CTICasesRadiation-Induced Pulmonary Artery-to-Bronchial Fistula and Pseudoaneurysm
Imaging findings
Serial CT scans after lobectomy and high-dose (50 Gy) stereotactic body radiotherapy (SBRT) for a subcarinal lymph node metastasis show progressive tissue necrosis at the subcarinal region, leading to the expectoration of a previously placed metallic fiducial marker. Follow-up CT angiogram during an episode of hemoptysis demonstrates a large pseudoaneurysm of the right pulmonary artery directly communicating with a large, necrotic cavity in the main airway (bronchial tree).
Key takeaways
High-dose radiation therapy to central or subcarinal mediastinal lesions carries a rare but catastrophic risk of airway and vascular necrosis. This can lead to the formation of a pulmonary artery-to-bronchial fistula and a pulmonary artery pseudoaneurysm. Clinicians should monitor for signposts of severe necrosis, such as a "ragged" airway appearance or expectorated fiducial markers, as these patients are at extreme risk for sudden, fatal massive hemoptysis.
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