Portal de Periódicos da CAPES

Pulmonary Artery Rupture After Attempted Removal of a Pulmonary Artery Catheter

2002; Lippincott Williams & Wilkins; Volume: 95; Issue: 2 Linguagem: Inglês

10.1213/00000539-200208000-00007

1526-7598

Go-Shine Huang, Hung-Jui Wang, Chi-Hou Chen, Shung-Tai Ho, Chih-Shung Wong,

Pulmonary Hypertension Research and Treatments

Measurement of pulmonary artery (PA) pressure and cardiac output (CO) has become the mainstay of hemodynamic monitoring during and immediately after surgery (1). Several complications are recognized with the insertion and use of the PA catheter (PAC). These include PA rupture, which is rare but life-threatening and usually necessitates prompt thoracotomy and lobectomy. Continuous CO (CCO) PAC for CO measurement is being used more frequently for open-heart surgery perioperatively. We report a case of accidental suture of the CCO PAC to the pulmonary arterial trunk while we closed the hole created in the pulmonary trunk for inserting a vent to decompress the left heart, with the pulmonary arterial trunk being ruptured during attempted postoperative removal of the CCO PAC in the intensive care unit (ICU). Case Report A 65-yr-old ASA physical status III 70-kg man was hospitalized with angina pectoris and congestive heart failure. Subsequent coronary catheterization and echocardiography revealed triple-vessel disease with total occlusion of the right coronary artery. The patient underwent coronary artery bypass surgery with general anesthesia and cardiopulmonary bypass (CPB). An Abbott TDQ™ CCO PAC was inserted easily via the right internal jugular vein; it was successfully guided into the PA, revealing an initial pressure of 34/15 mm Hg. The balloon was inflated with 1 mL of air to obtain a pulmonary capillary wedge pressure (PCWP) of 13 mm Hg at 50 cm insertion. The CCO PAC functioned properly before CPB. During CPB, the CCO PAC was not withdrawn and remained at the original insertion depth. A PA vent (a plastic sump catheter) was introduced into the pulmonary trunk and secured by a purse-string suture and whole-layer closure with 3-O polypropylene on pledgets. After termination of the CPB, the PA pressure was 40/15 mm Hg; however, the PCWP was not measured at that time. The patient was transported to the ICU after completion of surgery. The postoperative chest radiograph revealed the absence of abnormal collections of fluid or air in both lung fields. The CCO PAC had a sharp bend at the junction of the pulmonary trunk and the right PA (Fig. 1). Approximately 30 min after surgery, the PCWP was unobtainable after balloon inflation, and the surgeon tried to withdraw the CCO PAC in an attempt to reposition the catheter; however, a resistance was noted, and he abandoned attempts to reposition the catheter. The patient was tracheally extubated 3 h after arrival in the ICU. Sixteen hours later, because the patient was hemodynamically stable, the surgeon decided to remove the CCO PAC. During the attempted removal, the surgeon again noted resistance. Despite increased force to loosen the CCO PAC, it could not be removed. Ten minutes later, the PA and systemic artery pressures declined. Over the next 15 min, 900 mL of blood drained from the pericardial tube, the systemic arterial blood pressure decreased to 50/30 mm Hg, and hypovolemic shock and cardiac arrest followed.Figure 1: Postoperative chest radiograph showing that the location of the catheter tip suggested that it was not positioned optimally within the right pulmonary artery. The continuous cardiac output pulmonary artery catheter was noted to have a sharp bend at the junction of the pulmonary trunk with the right pulmonary artery.Rapid intubation with a single-lumen endotracheal tube and reopening the original incision, via median sternotomy, was immediately performed at the bedside. A large amount of blood was observed in the pericardial cavity. Rapid hemorrhage of blood occurred from an obvious hole in the lateral wall of the pulmonary trunk. The hole was located at the site of the left heart vent. The bleeding was temporary stopped by simple suture, and 8 U of whole blood and 6 U of fresh frozen plasma were given. The blood pressure increased to 100/60 mm Hg, and the patient was sent to the operating room for further surgical treatment. Under general anesthesia, the sutures securing the left heart vent hole on the pulmonary trunk were released, the catheter was pulled back without resistance, and the hole was sutured rapidly. The CCO PAC had a tear approximately 7 cm from the tip (Fig. 2). After careful irrigation, inspection, and blood transfusion, the chest was closed, and the patient's vital signs became stable. Unfortunately, the patient died from poor cardiac function and pulmonary edema 2 days later.Figure 2: The location of the catheter tear is (arrow) 7 cm from the tip.Discussion In this report, the rupture of the pulmonary vascular trunk was due to accidental suture of the CCO PAC during closure of the left heart vent hole on the pulmonary trunk and the subsequent attempted forced removal of the CCO PAC. PAC-related complications can be classified into four categories (2): those related to central venous cannulation, those occurring during passage of the catheter through the right heart and into the PA, those occurring while it is indwelling, and those associated with removal of the PAC (e.g., thromboembolism, air embolism, dysrhythmias, and injury of cardiac structures [e.g., pulmonary valve, tricuspid valve, chordae tendineae, PA rupture, and inability to withdraw]). This case is an example of PA rupture and inability to withdraw. This is a potential complication of use of a PA vent for cardiac venting. The mechanisms of injury in our case of PA perforation were studied by Barash et al. (3) and were multifactorial: (a) peripheral location of the tip of the catheter (the most common mechanism), (b) overinflation of the balloon, and (c) off-center positioning of the catheter after balloon inflation. There are five risk factors for PA rupture that occur because of these mechanisms (4): (a) age older than 60 years, (b) existence of PA hypertension, (c) improper balloon inflation, (d) improper catheter positioning, and (e) CPB and concomitant anticoagulant treatment. These may not apply to the mechanism responsible in our case. The diagnosis of this complication may be clinical, and hemoptysis is the main symptom (5). When the rupture is asymptomatic, it may be revealed radiologically or by chance (5). If PA perforation is suggested, this may be diagnosed by opacification with contrast medium given via the PAC and then, depending on the clinical severity, by pulmonary arteriography or a chest computed tomographic scan (5). General treatments include resuscitation and specific approach aimed at maintaining ventilatory function and stopping hemorrhage. Various treatments have been reported, including supportive care (6), reversion of anticoagulation and injection of vasopressin (4,5), balloon tamponade or transcatheter embolization (7,8), controlled ventilation with positive end-expiratory pressure (9), elective endotracheal intubation (10), or double-lumen endobronchial tube (11). Surgical interventions are either conservative (vessel ligature) or aggressive, ranging from segmentectomy to pneumectomy (4). Occlusion of the artery could lead to significant parenchymatous infarction of both lungs. In the event of a distal lesion of a segmentary or subsegmentary branch of the PA, occlusion of the artery lumen is indicated. In this case, there were three clues suggesting that the CCO PAC was sutured to the pulmonary trunk: the sharp angle of the CCO PAC seen in the chest radiograph, the feeling of resistance while pulling out the catheter, and an unobtainable PCWP. This complication may be recognized by a history of open-heart surgery under CPB and the rapid appearance of blood via chest tubes after forceful attempted CCO PAC removal; this is associated with hemodynamic instability, which suggests PA trunk rupture. If the vital signs had been relatively stable, diagnosis could have been achieved by PA angiography. The therapeutic strategy for pulmonary trunk rupture and perforation of great vessels and heart should include immediate resuscitation, blood transfusion, and thoracotomy with suture ligation of the torn site (12,13). If inadvertent snaring of a PAC by a suture is recognized before rupture, this can be treated with subsequent removal transvenously during reopening the heart via median sternotomy (12,13). Withdrawal of the CCO PAC is recommended as a routine procedure before initiation of CPB and may prevent this serious complication. It is a useful practice anytime a suture has been placed in any right-heart structure (e.g., vena cava, right atrium, right ventricle, or PA for cannulation or suture lines) while a PAC is in place that before the chest is closed, the PAC should be evaluated to verify that it has not been ensnared or punctured by a suture. This can be done by documenting that the PAC can be withdrawn and then floated back into the wedge position and that the pressure tracings (both the PA and the central venous pressure), CCO, and venous oxygen saturation are all working normally. When the PAC appears kinked on a chest radiograph, the PCWP cannot be measured, and resistance is obtained when attempting to remove the PAC, force should not be used at any time, and the potential complication of rupture of the pulmonary trunk should be considered. In current clinical practice, transesophageal echocardiography may provide more quantitative and qualitative information than the PAC. Use of alternative methods of hemodynamic monitoring, such as transesophageal echocardiography, to guide intraoperative management may also reduce the risks of such devastating complications (14).