Ann Thorac Surg 2000;70:656-658
© 2000 The Society of Thoracic Surgeons
Case report
Repair of pulmonary vein rupture after deceleration injury
David Varghese, MBChBa,
Hitesh Patel, FRCSa,
Ewan W.J. Cameron, FRCSa,
Mike Robson, FRCAa
a Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
Address reprint requests to Dr Patel, Department of Surgery, Chelsea and Westminster Hospital, Imperial College School of Medicine, 369 Fulham Rd, London SW10 9NH, England
e-mail: hitesh.patel{at}ic.ac.uk
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Abstract
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Injuries to the major pulmonary vessels are uncommon and are extremely difficult to manage. We report a case of an isolated pulmonary vein injury following a road traffic accident that was repaired successfully.
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Introduction
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Injuries to the major pulmonary vessels resulting from blunt chest trauma are uncommon and when encountered pose difficulties in management. An isolated injury to the pulmonary vein as a cause of a massive hemothorax is extremely rare. We present the case of a 43-year-old man who was admitted to a peripheral hospital after suffering blunt chest trauma. Subsequent thoracotomy revealed a torn left inferior pulmonary vein which was successfully repaired.
A 43-year-old male motorcyclist traveling at 40 miles per hour hit a stationary motor car. On admission to the Emergency Department, Queen Margaret Hospital, he was fully conscious and alert with a Glasgow Coma Scale of 15. He was complaining of chest pain and shortness of breath. He had a respiratory rate of 20 breaths per minute with an oxygen saturation of 85%, a regular pulse of 100 beats per minute, and blood pressure of 90/70 mm Hg.
On examination there was tenderness in the right upper quadrant of his abdomen with guarding, and decreased breath sounds along with surgical emphysema on the right side. There were no obvious external wounds or bony deformity and examination revealed no chest wall or pelvic tenderness.
He was resuscitated with intravenous colloids and was given oxygen through a nonrebreather facemask. His blood pressure rose to 111/76 mm Hg and his pulse rate decreased to 80 beats per minute. A chest roentgenogram showed a large right hemopneumothorax with mediastinal shift to the left and surgical emphysema. A right chest tube was inserted and drained 400 mL of blood. The patient subsequently had a computed tomography scan of the chest and abdomen. During the scan his blood pressure dropped to 70/40 mm Hg. He responded well to volume replacement with blood and colloid. The computed tomography scan (Fig 1) showed a persisting large right hemopneumothorax despite the presence of the chest tube. There was no significant mediastinal hematoma. The left lung contained a 3-cm pneumatocele in the lower lobe indicating a left pulmonary contusion. No fractured ribs were seen. Also, an irregular low attenuation area was seen within the superior liver in segment four, suggestive of hepatic laceration. The spleen and kidneys appeared normal. A second chest tube was placed more inferiorly in the right pleural cavity and the patient was transferred to the Royal Infirmary, Edinburgh.
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Fig 1. Computed tomography scan of thorax showing a large right hemopneumothorax with mediastinal shift, with extensive mediastinal and subcutaneous air.
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After transfer and admission it was evident that the release of blood through the chest drains was intermittent because of blockage by the thrombus. When there was an episode of rapid blood release the patient’s hemodynamics deteriorated with hypotension and tachycardia. Recovery occurred with ongoing volume replacement and clamping of the chest drains. This observation, along with the desaturation of the drained blood, led to the clinical diagnosis of pulmonary hilar vessel rupture, probably vein. The patient was taken to surgery with the chest drains clamped.
A right thoracotomy was performed. The chest was rapidly opened and the lung hilum compressed manually while the hemothorax was emptied of blood and blood clots. On release of the hilar compression it was evident that the inferior pulmonary vein was torn inferiorly at the level of the pericardium. Cross clamps were applied to control a 1-cm tear that was then repaired with continuous sutures. There was also some pulmonary parenchymal bleeding in the medial segment of the lower lobe that was closed with Teflon felt-supported sutures. The vascular clamps were released and a period of observation ensured that there was no infarction of the lower lobe. A peripheral laparotomy allowed confirmation that the liver injury was stable.
The patient made a steady postoperative recovery and was fit enough to be sent for rehabilitation 10 days after operation.
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Comment
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Blunt chest trauma occurs in up to 50% of all fatal motor accidents and is the primary cause of death in 12% to 25% [1] of such accidents. Pulmonary vein laceration as a cause of massive hemothorax is extremely rare. The clinical presentation is that of hypotension, hypovolemia, and massive hemothorax [2]. In such an injury, as in this case, the hemodynamic behavior of the patient reflects the fact that the left atrium and pulmonary venous circulation is a low-pressure, low-impedance system. It is theorized that following rupture of the pulmonary vein and subsequent development of a low-pressure hemothorax, the pleural cavity becomes part of this low-pressure system and effectively functions as a giant left atrium. Hence, retention of blood in the pleural cavity allows maintenance of hemodynamics (as during chest drain clamping), whereas release of blood from the hemothorax merely causes rapid volume depletion. Clearly blood loss into a pleural cavity from a high-pressure system such as a systemic artery has malevolent compression effects not present in an injury such as pulmonary vein rupture. The formation of thrombus within the right hemothorax occluded the first chest tube, which is why only 400 mL of blood were drained initially and subsequent drainage was for the same reason intermittent and not persistent and torrential, as might have been expected if the drains were at all times patent. This occurrence was fortunate for the patient because unblocked drains would simply have acted as a conduit allowing him to exsanguinate.
Many factors are involved in the decision to proceed to thoracotomy. We suggest earlier intervention in cases of cardiovascular instability after intercostal drainage and that the rate of blood loss via the chest tube [3] as the basis for urgent thoracotomy can be inaccurate because of the formation of clots.
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References
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Hawkins M.L., Carraway R.P., Ross S.E., Johnson R.C., Tyndal E.C., Laws H.L. Pulmonary artery disruption from blunt thoracic trauma. Am Surg 1988;54:148-152.[Medline]
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McKeown P.P., Rosemurgy A., Conant P. Blunt traumatic rupture of pulmonary vein, left atrium and bronchus. Ann Thorac Surg 1991;52:1171-1172.[Abstract]
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Miura H., Taira O., Hiraguri S., et al. Blunt thoracic injury. Jpn J Thorac Cardiovasc Surg 1998;46:556-560.[Medline]
Accepted for publication October 20, 1999.
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Invited commentary
- James W. Pate
Ann. Thorac. Surg. 2000 70: 658.
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Abstract
Introduction
