Ann Thorac Surg 2007;83:2213-2214
© 2007 The Society of Thoracic Surgeons
Case Reports
Extracorporeal Membrane Oxygenation for Swan-Ganz Induced Intraoperative Hemorrhage
Roberto Bianchini, MDa,
Giovanni Melina, MD, PhDa,*,
Umberto Benedetto, MDa,
Michele Rossi, MDb,
Brenno Fiorani, MD, PhDa,
Manuela Iasenzaniro, MDa,
Riccardo Sinatra, MDa
a Division of Cardiac Surgery, Ospedale S. Andrea, University of Rome "La Sapienza," Rome, Italy
b Division of Radiology, Ospedale S. Andrea, University of Rome "La Sapienza," Rome, Italy
Accepted for publication January 15, 2007.
* Address correspondence to Dr Melina, Division of Cardiac Surgery, Ospedale S. Andrea, University of Rome "La Sapienza," Via di Grottarossa 1035, Rome, 00189, Italy (Email: g.melina{at}imperial.ac.uk).
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Abstract
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We herein present the case of a 75-year-old woman undergoing double valve replacement who experienced a massive bronchial hemorrhage due to a Swan-Ganz catheter pulmonary artery perforation after weaning from cardiopulmonary bypass. Early institution of extracorporeal membrane oxygenation allowed treatment of severe hypoxemia, refractory to mechanical ventilation, and the discontinuation of hemoptysis. Once clinical stability was achieved, the patient underwent pulmonary artery angiography with successful pseudoaneurysm embolization. It is hoped that this information can provide further insight into the management of such a complication.
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Introduction
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Swan-Ganz catheters are widely used for monitoring and management of critically ill patients [1]. Several complications after insertion may occur. Pulmonary artery rupture is a rare complication, and despite early diagnosis and treatment the mortality is high [2]. If major airway hemorrhage due to Swan-Ganz catheter perforation occurs during cardiac surgery, treatment varies from direct arterial repair [3] to lobectomy or even pneumonectomy [4]. The use of extracorporeal membrane oxygenation (ECMO) for pulmonary artery rupture has been previously described after cardiopulmonary bypass, but mainly for circulatory and ventilatory assistance [3]. We present a case of pulmonary artery rupture by Swan-Ganz catheter after heart surgery, and we successfully treated it by promptly instituting ECMO, which allowed not only for circulatory and ventilatory support but also the control and possibly the discontinuation of bleeding from the airways.
A 75-year-old woman with a history of rheumatic fever, hypertension, and paroxysmal dyspnea was admitted for elective aortic and mitral valve replacement. In the operating room, after induction of anesthesia and orotracheal intubation, a Swan-Ganz catheter was placed according to the standard guidelines and technique [1]. Her double biological valve replacement was uneventful. Shortly after weaning from cardiopulmonary bypass, her arterial systolic blood pressure and arterial oxygen saturation fell to 50 mm Hg and 65%, respectively. Blood and froth suddenly engorged the endotracheal tube. Fiberoptic bronchoscopy showed massive fresh bleeding in the right and left middle and lower lobes, but no specific bleeder was found. Despite ventilation with oxygen at 100%, 8 cm H2O positive end-expiratory pressure, and infusion of epinephrine and norepinephrine, she remained hypoxemic, with low cardiac output and metabolic acidosis. An intraaortic balloon pump was then inserted percutaneously without any improvement. Then cardiopulmonary bypass was resumed, but despite the reduced pulmonary blood flow and pressure, extensive airway hemorrhage persisted, and a bleeding site still could not be identified. The extracorporeal support was soon modified. Having used a centrifugal blood pump from the beginning of the cardiopulmonary bypass, within 30 seconds of arrest a shunt was opened to exclude the reservoir from the circuit and ECMO was promptly started. At this stage, protamine sulphate was given to keep an activated clotting time between 160 and 180 seconds, and 9 units of fresh frozen plasma were also administered. The ECMO flow rate was kept at 2.0 L/min. Bleeding from the airway progressively improved, allowing for a satisfactory oxygenation and cardiac output. The ECMO was then discontinued in the operating room after 2.5 hours of support. The patient was then transferred to the intensive care unit where repeated aspirations of clots from the airway were performed by bronchoscopy. The intraaortic balloon pump was removed after 20 hours of support. Two days after the operation the patient underwent an elective pulmonary angiogram that showed a pseudoaneurysm of the inferior branch of the right pulmonary artery adjacent to the Swan-Ganz catheter (Fig 1). The pseudoaneurysm was then successfully embolized with multiple 8-mm and 10-mm coils (Fig 2), and the Swan-Ganz catheter was removed. The patient was extubated on postoperative day 3. An angiographic computed tomographic scan performed 3 weeks later showed complete embolization of the pseudoaneurysm. The patient did not experience any further hemoptysis. She was discharged to a rehabilitation center on postoperative day 18.
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Fig 1. Selective angiography of the inferior branch of the right pulmonary artery showing an enlargement of the artery consisting of a pseudoaneurysm (arrow).
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Comment
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The present case report serves to illustrate a rare but often lethal complication of pulmonary artery catheterization during cardiac surgery. Its management has been previously described in the setting of different situations [3]. Usually, in the presence of massive airway hemorrhage after weaning from extracorporeal circulation, full cardiopulmonary bypass should be resumed to reduce pulmonary flow and pressure to control bleeding, identify the bleeder site by bronchoscopy, and isolate that part of the airway [3]. If possible, direct arterial repair should be performed, but this is often technically difficult due to the extensive intrapulmonary hemorrhage [3]. In this challenging situation, the only options are a lobectomy or even a pneumonectomy with increased morbidity and mortality [4].
Use of ECMO for treatment of this complication in the setting of cardiopulmonary bypass has been described in only one case [3]. In the latter report, ECMO was percutaneously instituted for hemodynamic instability after bleeding control was already achieved by resuming full cardiopulmonary bypass. The patient survived in spite of possible increased risks of infection, leg ischemia, and prolonged ventilatory support through a tracheostomy [3]. In the present case we carefully inspected both lungs in the attempt to isolate the bleeding segment, but even after the addition of ECMO, this was unsuccessful.
Based on our report, we suggest prompt institution of ECMO circulatory support by a simple shunting from the cardiopulmonary bypass circuit. The ECMO allows for a lower level of activated clotting time than the total cardiopulmonary bypass, which also allows for a reduction of hemorrhaging. Meanwhile, systemic arterial perfusion and oxygenation are maintained until efficient airway ventilation becomes possible. As soon as the patient is stable in the intensive care unit, the injury should be evaluated because re-bleeding is reported to occur in 45% of such cases, and has been described from 48 hours to 14 days later [4]. Contrast computed tomography or preferably a pulmonary angiogram is recommended, followed by transcatheter embolization [5].
In conclusion, early recognition and prompt management of a catheter-induced pulmonary artery rupture is crucial in determining the outcome. In particular, in the operating room, ECMO offers an additional strategy to face pulmonary and circulatory failure, reducing the risk of recurrent bleeding and avoiding pulmonary resection.
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References
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- Practice guidelines for pulmonary artery catheterization: an updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization Anesthesiology 2003;99:988-1014.[Medline]
- Abreu AR, Campos MA, Krieger BP. Pulmonary artery rupture induced by a pulmonary artery catheter: a case report and review of the literature J Intensive Care Med 2004;19:291-296.[Abstract/Free Full Text]
- Mullerworth MH, Angelopoulos P, Couyant MA, et al. Recognition and management of catheter-induced pulmonary artery rupture Ann Thorac Surg 1998;66:1242-1245.[Abstract/Free Full Text]
- Urschel JD, Myerowitz PD. Catheter-induced pulmonary artery rupture in the setting of cardiopulmonary bypass Ann Thorac Surg 1993;56:585-589.[Abstract]
- Kierse R, Jensen U, Helmberger H, Muth G, Rieber A. Value of multislice CT in the diagnosis of pulmonary artery pseudoaneurysm from Swan-Ganz catheter placement J Vasc Interv Radiol 2004;15:1133-1137.[Medline]
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