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Ann Thorac Surg 2001;72:2056-2059
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Management of catheter-induced pulmonary artery perforation: a rare complication in cardiovascular operations

^a Department of Cardiovascular and Thoracic Surgery, Newark Beth Israel Medical Center, Newark, New Jersey, USA

Accepted for publication August 17, 2001.

* Address reprint requests to Dr Gielchinsky, 343 Forest Rd, South Orange, NJ 07079, USA
e-mail: gielchinsky{at}worldnet.att.net

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Pulmonary artery perforation is a rare but often fatal complication of the pulmonary artery catheter occurring in cardiovascular operations and at catheterization facilities. We used our experience and a review of the literature to formulate diagnostic and management strategies.

Methods. During a 13-year period, 12 patients with pulmonary artery perforations were treated in a center that performed an average of 860 open-heart procedures per year. Clinical presentation varied from minor hemoptysis to major airway hemorrhage, hypoxia, exsanguination, and cardiac arrest. Airway bleeding occurred shortly after weaning from cardiopulmonary bypass in 5 patients or postoperatively after wedging the catheter in 6. One patient developed a hemothorax and had a cardiac arrest. Treatment included assurance of gas exchange, endobronchial lavage, isolation of the bleeding bronchus and control of hemorrhage by conservative therapy, pulmonary resection, pulmonary artery repair, and arterial embolization.

Results. Five of the 12 patients died (42%). Recurrent hemorrhage occurred in 40% of patients (2 of 5) treated conservatively compared with none of the patients (0 of 7) having surgical treatment. Forty three percent of patients (3 of 7) treated surgically died; 20% of patients (1 of 5) treated conservatively died. One patient succumbed without treatment.

Conclusions. Pulmonary artery perforation is a rare and often fatal complication of pulmonary artery catheterization. This was apparent with patients who had airway hemorrhages as a result of weaning from cardiopulmonary bypass or after balloon inflation. Recurrent and fatal hemorrhage was frequent in patients treated by conservative therapy alone. Surgical intervention was effective in control of hemorrhage but did not reduce the number of deaths. Treatment remains highly individualized. It is advisable to be cautious in inserting Swan-Ganz catheters and to avoid their use unless absolutely necessary.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Among several iatrogenic complications related to insertion and maintenance of Swan-Ganz catheters, pulmonary artery perforation (PAP) is an infrequent but lethal complication occurring with an estimated frequency of 0.06% to 0.2% [1, 2]. Despite early diagnosis and treatment, the mortality of pulmonary artery (PA) rupture in patients undergoing cardiovascular operations is high, 45% to 65% [1, 3–5]. Risk factors for catheter-induced PAP include advanced age (age > 60 years), female gender, catheter stiffness, prolonged balloon inflation, multiple manipulations of the catheter, peripheral placement of the catheter, pulmonary hypertension, and anticoagulation [3, 6–7].

We report the summary of our experience with catheter-induced PAP in adult cardiac operations, and discuss the therapeutic options based on our experience and a review of the literature.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
During the 13-year period at Newark Beth Israel Medical Center from 1985 to 1998, an average of 850 pulmonary artery Swan-Ganz catheter insertions were done for hemodynamic monitoring in adult cardiovascular operations performed under cardiopulmonary bypass (CPB). The retrospective review identified 12 cases of catheter-induced PAP, an estimated incidence of 0.1%.

The patients ranged in age from 49 years to 82 years (mean age, 70.1 ± 5.7) with a female to male ratio of 2 to 1. The catheters were introduced in all patients after induction of anesthesia using standard guidelines and technique. The balloon of the catheter was kept deflated after positioning its tip in the pulmonary artery. Eight of the patients had isolated coronary artery bypass graft operations, 3 had combined valve replacement and coronary artery bypass grafting, and 1 had repair of an arch and descending aortic aneurysm.

Pulmonary artery perforation was recognized intraoperatively in 5 patients by the appearance of brisk endobronchial hemorrhage during weaning from CPB or shortly after CPB was discontinued. Pulmonary artery perforation was suspected in 3 patients postoperatively by the appearance of brisk endobronchial hemorrhage after balloon inflation, and in another 3 it was suspected after an episode of slight hemoptysis. In 1 patient it was recognized postoperatively during emergency chest exploration for a cardiac arrest, but without evidence of airway hemorrhage. In all 8 patients who developed brisk endobronchial hemorrhage (estimated to be 300 to 400 mL), the peak inspiratory airway pressures were increased (mean, 63.6 ± 7.8; range, 50 to 70 cm of water), associated with a fall in systolic arterial blood pressure (mean systolic, 78.6 ± 7.4; range, 70 to 90 mm Hg) and a slight fall in central venous pressure (8 to 10 mm Hg). Arterial desaturation also occurred, with a mean SAO₂ of 84 ± 4.1 (range, 80% to 90%) and hypoxia with a mean PO₂ of 67 ± 5.7 (range, 60 to 75 mm. Hg) on 100% FiO₂.

The PA catheter was withdrawn into the proximal PA in all patients. In patients with major airway hemorrhage the gas exchange was assured by endotracheal intubation and mechanical ventilation with added positive end-expiratory pressure. Fiber-optic bronchoscopy was instituted for endobronchial suctioning and the bleeding bronchus was isolated by a bronchial blocker (6 or 7 French Fogarty balloon inflated with saline) in 6 patients or by a double lumen endotracheal tube in 2. Further management of 12 patients with suspected PAP is described below.

If airway hemorrhage had occurred on weaning from cardiopulmonary bypass, the CPB was reinstituted to evaluate the nature of injury. The pulmonary artery and its branches and both lung parenchyma were examined. Injury to lobar branches of PA was suspected in 5 patients when lobar parenchymal hemorrhage and hematomas were found. In 1 patient there was an associated injury to the left branch pulmonary artery near the hilum. Extensive lobar parenchymal hemorrhage and hemothorax or pleural rupture required surgical resection by lobectomy in 3 patients and left pneumonectomy in 1. If the hemorrhage was contained and if it occupied only part of the lobe, the lung parenchyma was preserved and bleeding was controlled by mechanical ventilation and positive end-expiratory pressure; injury to the branch pulmonary artery was repaired in 1 patient.

Two patients with major airway hemorrhage during the postoperative period remained hemodynamically stable and were evaluated by serial chest roentgenograms or computerized tomography. Lobar hemorrhages, demonstrated as diffuse parenchymal infiltrates on chest radiograph were managed expectantly. One patient became hemodynamically unstable and required emergency thoracotomy. Extensive lobar hemorrhage and a small hemothorax were found on exploration. The hilum of the lung was clamped to arrest the hemorrhage. The patient died of hypoxia and cardiac arrest from flooding of the airways.

In 3 postoperative patients with minor and transient hemoptysis the injuries were evaluated by serial chest radiographs. In 1 patient the lobar infiltrate resolved completely. One patient developed a recurrent hemoptysis. A pulmonary artery angiogram demonstrated bleeding from a perforated lobar branch. Arterial embolization of the perforation site stopped the hemorrhage temporarily, but airway hemorrhage recurred 2 days later. The lobectomy was then performed and the patient recovered uneventfully. In yet another patient, after a minor episode of hemoptysis, a subsequent chest radiograph showed a dense lung infiltrate even though the patient was asymptomatic. On postoperative day 15 the patient died suddenly from a ruptured pulmonary artery pseudoaneurysm of the right lower lobe.

One patient suffered exsanguinating hemothorax and cardiac arrest from a right lower lobe injury. The lobe was replaced with a large intraparenchymal hematoma. The PA catheter was found in the distal right PA. The lung hilum was clamped and, after initial stabilization, a lobectomy was performed.

Ancillary treatment measures included correction of coagulation deficits with administration of protamine, fresh frozen plasma, and platelets. Blood and colloids were given to maintain adequate preload. Mild to moderate hyperventilation with positive end-expiratory pressure and FiO₂ of 1.0 were used in patients who were on mechanical ventilation. Intravenous bronchodilators (epinephrine, corticosteroids, and theophylline) were given to decrease bronchospasm and to lower high airway pressures. Inotropic support was given to maintain adequate cardiac function.

In summary, 5 patients in whom hemorrhage occurred postoperatively were at first managed expectantly. One required a lobectomy because of recurrent hemorrhage and 1 died of hemorrhage. One postoperative patient died before treatment could be initiated. All 5 patients who developed hemorrhage upon weaning from CPB, and 1 postoperative patient who exsanguinated, required an operation (five lobectomies and one arterial repair) for definitive control of hemorrhage.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Recurrent hemorrhage occurred in 2 of 5 patients treated conservatively. By contrast in all 7 patients who had surgical intervention (six lung resections and one arterial repair) the bleeding was controlled. Right-sided PAP occurred in 73% of injuries. Ninety three percent of perforations involved lobar branches (14 patients) and 7% (1 patient) of perforations involved a central branch pulmonary artery. The injury sites were in the right lower lobe in 6 patients (43%), middle lobe in 4 (29%), right upper lobe in 1 (7%), left upper lobe in 2 (14%), and left lower lobe in 1 (7%).

The overall hospital mortality rate was 42% (5 of 12). Mortality occurred in 50% of females (4 of 8) and 25% of males (1 of 4). The mortality was 80% for patients older than 65 years (4 of 5), 43% for surgical treatment (3 of 7), and 20% for conservative therapy (1 of 5). Death occurred in 3 of 6 patients (50%) who had parenchymal resections for control of hemorrhage. A postoperative patient who had a cardiac arrest and underwent an emergency lobar resection (preoperative PA 65/35 mm Hg and mitral valve replacement) needed prolonged mechanical ventilation and died of multiorgan failure and sepsis. Two patients died on the operating table; 1 patient with bilobular resection died of intractable hypoxia from flooding of the remaining airways with blood clots; and 1 patient died of massive air embolism to the coronary bypass grafts.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The catheter-induced PAP occurs with an equal frequency in patients undergoing cardiovascular operation using cardiopulmonary bypass and interventions that do not involve cardiopulmonary bypass [1–4]. The technical errors in insertion, high inflation pressures in balloon, advanced age, and hypothermia are important among several risk factors for pulmonary artery injury [4–9]. Females and patients more than 65 years of age are at increased risk of injury and death.

The right-sided pulmonary artery and its branches are commonly involved in PAP with a higher incidence in the right lower and middle lobe branches [4–5]. The injuries may consist of intimal tears, full thickness vessel wall perforation, or rarely retrograde dissection into the contralateral pulmonary artery [10, 11]. Injury to lobar branches causes pulmonary hemorrhage and hematomas, which may extend into the airways or rupture through visceral pleura causing hemothorax [2, 10]. The parenchymal hemorrhage may be self-limited if a defect in the arterial wall seals or forms a pulmonary artery pseudoaneurysm, which has a high potential for rupture [7, 8, 12].

Pulmonary artery perforation may manifest itself by seemingly trivial hemoptysis to massive endobronchial hemorrhage [13]. Minor hemoptysis with or without the appearance of a pulmonary infiltrate may be the only manifestation of PAP [8, 14]. Recurrent and fatal hemorrhage may occur in 45% of patients with perforations that are not initially controlled by operations [4, 8, 12]. The airway hemorrhage appears during weaning from cardiopulmonary bypass, at the time of resumption of mechanical ventilation, and at the time of restored pulmonary blood flow [4, 15]. Pulmonary artery perforation may result in arterial hypotension and or cardiac arrest if proximal pulmonary arterial branches are perforated or if the intrapulmonary hemorrhage is massive [5, 8, 13]

The principles of therapy of PAP involve (1) removal of PA catheter or withdrawing it into proximal PA; (2) establishment of adequate respiratory gas exchange; and (3) appraisal of the injury in order to achieve effective control of hemorrhage. Treatment of minor hemoptysis can be expectant, whereas aggressive treatment measures are reserved for patients with hypoxia, hemodynamic compromise, and major hemorrhage in the airways.

Adequate gas exchange is established through tracheal intubation, mechanical ventilation, and institution of positive end-expiratory pressure. Positive end-expiratory pressure, high-inspired oxygen concentration, and pharmacological interventions to reduce pulmonary artery pressure are beneficial in arresting hemorrhage by decreasing pulmonary blood flow [1, 15]. Bronchoscopy is done for lavage of the airways and for identifying the source of hemorrhage. The bleeding bronchus can be isolated to protect the airway either by use of a bronchial blocker or a double lumen endotracheal tube [6].

In hemodynamically stable patients with PAP, detected in the preoperative or postoperative period, the injury is evaluated by serial chest roentgenograms, computerized tomography, or pulmonary angiography, or a combination of these. Hemodynamically unstable patients may require emergency thoracotomy and temporary clamping of the affected PA at the hilum to arrest the hemorrhage, allowing thorough appraisal of injury [5]. Appearance of major hemorrhage in the airways during weaning from cardiopulmonary bypass demands appraisal of the injury and reinstitution of cardiopulmonary bypass [4, 15]. Once bleeding bronchus is isolated, proximal pulmonary arterial branches and both lungs can be inspected for injury.

Injuries to proximal pulmonary arterial branches are repaired [16]. Parenchymal hemorrhage occupying the greater portion of the lobe, or parenchymal hemorrhage resulting in hemothorax requires pulmonary resection [2, 4, 17]. Contained parenchymal hemorrhage within the lobe, as demonstrated by radiologic examination or surgical exploration, may be managed conservatively. As several incidences of recurrent and fatal hemorrhage were reported in patients in whom hemorrhagic lung tissue was conserved and also in patients after an episode of minor hemoptysis, angiographic localization of the site of perforation and selective embolization of a bleeding vessel was recommended [4, 7, 8, 14, 18]. Angiographic embolization was used to treat pulmonary artery pseudoaneurysm, delayed recurrent hemorrhage, and more recently PAP after initial bleeding episode [8, 12, 13]. The embolization of the bleeding vessel, however, does not preclude further hemorrhage and surgical parenchymal resection will be warranted if hemorrhage recurs.

Optimal therapy for control of hemorrhage in PAP is controversial. Surgical treatment was associated with an increased mortality compared with conservative therapy (43% vs 20%) in this study, as well as several other studies. Because of the added morbidity of combined cardiac operation and pulmonary resection, lung parenchyma may be conserved in extensive lobar hemorrhage, especially in patients with poor cardiopulmonary reserve [4]. Pulmonary arterial occlusion by a vessel loop also has been reported to control hemorrhage and the loop can be released after 2 days [3, 18]. Mullenworth and associates [19] have successfully supported a hypoxic patient due to extensive parenchymal hemorrhage of two lobes on 48 hours of extracorporeal life support.

In summary, the clinical and radiologic findings in suspected PAP determine the need for surgical intervention or conservative therapy. Operations are recommended in hemodynamically unstable patients with or without airway hemorrhage, in suspected injury to central branch pulmonary arteries, and in extensive lobar hemorrhage or intrapleural bleeding. Operations may also be indicated in a suspected PA pseudoaneurysm with its high propensity for rupture and if a hemorrhage recurs after embolization of a bleeding perforation. The need for parenchymal lung resection is dictated by operative findings and preoperative pulmonary function. Nonoperative therapy is generally relied on in patients with trivial hemoptysis and hemodynamically stable patients with contained parenchymal lung hemorrhage. Angiographic embolization of bleeding perforation is recommended in all patients in whom hemorrhagic lung tissue is conserved to avert recurrent hemorrhage.

Despite prompt recognition and management of PAP, the preventive strategies assume paramount importance because the mortality of PAP is very high. Strict adherence to standard techniques of insertion and maintenance of flow directed catheters, avoiding manipulation of the catheter and balloon inflation, and placement of the catheter tip into the proximal PA, or floating the catheter at the end of cardiopulmonary bypass may all reduce the risk of PAP. We do not recommend routine use of Swan-Ganz catheters in cardiac operations unless critically indicated. The pulmonary artery catheter insertion should also be avoided in patients who are prone to an increased risk of perforation [6, 18]. The treatment algorithm is proposed in Figure 1, addressing several issues in management.

View larger version (37K): [in this window] [in a new window]   Fig 1. Management of pulmonary artery perforation in cardiac operations. (BB = bronchial blocker; CPB = cardiopulmonary bypass; CT scan = computed tomographic scan; DLET = double lumen endotracheal tube; ECLS = extracorporeal life support; ET = endotracheal tube; MV = mechanical ventilation; PA = pulmonary artery; PEEP = positive-end expiratory pressure; Pre = preoperative; Post-op = postoperative.)

	References

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