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Ann Thorac Surg 1996;61:1241-1242
© 1996 The Society of Thoracic Surgeons

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Case Report

Massive Endobronchial Hemorrhage After Pulmonary Embolectomy

Second Department of Surgery, Kagoshima University Faculty of Medicine and Shinkyo Hospital, Kagoshima, Japan

Accepted for publication September 21, 1995.

	Abstract

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Massive endobronchial hemorrhage is a lethal complication in pulmonary embolectomy. We report a case of massive endobronchial hemorrhage occurring after successful restoration of pulmonary blood flow using cardiopulmonary bypass in a patient with pulmonary embolism. Two possible causative factors of this complication are described.

	Introduction

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Pulmonary embolectomy for massive embolism is a life-saving procedure. In 1961, Cooley and colleagues [1] first reported successful pulmonary embolectomy using cardiopulmonary bypass. They introduced a suction tip into the pulmonary artery, then compressed the lungs repeatedly to remove the peripherally lodged emboli. We employed this procedure and experienced massive endobronchial hemorrhage during the operation in a patient with pulmonary embolism. This article deals with the complication and its possible causative factors.

A 40-year-old man was first admitted to Shinkyo Hospital with pulmonary embolism. Pulmonary scintigram and arteriogram disclosed absent perfusion of the bilateral upper lobes. The pulmonary arterial pressure was 95/7 mm Hg. He was referred to our hospital under anticoagulation on the 13th day after admission. The pulmonary arterial pressure at admission was 40/15 mm Hg. Pulmonary scintigram revealed improvement in the blood flow distribution. No deep vein thrombus was found in either leg. After the examination, he left our hospital because of an inadequate operative indication. He received anticoagulation in the outpatient clinic.

Six months later, he began to have hemosputum, dyspnea, and general lassitude. At that time he was still under anticoagulation. He fell into shock suddenly and was brought into our hospital by ambulance after a bolus injection of urokinase. The diagnosis of recurrent massive pulmonary embolism was readily made through a few basic examinations together with typical signs and symptoms. He was taken immediately to the operating room for surgical treatment. Under total cardiopulmonary bypass, the pulmonary trunk and the right main pulmonary artery behind the ascending aorta were incised. Extensive clots were removed using forceps, balloon embolectomy catheter, and bolus saline flush with suction. Then plugged and lodged thrombi in the peripheral pulmonary arteries were repeatedly squeezed by manual compression of the lungs. For this purpose both mediastinal pleurae were opened longitudinally. During partial cardiopulmonary bypass after closure of the pulmonary arteries, we encountered blood gush from an endotracheal tube. Approximately 1,500 mL of blood was aspirated for 30 minutes. A flexible fiberoptic bronchoscopy clarified just the bleeding side, but could not show the actual bleeding point. Left thoracotomy through the fourth intercostal space was carried out. Several scarred lesions of pulmonary infarction were found on the surface of the apex of the lung. The lesions were resected by stapling technique with successful hemostasis. The cardiopulmonary bypass was discontinued without difficulty. He was ventilated for 6 days postoperatively. He left our hospital with slight exertional dyspnea.

Histologic examination of the resected lung disclosed parenchymal infarction. In the remaining parenchyma there was severe hemorrhage but no edema around the pulmonary artery within the thrombus. The arterial wall revealed necrotized change. The site of arterial perforation was not found.

	Comment

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There are several reports on massive endobronchial hemorrhage after pulmonary embolectomy [2–4]. Two etiologic factors can be considered in the occurrence of this complication. One is pulmonary arterial wall injury by a mechanical factor, that is, the introduction of a balloon embolectomy catheter and suction tip, balloon inflation, and excessively negative pressure in suction. Forced insertion of the embolectomy catheter to the peripheral pulmonary artery and balloon overinflation are frequently the causes of pulmonary artery injury. The injury may result in massive pulmonary parenchymal bleeding and subsequent bleeding into the major airway. Control of hemorrhage under heparinization for cardiopulmonary bypass is usually difficult [5]. In patients with pulmonary hypertension, especially with a chronic course, arterial wall fragility must always be considered [6]. Airway hemorrhage is usually recognized at the time of cardiopulmonary bypass discontinuation [5]. The site of artery injury is difficult to identify [7].

Reperfusion injury is another cause of endobronchial hemorrhage [2–4]. After embolectomy and after the reestablishment of pulmonary blood flow, massive parenchymal and intrabronchial hemorrhage may occur during or after cardiopulmonary bypass [8]. Restoration of flow to severely damaged pulmonary capillaries may cause their immediate rupture and result in massive hemorrhage, whereas plasma proteins may leak through less severely damaged capillaries and cause pulmonary edema at normal left-sided pressures before fatal hemorrhage ensues [9]. This hemorrhage begins as a blood-stained edema fluid, which becomes thicker and more like blood [3]. Pathologic examination of the lung shows severe intraalveolar hemorrhage with infarction of the parenchyma [3].

The procedure for pulmonary embolectomy by Cooley and colleagues [1] has been widely accepted since their successful report. Kieny and associates [10], however, never use surgical instruments but only a large aspirator gently introduced into the individual arterial branches. They also never compress the lungs. Robison and co-workers [11] avoid the use of embolectomy catheters for fear of injuring the pulmonary artery. Even in the cases of endobronchial reperfusion hemorrhage that were reported by Castleman [2] and Couves and colleagues [4], the possibility of pulmonary artery injury by a balloon catheter and compression of the lung is not completely undeniable. In our case the use of a balloon embolectomy catheter, compression of the lung, and possible reperfusion injury were the causes of massive endobronchial bleeding judging from the local hemorrhage. Fortunately we could save the patient, but the complication is sometimes lethal. The occurrence of the complication must be kept in mind when performing pulmonary embolectomy. Pulmonary artery injury and reperfusion injury are important causes to be considered for this complication.

	Footnotes

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Address reprint requests to Dr Shimokawa, Second Department of Surgery, Kagoshima University Faculty of Medicine, 8-35-1 Sakuragaoka, Kagoshima 890, Japan.

	References

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1. Cooley DA, Beall AC Jr, Alexander JK. Acute massive pulmonary embolism. Successful surgical treatment using temporary cardiopulmonary bypass. JAMA 1961;177:283–6.[Abstract/Free Full Text]
2. Castleman B, ed. Case records of the Massachusetts General Hospital. N Engl J Med 1964;271:40–50.[Medline]
3. Makey AR, Bliss BP, Ikram H, Sulcliffe MML, Emery ERJ. Fatal intra-alveolar pulmonary bleeding complicating pulmonary embolectomy. Thorax 1971;26:466–71.[Abstract/Free Full Text]
4. Couves CM, Nakai SS, Sterns LP, Callaghan JC, Sproule BJ. Hemorrhagic lung syndrome. Hemorrhagic lung infarction following pulmonary embolectomy. Ann Thorac Surg 1973;15:187–95.[Abstract/Free Full Text]
5. Urschel JD, Myerowitz PD. Catheter-induced pulmonary artery rupture in the setting of cardiopulmonary bypass. Ann Thorac Surg 1993;56:585–9.[Abstract/Free Full Text]
6. Barash PG, Nardi D, Hammond G, et al. Catheter-induced pulmonary artery perforation. Mechanisms, management, and modifications. J Thorac Cardiovasc Surg 1981;82:5–12.[Abstract]
7. Fraser RS. Catheter-induced pulmonary artery perforation: pathologic and pathogenic features. Hum Pathol 1987;18:1246–51.[Medline]
8. Sabiston DC Jr. Pulmonary embolism. In: Sabiston DC Jr, ed. Textbook of surgery. Philadelphia: Saunders, 1991:1502–19.
9. Brown S, Mulder O, Buckberg G. Massive pulmonary hemorrhage infarction. Following revascularization of ischemic lungs. Arch Surg 1974;108:795–7.[Abstract/Free Full Text]
10. Kieny R, Charpentier A, Kieny T. What is the place of pulmonary embolectomy today? J Cardiovasc Surg 1991;32:549–54.[Medline]
11. Robison RJ, Fehrenbacher J, Brown JW, Madura JA, King H. Emergent pulmonary embolectomy: the treatment for massive pulmonary embolus. Ann Thorac Surg 1986;42:52–4.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hitoshi Toyohira Akira Taira Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shimokawa, S. Articles by Miyahara, K. Search for Related Content PubMed PubMed Citation Articles by Shimokawa, S. Articles by Miyahara, K.