Massive Hemoptysis from a Pulmonary Artery Pseudoaneurysm during Cardiac Surgery

Abstract

Massive hemoptysis is a life-threatening condition usually related to a pathology of the bronchial arteries. Pulmonary artery pseudoaneurysms represent a relatively rare cause of severe airway bleeding, but are associated with a mortality rate of over 50%. A case of massive intraoperative hemoptysis treated with temporary occlusion of the right pulmonary artery and delayed endovascular occlusion of the feeding segmental artery is described. KEYWORDS:Hemoptysis, pseudoaneurysm, pulmonary artery catheterization, computed tomography INTRODUCTIONMassive hemoptysis is a life-threatening condition usually related to a pathology of the bronchial arteries [1]. Pulmonary artery pseudoaneurysms represent a relatively rare cause of severe airway bleeding, but are associated with a mortality rate of over 50% [2]. We report a case of massive intraoperative hemoptysis treated by temporary occlusion of the right pulmonary artery and delayed endovascular occlusion of the feeding segmental artery. CASE PRESENTATIONWe describe the case of an 80-year-old woman who presented with massive hemoptysis during an open heart procedure. The patient survived and gave her consent for the publication of the present case report.The patient underwent mitral repair at our institution. One hour after the procedure, she had asystolia and was reanimated. Echocardiography performed during cardiopulmonary resuscitation (CPR) showed severe biventricular dysfunction and demonstrated the presence of a right atrial thrombus. The patient underwent emergency surgical re-exploration. Cardiopulmonary bypass (CPB) with bi-caval cannulation was instituted, and the right atrium was explored without cross-clamping the aorta. A 2 × 1 × 0.5 cm thrombus was found in the superior vena cava, adherent to the central venous catheter, and was removed. A 2 cm longitudinal incision was then made on the main pulmonary artery, and the right atrium and ventricle were flushed with a heparin solution. A small sucker was advanced in the left pulmonary artery and retrieved a second small clot. It was then advanced in the right pulmonary artery (RPA), finding no additional thrombotic material. A 6-French Fogarty catheter (Edwards Lifesciences, Irvine, CA) was advanced in the left and RPA branches, but no other thrombi were retrieved. The left and right ventricular function recovered, the right atrium and pulmonary artery were sutured, and the patient was weaned from CPB. However, as soon as the pump flow was reduced, significant hypovolemia developed and massive hemoptysis was observed. Notably, the surface of both lungs appeared normal. CPB was started again and bronchoscopy was performed, but the exploration stopped at the carena due to excessive bleeding. A left-sided Robertshaw endotracheal tube (Covidien Spa, Segrate) was positioned, and the source of bleeding was identified in the right lung. The tracheal lumen was occluded, the patient was weaned from CPB during single lung ventilation, and protamine was administered. However, severe bleeding with hemodynamic instability ...

A rare cause of hemoptysis in childhood: peripheral pulmonary artery pseudoaneurysm to bronchial fistula in a case with tetralogy of Fallot

“…In addition, chronic lung infections, mushroom ball causes, etc.,or traffic accidents, stabbings, etc., and subsequent cases of hemoptysis to lung injury have been reported. [5][6][7] In addition, fine needle biopsy for the bronchial system, etc., and hemoptysis may develop after such invasive procedures. 8 In this case, in addition to the smooth post-operative period of the patient, no invasive interventions were made towards pulmonary arteries or the bronchial system during both the pre-operative and the post-operative period.…”

Massive Hemoptysis: Danger is Real, Promptness is Essential

“…Common causes are as follows: bronchiectasis, bronchogenic carcinoma, tuberculosis, fungal infections, lung abscess, polyangiitis (previously named as Wegener's granulomatosis), right heart catheterization, and pulmonary arteriovenous malformation. Massive hemoptysis has also been reported after and during cardiac surgery due to pulmonary artery pseudoaneurysm [6,7].…”

Post-operative imaging of pulmonary vessels

“…Most PAP present after thoracic trauma including chest tubes placement and intravascular catheters, from septic embolism, lung cancer, or vasculitis but may also occur after lung resection, lung biopsy or radiofrequency ablation (5). PAP could represent a life threatening condition which requires prompt diagnosis and intervention with either open surgical repair or endovascular surgery (6). In cases in which PAP develop as a postoperative complication, associated infection may be a contributing factor.…”