Balloon-occluded pulmonary arteriography and n-butyl cyanoacrylate embolization of angiographically occult pulmonary artery pseudoaneurysms

Angiographically occult pulmonary artery pseudoaneurysms — suspected on computed tomography but not shown at selective pulmonary angiography — have been presumed to have an occluded parent artery, and systemic-feeder embolization alone is often not curative. Three consecutive men with infection-related pseudoaneurysms presenting with massive hemoptysis were treated. In each, selective pulmonary angiography without occlusion showed proximal washout of injected contrast, consistent with reversed flow in the parent branch. The branch was occluded immediately proximal to the sac with a 4.0-mm microballoon — or, initially in one patient, a fortuitously wedged 5-F catheter — and hand injection under occlusion opacified the previously occult sac, which was then embolized with 25% n-butyl cyanoacrylate through a microballoon, without same-session systemic-artery embolization. All three achieved technical and clinical success, without recurrent hemoptysis over 17–22 months. Occultness does not equate to an occluded parent artery.