Emergency donor pericardial conduit for ruptured pulmonary artery in lung transplantation for severe PH: a case report

Abstract

Background

Intraoperative pulmonary artery (PA) rupture is a rare but catastrophic complication during lung transplantation, particularly in patients with severe pulmonary hypertension (PH). Effective salvage strategies in this setting are not well described. This case report details the successful emergency application of a readily available donor pericardial conduit to manage an uncontrollable PA rupture during lung transplantation for end-stage idiopathic pulmonary fibrosis (IPF) with severe PH.

Case presentation

A 58-year-old woman with end-stage IPF and severe PH (preoperative pulmonary artery systolic pressure 105 mmHg) underwent bilateral lung transplantation. Immediately upon reperfusion of the left lung, an acute longitudinal dissection and rupture of the recipient’s left main PA occurred, causing massive hemorrhage unresponsive to re-clamping due to extreme vessel friability. After emergent conversion from peripheral veno-arterial extracorporeal membrane oxygenation to full cardiopulmonary bypass, the damaged PA segment was resected. A 24-mm tubular conduit was fashioned intraoperatively from donor pericardium and anastomosed end-to-end to restore vascular continuity. The patient survived the procedure. Her postoperative course was complicated by a resistant Burkholderia cepacia infection, requiring prolonged treatment and tracheostomy. She was discharged on postoperative day 86. The follow-up CTA two months later showed that the catheter was widely patent and that the anastomosis had mild stenosis, which did not affect blood flow.

Conclusion

Emergency reconstruction of a ruptured PA using an on-site fabricated donor pericardial conduit is a feasible and life-saving salvage technique in the setting of severe PH. Although the technique itself is not novel, its application in this extreme scenario—where the native PA is exceptionally friable and direct repair is impossible—offers a practical, biocompatible, and infection-resistant solution. We highlight the critical decision-making, technical execution, and lessons learned for perioperative preparedness in high-risk transplant recipients.

Background

Idiopathic pulmonary fibrosis (IPF) with severe pulmonary hypertension (PH) carries a poor prognosis, and bilateral lung transplantation is the only definitive treatment [1–4]. Chronic severe PH renders the pulmonary artery (PA) wall exceptionally friable, making intraoperative rupture a rare but often fatal complication [5, 6]. While PA reconstruction using pericardium has been described in elective settings [7], its emergency application as an on-site salvage maneuver following an acute, uncontrollable PA rupture in a patient with severe PH is rarely detailed. This case report describes our decision-making, technical execution, and lessons learned using a donor pericardial conduit in this extreme scenario.

Case presentation

Preoperative clinical course

A 58-year-old woman (height 158 cm, weight 52 kg) with a twenty-year history of dry cough and progressive dyspnea was diagnosed with idiopathic pulmonary fibrosis (IPF) and severe pulmonary hypertension (PH). Pre-transplantation assessment revealed a pulmonary artery systolic pressure (PASP) of 105 mmHg, a 42% decrease in diffusion capacity of the lung for carbon monoxide (DLCO), and computed tomography (CT) imaging showing pulmonary artery enlargement and pulmonary fibrosis (Fig. 1A). She was subsequently listed for bilateral lung transplantation.

Fig. 1.

(A) Preoperative chest CT shows idiopathic pulmonary fibrosis and main pulmonary artery dilation. (MPA, LPA, RPA: the main, left, and right pulmonary arteries) (B) Preoperative three-dimensional CT angiography (CTA) reconstruction showed significant dilation of the main pulmonary artery (diameter 50 mm). (C) Schematic diagram of salvage surgery. During reperfusion, the recipient’s left main pulmonary artery ruptured longitudinally. The rectangular donor pericardium was trimmed and wrapped around a 24 mm expander, which was then closed with intermittent sutures to form a tubular catheter. A pericardial catheter replaces the ruptured left pulmonary artery to restore pulmonary artery continuity. (D) Two months after surgery, three-dimensional CT angiography showed only mild anastomotic stenosis in the reconstructed left pulmonary artery catheter. (E) Three months after surgery, chest CT showed that pulmonary edema had subsided and allograft lung function was stable.

Her condition was optimized through treatment with pirfenidone, methylprednisolone, sildenafil, and macitentan. This therapy reduced her pulmonary artery systolic pressure (PASP) to 65 mmHg. Despite this, her clinical condition deteriorated. Six months after being listed, she was hospitalized for pulmonary embolism and stabilized with anticoagulant therapy. Preoperative CT angiography measured a main pulmonary artery diameter of 50 mm and confirmed the presence of distal pulmonary embolism (Fig. 1B).

Intraoperative course and surgical technique

Bilateral sequential lung transplantation was performed via anterolateral thoracotomies under peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support, using right femoral cannulation (15-Fr arterial, 21-Fr venous). Intraoperatively, the lungs were firm and fibrotic, with notably dilated and atheromatous pulmonary arteries. The right lung was implanted without incident. The cold ischemic time for the right lung was 5 h and 30 min.

For the left pulmonary artery (PA), an anastomosis was completed using a running 5 − 0 polypropylene suture. Upon reperfusion of the left lung, however, an acute longitudinal dissection and rupture of the recipient’s left main PA occurred at the anastomosis, leading to massive hemorrhage. Immediate attempts to re‑clamp the left PA proximally were made, but the vessel wall was so friable that the clamp caused the PA to shatter, making direct repair impossible. In addition, in cases of continuous bleeding, we found that the existing extracorporeal membrane oxygenation (ECMO) flow rate was insufficient (< 3 L/min), unable to maintain hemodynamic stability, and the patient’s right lower limb turned purple and cold.

Because the recipient’s left PA stump was too short, the left main pulmonary artery trunk had been clamped within the pericardium to perform the anastomosis. After the rupture, any attempt at direct repair would have risked catastrophic bleeding without adequate circulatory support. A multidisciplinary team (lung transplant, cardiac surgery, anesthesia, and perfusion) therefore emergently convened and decided to establish full cardiopulmonary bypass (CPB). The cardiac surgery team performed central aortic and right atrial cannulation because the existing groin cannulas were too small to support full CPB flow. This allowed safe control of the left PA clamp and provided a bloodless field for vascular reconstruction. To ensure normal blood flow in the right lower limb, we reconfigured the original ECMO circuit to the left femoral vessel.

After stabilization, the damaged recipient PA segment was resected. A conduit was fashioned intraoperatively from donor pericardium: a pericardial segment was trimmed, wrapped around a 24-mm metal dilator, and the seam was closed with interrupted 5 − 0 polypropylene sutures. This 3-cm tubular conduit was then anastomosed end-to-end to the PA using a running 5 − 0 polypropylene suture, restoring vascular continuity (Fig. 1C). The transplantation was thereafter completed. The cold ischemic time for the left lung was 12 h and 15 min.

Total operative time was 18 h and 40 min, with an estimated blood loss of 5,000 mL. After the procedure, the patient was transferred to the surgical intensive care unit (SICU).

Postoperative outcome

The patient was weaned from ECMO on postoperative day 3. Her recovery was complicated by a resistant Burkholderia cepacia respiratory infection, requiring prolonged targeted therapy and a tracheostomy. The CTA performed two months later showed that the pericardial duct was widely patent with no thrombus formation; a mild anastomotic stenosis (approximately 20%) was observed in the main left pulmonary artery, but it was not hemodynamically significant (Fig. 1D). After a long recovery period, the patient was discharged on the 86th postoperative day. A pulmonary CT scan performed three months after surgery showed that pulmonary edema had resolved and the allograft lung function was stable (Fig. 1E).

Discussion and conclusions

We acknowledge that PA reconstruction using pericardium is not a novel technique and is part of the standard armamentarium of experienced lung transplant surgeons [7]. However, its application as an immediate salvage maneuver following an acute, uncontrollable PA rupture during reperfusion—in a patient with a PASP of 105 mmHg and severely atheromatous, friable vessels—is rarely detailed in the literature. In this extreme scenario, direct reclamping was impossible, and the successful use of a donor pericardial conduit demonstrates its life‑saving value.

Why donor pericardium? Our choice was multifactorial: (1) biocompatibility and compliance, which approximate native PA and may reduce anastomotic stenosis [7, 8]; (2) lower infection risk in contaminated or immunosuppressed fields compared to synthetic grafts [9]; and (3) immediate availability and versatility, allowing on‑site custom sizing without delays. Alternative materials include bovine pericardium (commercially available but less compliant), cryopreserved homografts (ideal but rarely emergent), and synthetic grafts (associated with higher infection risk). In our emergent, infected field, donor pericardium offered the best balance.

Perioperative lessons - For patients with severe PH (PASP > 60–80 mmHg) and PA atheroma, teams should anticipate extreme vascular fragility and have pericardium readily available. Moreover, a flexible circulatory support strategy is essential. In retrospect, a “hybrid” circuit allowing rapid conversion from peripheral ECMO to full cardiopulmonary bypass would have minimized blood loss. We recommend this preparedness measure.

Conclusion

Catastrophic PA rupture during lung transplantation for severe PH is a life‑threatening emergency. This case demonstrates that emergency reconstruction using an on‑site fabricated donor pericardial conduit is a feasible and effective salvage technique. We recommend that this biological option remain readily available in every lung transplant surgeon’s armamentarium for managing the worst‑case intraoperative complication.

Abbreviations

COPD

Chronic Obstructive Pulmonary Disease

COTRS

China Organ Transplant Response System

CT

Computed Tomography

CTA

Computed Tomography Angiography

DLCO

Diffusing Capacity of the Lungs for Carbon Monoxide

ECMO

Extracorporeal Membrane Oxygenation

IPF

Idiopathic Pulmonary Fibrosis

PA

Pulmonary Artery

MPA

Main Pulmonary Artery

LPA

Left Pulmonary Artery

RPA

Right Pulmonary Artery

PASP

Pulmonary Artery Systolic Pressure

PH

Pulmonary Hypertension

SICU

Surgical Intensive Care Unit

V-A

Venous-Arterial

3D

Three-Dimensional

Author contributions

JC and DL contributed equally to this work. JC and DL were involved in patient care, data collection, and manuscript drafting. JZ assisted in data interpretation and manuscript revision. WH, a senior surgeon who performed the salvage surgery, conceived the study, supervised the project, and critically revised the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by Noncommunicable Chronic Diseases-National Science and Technology Major Project (2024ZD0529001) to Weili Han.

Data availability

The datasets used and/or analyzed during the current case report are not publicly available due to patient privacy concerns, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This case report was conducted in accordance with the principles of the Declaration of Helsinki. It was approved by the Institutional Review Board of The First Affiliated Hospital, Zhejiang University School of Medicine.

Consent for publication

Written informed consent was obtained from the patient for the publication of this case report and any accompanying images.

Competing interests

The authors declare no competing interests.

Organ procurement statement

The organs were procured through the China Organ Transplant Response System (COTRS) in strict adherence to the ethical principles of the Declaration of Istanbul. Informed consent for donation was obtained from the donor’s legal guardian in accordance with national law and institutional protocols.