Clinical and radiological features associated with rupture of pulmonary artery pseudoaneurysm: a retrospective study

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This study aimed to elucidate the clinical and radiological features of PAP and identify the risk factors associated with rupture. Methods Patients who developed hemoptysis with PAP were collected from January 2019 to December 2022 retrospectively. Clinical data of the demographic characteristics, radiological findings, treatment strategies, and prognosis were collected. A comparative analysis was performed on the characteristics in the ruptured and non-ruptured cases. Results A total of 58 PAPs were identified in the 50 patients. The most common causes were infection (86%) and cancer (8%). The PAPs were located predominantly in the upper lobes of both lungs, and 57 (99.3%) were distributed in the segmental or subsegmental pulmonary arteries. The median diameter was 6.1(4.3–8.7) mm. A total of 29 PAPs were identified adjacent to pulmonary cavitations, with the median diameter of the cavity being 18.9 (12.4–34.8) mm. Rupture of pseudoaneurysm occurred in 21 cases (42%). Compared to unruptured group, the ruptured group had a significantly higher proportion of massive hemoptysis (57.1% vs. 6.9%, p < 0.001), larger pseudoaneurysm diameter (8.1 ± 3.2 mm vs. 6.0 ± 2.3 mm, p = 0.012), higher incidence of pulmonary cavitation (76.2% vs. 44.8%, p = 0.027), and larger cavitation diameters (32.9 ± 18.8 mm vs. 15.7 ± 8.4 mm, p = 0.005). The mean pulmonary artery pressure (mPAP) in the ruptured group was also significantly higher than that in the unruptured group [23.9 ± 7.4 mmHg vs. 19.2 ± 5.0 mmHg, p = 0.011]. Endovascular treatment was successfully performed in all 21 patients with ruptured PAP, of which the clinical success rate was 96.0%. Five patients experienced recurrent hemoptysis within one year. Conclusions Massive hemoptysis, pseudoaneurysm diameter, pulmonary cavitation, and elevated mPAP were the risk factors for rupture of pseudoaneurysm. Our findings facilitate early identification and timely intervention of PAP at high risk of rupture. Pulmonary artery pseudoaneurysm Hemoptysis Rupture Pulmonary cavitation Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Hemoptysis is a serious clinical complication, which can be fatal. The source of hemorrhage is mainly the bronchial artery. Hemoptysis due to pulmonary arterial origin is quite rare and it is estimated to occur in less than 10% of cases[ 1 ]. Pulmonary artery pseudoaneurysm (PAP) is one of causes associated with pulmonary artery. Histologically, a pseudoaneurysm comprises either the media, adventitia, or the soft tissue surrounding the vessel, unlike a true aneurysm which involves all three layers of the artery. As a consequence, the pseudoaneurysm has a higher risk of rupture [ 2 ]. Hemoptysis has been described as a possible warning sign for rupture of PAP. In patients with massive hemoptysis undergoing bronchial artery embolization, 5%-11% patients result from PAP rupture [ 3 ]. Once PAP ruptures, the mortality can be as high as 50% [ 4 ]. Therefore, risk assessment of the rupture of PAP is critical for early identification. As low incidence and asymptomatic manifestation, patients with PAP are frequently underdiagnosis or misdiagnosed. PAP may be congenital or acquired. It has been found that PAP was associated with infection, primary or metastatic lung neoplasm, traumatic injury, pulmonary arterial hypertension, or vasculitis [ 5 , 6 ]. Previous case series have reported that pseudoaneurysms secondary to aspergillus and tumors both tend to be adjacent to cavitary lesion [ 4 , 7 ]. Rasmussen's aneurysms were often accompanied by tuberculous cavities, which appeared to be more prone to rupture and cause fatal hemoptysis [ 4 ]. However, it remains uncertain whether the cavitary lesions and the rupture are clinically related. The diameter of abdominal aortic aneurysm (AAA) has been well-established as a crucial determinant and independent predictor of AAA rupture [ 8 ]. A reliable assessment of hemodynamics is also crucial for predicting the risk of AAA rupture [ 9 ]. Nevertheless, the relationship between pseudoaneurysm size and hemodynamics and PAP rupture has rarely been discussed. Currently, only case reports and series have described the etiology and radiological features. Little is known about the relevant factors for rupture of pseudoaneurysm in the lung. Therefore, this study aimed to illustrate the clinical characteristics of the rupture of pseudoaneurysm in a single center and further identify patients at high risk of rupture for early intervention. Methods Study population Clinical data were collected from individuals who underwent computed tomography angiography (CTA) or transcatheter pulmonary vascular intervention for hemoptysis between January 2019 and December 2022. The medical data collected included age, gender, clinical symptoms, medical history, volume of hemoptysis, underlying etiology, imaging characteristics, and intervention and treatment outcomes. Hemoptysis was defined as mild (≤ 39 ml/day), moderate (40–199 ml/day), or massive (≥ 200 ml/day) [ 10 ]. The study received approval from institutional review boards for the retrospective review of electronic records and imaging. Written informed consent was obtained from each participant. Imaging findings Computed tomography angiography A 64-detector CT scanner was used to conduct CTA, from the thoracic inlet to a position 5–10 cm above the upper abdomen, employing a slice thickness of 1.00 mm. PAP was identified as focal dilations of the pulmonary artery. Information regarding the location, number, size, and level of PAP was collected systematically. Other CT findings, such as cavitations adjacent to PAP were also documented. The size of the PAP was determined using the longest diameter observed on the axial CT scan [ 11 ]. The size of the cavitation was measured based on its maximum diameter [ 12 ]. Digital subtraction angiography All of the patients underwent bronchial and non-bronchial systemic collateral arterial angiography to identify the target vessels of hemoptysis. Right heart catheterization was conducted during digital subtraction angiography (DSA). This procedure involved measuring pressures at various sites and calculating the cardiac output (CO) using thermodilution. Pulmonary angiography was performed initially at the bifurcation of the right or left pulmonary artery to demonstrate the presence of any PAP and to delineate the anatomy of the pulmonary artery. Selective segmental or subsegmental angiography was performed to determine the location and feeding vessel. Based on imaging from CTA and DSA, the PAPs were classified into four types. Type A can be visualized by non-selective pulmonary arteriography, type B by selective segmental or subsegmental pulmonary arteriography, type C by bronchial and non-bronchial systemic arteriography, while type D is only visible on pulmonary CT angiography and not on catheter-directed angiography [ 13 ]. If a PAP was not visualized on CTA but appeared on DSA pulmonary angiography, the maximum diameter of the PAP observed by DSA was measured to determine its size. The criteria of identification of rupture: 1) the presence of pseudoaneurysm and extravasation of contrast agent in angiography. 2) no signs of bronchial artery rupture were observed during angiography in patients with paroxysmal hemoptysis. 3) cessation or significant reduction of hemoptysis after embolization of PAP. Treatment methods A 5F angiography catheter (Cook, USA) was superselected into the feeding vessels of the PAP and a 1.98F microcatheter (Asahi, Japan) was superselected into the pseudoaneurysm sac to embolize with the coil. In a case in which the microcatheter could not reach the aneurysm sac, a pseudoaneurysm was excluded by coil embolization of the feeding vessel. The neck of the pseudoaneurysm was embolized when the pseudoaneurysm sac was too large to embolize fully. Patients were observed for 72 hours postoperatively to assess complications and treatment effects. The evaluation of PAP embolization included technical success and clinical success [ 14 ]. Technical success was defined as a pseudoaneurysm no longer visible after embolization, while clinical success was defined as cessation of hemoptysis or a significant reduction after the procedure. Statistical analyses All the statistical analyses were conducted using SPSS (version 24.0, IBM Corp). The data were expressed as either median and the first and third quartiles (Q1-Q3), mean ± standard deviation (SD), or absolute number and percentage of patients. For normally distributed data, the t-test was used to compare differences between the two groups. If the data were non-normally distributed, the Mann-Whitney U test was performed. Chi-square (χ2) tests or Fisher exact tests were used to compare proportions between the two groups. Statistical significance was defined as p < 0.05. Results Study population From January 2019 to December 2022, a total of 2782 inpatients presented with hemoptysis. PAP was detected in 50 cases by pulmonary artery CTA or DSA arteriography. The flowchart for selecting the study population is shown in Fig. 1 . The baseline characteristics of these patients are summarized in Table 1 . The mean age was 62.1 ± 13.4 years, with 36 (72%) of them being male. The proportion of patients with massive hemoptysis was 14 (28%), and three of them received preoperative endotracheal intubation due to asphyxia. The cause of PAP is listed in Table 2 . Notably, the most common causes were infection and pulmonary malignancy. Infection was presented in 43 cases (86%), including obsolete and active tuberculosis (40% and 12%, respectively), bronchiectasis (12%), and focal pneumonia (8%). Fungal infection was observed in 5 patients (10%) and 3 of them were identified as Aspergillus infection through sputum culture (Fig. 2 ). Four cases (8%) were caused by malignant tumors, including primary lung cancer and liver cancer with lung metastasis. Table 1 Baseline characteristics of pulmonary artery pseudoaneurysm in 50 patients with hemoptysis Parameters Case Number Age, (years) 62.1 ± 13.4 Male, n(%) 36 (72) Signs and symptoms Heart rate (bpm) 85.6 ± 12.8 Systolic blood pressure (mmHg) 122.9 ± 15.3 Diastolic blood pressure, (mmHg) 75.9 ± 10.7 Respiratory rate, (times/min) 20 ± 2.0 Fever 3 (6) Cough 9 (18) Dyspnea 4 (8) Chest tightness 7 (14) Disorders of consciousness 1 (2) Hemoptysis, n(%) Mild 16 (32) Moderate 20 (40) Massive 14 (28) Comorbidities, n(%) Chronic obstructive pulmonary disease 7 (14) Pneumoconiosis 3 (6) Prior thoracic surgery 5 (10) Hypertension 9 (18) Coronary heart disease 2 (4) Diabetes mellitus 9 (18) Table 2 Causes of pulmonary artery pseudoaneurysms in patients with hemoptysis Underlying disease Case Number Infection, n(%) 43 (86) Tuberculosis 26 (52) Bronchiectasis 6 (12) Fungal pneumonia 5 (10) Focal pneumonia 4 (8) Lung abscess 2 (4) Malignant tumor, n(%) 4 (8) Lung adenocarcinoma 1 (2) Lung squamous cell carcinoma 2 (4) Pulmonary metastasis 1 (2) Percutaneous lung biopsy 1 (2) Congenital heart disease, n(%) 1 (2) Pulmonary fibrosis, n(%) 1 (2) Imaging features A total of 58 PAPs were identified in all the patients with hemoptosis. The imaging features are detailed in Table 3 . The PAPs were located primarily in the upper lobes of the lungs, with 24 (41.4%) in the left upper lobe, and 18 (31.0%) in the right upper lobe. They had a strong predilection for the peripheral pulmonary arteries and 57 (99.3%) were located in the segmental or subsegmental pulmonary arteries. The median diameter of PAP was 6.1(4.3–8.7) mm, and the maximum diameter was 15.2 mm. A total of 29 PAPs were identified adjacent to pulmonary cavitations (Fig. 3 ). The median diameter of the cavity was 18.9 (12.4–34.8) mm, with the maximum diameter being 77.4 mm. Four cases (8%) coexisted with bronchial artery aneurysms. pseudoaneurysm in 21 cases (42%) were considered as ruptured, of which most presented massive hemoptysis (Fig. 4 ). Table 3 Imaging features and treatment of 58 pulmonary artery pseudoaneurysms in patients with hemoptysis Imaging features and treatment Value Side, n(%) Left 29 (50) Right 29 (50) Lobar distribution, n(%) Left upper lobe 24 (41.4) Left lower lobe 5 (8.6) Right upper lobe 18 (31.0) Right middle lobe 3 (5.2) Right lower lobe 8 (13.8) Level of distribution, n(%) Lobar 1 (1.7) Segmental 11 (20.0) Subsegmental 46 (79.3) Classification, n A/B/C/D 0/31/25/2 Maximum diameter of PAP (mm) 6.1 (4.3–8.7) Ruptured pseudoaneurysms, n (%) 21 (42) Cavitary lesion, n(%) 29 (50) Maximum diameter of cavitary lesion (mm) 18.9 (12.4–34.8) The site of embolization Aneurysmal sac 13 (61.9) Aneurysmal neck 1 (4.8) Feeding vessel 10 (47.6) Embolization materials, n (%) Coil 20 (95.2) Covered stent 1 (4.8) Clinical characteristics of ruptured pulmonary artery pseudoaneurysm To identify the risk factors for rupture of PAP, we compared the clinical features between ruptured and unruptured patients. The clinical characteristics and hemodynamic features of the two groups are summarized in Table 4 . No significant differences were observed between the two groups across gender, age, etiology, and distribution. Compared to the non-rupture group, the rupture group had a significantly higher proportion of massive hemoptysis (57.1% vs. 6.9%, p < 0.001), larger pseudoaneurysm diameter (8.1 ± 3.2 mm vs. 6.0 ± 2.3 mm, p = 0.012), higher incidence of pulmonary cavitation (76.2% vs. 44.8%, p = 0.027), and larger cavitation diameters (32.9 ± 18.8 mm vs. 15.7 ± 8.4 mm, p = 0.005). The mean pulmonary artery pressure (mPAP) in the ruptured group was also significantly higher than that in the unruptured group (23.9 ± 7.4 mmHg vs. 19.2 ± 5.0 mmHg, p = 0.011). Meanwhile, there was no statistical significance in the other hemodynamic parameters. Table 4 Comparison of clinical characteristics of patients with ruptured and unruptured pulmonary artery pseudoaneurysms Characteristics Ruptured group (n = 21) unruptured group (n = 29) P value Age, (years) 61.3 ± 10.2 62.6 ± 15.5 0.748 Male, n(%) 18 (85.7) 18 (62.1) 0.066 Massive hemoptysis, n(%) 12 (57.1) 2 (6.9) <0.001 Underlying disease, n(%) Tuberculosis 12 (57.1) 14 (48.3) 0.536 Bronchiectasis 2 (9.5) 4 (13.8) 0.986 Fungal pneumonia 3 (14.3) 2 (6.9) 0.702 Malignant tumor 1 (4.8) 3 (10.3) 0.849 Location of PAP*, n(%) Total 26 32 Left 11 (42.3) 18 (56.3) 0.291 Right 15 (57.7) 14 (43.7) Upper lobes 23 (88.5) 22 (68,7) 0.073 Lower lobes 3 (11.5) 10 (31.3) Segmental 7 (26.9) 4 (12.5) 0.184 Subsegmental 18 (69.2) 28 (87.5) Maximum diameter of PAP (mm) 8.1 ± 3.2 6.0 ± 2.3 0.012 Cavitary lesion, n(%) 16 (76.2) 13 (44.8) 0.027 Maximum diameter of cavitary lesion (mm) 32.9 ± 18.8 15.7 ± 8.4 0.005 Hemodynamics CO (L/min) 5.5 ± 0.9 5.3 ± 1.4 0.570 CI (L/min/m2) 3.5 (3.3-4.0) 3.2 (2.8-4.0) 0.232 mPAP (mmHg) 23.9 ± 7.4 19.2 ± 5.0 0.011 PAWP (mmHg) 11.8 ± 4.1 10.0 ± 3.8 0.137 PVR (Wood) 2.1 (1.3-3.0) 1.8 (1.4–2.3) 0.647 Abbreviations: CO, cardiac output; CI, cardiac index; mPAP, mean pulmonary artery pressure; PAWP, pulmonary artery wedge pressure; PVR, pulmonary vascular resistance. * The analyses of location included 26 PAPs in ruptured group and 32 PAPs in unruptured group. Treatment and outcome Endovascular treatment was conducted in all patients with PAP rupture. As shown in Table 2 . Coil embolization was performed in 20 cases (95.2%), including pseudoaneurysm sac embolization in 13 cases (61.9%), pseudoaneurysm neck embolization in 1 case (4.8%), feeding vessel embolization in 10 cases (47.6%). One PAP was excluded with covered stents. No patient underwent surgical resection. The outcome and complication of patients with PAP rupture are listed in Table 5. During the operation, one patient experienced stress-induced hypertension, and another one sustained a pulmonary artery injury. One patient suffered massive hemoptysis due to rupture of PAP during pulmonary angiography, and the hemoptysis stopped after immediate embolization. After the operation, fever, chest tightness, and chest pain were complained by patients with interventional treatment. All of the complications resolved spontaneously or following symptomatic treatment. None of the patients had pulmonary infarction. The technical and clinical success rate was 100% and,96.0%, respectively. One patient died of massive hemoptysis during hospitalization. Table 5 Outcome and complications of patients with ruptured pulmonary artery pseudoaneurysm Parameters Case Number Outcome Technical success 21 (100) Clinical Success 19 (90.5) Intraoperative complication Stress-induced hypertension 1 (4.8) Aneurysm rupture 1 (4.8) Pulmonary artery injury 1 (4.8) Postoperative complication Fever 2 (9.5) Chest tightness 1 (4.8) Chest pain 1 (4.8) Of the patients received intravascular intervention for patients with PAP rupture, 17 patients completed one-year follow-up. One patient died of heart failure. Meanwhile, five patients had recurrences of hemoptysis, of which four occurred within 6 months. Discussion This study described the clinical and imaging features of patients with hemoptysis and PAP, and further investigated the risk factors for rupture of PAP. The findings of this study indicated that massive hemoptysis, pseudoaneurysm diameter, cavitary lesions, and elevated mPAP were associated with an increased risk of PAP rupture. To our knowledge, this is the first study identifying risk factors for rupture of pseudoaneurysm. This study could assist clinicians in identifying high-risk patients of PAP rupture, offering insights into treatment strategies that could prevent delays in critical interventions. The mechanism of PAP formation is vessel wall destruction and further replaced by granulomatous, neoplastic, or fibrotic tissue, resulting in the weakening of the arterial wall. Under sustained arterial pressure, blood dissects the injured artery and forms a perfused sac. Infection was the most common cause of acquired PAP in our patient population, which is consistent with previous studies [ 5 , 6 ]. Previous studies have reported that PAPs were often accompanied by cavitary lesions [ 3 , 4 , 7 ]. It revealed that PAP may have a predilection for pulmonary cavitation. In our study, PAPs were adjacent to pulmonary cavities in 29 patients (58%). Compared with the unruptured patients, the ruptured ones had a significantly higher proportion of pulmonary cavitation and the size of cavitary lesions was larger. The underlying pathogenesis may be direct invasion of vessels by pathogenic bacteria and persistent damage by pulmonary lesions associated with tissue necrosis or inflammation. Cystic medial necrosis was observed in many perioperative samples of the vascular wall [ 15 ]. Inflammation has been considered as a central driving cause in the development of arterial aneurysm. Studies have demonstrated that Chlamydia pneumoniae is detected in AAA with infiltration of inflammatory cells including macrophages, lymphocytes, and plasma cells in the aortic walls [ 16 – 18 ]. In terms of lung infection, patients with tuberculosis, necrotizing pneumonia, and suppurative bacterial and fungal infections were more likely to have PAP [ 19 ]. Of note, these pathogens could cause necrotic lesion and pulmonary cavitation. Therefore, it is reasonable to infer that pulmonary cavities may be associated with the formation and rupture of PAP. The degeneration of the pathological structure is not sufficient to produce an abnormal balloon shape. The formation and rupture of this abnormal structure are also influenced by intravascular hemodynamic effects in addition to the weakened arterial wall. In an observational study about a cohort of patients with pulmonary hypertension, the incidence of pulmonary artery aneurysm was about 38%, especially in patients with long disease duration [ 20 ]. In patients with hemoptysis due to PAP rupture, especially those with systemic-pulmonary shunts, pulmonary artery pressure is maintained between 35–69 mmHg [ 4 ]. Our data indicated that PAP in the ruptured group exhibited larger diameter and higher mPAP in comparison to the unruptured group. Similar to AAA, vessel wall tension escalates with both diameter and transmural pressure. Arterial wall tension is directly proportional to both pressure and the radius of the diseased vessel while inversely correlated with arterial wall thickness according to the Laplace’s law. Rupture occurs when stress induced by blood flow exceeds the limit of wall tissue strength. Thus, risk of rupture in the PAP is closely associated with both size and pressure. There are no guidelines for the indication of treatment and the best therapeutic approach. The main treatment for PAP were surgery and intravascular intervention. Surgical treatments such as lobectomy or aneurysmectomy were associated with high mortality [ 22 ]. Endovascular coil embolization and stent placement are currently preferred due to less invasive and fewer complications [ 1 , 23 ]. The selection of embolization material depends on the location, size, and classification of PAP. Coil embolization may be an effective choice for preserving distal pulmonary artery perfusion and avoiding lung perfusion injury. The stent is generally recommended for fusiform or lobar arterial pseudoaneurysm in the pulmonary. Of the current study, most of the patients received coil embolization and only one PAP located in the lobar branch was excluded with a covered stent. Due to vulnerability to rupture of PAP, the operator should be alert to sudden rupture during the operation [ 24 ]. In our series, one rupture occurred during pulmonary angiography. The possible reason might be a transient increase in pulmonary perfusion and local pressure with contrast agent injection, or direct damage to microcatheters and microwires during the procedure. We acknowledge several limitations of our study. First, although our study cohort was relatively large compared to the previous studies, it was still limited by the small number of cases due to the rarity of PAPs. Furthermore, the natural history of PAP has not yet been extensively studied and remains largely unknown. Experts evaluated the cause of PAP based on the history and imaging of patients. Thus, its accuracy and conclusiveness may be limited. Additionally, longer-term follow-up studies are crucial for evaluating the extended prognosis of patients with PAP and hemoptysis. Conclusions In conclusion, we found that PAP patients with rupture had a significantly higher proportion of massive hemoptysis and pulmonary cavitation, larger pseudoaneurysm and cavitation diameter, as well as higher mPAP. Collectively, we have characterized the clinical features of PAPs and explored risk factors of rupture, providing novel insights into the early identification of PAPs with high risk of rupture. Abbreviations PAP Pulmonary artery pseudoaneurysm AAA Abdominal aortic aneurysm CTA Computed tomography angiography DSA Digital subtraction angiography CO Cardiac output CI Cardiac index mPAP Mean pulmonary artery pressure PAWP Pulmonary artery wedge pressure PVR pulmonary vascular resistance Declarations Acknowledgements The authors thank all the patients who participated in this study. Author contributions ML, JL conceived the project, collected the data, drafted and revised the manuscript. WY, XG, SC, WQ, ZZ collected patient information, provided the figures and interpreted data. CL, FL, ZZ reviewed and revised the final draft of the manuscript. All the authors have read, discussed and approved the manuscript. Funding This work was supported by National Natural Science Foundation of China (No. 82241029), National High Level Hospital Clinical Research Funding (2022-NHLHCRF-LX-01-0203), China Postdoctoral Science Foundation (2023TQ0383) and Wuhan Medical Research project (WX20D85). Availability of data and materials The data used and analyzed in the study are available from the corresponding author on reasonable request. Ethics approval and consent to participate The Ethics Committee of the Affiliated Hospital of Jianghan University approved this retrospective study. All participants provided the written informed consents prior to study. All methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable. Competing interests The authors declared that they have no competing interests. References Spinu C, Castaner E, Gallrado X, et al. Multidetector computed tomography in life-threatening hemoptysis. Radiologia. 2013;55(6):483–98. https://doi.org/10.1016/j.rx.2013.05.006 . Guillaume B, Vendrell A, Stefanovic X, et al. Acquired pulmonary artery pseudoaneurysms: a pictorial review. Br J Radiol. 2017;90(1073):20160783. https://doi.org/10.1259/bjr.20160783 . Chen Y, Gilman MD, Humphrey KL, et al. 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Am J Cardiol. 2019;123(3):474–81. https://doi.org/10.1016/j.amjcard.2018.10.028 . Kalra-Lall A, Donaldson J, Martin C 3rd. Brief review: Pulmonary artery aneurysms and pseudoaneurysms. Int J Cardiovasc Imaging. 2019;35(7):1357–64. https://doi.org/10.1007/s10554-019-01547-3 . Theodoropoulos P, Ziganshin BA, Tranquilli M, et al. Pulmonary artery aneurysms: four case reports and literature review. Int J Angiol. 2013;22(3):143–8. https://doi.org/10.1055/s-0033-1347907 . Krokidis M, Spiliopoulos S, Ahmed I, et al. Emergency endovascular management of pulmonary artery aneurysms and pseudoaneurysms for the treatment of massive haemoptysis. Hellenic J Cardiol. 2014;55(3):204–10. Shin TB, Yoon SK, Lee KN, et al. The role of pulmonary CT angiography and selective pulmonary angiography in endovascular management of pulmonary artery pseudoaneurysms associated with infectious lung diseases. J Vasc Interv Radiol. 2007;18(7):882–7. https://doi.org/10.1016/j.jvir.2007.04.023 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Aug, 2024 Read the published version in BMC Pulmonary Medicine → Version 1 posted Editorial decision: Revision requested 29 May, 2024 Reviews received at journal 17 May, 2024 Reviews received at journal 16 May, 2024 Reviewers agreed at journal 04 May, 2024 Reviewers agreed at journal 02 May, 2024 Reviewers invited by journal 02 May, 2024 Editor assigned by journal 02 May, 2024 Editor invited by journal 02 May, 2024 Submission checks completed at journal 02 May, 2024 First submitted to journal 25 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. 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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-4326756","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":298691802,"identity":"2435626c-4614-4541-9d41-d971ce955488","order_by":0,"name":"min liu","email":"","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"min","middleName":"","lastName":"liu","suffix":""},{"id":298691803,"identity":"9442e4f0-dad7-416b-b332-80b69e97b7e3","order_by":1,"name":"jixiang liu","email":"","orcid":"","institution":"Affiliated Hospital of Jianghan University","correspondingAuthor":false,"prefix":"","firstName":"jixiang","middleName":"","lastName":"liu","suffix":""},{"id":298691804,"identity":"b447e491-d219-49f4-8356-9c2080802547","order_by":2,"name":"Wei Yu","email":"","orcid":"","institution":"Affiliated Hospital of Jianghan University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Yu","suffix":""},{"id":298691805,"identity":"a5271ac7-7d5b-4069-8efb-44e1cb1ba8fe","order_by":3,"name":"Xiaoyan Gao","email":"","orcid":"","institution":"Affiliated Hospital of Jianghan University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoyan","middleName":"","lastName":"Gao","suffix":""},{"id":298691806,"identity":"30984f57-2ac1-4d0b-a52f-d795cb773f98","order_by":4,"name":"Shi Chen","email":"","orcid":"","institution":"Affiliated Hospital of Jianghan University","correspondingAuthor":false,"prefix":"","firstName":"Shi","middleName":"","lastName":"Chen","suffix":""},{"id":298691807,"identity":"29d01407-e237-44c2-aa0f-7532609ec173","order_by":5,"name":"Wei Qin","email":"","orcid":"","institution":"Affiliated Hospital of Jianghan University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Qin","suffix":""},{"id":298691808,"identity":"d2fdbf7f-bdbf-4c06-8328-f3df25327085","order_by":6,"name":"Ziyang Zhu","email":"","orcid":"","institution":"Affiliated Hospital of Jianghan University","correspondingAuthor":false,"prefix":"","firstName":"Ziyang","middleName":"","lastName":"Zhu","suffix":""},{"id":298691811,"identity":"87b616e4-4c51-4219-bbcc-0d0cc7d73915","order_by":7,"name":"Chenghong Li","email":"","orcid":"","institution":"Affiliated Hospital of Jianghan University","correspondingAuthor":false,"prefix":"","firstName":"Chenghong","middleName":"","lastName":"Li","suffix":""},{"id":298691812,"identity":"60eb9003-4f9d-4bc5-8587-8dec86960911","order_by":8,"name":"Fajiu Li","email":"","orcid":"","institution":"Affiliated Hospital of Jianghan University","correspondingAuthor":false,"prefix":"","firstName":"Fajiu","middleName":"","lastName":"Li","suffix":""},{"id":298691813,"identity":"86a4d738-3a42-4d9c-88ba-9a5d06b33fb7","order_by":9,"name":"Zhenguo Zhai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIie3Pv0sDMRTA8YSDuATnVwTjn/COLg7i3+GYEOgtUQouN0lLIS7ifKB4/4IiiOM7CnWpu+BSEZyv2xUEfxwiIty1o2C+UwLvQ/IYC4X+YsAY8UF95DONsCnWRrQyibDsb3fX5UQvJeyLiE5WpuYC3FarUGejp2Jxu3Og9ixtSITEM8dYld40En4+QepMe4fxQ093P8i+Z/fET6aPjSQCjRT7sbnKHNqa8FMdcd9MBCQlGf9Wk/Hnx0QksZVIcEiFJ5ODi4cZghZiCQFw/WLorbmUL5aVCLGXQhdtu6gsuZ4v/K7Jj+1dpV+PlMqfi1mVNpPvkH5cqGHo13ODlcZCoVDoP/YO9YFba+wHZl8AAAAASUVORK5CYII=","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":true,"prefix":"","firstName":"Zhenguo","middleName":"","lastName":"Zhai","suffix":""}],"badges":[],"createdAt":"2024-04-26 02:40:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4326756/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4326756/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12890-024-03225-0","type":"published","date":"2024-08-28T15:58:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56197130,"identity":"4fb5725b-60ad-43fc-93fe-ed231e955f57","added_by":"auto","created_at":"2024-05-09 18:21:30","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":258822,"visible":true,"origin":"","legend":"\u003cp\u003eThe flowchart o\u003cu\u003ef\u003c/u\u003e selecting the study population.\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4326756/v1/5e2f3ef771a8fc36af8a5cee.jpg"},{"id":56198243,"identity":"6867e584-2467-41eb-9576-ae68c7352b20","added_by":"auto","created_at":"2024-05-09 18:29:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":969334,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative images of Aspergillus infection combined with pulmonary artery pseudoaneurysm.\u003c/p\u003e\n\u003cp\u003eA 48-year-old male was admitted with massive hemoptysis. Sputum culture confirmed aspergillus infection. Bronchial artery embolization was performed six months ago due to hemoptysis. (\u003cstrong\u003ea)\u003c/strong\u003e The axial enhanced CT scan reveals a PAP (arrow) located in the segmental pulmonary artery of the right upper lobe. The PAP is accompanied by cavitary lesions; (\u003cstrong\u003eb)\u003c/strong\u003e The axial enhanced CT scan displayed a crescent-shaped cavity (red arrow) in the right upper lobe, indicating a typical imaging manifestation of aspergillus infection; (\u003cstrong\u003ec)\u003c/strong\u003e Selective subsegmental pulmonary artery angiography confirmed the PAP (arrow) ; (\u003cstrong\u003ed)\u003c/strong\u003e The aneurysmal sac (arrow) was embolized with coils.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4326756/v1/e9503d69d091c1d154a9d444.png"},{"id":56197131,"identity":"72cf666e-77ca-49e7-93b1-40026eee7489","added_by":"auto","created_at":"2024-05-09 18:21:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":226198,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative images of tuberculous cavity combined with pulmonary artery pseudoaneurysm.\u003c/p\u003e\n\u003cp\u003eA 54-year-old male was admitted to the hospital due to massive hemoptysis. He was diagnosed with sputum smear-positive pulmonary tuberculosis. (\u003cstrong\u003ea)\u003c/strong\u003e Axial contrast-enhanced CT scan shows a pseudoaneurysm (arrow) in the segmental pulmonary artery of the left upper lobe; (\u003cstrong\u003eb)\u003c/strong\u003e Axial contrast-enhanced CT scan shows a large cavitary lesion (red arrow) adjacent to the PAP.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4326756/v1/c1015521f671e9d26117d7d4.png"},{"id":56197133,"identity":"715baf39-71da-4913-9d4a-4ac76bdc2b8d","added_by":"auto","created_at":"2024-05-09 18:21:32","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":725958,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative images of ruptured pulmonary artery pseudoaneurysm.\u003c/p\u003e\n\u003cp\u003eA 76-year-old male was hospitalized due to sudden massive hemoptysis. The patient had a history of tuberculosis and a positive sputum smear indicated the recurrence of tuberculosis. (\u003cstrong\u003ea)\u003c/strong\u003e Axial contrast-enhanced CT scan shows a pseudoaneurysm (arrow) distributed in the segmental pulmonary artery of the left upper lobe; (\u003cstrong\u003eb)\u003c/strong\u003e Axial contrast-enhanced CT scan shows that the PAP is adjacent to a cavitary lesion (red arrow); (\u003cstrong\u003ec)\u003c/strong\u003e Selective subsegmental pulmonary arteriography shows contrast agent extravasation from the PAP to the cavity(arrow) and trachea (arrowhead), confirming its rupture; (\u003cstrong\u003ed)\u003c/strong\u003e Final angiography shows occlusion of pseudoaneurysm (arrow) and the proximal of the feeding vessel (arrowhead) after coil embolization.\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4326756/v1/ff729b56e5a66aed0ac917ed.png"},{"id":63821157,"identity":"9c162264-0571-42a9-b3e0-141d46173266","added_by":"auto","created_at":"2024-09-02 16:12:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3475349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4326756/v1/5d2faeaa-4f8d-41d5-a24c-d85db3902b92.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical and radiological features associated with rupture of pulmonary artery pseudoaneurysm: a retrospective study","fulltext":[{"header":"Background","content":"\u003cp\u003eHemoptysis is a serious clinical complication, which can be fatal. The source of hemorrhage is mainly the bronchial artery. Hemoptysis due to pulmonary arterial origin is quite rare and it is estimated to occur in less than 10% of cases[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Pulmonary artery pseudoaneurysm (PAP) is one of causes associated with pulmonary artery. Histologically, a pseudoaneurysm comprises either the media, adventitia, or the soft tissue surrounding the vessel, unlike a true aneurysm which involves all three layers of the artery. As a consequence, the pseudoaneurysm has a higher risk of rupture [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Hemoptysis has been described as a possible warning sign for rupture of PAP. In patients with massive hemoptysis undergoing bronchial artery embolization, 5%-11% patients result from PAP rupture [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Once PAP ruptures, the mortality can be as high as 50% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Therefore, risk assessment of the rupture of PAP is critical for early identification.\u003c/p\u003e \u003cp\u003eAs low incidence and asymptomatic manifestation, patients with PAP are frequently underdiagnosis or misdiagnosed. PAP may be congenital or acquired. It has been found that PAP was associated with infection, primary or metastatic lung neoplasm, traumatic injury, pulmonary arterial hypertension, or vasculitis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Previous case series have reported that pseudoaneurysms secondary to aspergillus and tumors both tend to be adjacent to cavitary lesion [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Rasmussen's aneurysms were often accompanied by tuberculous cavities, which appeared to be more prone to rupture and cause fatal hemoptysis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, it remains uncertain whether the cavitary lesions and the rupture are clinically related.\u003c/p\u003e \u003cp\u003eThe diameter of abdominal aortic aneurysm (AAA) has been well-established as a crucial determinant and independent predictor of AAA rupture [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A reliable assessment of hemodynamics is also crucial for predicting the risk of AAA rupture [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Nevertheless, the relationship between pseudoaneurysm size and hemodynamics and PAP rupture has rarely been discussed. Currently, only case reports and series have described the etiology and radiological features. Little is known about the relevant factors for rupture of pseudoaneurysm in the lung. Therefore, this study aimed to illustrate the clinical characteristics of the rupture of pseudoaneurysm in a single center and further identify patients at high risk of rupture for early intervention.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eClinical data were collected from individuals who underwent computed tomography angiography (CTA) or transcatheter pulmonary vascular intervention for hemoptysis between January 2019 and December 2022. The medical data collected included age, gender, clinical symptoms, medical history, volume of hemoptysis, underlying etiology, imaging characteristics, and intervention and treatment outcomes. Hemoptysis was defined as mild (\u0026le;\u0026thinsp;39 ml/day), moderate (40\u0026ndash;199 ml/day), or massive (\u0026ge;\u0026thinsp;200 ml/day) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The study received approval from institutional review boards for the retrospective review of electronic records and imaging. Written informed consent was obtained from each participant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eImaging findings\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eComputed tomography angiography\u003c/h2\u003e \u003cp\u003eA 64-detector CT scanner was used to conduct CTA, from the thoracic inlet to a position 5\u0026ndash;10 cm above the upper abdomen, employing a slice thickness of 1.00 mm. PAP was identified as focal dilations of the pulmonary artery. Information regarding the location, number, size, and level of PAP was collected systematically. Other CT findings, such as cavitations adjacent to PAP were also documented. The size of the PAP was determined using the longest diameter observed on the axial CT scan [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The size of the cavitation was measured based on its maximum diameter [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDigital subtraction angiography\u003c/h2\u003e \u003cp\u003eAll of the patients underwent bronchial and non-bronchial systemic collateral arterial angiography to identify the target vessels of hemoptysis. Right heart catheterization was conducted during digital subtraction angiography (DSA). This procedure involved measuring pressures at various sites and calculating the cardiac output (CO) using thermodilution. Pulmonary angiography was performed initially at the bifurcation of the right or left pulmonary artery to demonstrate the presence of any PAP and to delineate the anatomy of the pulmonary artery. Selective segmental or subsegmental angiography was performed to determine the location and feeding vessel.\u003c/p\u003e \u003cp\u003eBased on imaging from CTA and DSA, the PAPs were classified into four types. Type A can be visualized by non-selective pulmonary arteriography, type B by selective segmental or subsegmental pulmonary arteriography, type C by bronchial and non-bronchial systemic arteriography, while type D is only visible on pulmonary CT angiography and not on catheter-directed angiography [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. If a PAP was not visualized on CTA but appeared on DSA pulmonary angiography, the maximum diameter of the PAP observed by DSA was measured to determine its size. The criteria of identification of rupture: 1) the presence of pseudoaneurysm and extravasation of contrast agent in angiography. 2) no signs of bronchial artery rupture were observed during angiography in patients with paroxysmal hemoptysis. 3) cessation or significant reduction of hemoptysis after embolization of PAP.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eTreatment methods\u003c/h2\u003e \u003cp\u003eA 5F angiography catheter (Cook, USA) was superselected into the feeding vessels of the PAP and a 1.98F microcatheter (Asahi, Japan) was superselected into the pseudoaneurysm sac to embolize with the coil. In a case in which the microcatheter could not reach the aneurysm sac, a pseudoaneurysm was excluded by coil embolization of the feeding vessel. The neck of the pseudoaneurysm was embolized when the pseudoaneurysm sac was too large to embolize fully. Patients were observed for 72 hours postoperatively to assess complications and treatment effects. The evaluation of PAP embolization included technical success and clinical success [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Technical success was defined as a pseudoaneurysm no longer visible after embolization, while clinical success was defined as cessation of hemoptysis or a significant reduction after the procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eAll the statistical analyses were conducted using SPSS (version 24.0, IBM Corp). The data were expressed as either median and the first and third quartiles (Q1-Q3), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), or absolute number and percentage of patients. For normally distributed data, the t-test was used to compare differences between the two groups. If the data were non-normally distributed, the Mann-Whitney U test was performed. Chi-square (χ2) tests or Fisher exact tests were used to compare proportions between the two groups. Statistical significance was defined as \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eFrom January 2019 to December 2022, a total of 2782 inpatients presented with hemoptysis. PAP was detected in 50 cases by pulmonary artery CTA or DSA arteriography. The flowchart for selecting the study population is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The baseline characteristics of these patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age was 62.1\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4 years, with 36 (72%) of them being male. The proportion of patients with massive hemoptysis was 14 (28%), and three of them received preoperative endotracheal intubation due to asphyxia. The cause of PAP is listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Notably, the most common causes were infection and pulmonary malignancy. Infection was presented in 43 cases (86%), including obsolete and active tuberculosis (40% and 12%, respectively), bronchiectasis (12%), and focal pneumonia (8%). Fungal infection was observed in 5 patients (10%) and 3 of them were identified as Aspergillus infection through sputum culture (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Four cases (8%) were caused by malignant tumors, including primary lung cancer and liver cancer with lung metastasis.\u003c/p\u003e\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of pulmonary artery pseudoaneurysm in 50 patients with hemoptysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase Number\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.1\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSigns and symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart rate (bpm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.6\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic blood pressure (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122.9\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiastolic blood pressure, (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory rate, (times/min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyspnea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest tightness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisorders of consciousness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHemoptysis, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumoconiosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior thoracic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCauses of pulmonary artery pseudoaneurysms in patients with hemoptysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderlying disease\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase Number\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInfection, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTuberculosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBronchiectasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFungal pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFocal pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMalignant tumor, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung adenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung squamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary metastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePercutaneous lung biopsy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCongenital heart disease, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePulmonary fibrosis, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImaging features\u003c/h2\u003e \u003cp\u003eA total of 58 PAPs were identified in all the patients with hemoptosis. The imaging features are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The PAPs were located primarily in the upper lobes of the lungs, with 24 (41.4%) in the left upper lobe, and 18 (31.0%) in the right upper lobe. They had a strong predilection for the peripheral pulmonary arteries and 57 (99.3%) were located in the segmental or subsegmental pulmonary arteries. The median diameter of PAP was 6.1(4.3\u0026ndash;8.7) mm, and the maximum diameter was 15.2 mm. A total of 29 PAPs were identified adjacent to pulmonary cavitations (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The median diameter of the cavity was 18.9 (12.4\u0026ndash;34.8) mm, with the maximum diameter being 77.4 mm. Four cases (8%) coexisted with bronchial artery aneurysms. pseudoaneurysm in 21 cases (42%) were considered as ruptured, of which most presented massive hemoptysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImaging features and treatment of 58 pulmonary artery pseudoaneurysms in patients with hemoptysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImaging features and treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide, n(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLobar distribution, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft upper lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (41.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft lower lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (8.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight upper lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (31.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight middle lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight lower lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (13.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel of distribution, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLobar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSegmental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubsegmental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (79.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClassification, n\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA/B/C/D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/31/25/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaximum diameter of PAP (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.1 (4.3\u0026ndash;8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRuptured pseudoaneurysms, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCavitary lesion, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaximum diameter of cavitary lesion (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.9 (12.4\u0026ndash;34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe site of embolization\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAneurysmal sac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (61.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAneurysmal neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeeding vessel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (47.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmbolization materials, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (95.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCovered stent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClinical characteristics of ruptured pulmonary artery pseudoaneurysm\u003c/h2\u003e \u003cp\u003eTo identify the risk factors for rupture of PAP, we compared the clinical features between ruptured and unruptured patients. The clinical characteristics and hemodynamic features of the two groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. No significant differences were observed between the two groups across gender, age, etiology, and distribution. Compared to the non-rupture group, the rupture group had a significantly higher proportion of massive hemoptysis (57.1% vs. 6.9%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), larger pseudoaneurysm diameter (8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 mm vs. 6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 mm, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012), higher incidence of pulmonary cavitation (76.2% vs. 44.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.027), and larger cavitation diameters (32.9\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8 mm vs. 15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4 mm, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005). The mean pulmonary artery pressure (mPAP) in the ruptured group was also significantly higher than that in the unruptured group (23.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 mmHg vs. 19.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0 mmHg, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011). Meanwhile, there was no statistical significance in the other hemodynamic parameters.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of clinical characteristics of patients with ruptured and unruptured pulmonary artery pseudoaneurysms\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRuptured group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eunruptured group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.748\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (85.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (62.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMassive hemoptysis, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnderlying disease, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTuberculosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.536\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBronchiectasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.986\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFungal pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.702\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.849\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation of PAP*, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.291\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (43.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper lobes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (88.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (68,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower lobes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (31.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSegmental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (26.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubsegmental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (87.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaximum diameter of PAP (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCavitary lesion, n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaximum diameter of cavitary lesion (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.9\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHemodynamics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCO (L/min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.570\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCI (L/min/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5 (3.3-4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2 (2.8-4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.232\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emPAP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePAWP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePVR (Wood)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1 (1.3-3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8 (1.4\u0026ndash;2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: CO, cardiac output; CI, cardiac index; mPAP, mean pulmonary artery pressure; PAWP, pulmonary artery wedge pressure; PVR, pulmonary vascular resistance.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* The analyses of location included 26 PAPs in ruptured group and 32 PAPs in unruptured group.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTreatment and outcome\u003c/h2\u003e \u003cp\u003eEndovascular treatment was conducted in all patients with PAP rupture. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Coil embolization was performed in 20 cases (95.2%), including pseudoaneurysm sac embolization in 13 cases (61.9%), pseudoaneurysm neck embolization in 1 case (4.8%), feeding vessel embolization in 10 cases (47.6%). One PAP was excluded with covered stents. No patient underwent surgical resection. The outcome and complication of patients with PAP rupture are listed in Table\u0026nbsp;5. During the operation, one patient experienced stress-induced hypertension, and another one sustained a pulmonary artery injury. One patient suffered massive hemoptysis due to rupture of PAP during pulmonary angiography, and the hemoptysis stopped after immediate embolization. After the operation, fever, chest tightness, and chest pain were complained by patients with interventional treatment. All of the complications resolved spontaneously or following symptomatic treatment. None of the patients had pulmonary infarction. The technical and clinical success rate was 100% and,96.0%, respectively. One patient died of massive hemoptysis during hospitalization.\u003c/p\u003e \n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e Outcome and\u0026nbsp;complications\u0026nbsp;of patients with ruptured\u0026nbsp;pulmonary artery pseudoaneurysm\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"470\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase Number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003eTechnical success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e21 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003eClinical Success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e19 (90.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003eStress-induced hypertension\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003eAneurysm rupture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003ePulmonary artery injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003eChest tightness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.255319148936174%\"\u003e\n \u003cp\u003eChest pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.744680851063826%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\u003c/br\u003e\n\u003cp\u003eOf the patients received intravascular intervention for patients with PAP rupture, 17 patients completed one-year follow-up. One patient died of heart failure. Meanwhile, five patients had recurrences of hemoptysis, of which four occurred within 6 months.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study described the clinical and imaging features of patients with hemoptysis and PAP, and further investigated the risk factors for rupture of PAP. The findings of this study indicated that massive hemoptysis, pseudoaneurysm diameter, cavitary lesions, and elevated mPAP were associated with an increased risk of PAP rupture. To our knowledge, this is the first study identifying risk factors for rupture of pseudoaneurysm. This study could assist clinicians in identifying high-risk patients of PAP rupture, offering insights into treatment strategies that could prevent delays in critical interventions.\u003c/p\u003e \u003cp\u003eThe mechanism of PAP formation is vessel wall destruction and further replaced by granulomatous, neoplastic, or fibrotic tissue, resulting in the weakening of the arterial wall. Under sustained arterial pressure, blood dissects the injured artery and forms a perfused sac. Infection was the most common cause of acquired PAP in our patient population, which is consistent with previous studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Previous studies have reported that PAPs were often accompanied by cavitary lesions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It revealed that PAP may have a predilection for pulmonary cavitation. In our study, PAPs were adjacent to pulmonary cavities in 29 patients (58%). Compared with the unruptured patients, the ruptured ones had a significantly higher proportion of pulmonary cavitation and the size of cavitary lesions was larger. The underlying pathogenesis may be direct invasion of vessels by pathogenic bacteria and persistent damage by pulmonary lesions associated with tissue necrosis or inflammation. Cystic medial necrosis was observed in many perioperative samples of the vascular wall [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Inflammation has been considered as a central driving cause in the development of arterial aneurysm. Studies have demonstrated that Chlamydia pneumoniae is detected in AAA with infiltration of inflammatory cells including macrophages, lymphocytes, and plasma cells in the aortic walls [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In terms of lung infection, patients with tuberculosis, necrotizing pneumonia, and suppurative bacterial and fungal infections were more likely to have PAP [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Of note, these pathogens could cause necrotic lesion and pulmonary cavitation. Therefore, it is reasonable to infer that pulmonary cavities may be associated with the formation and rupture of PAP.\u003c/p\u003e \u003cp\u003eThe degeneration of the pathological structure is not sufficient to produce an abnormal balloon shape. The formation and rupture of this abnormal structure are also influenced by intravascular hemodynamic effects in addition to the weakened arterial wall. In an observational study about a cohort of patients with pulmonary hypertension, the incidence of pulmonary artery aneurysm was about 38%, especially in patients with long disease duration [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In patients with hemoptysis due to PAP rupture, especially those with systemic-pulmonary shunts, pulmonary artery pressure is maintained between 35\u0026ndash;69 mmHg [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Our data indicated that PAP in the ruptured group exhibited larger diameter and higher mPAP in comparison to the unruptured group. Similar to AAA, vessel wall tension escalates with both diameter and transmural pressure. Arterial wall tension is directly proportional to both pressure and the radius of the diseased vessel while inversely correlated with arterial wall thickness according to the Laplace\u0026rsquo;s law. Rupture occurs when stress induced by blood flow exceeds the limit of wall tissue strength. Thus, risk of rupture in the PAP is closely associated with both size and pressure.\u003c/p\u003e \u003cp\u003e There are no guidelines for the indication of treatment and the best therapeutic approach. The main treatment for PAP were surgery and intravascular intervention. Surgical treatments such as lobectomy or aneurysmectomy were associated with high mortality [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Endovascular coil embolization and stent placement are currently preferred due to less invasive and fewer complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The selection of embolization material depends on the location, size, and classification of PAP. Coil embolization may be an effective choice for preserving distal pulmonary artery perfusion and avoiding lung perfusion injury. The stent is generally recommended for fusiform or lobar arterial pseudoaneurysm in the pulmonary. Of the current study, most of the patients received coil embolization and only one PAP located in the lobar branch was excluded with a covered stent. Due to vulnerability to rupture of PAP, the operator should be alert to sudden rupture during the operation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In our series, one rupture occurred during pulmonary angiography. The possible reason might be a transient increase in pulmonary perfusion and local pressure with contrast agent injection, or direct damage to microcatheters and microwires during the procedure.\u003c/p\u003e \u003cp\u003eWe acknowledge several limitations of our study. First, although our study cohort was relatively large compared to the previous studies, it was still limited by the small number of cases due to the rarity of PAPs. Furthermore, the natural history of PAP has not yet been extensively studied and remains largely unknown. Experts evaluated the cause of PAP based on the history and imaging of patients. Thus, its accuracy and conclusiveness may be limited. Additionally, longer-term follow-up studies are crucial for evaluating the extended prognosis of patients with PAP and hemoptysis.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, we found that PAP patients with rupture had a significantly higher proportion of massive hemoptysis and pulmonary cavitation, larger pseudoaneurysm and cavitation diameter, as well as higher mPAP. Collectively, we have characterized the clinical features of PAPs and explored risk factors of rupture, providing novel insights into the early identification of PAPs with high risk of rupture.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePulmonary artery pseudoaneurysm\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAbdominal aortic aneurysm\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDigital subtraction angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiac output\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiac index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emPAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMean pulmonary artery pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAWP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePulmonary artery wedge pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epulmonary vascular resistance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the patients who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eML, JL conceived the project, collected the data, drafted and revised the manuscript. WY, XG, SC, WQ, ZZ collected patient information, provided the figures and interpreted data. CL, FL, ZZ reviewed and revised the final draft of the manuscript. All the authors have read, discussed and approved the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by National Natural Science Foundation of China (No. 82241029), National High Level Hospital Clinical Research Funding (2022-NHLHCRF-LX-01-0203), China Postdoctoral Science Foundation (2023TQ0383) and Wuhan Medical Research project (WX20D85).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used and analyzed in the study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethics Committee of the Affiliated Hospital of Jianghan University approved this \u0026nbsp;retrospective study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAll participants provided the written informed consents prior to study. All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSpinu C, Castaner E, Gallrado X, et al. Multidetector computed tomography in life-threatening hemoptysis. Radiologia. 2013;55(6):483\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.rx.2013.05.006\u003c/span\u003e\u003cspan address=\"10.1016/j.rx.2013.05.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuillaume B, Vendrell A, Stefanovic X, et al. 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J Vasc Interv Radiol. 2007;18(7):882\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jvir.2007.04.023\u003c/span\u003e\u003cspan address=\"10.1016/j.jvir.2007.04.023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\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":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pulmonary artery pseudoaneurysm, Hemoptysis, Rupture, Pulmonary cavitation","lastPublishedDoi":"10.21203/rs.3.rs-4326756/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4326756/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHemoptysis resulting from rupture of the pulmonary artery pseudoaneurysm (PAP) is massive and fatal, while factor contributing to the rupture of pseudoaneurysm remains elusive. This study aimed to elucidate the clinical and radiological features of PAP and identify the risk factors associated with rupture.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients who developed hemoptysis with PAP were collected from January 2019 to December 2022 retrospectively. Clinical data of the demographic characteristics, radiological findings, treatment strategies, and prognosis were collected. A comparative analysis was performed on the characteristics in the ruptured and non-ruptured cases.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 58 PAPs were identified in the 50 patients. The most common causes were infection (86%) and cancer (8%). The PAPs were located predominantly in the upper lobes of both lungs, and 57 (99.3%) were distributed in the segmental or subsegmental pulmonary arteries. The median diameter was 6.1(4.3\u0026ndash;8.7) mm. A total of 29 PAPs were identified adjacent to pulmonary cavitations, with the median diameter of the cavity being 18.9 (12.4\u0026ndash;34.8) mm. Rupture of pseudoaneurysm occurred in 21 cases (42%). Compared to unruptured group, the ruptured group had a significantly higher proportion of massive hemoptysis (57.1% vs. 6.9%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), larger pseudoaneurysm diameter (8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 mm vs. 6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 mm, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012), higher incidence of pulmonary cavitation (76.2% vs. 44.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.027), and larger cavitation diameters (32.9\u0026thinsp;\u0026plusmn;\u0026thinsp;18.8 mm vs. 15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4 mm, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005). The mean pulmonary artery pressure (mPAP) in the ruptured group was also significantly higher than that in the unruptured group [23.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 mmHg vs. 19.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0 mmHg, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011]. Endovascular treatment was successfully performed in all 21 patients with ruptured PAP, of which the clinical success rate was 96.0%. Five patients experienced recurrent hemoptysis within one year.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMassive hemoptysis, pseudoaneurysm diameter, pulmonary cavitation, and elevated mPAP were the risk factors for rupture of pseudoaneurysm. Our findings facilitate early identification and timely intervention of PAP at high risk of rupture.\u003c/p\u003e","manuscriptTitle":"Clinical and radiological features associated with rupture of pulmonary artery pseudoaneurysm: a retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-09 18:21:18","doi":"10.21203/rs.3.rs-4326756/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-29T11:06:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-17T22:55:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-16T07:42:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4ea87023-4a71-4589-b569-ff523d1265ea","date":"2024-05-04T13:21:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4411afd4-1a56-4925-b76a-21f734a7b10f","date":"2024-05-02T13:37:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-02T13:13:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-02T13:02:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-02T09:30:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-02T09:22:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2024-04-26T02:33:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"322f260d-6c1a-43c1-8c5b-2b9812257523","owner":[],"postedDate":"May 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-02T16:05:10+00:00","versionOfRecord":{"articleIdentity":"rs-4326756","link":"https://doi.org/10.1186/s12890-024-03225-0","journal":{"identity":"bmc-pulmonary-medicine","isVorOnly":false,"title":"BMC Pulmonary Medicine"},"publishedOn":"2024-08-28 15:58:08","publishedOnDateReadable":"August 28th, 2024"},"versionCreatedAt":"2024-05-09 18:21:18","video":"","vorDoi":"10.1186/s12890-024-03225-0","vorDoiUrl":"https://doi.org/10.1186/s12890-024-03225-0","workflowStages":[]},"version":"v1","identity":"rs-4326756","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4326756","identity":"rs-4326756","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}