Ann Thorac Surg 2009;87:939-940. doi:10.1016/j.athoracsur.2008.07.026
© 2009 The Society of Thoracic Surgeons
Case Reports
Repair of Right Pulmonary Artery Transection after Blunt Trauma
Sara J. Pereira, MD*,
James A. Narrod, MD
Division of Cardiothoracic Surgery, St. Mary's Hospital and Medical Center, Grand Junction, Colorado
Accepted for publication July 9, 2008.
* Address correspondence to Dr Pereira, Division of Cardiothoracic Surgery, St. Mary's Hospital and Medical Center, 425 Patterson Rd, Suite 506, Grand Junction, CO 81506 (Email: sara.pereira{at}stmarygj.org).
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Abstract
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Acute pulmonary artery transection after blunt trauma is presumed to be a fatal injury. We report a case of right pulmonary artery transection successfully repaired with cardiopulmonary bypass and primary end-to-end anastomosis.
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Introduction
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Laceration of the right and left pulmonary arteries is a rarely reported traumatic injury and carries an extremely high mortality rate. The vast majority of patients expire during the pre-hospital or emergency room phase. Transection of the pulmonary artery is presumed to be a fatal injury and has not been reported in the surgical literature.
A 55-year-old woman was involved in a high-speed motorcycle collision and ejected from her motorcycle. Her posterior chest was run over by a small pick-up truck. She was unresponsive at the scene. She was hypoxic and intubated on arrival to an outside hospital and bilateral chest tubes were placed for hemopneumothoraxes. Both chest tubes were placed to one chest drainage canister and the total drainage was 500 cc. She had several transient episodes of hypotension and was given 2 units of blood en route to our facility. The chest roentgenogram (Fig 1) revealed bilateral pleural effusions, numerous bilateral rib fractures, and bilateral pulmonary contusions. The mediastinum was not widened. The computed chest tomography (Fig 2) was suspicious for pulmonary artery pseudoaneurysm of the right main pulmonary artery. The pulmonary angiogram (Fig 3) confirmed a large pseudoaneurysm at the right main pulmonary artery. She was taken to the operating room for a median sternotomy. The right pulmonary artery was freed under the aorta. There was a large hematoma overlying the artery with impending rupture. Cardiopulmonary bypass with low-flow hypothermia was instituted for complete visualization of the extent of the injury. There was a nearly complete transection of the right main pulmonary artery with pseudoaneurysm formation. When the surgeon visualized the injury from the right chest, the transection occurred from the 7 o'clock to the 5 o'clock positions on the right pulmonary artery in a clockwise direction. This full thickness injury occupied 80% of the pulmonary artery circumference. The artery was repaired with an end-to-end repair using interrupted full thickness pledgeted sutures followed by a second layer continuous repair. The patient recovered uneventfully from her pulmonary contusions and arterial repair. She was discharged home on postoperative day 6.
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Fig 1. Chest roentgenogram shows bilateral chest tubes, rib fractures, and pulmonary contusions. The mediastinum was not widened.
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Fig 2. Spiral chest computed tomographic scan shows pulmonary artery pseudoaneurysm of the right main pulmonary artery.
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Comment
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Pulmonary artery transection with pseudoaneurysm formation has not been previously reported in the surgical literature. Pulmonary artery lacerations after blunt trauma have been previously reported in only 7 patients [1–6]. Six of these were managed surgically by direct repair without cardiopulmonary bypass; however, 1 patient expired in the operating room. One patient underwent an emergent left thoracotomy for a laceration of the main pulmonary artery involving half of its circumference. This was repaired with interrupted pledgeted sutures without cardiopulmonary bypass [1]. One patient had a 0.5-cm right main pulmonary artery laceration requiring the urgent initiation of cardiopulmonary bypass for right ventricular failure. The right pulmonary artery was repaired with a pericardial patch [2]. One patient had a "large disruption of the main right pulmonary artery" and expired on the operating room table during a right thoracotomy [3]. This case likely represents a pulmonary artery transection that may have been survivable with cardiopulmonary bypass through a median sternotomy.
Patients with pulmonary artery injuries may present to the emergency department in various hemodynamic states. They may arrive with massive hemothorax from a hilar arterial injury or with a wide mediastinum from a proximal arterial injury. In the latter group, a contained pseudoaneurysm may develop or acute pericardial tamponade can occur from active bleeding. In this case, the injury was suspected based on the mechanism of injury with associated rib fractures and pulmonary contusions. The majority of patients will require emergent exploration based on the clinical suspicion of injury. If the patient arrives hemodynamically stable, a chest computed tomographic scan will provide information on the location of injury for operative planning. In 2 of 7 reported cases of pulmonary artery injury, chest computed tomography was "suggestive" of the injury. It "confirmed" the injury in only one case. In our patient, the computed tomographic scan accurately identified the injury; however, the scan depicted a smaller controlled pseudoaneurysm type of injury and underestimated the extent of transection identified intraoperatively. Simple arterial lacerations may be repaired primarily without cardiopulmonary bypass. We believe that more extensive injuries greater that 50% circumference of the pulmonary artery are consistent with an arterial transection and require the institution of cardiopulmonary bypass for complete visualization and repair.
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References
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- Ambrose G, Barrett LO, Angus GL, Absi T, Shaftan GW. Main pulmonary artery laceration after blunt trauma: accurate preoperative diagnosis Ann Thorac Surg 2000;70:955-957.[Abstract/Free Full Text]
- Daon E, Gorton ME. Traumatic disruption of the innominate and right pulmonary arteries: case report J Trauma 1997;43:701-702.[Medline]
- Hawkins ML, Carraway RP, Ross SE, Johnson RC, Tyndal EC, Laws HL. Pulmonary artery disruption from blunt thoracic trauma Am Surg 1988;54:148-152.[Medline]
- Ohta Y, Satoh H, Seki M, Endoh Y, Tsubota M, Iwa T. [Injury of pulmonary artery and intrathoracic artery—a surgical case report] Nippon Kyobu Geka Gakkai Zasshi 1993;41:337-340.[Medline]
- Nishimoto T, Fukumoto H, Irie H. [Main pulmonary artery injury caused by golf swing.] Nippon Kyobu Geka Gakkai Zasshi 1991;10:1953-1955.
- Katz DS, Groskin SA. Pulmonary artery laceration and tension pneumothorax in blunt chest trauma J Thorac Imaging 1993;8:156-158.[Medline]
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Abstract
Introduction
