hyperthermia, 2015; 31(1): 1–4
9. 10.
Int J Hyperthermia Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
Conclusion This report alerts both oncologists and radiologists to this rare but possibly fatal complication following lung RF ablation. Pulmonary arterial embolisation is the first choice among treatments for haemorrhagic PAs, but one must keep in mind that rebleeding, which occurs in 30–40% of cases, leads to death in nearly all cases. The long ablation duration and the multiple repositioning of the electrodes seem to have been risk factors for developing this rare and potentially lethal complication in our two cases.
Acknowledgements The work presented here was carried out in collaboration between all authors. S.B., N.F. and H.T. defined the research theme. S.B., A.C., N.A. and N.F. designed the methods and analysed the data, interpreted the results and wrote the paper. S.B., A.C., N.F., N.A., P.B., M.M., A.R. and H.T. discussed analyses, interpretation, and presentation. All authors have contributed to, seen and approved the manuscript.
Declaration of interest
11.
12.
13.
14. 15. 16.
17. 18.
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper. 19.
References 1. De Baere T, Elias D, Dromain C, Din MG, Kuoch V, Ducreux M, et al. Radiofrequency ablation of 100 hepatic metastases with a mean follow-up of more than 1 year. Am J Roentgenol 2000;175: 1619–25. 2. McGrane S, McSweeney SE, Maher MM. Which patients will benefit from percutaneous radiofrequency ablation of colorectal liver metastases? Critically appraised topic. Abdom Imaging 2008; 33:48–53. 3. Suppiah A, White TJ, Roy-Choudhury SH, Breen DJ, Cast J, Maraveyas A, et al. Long-term results of percutaneous radiofrequency ablation of unresectable colorectal hepatic metastases: Final outcomes. Dig Surg 2007;24:358–60. 4. Dupuy DE, Goldberg SN. Image-guided radiofrequency tumor ablation: Challenges and opportunities – Part II. J Vasc Interv Radiol 2001;12:1135–48. 5. Zagoria RJ, Traver MA, Werle DM, Perini M, Hayasaka S, Clark PE. Oncologic efficacy of CT-guided percutaneous radiofrequency ablation of renal cell carcinomas. Am J Roentgenol 2007;189: 429–36. 6. Park S, Cadeddu JA. Outcomes of radiofrequency ablation for kidney cancer. Cancer Control 2007;14:205–10. 7. Link TM, de Mayo R, O’Donnell RJ. Radiofrequency ablation – An alternative for definitive treatment of solitary bone metastases. Eur Radiol 2007;17:3012–13. 8. Alberti N, Ferretti G, Buy X, Desjardin M, Al Ammari S, Cazzato R-L, et al. Diaphragmatic Hernia After Lung Percutaneous
20.
21.
22. 23. 24. 25. 26. 27. 28.
Radiofrequency Ablation: Incidence and Risk Factors. Cardiovasc Intervent Radiol 2014;37:1516–22. Zorbas G, Samaras T. Simulation of radiofrequency ablation in real human anatomy. Int J Hyperthermia 2014;30:570–78. Dillon P, Sato KT. Radiofrequency ablation of pulmonary neoplasm complicated by pulmonary hemorrhage. Semin Interv Radiol 2011; 28:175–8. Steinke K, King J, Glenn D, Morris DL. Pulmonary hemorrhage during percutaneous radiofrequency ablation: A more frequent complication than assumed? Interact Cardiovasc Thorac Surg 2003; 2:462–5. Nour-Eldin NE, Naguib NN, Mack M, Abskharon JE, Vogl TJ. Pulmonary hemorrhage complicating radiofrequency ablation, from mild hemoptysis to life-threatening pattern. Eur Radiol 2011;21: 197–204. Yamakado K, Takaki H, Takao M, Murashima S, Kodama H, Kashima M, et al. Massive hemoptysis from pulmonary artery pseudoaneurysm caused by lung radiofrequency ablation: Successful treatment by coil embolization. Cardiovasc Intervent Radiol 2010;33:410–12. Sakurai J, Mimura H, Gobara H, Hiraki T, Kanazawa S. Pulmonary artery pseudoaneurysm related to radiofrequency ablation of lung tumor. Cardiovasc Intervent Radiol 2010;33:413–16. Vaughn C, Mychaskiw G, Sewell P. Massive hemorrhage during radiofrequency ablation of a pulmonary neoplasm. Anesth Analg 2002;94:1149–51. Kashima M, Yamakado K, Takaki H, Kodama H, Yamada T, Uraki J, et al. Complications after 1000 lung radiofrequency ablation sessions in 420 patients: A single center’s experiences. Am J Roentgenol 2011;197:W576–80. Sbano H, Mitchell AW, Ind PW, Jackson JE. Peripheral pulmonary artery pseudoaneurysms and massive hemoptysis. Am J Roentgenol 2005;184:1253–9. Kierse R, Jensen U, Helmberger H, Muth G, Rieber A. Value of multislice CT in the diagnosis of pulmonary artery pseudoaneurysm from Swan-Ganz catheter placement. J Vasc Interv Radiol JVIR 2004;15:1133–7. Abreu AR, Campos MA, Krieger BP. Pulmonary artery rupture induced by a pulmonary artery catheter: A case report and review of the literature. J Intensive Care Med 2004;19:291–6. Lu DSK, Raman SS, Limanond P, Aziz D, Economou J, Busuttil R, et al. Influence of large peritumoral vessels on outcome of radiofrequency ablation of liver tumors. J Vasc Interv Radiol 2003;14:1267–74. Soh J, Toyooka S, Gobara H, Hiraki T, Sugimoto S, Yamane M, et al. A case of delayed massive hemothorax caused by the rupture of a pulmonary artery pseudoaneurysm after radiofrequency ablation of lung tumors. Jpn J Clin Oncol 2012;42:646–9. Sanderson DR, Neel HB, Fontana RS. Bronchoscopic cryotherapy. Ann Otol Rhinol Laryngol 1981;90:354–8. Maiwand MO. The role of cryosurgery in palliation of tracheobronchial carcinoma. Eur J Cardio-Thorac Surg 1999;15:764–8. Mathur PN, Wolf KM, Busk MF, Briete WM, Datzman M. Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction. Chest 1996;110:718–23. Deygas N, Froudarakis M, Ozenne G, Vergnon JM. Cryotherapy in early superficial bronchogenic carcinoma. Chest 2001;120:26–31. Littrup PJ, Mody A, Sparschu R, Prchevski P, Montie J, Zingas AP, et al. Prostatic cryotherapy: Ultrasonographic and pathologic correlation in the canine model. Urology 1994;44:175–83. Bussie`res JS. Iatrogenic pulmonary artery rupture. Curr Opin Anaesthesiol 2007;20:48–52. De Baere T, Robinson JM, Rao P, Teriitehau C, Deschamps F. Radiofrequency ablation of lung metastases close to large vessels during vascular occlusion: Preliminary experience. J Vasc Interv Radiol 2011;22:749–54.
RESEARCH ARTICLE – CASE HISTORY
Pulmonary artery pseudoaneurysm after radiofrequency ablation: Report of two cases
Int J Hyperthermia Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
Sophie Borghol1, Nicolas Alberti1, Nora Frulio1, Amandine Crombe1, Marion Marty2, Alain Rolland1,3 & Herve Trillaud1 1
Department of Radiology, Saint Andre´ Hospital, Bordeaux, France, 2Department of Pathology, Haut-Le´veˆque Hospital, Pessac, France, and Department of Radiology, La Rochelle Hospital, La Rochelle, France
3
Abstract
Keywords
We report two cases of pulmonary arterial pseudoaneurysms (PAs) following percutaneous radiofrequency ablation (PRFA). The first patient was a 74-year-old Caucasian man who was treated for a secondary location of an advanced melanoma. A computed tomography scan at 72 h after the procedure, performed for basithoracic pain, hyperthermia and haemoptysis, revealed a 17-mm PA within the ablative zone. A lobectomy was performed. The second patient was an 80-year-old white man followed up for a right apical lung adenocarcinoma. Massive haemoptysis occurred 24 h after PRFA; emergent contrast-enhanced CT and pulmonary arteriography revealed a pulmonary artery PA (20 mm diameter), which was embolised with coils. The initial clinical course was satisfactory; however, 15 days after the procedure, the patient unfortunately presented a new massive haemoptysis and died a few hours later. The long ablation duration and the multiple repositioning of the electrodes might have been risk factors for this rare and potentially lethal complication.
Complication, lung, metastasis, pseudoaneurysm, pulmonary artery, radiofrequency ablation
Introduction Tumour destruction by percutaneous radiofrequency ablation (PRFA) is a minimally invasive procedure to treat lung tumours, primary or secondary, especially in inoperable patients. At high temperatures, it results in immediate coagulative necrosis adjacent to the electrode [1–9]. Haemorrhagic complications are rare but potentially lethal [10–15]. We report two cases of pulmonary arterial pseudoaneurysms (PAs) following PRFA. This work has no disclosure of funding and was approved by the Institutional Review Board of our institution.
Case 1 The first patient was a 74-year-old Caucasian man, referred to us 9 years ago for advanced melanoma and treated by systemic chemotherapy. In 2011, one unique metastasis was diagnosed in the right basal pyramid of the lung (17 mm) (Figure 1A). Coagulability was within the normal range. No thrombocythemia was found. The patient did not receive any anticoagulant therapy. As the patient was frail, with many comorbidities, PRFA was preferred over lung surgery and was performed 15 days later using a multi-tined expandable electrode with 3-cm diameter arrays (LeVeen, Boston Scientific, Natick, MA, USA) under general anaesthesia. Correspondence: Sophie Borghol, Department of Radiology, Saint Andre´ Hospital, 1 Rue Jean Burguet, 33000 Bordeaux, France. Tel: +33 (0) 5 56 795679. Fax: +33 (0) 5 56 795899. E-mail: [email protected]
History Received 16 November 2014 Revised 1 December 2014 Accepted 2 December 2014 Published online 20 January 2015
The nodule, located in the right costophrenic angle, was barely accessible; therefore the needle was repeatedly repositioned. Although parenchymal haemorrhage followed the lung RF ablation immediately, the patient remained asymptomatic. The ablation lasted 42 min. The maximum energy used was 60 W. By 72 h after the treatment; the patient was febrile and complained of chest pain associated with the expectoration of small quantities of blood. Emergent contrastenhanced CT revealed a 17-mm PA inside the ablation zone (Figures 1B and C). Subsequently the patient was moved to the angiographic suite. Interestingly, the angiography did not show any PA. However, surgery was decided because of the risk of rebleeding and 13 days after the PRFA, a right inferior lobectomy was performed. The histological analysis of the specimen did not reveal vascular malformation, or tumour tissue. The patient is alive 3 years after the initial lung RF ablation. No recurrence of the melanoma has been observed.
Case 2 The second patient was an 80-year-old white man with a history of tuberculosis and chronic obstructive pulmonary disease. Computed tomography (CT) scan showed a nodular lesion 26 mm in diameter in the right apical lobe (Figure 2A). Histological analysis after CT-guided lung needle biopsy confirmed the presence of lung adenocarcinoma. The patient did not receive any anticoagulant therapy. Coagulability was within the normal range. PRFA was decided on and performed 1 month later using a multi-tined expandable electrode with 3-cm diameter arrays (LeVeen) under general anaesthesia.
Int J Hyperthermia Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
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Int J Hyperthermia, 2015; 31(1): 1–4
Figure 1. Chest CT. A 74-year-old man received lung PRFA for lung metastases from melanoma. (A) Axial slice (parenchymal window) showing a right basal nodule, 15 mm in diameter (arrow). Low haemoptysis occurred 72 h after the procedure. (B) and (C), axial and coronal (minimum intensity projection) slices (mediastinal window) performed 72 h after the procedure, showing the occurrence of a 17-mm PA in the ablation zone (arrows).
The electrode was repeatedly repositioned. The ablation lasted 90 min. The maximum energy used was 180 W. A small alveolar haemorrhage was noticed during deployment of the needle, and there was also a minor antero-inferior pneumothorax. Massive haemoptysis developed 24 h after PRFA; emergent contrast-enhanced CT and pulmonary arteriography revealed a pulmonary artery PA (20 mm in diameter) inside the ablation zone (Figures 2B and C), which was embolised with five microcoils (Interlock-18 Fibered IDC Occlusion System; Boston Scientific, Natick). The final arteriography did not reveal further filling of the PA (Figure 2D). The patient’s clinical course was uneventful after the pulmonary arterial embolisation. Indeed, while no complications associated with embolisation (such as pulmonary infarction, pleural effusion or haemoptysis) were observed during the immediate follow-up period, the patient unfortunately presented a new massive haemoptysis 15 days after the procedure and died a few hours later.
Discussion PRFA is very well tolerated in the lung, and most of the complications, which occur in 50% of cases, are minor. In a series of 1000 lung PRFA, major complications included aseptic pleuritis (2.3%), pneumonia (1.8%), lung abscess (1.6%), bleeding requiring blood transfusion (1.6%), pneumothorax requiring pleural sclerosis (1.6%), bronchopleural fistula (0.4%), brachial nerve injury (0.3%). and tumour seeding (0.1%)[16]. Little is known about potential rare
complications after PRFA. It is difficult to estimate the prevalence of haemorrhagic complications after PRFA because only few cases have been described in the literature published in English [10–15]. However, spontaneous resolution of PAs has also been reported; and the incidence of pulmonary artery rupture is probably underestimated [11]. Pulmonary arterial PAs develop after pulmonary artery rupture and result from the accumulation of self-contained blood in an aneurysmal sac compressed by the lung parenchyma. A PA is a contained rupture; there is a disruption in all three layers of the arterial wall. The causes of PAs include vasculitis, infection, direct tumour invasion, and trauma [17] (often iatrogenic, with Swan-Ganz catheterisation as the most common cause [18,19]). During the PRFA, PAs may result from thermal (indirect) and/or mechanical (direct) injury to the vessels. We speculate that these were associated in our two cases but the exact causes could not be determined. However, our report also suggests that a long ablation time as well as multiple repositioning of the electrode might be risk factors involved in this rare complication. These two factors were indeed present in our cases. The underlying mechanism could be an increased risk for vessel wall injuries because of the length of the procedure and the repositioning of the electrodes several times. Further reports are necessary to validate or invalidate this hypothesis. Thus, the treatment strategy for lung neoplasms located adjacent to vessels should be decided after thorough discussion. We believe that surgical management should be preferred over PRFA for the local treatment of tumours
Int J Hyperthermia Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
DOI: 10.3109/02656736.2014.995239
Pulmonary pseudoaneurysm after radiofrequency
3
Figure 2. Occurrence of a lung adenocarcinoma in an 80-year-old patient. (A) CT, axial slice (parenchymal window) showing the right apical 26-mm lesion before PRFA (arrow). Massive haemoptysis occurred 24 h after lung PRFA. (B) CT axial slice (mediastinal window). Contrast-enhanced CT scan showed a haematoma adjacent to the ablative zone. A pulmonary artery P was observed in the haematoma (arrow). (C) Pulmonary arteriography confirmed the apparition of a PA in the lower right lobe pulmonary artery (black arrow) associated with an active extravasation of contrast (white arrow). (D) Angiography: pulmonary arteriography immediately after coil embolisation. Coils were placed into and proximal to the PA. The PA was excluded.
located adjacent to large vessels because of the bleeding risk and also the so-called ‘heat-sink effect’, which can result in sub-lethal temperatures in target tissues and explains why the tumours located adjacent to vessels 3 mm or greater in diameter are difficult to completely ablate [20]. Rupture occurs in 0.01–0.47% of cases with a mortality rate as high as 33–80%. Rupture is often associated with tuberculosis (case 2) and advanced age (cases 1 and 2), as well as with bronchiectasis, aspergillomas, penetrating trauma or pulmonary hypertension [17]. In our two cases, haemoptysis occurred 72 and 24 h respectively after PRFA. However, delayed haemoptysis has already been reported [13,14,21]. Prompt intervention is necessary because rebleeding occurs in 30–40% of cases, nearly always leading to death [13,14]. When a significant or prolonged haemoptysis is observed after PRFA, contrast-enhanced CT could be recommended for the diagnosis of PA. Protective measures are necessary to avoid this complication. Taking care not to penetrate the vessel wall with the electrode tines is essential. Moreover, different devices are available in PRFA; among unipolar devices, electrodes are
mainly expandable or straight. The use of straight electrodes might decrease the risk of PA (low-risk of trauma). And lastly, cold-based treatments, such as cryotherapy, have been reported to preserve the collagenous architecture of central vasculature [22–26]. Several therapeutic options are available for the treatment of pulmonary artery PAs. Transcatheter embolisation is now the first choice among treatments for haemorrhagic PAs because it causes less morbidity and mortality than surgical intervention [13]. In patient 2, the pulmonary arteriography clearly exhibited the PA that we then occluded with five microcoils. Immediately after coil embolisation, the PA was successfully excluded. Nevertheless, rebleeding occurred 15 days later and the patient died a few hours later. Asphyxia, rather than hypovolemia, is the cause of death in most patients [27]. In patient 1, it was not possible to visualise the PA from the pulmonary arteriography performed on day 3. Hence, the PA could not be embolised and we decided to perform surgery because of the rebleeding risk. The combination with a temporary balloon occlusion of a large pulmonary artery adjacent to the metastatic lung tumour treated with PRFA,
4
S. Borghol et al.
might reduce the risk of bleeding. However, this technique seems to induce atelectasis and long-lasting vascular occlusion responsible for a high rate of readmission [28].
Int J Hyperthermia, 2015; 31(1): 1–4
9. 10.
Int J Hyperthermia Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
Conclusion This report alerts both oncologists and radiologists to this rare but possibly fatal complication following lung RF ablation. Pulmonary arterial embolisation is the first choice among treatments for haemorrhagic PAs, but one must keep in mind that rebleeding, which occurs in 30–40% of cases, leads to death in nearly all cases. The long ablation duration and the multiple repositioning of the electrodes seem to have been risk factors for developing this rare and potentially lethal complication in our two cases.
Acknowledgements The work presented here was carried out in collaboration between all authors. S.B., N.F. and H.T. defined the research theme. S.B., A.C., N.A. and N.F. designed the methods and analysed the data, interpreted the results and wrote the paper. S.B., A.C., N.F., N.A., P.B., M.M., A.R. and H.T. discussed analyses, interpretation, and presentation. All authors have contributed to, seen and approved the manuscript.
Declaration of interest
11.
12.
13.
14. 15. 16.
17. 18.
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper. 19.
References 1. De Baere T, Elias D, Dromain C, Din MG, Kuoch V, Ducreux M, et al. Radiofrequency ablation of 100 hepatic metastases with a mean follow-up of more than 1 year. Am J Roentgenol 2000;175: 1619–25. 2. McGrane S, McSweeney SE, Maher MM. Which patients will benefit from percutaneous radiofrequency ablation of colorectal liver metastases? Critically appraised topic. Abdom Imaging 2008; 33:48–53. 3. Suppiah A, White TJ, Roy-Choudhury SH, Breen DJ, Cast J, Maraveyas A, et al. Long-term results of percutaneous radiofrequency ablation of unresectable colorectal hepatic metastases: Final outcomes. Dig Surg 2007;24:358–60. 4. Dupuy DE, Goldberg SN. Image-guided radiofrequency tumor ablation: Challenges and opportunities – Part II. J Vasc Interv Radiol 2001;12:1135–48. 5. Zagoria RJ, Traver MA, Werle DM, Perini M, Hayasaka S, Clark PE. Oncologic efficacy of CT-guided percutaneous radiofrequency ablation of renal cell carcinomas. Am J Roentgenol 2007;189: 429–36. 6. Park S, Cadeddu JA. Outcomes of radiofrequency ablation for kidney cancer. Cancer Control 2007;14:205–10. 7. Link TM, de Mayo R, O’Donnell RJ. Radiofrequency ablation – An alternative for definitive treatment of solitary bone metastases. Eur Radiol 2007;17:3012–13. 8. Alberti N, Ferretti G, Buy X, Desjardin M, Al Ammari S, Cazzato R-L, et al. Diaphragmatic Hernia After Lung Percutaneous
20.
21.
22. 23. 24. 25. 26. 27. 28.
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