Ann Thorac Surg 1998;65:548
© 1998 The Society of Thoracic Surgeons
Case Reports
Pulmonary Vein Injury Through Repetitive Clip Friction: An Unusual Cause of Hemothorax
Horia Sîrbu, MD,
Bernhard Herse, MD,
Thomas Busch, MD,
Harald Dalichau, MD
Department of Thoracic and Cardiovascular Surgery, Georg-August University, Göttingen, Germany
Accepted for publication September 22, 1997.
Dr Sîrbu, Department of Thoracic and Cardiovascular Surgery, Georg-August University Göttingen, Robert Koch Straße 40, D-37075 Göttingen, Germany.
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Abstract
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Massive hemothorax developed in a 58-year-old man 12 hours after a left pneumonectomy. The source of bleeding was a tear in the pulmonary vein stump caused by a titanium clip that had been used during mediastinal lymphadenectomy. Postoperatively, the clip progressively sawed through the vascular wall of the pulmonary vein due to friction during the cardiac cycle.
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Introduction
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Major postoperative complications after lung resections necessitating emergency rethoracotomy are rare. The incidence of massive bleeding requiring reoperation reported in the literature ranges from 0.1% to 4.3% [1] [2]. We present a patient in whom a dramatic hemothorax progressively developed 12 hours after an initially uneventful postoperative course. This case of major postoperative bleeding was produced by a very unusual mechanism.
A 58-year-old male smoker presented at our thoracic surgery department with a lung carcinoma located in the left lower lobe. Preoperative bronchoscopy showed intrabronchial extension of the tumor to the distal part of the left primary bronchus. Histopathologic examination revealed squamous cell carcinoma (clinical T2 N0 M0). The operation was performed through a left lateral thoracotomy (fifth intercostal space). Intraoperatively, the tumor was limited to the left lower lobe but the hilar lymph nodes showed macroscopic and histologic signs of malignancy (surgical T2 N1 M0). With regard to the bronchoscopic findings, left pneumonectomy with radical systematic lymphadenectomy was performed. We completely removed the intrapulmonary and the following extrapulmonary lymph node stations according to the American Thoracic Society map: the hilar and peribronchial, paratracheal, subaortic, aortopulmonary window, subcarinal, paraaortic, and the pulmonary ligament nodes. As an anatomic individuality, the patient presented at hilar dissection only one left common pulmonary vein. All pulmonary vessels were ligated with 2-0 nonabsorbable sutures (Ethibond; Ethicon, Norderstedt, Germany) and then transected. The vascular stumps were additionally secured with 4-0 monofilament polypropylene sutures (Prolene; Ethicon). Bronchial division was made with a TA-Premium 30-4.8 stapler (Auto-Suture, Norwalk, CT). Lymphadenectomy was performed using medium ligating and marking titanium clips (Horizon Surgical, Evergreen). The lymphatic pedicles were dissected, ligated, and than transected. After thorough hemostasis and final inspection, the chest was closed.
Postoperatively, the patient was transferred to the intensive care unit and was extubated soon thereafter. The postoperative course was initially uneventful. The patient was hemodynamically stable, with no significant blood loss over the chest tube drainage. Twelve hours postoperatively insidious onset of bleeding was noted. Progressively more fresh blood came through the tube drainage. The clinical status worsened dramatically. The patient was reintubated and received assisted ventilation. Catecholamines were given in high doses (epinephrine, 40 µg/min), and massive blood transfusion was required. The chest roentgenogram showed a massive overshadowing of the left hemithorax with mediastinal shifting to the right (Fig 1). Eventually, signs of massive hypovolemic shock due to loss of more than 1,500 mL of fresh blood over a short period of time (15 minutes) and respiratory insufficiency were noted.
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Chest roentgenogram 14 hours after left pneumonectomy. Note the massive hemothorax with mediastinal shifting to the right.
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Major bleeding from a hilar vessel was suspected and emergency left rethoracotomy was performed. After blood and clot removal, the hilar region was inspected. All vascular stumps were found to be properly secured. No vascular ligature or hemostatic clip had slipped down. The left pulmonary vein stump, however, presented a 2.0-cm longitudinal tear proximal to the stump ligature, which was at the origin of the massive blood loss (Fig 2). From the tear side we removed a medium titanium clip that had been used during lymphadenectomy. Postoperatively, through friction during the cardiac cycle, the clip progressively penetrated the vascular wall of the pulmonary vein through a "saw-and-cut" mechanism.
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Artist’s drawing of the pathology as seen at rethoracotomy. The titanium clip had eroded a tear into the left pulmonary vein stump. All vascular stumps were properly ligated. (1 = pulmonary vein; 2 = pulmonary artery; 3 = left main bronchus.)
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Hemostasis was performed using two Teflon-pledgeted 4-0 polypropylene sutures (Prolene). The recovery after rethoracotomy was uneventful, and the patient was discharged in oncologic aftercare on the eighth postoperative day.
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Comment
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Postoperative bleeding after lung resections that requires rethoracotomy most frequently originates from the site where the thoracotomy was performed (diffuse bleeding from intercostal muscles or capillary hemorrhage from a lacerated pleura), or from a intercostal, internal mammary, or bronchial artery. The once-feared major hemorrhages from the stumps of the pulmonary artery or vein due to improper hilar vessel securing or ligature slip-down have become a rarity since modern hemostatic materials and vascular surgical techniques (ligature of the central vascular stumps before transection and securing of the vascular endings by polypropylene sutures) have been developed.
In a retrospective study of 961 patients who underwent operations for lung carcinoma, Nagasaki and associates [1] found the incidence of massive surgical bleeding to be 0.1%. Other studies demonstrate an even higher incidence of 1.0% up to 4.3% [2] [3].
Securing the hilar vascular stumps with monofilar polypropylene (Prolene) is today a routine procedure for almost every thoracic surgeon. Hemostatic ligature with clips of the hilar and mediastinal lymphatic node pedicle has also become standard practice. A source of massive postoperative hemothorax requiring reoperation is the slipping of a mediastinal or hilar titanium clip with bleeding from the retracted lymphatic node pedicle.
With the introduction of modern hemostatic techniques in the practice of surgery, we are noticing new postoperative complications. Complications related to the application of clips generally focus on their ability to slip and migrate [4] or on injury of structures near the transection plane [5]. These complications occur most frequently during video-assisted procedures when clips are improperly placed.
Here we report massive bleeding from a hilar vessel caused by a clip that had been placed close to a great vessel and that injured the pulmonary vein stump by a "saw-and-cut" mechanism. Although hypothetic, the most likely pathogenesis of this life-threatening hemothorax is a friction-induced repetitive abrasion of the pulmonary vein stump. An injury of the pulmonary vein during primary operation would have been recognized intraoperatively and would not have appeared after a 12-hour delay. During the tissue excursions triggered by the cardiac cycle, the hilar clip placed close to the pulmonary vein stump progressively abraded the vascular wall. This explains the gradual onset of thoracic bleeding after an initial complication-free interval. In this time the stump tear reached 2 cm and was associated with a massive hemorrhagic shock.
Independent of the precise mechanism involved, this case should raise the awareness of postoperative hemothorax as a potential complication due to unforeseen side effects of modern hemostatic devices.
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References
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- Nagasaki F, Flehinger BJ, Martini N Complications of surgery in the treatment of carcinoma of the lung. Chest 1982;82:25-29.[Abstract/Free Full Text]
- Marcchiarini P, Chapelier AR, Monnet I, et al. Extended operations after induction therapy for stage IIIb (T4) non–small cell lung cancer. Ann Thorac Surg 1994;57:966-973.[Abstract]
- Busch E, Verazin G, Antkowiak JG, Driscoll D, Takita H Pulmonary complications in patients undergoing thoracotomy for lung carcinoma. Chest 1994;105:760-766.[Abstract/Free Full Text]
- Arnaud JP, Bergamaschi R Migration and slipping of metal clips after celioscopic cholecystectomy. Surg Laparosc Endosc 1993;3:487-488.[Medline]
- Laborde F, Folliguet T, Batisse A, Dibie A, da-Cruz E, Carbognani D Video-assisted thoracoscopic surgical interruption: the technique of choice for patent ductus arteriosus. Routine experience in 230 pediatric cases. J Thorac Cardiovasc Surg 1995;110:1681-1684.[Abstract/Free Full Text]
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Abstract
Introduction
