{"paper_id":"163f6085-3a2b-460f-9a29-d5f5c328618e","body_text":"Selective embolisation of an idiopathic bronchial artery pseudoaneurysm presenting with recurrent laryngeal nerve palsy: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Selective embolisation of an idiopathic bronchial artery pseudoaneurysm presenting with recurrent laryngeal nerve palsy: a case report Ross Copping, Nico Ng, Shady Osman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4281597/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Aug, 2024 Read the published version in CVIR Endovascular → Version 1 posted 5 You are reading this latest preprint version Abstract Background: Bronchial artery pseudoaneurysms (BAP) or aneurysms (BAA) are rare, potentially life-threatening and remain poorly understood. They are most commonly idiopathic but may be associated with a number of other disease processes. Bronchial artery embolisation (BAE) is considered the first line treatment while surgical techniques are reserved for patients with a clear contraindication to embolisation or where anatomical factors preclude an endovascular approach. Case presentation: We present an interesting case of a 56 year-old male presenting with an idiopathic unruptured right BAP causing clinical and radiological signs of left recurrent laryngeal nerve (RLN) palsy. He was otherwise clinically well with no other reported symptoms and no significant past medical history. There were no significant findings on work-up and investigation. He was ultimately treated successfully with selective transarterial coil embolization of the right bronchial artery. This is an atypical presentation of a rare clinical entity and has not previously been published in the literature to our knowledge. Conclusions: BAPs and BAAs are highly variable in their presentation, ranging from incidental asymptomatic findings to catastrophic haemorrhage, depending on their location and if they are contained or ruptured. Timely diagnosis and referral to facilitate urgent embolisation is essential to prevent potentially serious clinical sequelae. Endovascular treatment in the form of BAE is considered first line. Bronchial artery pseudoaneurysm bronchial artery aneurysm embolisation bronchial artery embolisation recurrent laryngeal nerve palsy. Figures Figure 1 Figure 2 Figure 3 Background Bronchial artery pseudoaneurysms (BAP) are rare, potentially life-threatening and remain poorly understood [1]. The terms bronchial artery aneurysm (BAA) and pseudoaneurysm are used interchangeably as the underlying aetiology and pathogenesis are often unknown and not able to be distinguished and they share the same management. They confer high risk of rupture and therefore high mortality. The true incidence is unknown, but it has been reported on less than 1% of selective bronchial angiograms [2]. Presentation is dependent on location and ruptured status, ranging from an incidental finding in an asymptomatic patient to catastrophic haemorrhage resulting in shock. We present an interesting and atypical presentation of an unruptured right BAP presenting with left recurrent laryngeal nerve (RLN) palsy, subsequently treated successfully with selective bronchial artery embolisation (BAE) with microcoils. Case presentation A 56 year-old male patient presented with a four-week history of dysphonia (voice hoarseness), reportedly of sudden onset and constant severity, eventually prompting presentation to his local doctor. He had been recently well with no signs of symptoms of infection and reported no history of prior trauma, surgery, lung disease or malignancy. He had no constitutional symptoms, no known vascular risk factors or bleeding diathesis and was a non-smoker. He was not on anticoagulation. He had positive antinuclear antibodies (ANA) and negative extractable nuclear antigens (ENA) while all other blood tests were normal. There was no personal or family history of connective tissue disease. A contrast-enhanced CT (CECT) of the neck, chest, abdomen and pelvis was performed in the outpatient setting, with the primary diagnosis of exclusion at that point being malignancy. The bronchial artery pseudoaneurysm was diagnosed on non-angiographic CT. In addition, the CT neck demonstrated indirect features of left RLN palsy including ipsilateral laryngeal ventricle dilatation, medialization of the aryepiglottic fold, medial rotation of the vocal process of the arytenoid cartilage and mild dilatation of the pyriform sinus ( Figure 1 ). The coronal reconstruction also showed reduced bulk and pointed morphology of the vocal cord with loss of normal shouldering in the subglottic arch ( Figure 1 ). No medialisation of the vocal cord was evident on CT. The radiological signs were suggestive of RLN palsy in the context of dysphonia and the pseudoaneurysm in the expected location of the left RLN posteroinferior to the aortic arch involving the tracheo-eosophageal groove. The findings resulted in immediate referral to our tertiary centre for further investigation and management. Dedicated work-up CT thoracic angiogram confirmed a 20 x 22 x 20 mm pseudoaneurysm, following the enhancement of the aortic lumen. The pseudoaneurysm was located 16 mm anteromedial to the proximal descending thoracic aorta, abutting the thoracic oesophagus and lower trachea just above the left main bronchus ( Figure 2 ). Two right bronchial arteries were visualised arising orthotopically from the aorta at the T5 level, one coming off an intercostobronchial trunk (ICBT) and the other directly from the aorta, and a single left bronchial artery directly off the aorta (type IV) [3]. The pseudoaneurysm was associated with the right bronchial artery off the ICBT ( Figure 2 ). There was irregularity and mild dilatation of the vessel just proximal and distal to the pseudoaneurysm and the artery was patent distally extending down to the right main bronchus. Nasendoscopy in the emergency department confirmed medialisation of the left vocal cord and no other cause for dysphonia. After multidisciplinary review, a decision was made for BAE. Right femoral access was obtained under ultrasound guidance and local anaesthesia before placement of a 6 Fr sheath. The ICBT was selected with a 5 Fr C2 catheter and glidewire (Terumo). A 2.4 Fr progreat microcatheter (Terumo) was then advanced to the pseudoaneurysm and selective coil embolisation performed with detachable smart coils (Penumbra), successfully occluding the arterial inflow to the pseudoaneurysm.( Figure 3 ) Completion angiogram and follow-up CT aortogram one day post procedure confirmed successful exclusion with no residual enhancement/flow in the BAP ( Figure 3 ). Further investigation post embolisation was unremarkable. His bloods remained normal. The screen for atypical infections, including tuberculous and non-tuberculous mycobacteria, was negative. COVID swabs were negative. Positron emission tomography (PET) showed no significant FDG-avidity to suggest malignancy or infection, in the mediastinum or elsewhere. It was therefore concluded that the BAP was most likely idiopathic, although underlying connective tissue disorder remained a possibility, and the patient was discharged home two days post procedure remaining asymptomatic and without any other issues. Discussion It has been proposed that four factors predispose to BAPs, namely increased flow, increased pressure, focal vessel wall weakening, vessel wall injury but the aetiology and pathogenesis are not well understood [4]. They can be classified according to location, divided into mediastinal, intrapulmonary or both [2]. The most comprehensive review to date by Noberto et al in 2018 [5] found 108 cases of bronchial artery aneurysm or pseudoaneurysm reported in the literature with the aetiology unknown in almost one half of cases (49.1% idiopathic). Underlying lung disease such as bronchiectasis (including cystic fibrosis), recurrent infection, silicosis, inflammatory lung diseases and lung cancer are frequently associated [6]. Trauma and iatrogenesis are other important considerations. Vascular risk factors are also important, including atherosclerosis, hypertension, vasculitis and vascular syndromes such as hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu) [5,7]. Anticoagulation may also be contributory. Norberto et al reported a mean age at presentation of 57.9 years (range 15 to 89 years) [5]. Contained pseudoaneurysms without overt rupture tend to be indolent, either asymptomatic and found incidentally on CT with symptoms only elucidated retrospectively [8,9], but may present with dysphagia, discomfort, cough or vague symptoms that raise suspicion of occult malignancy. Ruptured pseudoaneurysms most frequently present with thoracodynia or haemoptysis but can also manifest with acute dyspnoea, compressive effects of mediastinal hematoma, haematemesis, haemothorax or shock depending on the site and extent of haemorrhage [1,10]. Importantly, BAP rupture can result in life-threatening haemorrhage. Rupture into the mediastinum can cause superior vena cava syndrome [11] or mimic aortic dissection [2,7,12]. Intrapulmonary BAPs are most likely to present with haemoptysis [4]. Massive haemoptysis, defined as greater than 300 mL within a 24-hour period, most commonly comes from a bronchial arterial source (>90%) and carries a mortality exceeding 50% [13,14]. The variable size of ruptured BAPs in the literature has led to the inference that diameter is not necessarily an incremental risk factor for rupture [12,15]. It should also be noted that the risk of rupture with false aneurysm is higher than with a true aneurysm, although making the distinction in diagnosis is not always possible [1]. For these reasons, timely diagnosis, early referral and urgent elective treatment is recommended whenever possible, regardless of size or symptomatology [16]. CECT tends to be the first line imaging modality to diagnose and characterise BAPs and guide subsequent treatment. Chest radiography has extremely low sensitivity even in the event of overt rupture. Digital subtraction angiography (DSA) is the gold standard and confirmatory of the diagnosis at the time of endovascular treatment. DSA has a reported sensitivity of 100% compared to CT which is 67% [17]. MRI is another consideration, especially in young patients or the subacute setting, but is limited by cost, availability, time and numerous artefacts [18]. It is recognised that thrombosis of the BAP limits flow and may result in delayed enhancement or non enhancement, thereby confounding the diagnosis [18,19]. The main differential diagnoses on imaging would be a saccular aneurysm arising from the aorta, ductus arteriosus, aberrant right subclavian artery or another aortic branch. Up to 40% of patients with unilateral vocal cord palsy are asymptomatic at the time of diagnosis and this may be further masked by the presence of other symptoms or other cranial nerves involved with the underlying disease process [20]. The two main treatment options are endovascular repair or open surgery. Whilst they have a comparable success rate (93.1% vs 90.0% respectively), endovascular techniques are recognised as safer, less invasive, less painful, more selective, lower in cost and offer shorter hospital stays and improved quality of life [5,16]. Embolisation is generally accepted as first line, most commonly with coils alone or in combination with liquid embolics such as gelatin sponge, polyvinyl acetate (PVA), cynanoacrylate (glue) or onyx [5]. Placement of an aortic stent-graft is another endovascular option but limits access back into the bronchial arteries if retreatment is required, can be problematic in the setting of infection and is associated with increased cost, time and risk [21,22,23]. Surgery may be considered where there is a contraindication to angioembolisation (e.g. documented iodine anaphylaxis) or where the anatomical configuration makes definitive embolisation impossible [24]. Surgical techniques include pseudoaneurysm excision/resection or ligation (with or without vascular reconstruction depending on collaterals), lobectomy or pneumonectomy [25]. In our reported case, coil embolisation via a microcatheter successfully treated the BPA without the need for adjunctive liquid embolics and without complication. Conclusions BAPs are rare and potentially life-threatening. Whilst the age and idiopathic nature of the case we present is most common for this disease, the presentation with clinical and radiological signs of RLN palsy is atypical and has not been previously published in the literature to our knowledge. Timely diagnosis and referral to facilitate urgent BAE is essential to prevent potentially serious clinical sequelae, regardless of size or associated symptoms. Endovascular treatment in the form of BAE is considered first line. Abbreviations BAP bronchial artery pseudoaneurysm BAA bronchial artery aneurysm BAE bronchial artery embolization ICBT intercostobronchial trunk RLN recurrent laryngeal nerve ANA antinuclear antibodies ENA extractable nuclear antigens CECT contrast-enhanced computed tomography PET positron emission tomography MRI magnetic resonance imaging Declarations 1. Ethics approval and consent to participate The need for ethics approval was waived by the institutional review board in accordance with institutional guidelines. The manuscript does not report on or involve the use of animal data. 2. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. 3. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Further information can be made available by the authors on request. 4. Competing interests The authors declare that they have no competing interests. 5. Funding The authors declare that no funding was sought or received for this study. 6. Authors' contributions RC obtained the clinical and procedural information, performed the literature review and was the primary author of the manuscript. SO helped with the case discussion and writing the manuscript. NN prepared the figures for publication and helped review the manuscript. All authors read and approved the final manuscript. 7. Acknowledgements Not applicable. 8. Authors' information RC and SO are interventional radiologists at Liverpool Hospital in Sydney, New South Wales, Australia. SO holds EBIR qualification. RC is a Conjoint Lecturer with the Clinical School of Medicine, UNSW Health & Medicine, South West Sydney Clinical Campuses. References Pitton MB, Dappa E, Jungmann F et al (2015) Visceral artery aneurysms: incidence, management, and outcome analysis in a tertiary care center over one decade. Eur Radiol 25:2004–2014 Tanaka K, Ihaya A, Horiuci T, Morioka K, Kimura T, Uesaka T et al (2003) Giant mediastinal bronchial artery aneurysm mimicking benign esophageal tumor: a case report and review of 26 cases from literature. J Vasc Surg 38:1125–1129 Cauldwell EW, Siekert RG, Lininger RE, Anson BJ (1948) The bronchial arteries: an anatomic study of 150 human cadavers. Surg Gynecol Obstet 86(4):395–412 Sancho C, Dominguez J, Escalante E, Hernandez E, Cairols M, Martinez X (1999) Embolization of an anomalous bronchial artery aneurysm in a patient with agenesis of the left pulmonary artery. J Vasc Interv Radiol 10:1122–1126 San Norberto EM, Urbano García J, Montes JM, Vaquero C (2018) Endovascular treatment of bronchial aneurysms. J Thorac Cardiovasc Surg 156(2):e109–e117 Kasashima F, Endo M, Kosugi I, Matsumoto Y, Abe Y, Sasaki H et al (2003) Mediastinal bronchial artery aneurysm treated with a stent-graft. J Endovasc Ther 10:381–385 Lioulias A, Misthos P, Kokotsakis J, Papagiannakis G, Skouteli E (2008) Recurrent massive hemoptysis due to post bronchotomy bronchial artery aneurysm: a case report. Can Respir J 15:127–128 Kaufman C, Kabutey NK, Sgroi M, Kim D (2014) Bronchial artery pseudoaneurysm with symptomatic mediastinal hematoma. Clin Imaging 38:536–539 Suen HC, Dumontier CC, Boeren J, Charland W (2003) Daily B. B. Ruptured bronchial artery aneurysm associated with sarcoidosis. J Thorac Cardiovasc Surg 125:1153–1154 Restrepo CS, Carswell AP (2012) Aneurysms and pseudoaneurysms of the pulmonary vasculature. Semin Ultrasound CT MR 33(6):552–566 Hoffmann V, Ysebaert D, De Schepper A, Colpaert C, Jorens P (1996) Acute superior vena cava obstruction after rupture of a bronchial artery aneurysm. Chest 110:1356–1358 Kalina M, Giberson F (2007) Hemoptysis secondary to pulmonary artery pseudoaneurysm after necrotizing pneumonia. Ann Thorac Surg 84:1386–1387 Crocco JA, Rooney JJ, Fankushen DS, DiBenedetto RJ, Lyons HA (1968) Massive hemoptysis. Arch Intern Med 121(6):495–498 Jean-Baptiste E (2000) Clinical assessment and management of massive hemoptysis. Crit Care Med 28(5):1642–1647 Kalangos A, Khatchatourian G, Panos A, Faidutti B (1997) Ruptured mediastinal bronchial artery aneurysm: a dilemma of diagnosis and therapeutic approach. J Thorac Cardiovasc Surg 114:853–856 Cordova AC, Sumpio BE (2013) Visceral artery aneurysms and pseudoaneurysms—should they all be managed by endovascular techniques? Ann Vasc Dis 6:687–693 Habib N, Hassan S, Abdou R et al (2013) Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review. Ann Surg Innov Res 7:4 Fukunaga A, Okushiba S, Ohno K, Kitashiro S, Kawarada Y, Shitinohe T et al (2003) Mediastinal bronchial artery aneurysm with hematemesis. Dis Esophagus 16:328–331 Tringali S, Tiffet O, Berger JL, Cuilleret J (2002) Bronchial artery aneurysm disguised as a leiomyoma of the esophagus. Ann Thorac Surg 73:632–633 Montoya S, Portanova A, Bhatt AA (2019) A radiologic review of hoarse voice from anatomic and neurologic perspectives. Insights Imaging 10(1):108 Sanchez E, Alados P, Zurera L, Canis M, Muñoz I, Casares J et al (2007) Bronchial artery aneurysm treated with aortic stent graft and fibrin sealant. Ann Thorac Surg 83:693–695 Fiorucci B, Simonte G (2016) Treatment of a bronchial artery aneurysm with placement of an aortic thoracic stent-graft. Eur J Vasc Endovasc Surg 51:717 Izaaryene J, Vidal V, Bartoli JM, Gaubert JY (2016) Multiple bronchial artery aneurysms: successful treatment with ethylene-vinyl alcohol copolymer (Onyx). Diagn Interv Imaging 97:125–127 Chatterjee A, Ghosh S, Salhiyyah K, Gaines P, Rocco G (2004) A rare presentation of a ruptured bronchial artery aneurysm. Thorax 59:912 Nakamura R, Inage Y, Tsuchiya A, Kato T, Yuzawa K, Koizumi M et al (2014) Bronchial artery aneurysm treated with video-assisted thoracoscopic surgery. Ann Vasc Surg 28:1321e1–1321e3 Cite Share Download PDF Status: Published Journal Publication published 14 Aug, 2024 Read the published version in CVIR Endovascular → Version 1 posted Editorial decision: Major revision 27 May, 2024 Reviewers agreed at journal 04 May, 2024 Reviewers invited by journal 04 May, 2024 Editor assigned by journal 02 May, 2024 First submitted to journal 30 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4281597\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":298655478,\"identity\":\"947b8d46-660c-4aca-920a-5d6fd968160e\",\"order_by\":0,\"name\":\"Ross Copping\",\"email\":\"\",\"orcid\":\"https://orcid.org/0000-0001-9692-7502\",\"institution\":\"Liverpool Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ross\",\"middleName\":\"\",\"lastName\":\"Copping\",\"suffix\":\"\"},{\"id\":298655479,\"identity\":\"cd542264-f1db-43af-81c4-7f3e99f87bdb\",\"order_by\":1,\"name\":\"Nico Ng\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Liverpool Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Nico\",\"middleName\":\"\",\"lastName\":\"Ng\",\"suffix\":\"\"},{\"id\":298655480,\"identity\":\"77d67c0f-8b96-49e9-b04f-73e366b12e63\",\"order_by\":2,\"name\":\"Shady Osman\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Liverpool Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Shady\",\"middleName\":\"\",\"lastName\":\"Osman\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-04-17 11:31:29\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4281597/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4281597/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s42155-024-00474-2\",\"type\":\"published\",\"date\":\"2024-08-14T15:57:06+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":56410057,\"identity\":\"27ec7bd1-cd9b-47ab-8c88-c131207b95de\",\"added_by\":\"auto\",\"created_at\":\"2024-05-13 20:15:06\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1310888,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eContrast enhanced CT neck demonstrating indirect features of left RLN palsy. (a) Axial slice demonstrating ipsilateral laryngeal ventricle dilatation (+) and medial rotation of the arytenoid cartilage (←). (b) Axial slice showing medialization of the aryepiglottic fold (*) and mild dilatation of the pyriform sinus (★). (c) Coronal reformat showing reduced bulk and pointed morphology of the vocal cord with loss of normal shouldering in the subglottic arch.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4281597/v1/ff85e4378c7f9b28e83ab117.png\"},{\"id\":56410055,\"identity\":\"2e2896d6-16ad-4afc-9221-bc2840ea8e7f\",\"added_by\":\"auto\",\"created_at\":\"2024-05-13 20:15:04\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1268872,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePre-treatment imaging of the bronchial artery pseudoaneurysm. (a \\u0026amp; b) CT angiogram axial slices demonstrating filling of the pseudoaneurysm between the descending thoracic aorta and trachea with surrounding haematoma. (c) CT angiogram coronal reconstruction showing the pseudoaneurysm adjacent to the oesophagus and left main bronchus. (d) 3D volume rendered reconstruction of the pseudoaneurysm.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4281597/v1/e48ed488ce0a07c082f5bae3.png\"},{\"id\":56410056,\"identity\":\"1df7c767-bdee-44dd-8594-0aa419a5a6af\",\"added_by\":\"auto\",\"created_at\":\"2024-05-13 20:15:06\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1455160,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eBronchial artery pseudoaneurysm pre and post embolization. (a) Selective angiogram via a microcatheter in the right bronchial artery showing the pseudoaneurysm. (b) Selective angiogram post coil embolization demonstrating no residual filling in the pseudoaneurysm. (c) Follow-up CT angiogram one day post procedure demonstrating successful exclusion of pseudoaneurysm.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4281597/v1/8ab122846cf04fb855e7a7dd.png\"},{\"id\":63071522,\"identity\":\"ab65851a-3161-48df-a894-0f3efed3dda5\",\"added_by\":\"auto\",\"created_at\":\"2024-08-22 20:08:02\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":5322544,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4281597/v1/d1b0e266-ae67-4d25-b1ef-2dfc84b2685f.pdf\"}],\"financialInterests\":\"\",\"formattedTitle\":\"Selective embolisation of an idiopathic bronchial artery pseudoaneurysm presenting with recurrent laryngeal nerve palsy: a case report\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eBronchial artery pseudoaneurysms (BAP) are rare, potentially life-threatening and remain poorly understood [1]. The terms bronchial artery aneurysm (BAA) and pseudoaneurysm are used interchangeably as the underlying aetiology and pathogenesis are often unknown and not able to be distinguished and they share the same management. They confer high risk of rupture and therefore high mortality. The true incidence is unknown, but it has been reported on less than 1% of selective bronchial angiograms [2]. Presentation is dependent on location and ruptured status, ranging from an incidental finding in an asymptomatic patient to catastrophic haemorrhage resulting in shock.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eWe present an interesting and atypical presentation of an unruptured right BAP presenting with left recurrent laryngeal nerve (RLN) palsy, subsequently treated successfully with selective bronchial artery embolisation (BAE) with microcoils.\\u003c/p\\u003e\"},{\"header\":\"Case presentation \",\"content\":\"\\u003cp\\u003eA 56 year-old male patient presented with a four-week history of dysphonia (voice hoarseness), reportedly of sudden onset and constant severity, eventually prompting presentation to his local doctor. He had been recently well with no signs of symptoms of infection and reported no history of prior trauma, surgery, lung disease or malignancy. He had no constitutional symptoms, no known vascular risk factors or bleeding diathesis and was a non-smoker. He was not on anticoagulation. He had positive antinuclear antibodies (ANA) and negative extractable nuclear antigens (ENA) while all other blood tests were normal. There was no personal or family history of connective tissue disease.\\u003c/p\\u003e\\n\\u003cp\\u003eA contrast-enhanced CT (CECT) of the neck, chest, abdomen and pelvis was performed in the outpatient setting, with the primary diagnosis of exclusion at that point being malignancy. The bronchial artery pseudoaneurysm was diagnosed on non-angiographic CT. In addition, the CT neck demonstrated indirect features of left RLN palsy including ipsilateral laryngeal ventricle dilatation, medialization of the aryepiglottic fold, medial rotation of the vocal process of the arytenoid cartilage and mild dilatation of the pyriform sinus (\\u003cem\\u003eFigure 1\\u003c/em\\u003e). The coronal reconstruction also showed reduced bulk and pointed morphology of the vocal cord with loss of normal shouldering in the subglottic arch (\\u003cem\\u003eFigure 1\\u003c/em\\u003e). No medialisation of the vocal cord was evident on CT. The radiological signs were suggestive of RLN palsy in the context of dysphonia and the pseudoaneurysm in the expected location of the left RLN posteroinferior to the aortic arch involving the tracheo-eosophageal groove. The findings resulted in immediate referral to our tertiary centre for further investigation and management.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDedicated work-up CT thoracic angiogram confirmed a 20 x 22 x 20 mm pseudoaneurysm, following the enhancement of the aortic lumen. The pseudoaneurysm was located 16 mm anteromedial to the proximal descending thoracic aorta, abutting the thoracic oesophagus and lower trachea just above the left main bronchus (\\u003cem\\u003eFigure 2\\u003c/em\\u003e). Two right bronchial arteries were visualised arising orthotopically from the aorta at the T5 level, one coming off an intercostobronchial trunk (ICBT) and the other directly from the aorta, and a single left bronchial artery directly off the aorta (type IV) [3]. The pseudoaneurysm was associated with the right bronchial artery off the ICBT (\\u003cem\\u003eFigure 2\\u003c/em\\u003e). There was irregularity and mild dilatation of the vessel just proximal and distal to the pseudoaneurysm and the artery was patent distally extending down to the right main bronchus. Nasendoscopy in the emergency department confirmed medialisation of the left vocal cord and no other cause for dysphonia.\\u003c/p\\u003e\\n\\u003cp\\u003eAfter multidisciplinary review, a decision was made for BAE. Right femoral access was obtained under ultrasound guidance and local anaesthesia before placement of a 6 Fr sheath. The ICBT was selected with a 5 Fr C2 catheter and glidewire (Terumo). A 2.4 Fr progreat microcatheter (Terumo) was then advanced to the pseudoaneurysm and selective coil embolisation performed with detachable smart coils (Penumbra), successfully occluding the arterial inflow to the pseudoaneurysm.(\\u003cem\\u003eFigure 3\\u003c/em\\u003e) Completion angiogram and follow-up CT aortogram one day post procedure confirmed successful exclusion with no residual enhancement/flow in the BAP (\\u003cem\\u003eFigure 3\\u003c/em\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003eFurther investigation post embolisation was unremarkable. His bloods remained normal. The screen for atypical infections, including tuberculous and non-tuberculous mycobacteria, was negative. COVID swabs were negative. Positron emission tomography (PET) showed no significant FDG-avidity to suggest malignancy or infection, in the mediastinum or elsewhere. It was therefore concluded that the BAP was most likely idiopathic, although underlying connective tissue disorder remained a possibility, and the patient was discharged home two days post procedure remaining asymptomatic and without any other issues.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eIt has been proposed that four factors predispose to BAPs, namely increased flow, increased pressure, focal vessel wall weakening, vessel wall injury but the aetiology and pathogenesis are not well understood [4]. They can be classified according to location, divided into mediastinal, intrapulmonary or both [2].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe most comprehensive review to date by Noberto et al in 2018 [5] found 108 cases of bronchial artery aneurysm or pseudoaneurysm reported in the literature with the aetiology unknown in almost one half of cases (49.1% idiopathic). Underlying lung disease such as bronchiectasis (including cystic fibrosis), recurrent infection, silicosis, inflammatory lung diseases and lung cancer are frequently associated [6]. Trauma and iatrogenesis are other important considerations. Vascular risk factors are also important, including atherosclerosis, hypertension, vasculitis and vascular syndromes such as hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu) [5,7]. Anticoagulation may also be contributory. Norberto et al reported a mean age at presentation of 57.9 years (range 15 to 89 years) [5].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eContained pseudoaneurysms without overt rupture tend to be indolent, either asymptomatic and found incidentally on CT with symptoms only elucidated retrospectively [8,9], but may present with dysphagia, discomfort, cough or vague symptoms that raise suspicion of occult malignancy. Ruptured pseudoaneurysms most frequently present with thoracodynia or haemoptysis but can also manifest with acute dyspnoea, compressive effects of mediastinal hematoma, haematemesis, haemothorax or shock depending on the site and extent of haemorrhage [1,10]. Importantly, BAP rupture can result in life-threatening haemorrhage. Rupture into the mediastinum can cause superior vena cava syndrome [11] or mimic aortic dissection [2,7,12]. Intrapulmonary BAPs are most likely to present with haemoptysis [4]. Massive haemoptysis, defined as greater than 300 mL within a 24-hour period, most commonly comes from a bronchial arterial source (\\u0026gt;90%) and carries a mortality exceeding 50% [13,14]. The variable size of ruptured BAPs in the literature has led to the inference that diameter is not necessarily an incremental risk factor for rupture [12,15]. It should also be noted that the risk of rupture with false aneurysm is higher than with a true aneurysm, although making the distinction in diagnosis is not always possible [1]. For these reasons, timely diagnosis, early referral and urgent elective treatment is recommended whenever possible, regardless of size or symptomatology [16].\\u003c/p\\u003e\\n\\u003cp\\u003eCECT tends to be the first line imaging modality to diagnose and characterise BAPs and guide subsequent treatment. Chest radiography has extremely low sensitivity even in the event of overt rupture. Digital subtraction angiography (DSA) is the gold standard and confirmatory of the diagnosis at the time of endovascular treatment. DSA has a reported sensitivity of 100% compared to CT which is 67% [17]. MRI is another consideration, especially in young patients or the subacute setting, but is limited by cost, availability, time and numerous artefacts [18]. It is recognised that thrombosis of the BAP limits flow and may result in delayed enhancement or non enhancement, thereby confounding the diagnosis [18,19]. The main differential diagnoses on imaging would be a saccular aneurysm arising from the aorta, ductus arteriosus, aberrant right subclavian artery or another aortic branch.\\u003c/p\\u003e\\n\\u003cp\\u003eUp to 40% of patients with unilateral vocal cord palsy are asymptomatic at the time of diagnosis and this may be further masked by the presence of other symptoms or other cranial nerves involved with the underlying disease process [20].\\u003c/p\\u003e\\n\\u003cp\\u003eThe two main treatment options are endovascular repair or open surgery. Whilst they have a comparable success rate (93.1% vs 90.0% respectively), endovascular techniques are recognised as safer, less invasive, less painful, more selective, lower in cost and offer shorter hospital stays and improved quality of life [5,16]. Embolisation is generally accepted as first line, most commonly with coils alone or in combination with liquid embolics such as gelatin sponge, polyvinyl acetate (PVA), cynanoacrylate (glue) or onyx [5]. Placement of an aortic stent-graft is another endovascular option but limits access back into the bronchial arteries if retreatment is required, can be problematic in the setting of infection and is associated with increased cost, time and risk [21,22,23]. Surgery may be considered where there is a contraindication to angioembolisation (e.g. documented iodine anaphylaxis) or where the anatomical configuration makes definitive embolisation impossible [24]. Surgical techniques include pseudoaneurysm excision/resection or ligation (with or without vascular reconstruction depending on collaterals), lobectomy or pneumonectomy [25].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn our reported case, coil embolisation via a microcatheter successfully treated the BPA without the need for adjunctive liquid embolics and without complication.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eBAPs are rare and potentially life-threatening. Whilst the age and idiopathic nature of the case we present is most common for this disease, the presentation with clinical and radiological signs of RLN palsy is atypical and has not been previously published in the literature to our knowledge. Timely diagnosis and referral to facilitate urgent BAE is essential to prevent potentially serious clinical sequelae, regardless of size or associated symptoms. Endovascular treatment in the form of BAE is considered first line.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eBAP\\u0026nbsp; \\u0026nbsp;\\u0026nbsp;bronchial artery pseudoaneurysm\\u003cbr\\u003eBAA\\u0026nbsp; \\u0026nbsp;bronchial artery aneurysm\\u003c/p\\u003e\\n\\u003cp\\u003eBAE\\u0026nbsp; \\u0026nbsp;\\u0026nbsp;bronchial artery embolization\\u003cbr\\u003eICBT\\u0026nbsp; \\u0026nbsp;intercostobronchial trunk\\u003c/p\\u003e\\n\\u003cp\\u003eRLN\\u0026nbsp; \\u0026nbsp;\\u0026nbsp;recurrent laryngeal nerve\\u003cbr\\u003eANA\\u0026nbsp; \\u0026nbsp;antinuclear antibodies\\u003c/p\\u003e\\n\\u003cp\\u003eENA\\u0026nbsp; \\u0026nbsp;\\u0026nbsp;extractable nuclear antigens\\u003c/p\\u003e\\n\\u003cp\\u003eCECT\\u0026nbsp;\\u0026nbsp;contrast-enhanced computed tomography\\u003c/p\\u003e\\n\\u003cp\\u003ePET\\u0026nbsp; \\u0026nbsp; \\u0026nbsp;positron emission tomography\\u003c/p\\u003e\\n\\u003cp\\u003eMRI\\u0026nbsp; \\u0026nbsp;\\u0026nbsp;magnetic resonance imaging\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e1. Ethics approval and consent to participate\\u003c/p\\u003e\\n\\u003cp\\u003eThe need for ethics approval was waived by the institutional review board in accordance with institutional guidelines. The manuscript does not report on or involve the use of animal data.\\u003cbr\\u003e \\u003cbr\\u003e2. Consent for publication\\u003cbr\\u003e\\u003cstrong\\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\\u003c/strong\\u003e\\u003cstrong\\u003e\\u003cbr\\u003e \\u003cbr\\u003e \\u003c/strong\\u003e3. Availability of data and materials\\u003cbr\\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study. Further information can be made available by the authors on request.\\u003cbr\\u003e \\u003cbr\\u003e4. Competing interests\\u003cbr\\u003e The authors declare that they have no competing interests.\\u003cbr\\u003e \\u003cbr\\u003e5. Funding\\u003cbr\\u003e The authors declare that no funding was sought or received for this study.\\u003cbr\\u003e \\u003cbr\\u003e6. Authors' contributions\\u003cbr\\u003e RC obtained the clinical and procedural information, performed the literature review and was the primary author of the manuscript. SO helped with the case discussion and writing the manuscript. NN prepared the figures for publication and helped review the manuscript. All authors read and approved the final manuscript.\\u003cbr\\u003e \\u003cbr\\u003e7. Acknowledgements\\u003cbr\\u003e Not applicable.\\u003cbr\\u003e \\u003cbr\\u003e8. Authors' information\\u003cbr\\u003e RC and SO are interventional radiologists at Liverpool Hospital in Sydney, New South Wales, Australia. SO holds EBIR qualification. RC is a Conjoint Lecturer with the Clinical School of Medicine, UNSW Health \\u0026amp; Medicine, South West Sydney Clinical Campuses.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003ePitton MB, Dappa E, Jungmann F et al (2015) Visceral artery aneurysms: incidence, management, and outcome analysis in a tertiary care center over one decade. Eur Radiol 25:2004\\u0026ndash;2014\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTanaka K, Ihaya A, Horiuci T, Morioka K, Kimura T, Uesaka T et al (2003) Giant mediastinal bronchial artery aneurysm mimicking benign esophageal tumor: a case report and review of 26 cases from literature. J Vasc Surg 38:1125\\u0026ndash;1129\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCauldwell EW, Siekert RG, Lininger RE, Anson BJ (1948) The bronchial arteries: an anatomic study of 150 human cadavers. Surg Gynecol Obstet 86(4):395\\u0026ndash;412\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSancho C, Dominguez J, Escalante E, Hernandez E, Cairols M, Martinez X (1999) Embolization of an anomalous bronchial artery aneurysm in a patient with agenesis of the left pulmonary artery. J Vasc Interv Radiol 10:1122\\u0026ndash;1126\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSan Norberto EM, Urbano Garc\\u0026iacute;a J, Montes JM, Vaquero C (2018) Endovascular treatment of bronchial aneurysms. J Thorac Cardiovasc Surg 156(2):e109\\u0026ndash;e117\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKasashima F, Endo M, Kosugi I, Matsumoto Y, Abe Y, Sasaki H et al (2003) Mediastinal bronchial artery aneurysm treated with a stent-graft. J Endovasc Ther 10:381\\u0026ndash;385\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLioulias A, Misthos P, Kokotsakis J, Papagiannakis G, Skouteli E (2008) Recurrent massive hemoptysis due to post bronchotomy bronchial artery aneurysm: a case report. Can Respir J 15:127\\u0026ndash;128\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKaufman C, Kabutey NK, Sgroi M, Kim D (2014) Bronchial artery pseudoaneurysm with symptomatic mediastinal hematoma. Clin Imaging 38:536\\u0026ndash;539\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSuen HC, Dumontier CC, Boeren J, Charland W (2003) Daily B. B. Ruptured bronchial artery aneurysm associated with sarcoidosis. J Thorac Cardiovasc Surg 125:1153\\u0026ndash;1154\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRestrepo CS, Carswell AP (2012) Aneurysms and pseudoaneurysms of the pulmonary vasculature. Semin Ultrasound CT MR 33(6):552\\u0026ndash;566\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHoffmann V, Ysebaert D, De Schepper A, Colpaert C, Jorens P (1996) Acute superior vena cava obstruction after rupture of a bronchial artery aneurysm. Chest 110:1356\\u0026ndash;1358\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKalina M, Giberson F (2007) Hemoptysis secondary to pulmonary artery pseudoaneurysm after necrotizing pneumonia. Ann Thorac Surg 84:1386\\u0026ndash;1387\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCrocco JA, Rooney JJ, Fankushen DS, DiBenedetto RJ, Lyons HA (1968) Massive hemoptysis. Arch Intern Med 121(6):495\\u0026ndash;498\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJean-Baptiste E (2000) Clinical assessment and management of massive hemoptysis. Crit Care Med 28(5):1642\\u0026ndash;1647\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKalangos A, Khatchatourian G, Panos A, Faidutti B (1997) Ruptured mediastinal bronchial artery aneurysm: a dilemma of diagnosis and therapeutic approach. J Thorac Cardiovasc Surg 114:853\\u0026ndash;856\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCordova AC, Sumpio BE (2013) Visceral artery aneurysms and pseudoaneurysms\\u0026mdash;should they all be managed by endovascular techniques? Ann Vasc Dis 6:687\\u0026ndash;693\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHabib N, Hassan S, Abdou R et al (2013) Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review. Ann Surg Innov Res 7:4\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFukunaga A, Okushiba S, Ohno K, Kitashiro S, Kawarada Y, Shitinohe T et al (2003) Mediastinal bronchial artery aneurysm with hematemesis. Dis Esophagus 16:328\\u0026ndash;331\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTringali S, Tiffet O, Berger JL, Cuilleret J (2002) Bronchial artery aneurysm disguised as a leiomyoma of the esophagus. Ann Thorac Surg 73:632\\u0026ndash;633\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMontoya S, Portanova A, Bhatt AA (2019) A radiologic review of hoarse voice from anatomic and neurologic perspectives. Insights Imaging 10(1):108\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSanchez E, Alados P, Zurera L, Canis M, Mu\\u0026ntilde;oz I, Casares J et al (2007) Bronchial artery aneurysm treated with aortic stent graft and fibrin sealant. Ann Thorac Surg 83:693\\u0026ndash;695\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFiorucci B, Simonte G (2016) Treatment of a bronchial artery aneurysm with placement of an aortic thoracic stent-graft. Eur J Vasc Endovasc Surg 51:717\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eIzaaryene J, Vidal V, Bartoli JM, Gaubert JY (2016) Multiple bronchial artery aneurysms: successful treatment with ethylene-vinyl alcohol copolymer (Onyx). Diagn Interv Imaging 97:125\\u0026ndash;127\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChatterjee A, Ghosh S, Salhiyyah K, Gaines P, Rocco G (2004) A rare presentation of a ruptured bronchial artery aneurysm. Thorax 59:912\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNakamura R, Inage Y, Tsuchiya A, Kato T, Yuzawa K, Koizumi M et al (2014) Bronchial artery aneurysm treated with video-assisted thoracoscopic surgery. Ann Vasc Surg 28:1321e1\\u0026ndash;1321e3\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"cvir-endovascular\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"cire\",\"sideBox\":\"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/cire/default.aspx\",\"title\":\"CVIR Endovascular\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Bronchial artery pseudoaneurysm, bronchial artery aneurysm, embolisation, bronchial artery embolisation, recurrent laryngeal nerve palsy.\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4281597/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4281597/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eBackground: Bronchial artery pseudoaneurysms (BAP) or aneurysms (BAA) are rare, potentially life-threatening and remain poorly understood. They are most commonly idiopathic but may be associated with a number of other disease processes. Bronchial artery embolisation (BAE) is considered the first line treatment while surgical techniques are reserved for patients with a clear contraindication to embolisation or where anatomical factors preclude an endovascular approach. \\u003cbr\\u003e\\nCase presentation: We present an interesting case of a 56 year-old male presenting with an idiopathic unruptured right BAP causing clinical and radiological signs of left recurrent laryngeal nerve (RLN) palsy. He was otherwise clinically well with no other reported symptoms and no significant past medical history. There were no significant findings on work-up and investigation. He was ultimately treated successfully with selective transarterial coil embolization of the right bronchial artery. This is an atypical presentation of a rare clinical entity and has not previously been published in the literature to our knowledge. \\u003cbr\\u003e\\nConclusions: BAPs and BAAs are highly variable in their presentation, ranging from incidental asymptomatic findings to catastrophic haemorrhage, depending on their location and if they are contained or ruptured. Timely diagnosis and referral to facilitate urgent embolisation is essential to prevent potentially serious clinical sequelae. Endovascular treatment in the form of BAE is considered first line.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Selective embolisation of an idiopathic bronchial artery pseudoaneurysm presenting with recurrent laryngeal nerve palsy: a case report\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-05-13 20:14:53\",\"doi\":\"10.21203/rs.3.rs-4281597/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Major revision\",\"date\":\"2024-05-28T03:20:51+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2024-05-04T18:04:19+00:00\",\"index\":0,\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2024-05-04T10:11:38+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-05-03T00:10:16+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"CVIR Endovascular\",\"date\":\"2024-04-30T21:27:55+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"cvir-endovascular\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"cire\",\"sideBox\":\"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/cire/default.aspx\",\"title\":\"CVIR Endovascular\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"aec694a5-9811-4108-b75f-6e7083d9dfd1\",\"owner\":[],\"postedDate\":\"May 13th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2024-08-22T19:39:49+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-4281597\",\"link\":\"https://doi.org/10.1186/s42155-024-00474-2\",\"journal\":{\"identity\":\"cvir-endovascular\",\"isVorOnly\":false,\"title\":\"CVIR Endovascular\"},\"publishedOn\":\"2024-08-14 15:57:06\",\"publishedOnDateReadable\":\"August 14th, 2024\"},\"versionCreatedAt\":\"2024-05-13 20:14:53\",\"video\":\"\",\"vorDoi\":\"10.1186/s42155-024-00474-2\",\"vorDoiUrl\":\"https://doi.org/10.1186/s42155-024-00474-2\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4281597\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4281597\",\"identity\":\"rs-4281597\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}