喀血で発症した胸部大動脈瘤破裂に対する胸部ステントグラフト内挿術後遅発性に再喀血をきたした1例

Repeated Hemoptysis after Thoracic Endovascular Aortic Repair for Ruptured Thoracic Aortic Aneurysm with Hemoptysis；Report of a Case

はじめに　胸部大動脈瘤に対し胸部ステントグラフト内挿術（TEVAR）が広く行われるようになり，待機的胸部大動脈瘤の標準治療として確立している1）．破裂症例に対してもTEVARが施行され，良好な結果が報告されている2）．一方で，エンドリーク残存による再破裂の症例も報告されている3）．われわれは，胸部大動脈瘤破裂肺内穿破による喀血に対しTEVARを施行後，遅発性に再度の喀血を認め，左肺上葉切除を施行した症例を経験したので報告する．

In recent years, re-rupture due to endoleaks after thoracic endovascular aortic repair （TEVAR） for ruptured thoracic aortic aneurysms has become a problem. Hemoptysis has been reported in patients after pneumocentesis. We report a patient who developed delayed hemoptysis not related to endoleak after TEVAR. An 80-year-old male underwent emergent TEVAR due to a ruptured thoracic aortic aneurysm accompanying sudden hemoptysis. Eleven days after the operation, recurrent hemoptysis was noted, but contrast-enhanced computed tomography （CT） revealed no endoleak or re-rupture. Bronchoscopy demonstrated hemorrhage from the left upper lobe. As hemostasis was difficult by conservative treatment, left upper lobectomy was performed. The aortic rupture hole exhibited thrombus, and there was no hemorrhage. On histopathological examination of the resected lung, formation accompanied by severe intra-alveolar fibrosis and cholesterin clefts, and marked foreign body reactions in the interstitium and small blood vessels of the lung were observed. Cholesterol embolism is associated with not only organ ischemia due to microembolism, but also immunological mechanisms. Thus, cholesterol embolism due to aorta-derived cholesterin may have led to the delayed pulmonary hemorrhage. Differentiation from re-rupture due to endoleaks is important.