Abstract
Since its introduction three decades ago, the pulmonary artery (PA) catheter has brought insights into pathophysiology of many diseases enabling intensivists to treat critical conditions much more precisely and securely. PA indications are widening, and those working in an intensive care environment feel more secure in handling critical conditions with objective data. However, PA-induced pulmonary haemorrhage is a well-recognised, uncommon, yet potentially lethal, complication of PA catheter. We report a case with PA haemorrhage induced by placement of the PA catheter during coronary artery bypass surgery. A contrast-enhanced CT scan of the chest confirmed spontaneous remission of the haemorrhage after 7 weeks of the injury without the need for any intervention.
BACKGROUND
This report is a good reminder of the uncommon, yet potentially fatal, complication of the pulmonary artery (PA) floating catheter. It also gives us an insight into the important steps in managing such cases bearing in mind that spontaneous remission and full recovery is possible in some cases.
CASE PRESENTATION
A 66-year-old woman presented with a 2 month history of progressive shortness of breath. Her past medical history included hypertension, hypercholesterolemia and peripheral vascular disease. She was an ex-smoker of 20 packs a year who stopped 15 years ago. Clinical examination revealed no abnormalities. Her routine blood tests and CXR were normal. She had a positive exercise test at 5 minutes of Bruce protocol.
Coronary angiography confirmed the presence of tight left main stem, two-vessel disease and good left ventricular function; therefore, she was referred for surgery.
The antiplatelet treatment was stopped 5 days prior to her admission for coronary artery bypass grafts surgery (CABG).
On the day of surgery, the patient was anaesthetised and a swan-Ganz catheter was placed for monitoring during the proposed CABG surgery. Immediately following the catheter placement, the patient developed a sudden onset of haemoptysis, which appeared in the endotracheal tube.
INVESTIGATIONS
The Swan-Ganz catheter was removed instantly and a fibro-optic bronchoscopy was carried out. There were a few blood clots in the right main bronchus, but no active bleeding source was identified. Subsequently, the operation was cancelled and the patient underwent a CT scan of the chest.
The contras-enhanced CT scan showed a coin lesion in the right lower lobe, which represented haemorrhage induced by the PA catheter injury (fig 1).
Figure 1.
Contrast-enhanced chest CT scan showing pulmonary haemorrhage at the right lower lobe after the placement of the pulmonary artery catheter.
DIFFERENTIAL DIAGNOSIS
Pulmonary artery rupture, pulmonary artery pseudo aneurysm, lung pathology and airway injury during intubation.
TREATMENT
The Swan-Ganz catheter was removed instantly following the episode of haemoptysis and the operation was cancelled. A fibro-optic bronchoscopy was carried out to identify the source of bleeding and to rule out any lung pathology. The patient was haemodynamically stable throughout the process and a CT scan of the chest was arranged as above.
The patient then was observed in the intensive care unit for 24 hours and subsequently was discharged home 2 days later.
OUTCOME AND FOLLOW-UP
A repeat CT scan at 7 weeks confirmed the disappearance of the lesion (fig 2) and the patient was rescheduled for CABG.
Figure 2.
Repeat contrast-enhanced chest CT scan 7 weeks later showing complete resolution of the previous haemorrhage.
A few weeks later the patient underwent on-pump CABG and we elected not to use Swan-Ganz catheter this time. Surgery was uneventful and the patient made a good recovery and was discharged home 5 days later.
DISCUSSION
PA injury induced by PA catheter placement is a well-known complication. It is estimated to occur in up to 0.2% of cases where a PA catheter is used and carries a mortality rate of 45–65% when PA rupture occurs.1,2 The following factors have been associated with increase risks of PA injury: female gender, age >60 years, pulmonary hypertension and active anticoagulation treatment.3,4
The mechanism of injury can be explained by the use of stiff catheters tips, the repeat manipulations of PA catheter during cardiopulmonary bypass and the excessive inflation of the balloon.2
A retrospective study involving 32 442 patients by Kearney and Shabot revealed that in 7 out of 10 patients who developed PA rupture, there was either difficulty in inflating the balloon or resistance was felt when the catheter was advanced.3
Huang et al reported a PA rupture after attempted removal of the PA catheter post-CABG. The resistance experienced during removal of the catheter was due to the accidental suture of the PA catheter during closure of the left heart vent hole on the pulmonary trunk.5
The most apparent sign of PA rupture is haemoptysis due to the laceration of the vessel wall with direct bleeding into the pulmonary parenchyma that might extend into the airways. Moreover, haemothorax could well develop when the injury involves the visceral pleura.6
Patients on anticoagulation treatment are at a higher risk of developing PA false aneurysm as the body’s ability to seal any vascular injury is inhibited.3
The aneurysmal sac does not have any intact vessel layer and is formed only by compressed lung parenchyma. This leaves these aneurysms prone to rupture since they are inherently unstable.
The preferential non-invasive method in diagnosing PA haemorrhage has always been contrast enhanced CT scans, especially in patients with pulmonary hypertension. Although PA angiography is considered as the valuable diagnostic and therapeutic tool of PA rupture, contrast enhanced CT scan is the preferential non-invasive method for the diagnosis of PA rupture.7
The goals of initial treatment are to control bleeding, correct hypovolaemia and preserve the function of the unaffected lung until the area of bleeding is identified and dealt with.
To achieve the above goals, it is recommended to position the patient with the affected lung inferior to prevent soiling of the contralateral lung. After separation of the lungs (either with a double-lumen tube or with a bronchial blocker) the injured lung should be positioned up most to decrease the PA pressure.
The next objective is haemostasis by correction of coagulation—for example, reversal of heparin when used, replacement of platelets and administration of fresh frozen plasma.2
Once the patient is stable enough, diagnosis should be formed and immediate treatment options should be considered, such as embolisation of the affected branch of the pulmonary artery,8 and other surgical therapeutic options, such as direct repair of the injured vessel or resection of the affected lung segment.
However, in cases with massive bleeding, an aggressive surgical approach is needed. Kearney and Shabot reported that the presence of haemothorax demands immediate thoracotomy with direct surgical repair and patients will not survive if treated non-operatively.3 However, patients without haemothorax had a similar outcome with surgical or non-surgical management.3
In our case, we were fortunate enough that the bleeding stopped immediately following the withdrawal of the catheter; therefore, an active intervention was not required. Moreover, the repeat contrast enhanced chest CT scan confirmed no residual injury or false aneurysm of the PA and, therefore, the use of cardiopulmonary bypass during the CABG procedure was safe.
LEARNING POINTS
A diagnosis of pulmonary artery injury should be considered in all patients who experience haemoptysis after the placement of a pulmonary artery catheter with a possibility of pseudoaneurysm formation.
Rapid diagnosis with contrast CT or angiography of the pulmonary arteries is essential.
Prompt management of the pulmonary artery injury can be life-saving although, as seen in our case, spontaneous remission is possible.
Footnotes
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication.
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