A Novel Treatment for Pulmonary Hemorrhage During Thromboendarterectomy Surgery Devi Prasad Shetty, FRCS, Hema C. Nair, MD, Varun Shetty, MBBS, and Julius Punnen, MCh Department of Anesthesia and Critical Care Services, Institute of Cardiac Sciences, Narayana Health City, Bangalore, India
Injury to the pulmonary artery during thromboendarterectomy is a rare but potentially fatal complication with no reported surgical techniques to combat it. Treatment is only supportive and morbidity is high. We report the intraoperative diagnosis and surgical management
of pulmonary hemorrhage in 3 patients after pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. (Ann Thorac Surg 2015;99:e77–8) Ó 2015 by The Society of Thoracic Surgeons
P
circulation was then stopped for better visualization, and that particular branch of the PA was sealed with a hemostatic agent (Surgicel wick; Ethicon LLC, San Lorenzo, Puerto Rico). The key here is to not block the branch by rolling the Surgicel like a ball; rather a forceps is used to introduce a rolled up wick that fills the PA branch gradually. A ball of Surgicel cannot reach the segmental branch; however, a long strip can reach the segmental or subsegmental branch and will be held in position by the forward flow of the pulmonary circulation and the wind sock–like shape of the PA radicals. Placed thus, it will not require anything to tether it in place. Because this was the first case, and faced with the prospect of torrential bleeding into the airways as witnessed earlier, the patient was also connected to an extracorporeal membrane oxygenator circuit, and a double-lumen endotracheal tube (DLT) was inserted. When weaning off cardiopulmonary bypass commenced, the bleeding from the right endobronchial tube appeared moderate enough to be stemmed by reversing the heparin. As a result of protamine administration, anticoagulation was reduced to levels not compatible with extracorporeal membrane oxygenation and so it was discontinued. The patient had blood staining from the right side of the DLT that improved with repeated bronchoalveolar lavage and suctioning. He was extubated after 48 hours of elective ventilation when he showed improvement in both gas exchange and PA pressures. The second patient was a 41-year-old man who presented with grade III dyspnea. He had deep vein thrombosis and an inferior vena caval filter put in previously. He exhibited an air leak from the right lower lobe after endarterectomy that was plugged with Surgicel in the manner described. Before weaning off cardiopulmonary bypass, both lumens of the DLT were cleared with saline solution and suction. Initially approximately 100 mL of blood was suctioned out of the right PA, but once weaning was begun, the bleeding was reduced and completely stopped with protamine. The DLT was retained overnight and then changed to a single-lumen
ulmonary thromboendarterectomy is the definitive treatment for chronic thromboembolic pulmonary hypertension in patients far advanced into the natural course of the illness and manifesting with severe debilitating dyspnea and sometimes cyanosis [1]. During surgery, an endarterectomy of the pulmonary artery (PA) is performed from the branch PA onward extending into the segmental and subsegmental branches. Respecting the tissue plane and dissecting in the right plane will prevent injury to the PA, but injury can still occur in rare cases when the PA wall is breached [2]. Left untreated, this results in massive bleeding into the bronchus when the heart starts ejecting. Detecting this breach has hitherto been deemed impossible at this stage of the surgery because the circulation is stopped and the PA is open [3]. In this report we describe the techniques we used in 3 patients to detect injury sustained to the PA soon after performing the endarterectomy and its treatment.
Technique A 58-year-old man with grade IV dyspnea, cyanosis, and right heart failure underwent pulmonary thromboendarterectomy under cardiopulmonary bypass and deep hypothermic circulatory arrest in the standard fashion [2]. After endarterectomy was completed in the right lung and circulation reestablished, the PA lumen slowly filled up with blood. At this time, gentle positive pressure was delivered to the airway through the anesthetic circuit, and bubbling was noticed in the PA lumen. The area was then flooded with saline solution and rechecked with hand ventilation, much like finding a hole in a punctured tire (Fig 1). The site of the leak was ascertained by visualising the air bubbles streaming in from the affected ostia. The Accepted for publication Nov 24, 2014. Address correspondence to Dr Nair, Department of Anesthesia and Critical Care Services, Institute of Cardiac Sciences, Narayana Health City, Anekal Taluk, Hosur Rd, Bangalore, India 560099; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.060
e78
HOW TO DO IT SHETTY ET AL TREATING PULMONARY ARTERY HEMORRHAGE
Fig 1. Pulmonary artery after the endarterectomy showing back bleeding and air bubbles collecting within its lumen during lung inflation by ventilation. The persistent bubbling alerts the surgeon to the possibility of injury to the pulmonary artery branch, which can then be sealed. (RPA ¼ right pulmonary artery; SVC ¼ superior vena cava.)
tube for 36 more hours before extubation. His arterial partial pressure of oxygen was less than 100 mm Hg for 6 hours, but then it steadily improved during the next 48 hours, enabling extubation on the second postoperative day. The third patient was a 50-year-old man with a longstanding history of exercise intolerance and no history of deep vein thrombosis, but who was diagnosed as having chronic thromboembolic pulmonary hypertension on extensive investigation. Surgery proceeded uneventfully until the right lower lobe air leak was detected after endarterectomy by means of the ventilating technique that we now routinely follow in our institute. After sealing the branch of the PA with Surgicel, the PA was once again tested under water. This time no air bubbles were seen and the seal appeared to be working. As is protocol now, a DLT was placed before starting pulmonary perfusion. A total of 150 mL of blood was suctioned out from the right lumen of the DLT while in the operating room. This slowed down to a trickle after protamine and then stopped by the time of chest closure. In the critical care unit, suction from the right side only yielded bloodstained secretions. Gas exchange improved overnight, the DLT was changed in the morning to a single-lumen tube, and he was extubated after 48 hours of ventilation.
Comment Pulmonary hemorrhage after pulmonary thromboendarterectomy is a rare but life-threatening complication in
Ann Thorac Surg 2015;99:e77–8
which it is imperative to prevent exsanguination and allow for adequate gas exchange. Several techniques have been described to deal with this complication, including isolating the affected lung and controlling the bleed with vasoconstrictors and procoagulants and use of a Fogarty catheter and clamp to occlude the injured PA [3–6]. If the bleeding persists, then gas exchange can be maintained with venoarterial or venovenous extracorporeal membrane oxygenation [4, 5]. In the past we had to resort to the above methods, but none have been as successful as our current technique. For the hemostatic plug, we used Surgicel because the fiber it contains gives it a tenacity, enabling it to be fashioned into a filiform wick that can be placed deep into the PA radicals. Some authors have described their inability to test the integrity of the PA while on deep hypothermic circulatory arrest [1, 3, 6]. We have found that irrigating the PA with normal saline solution while the anesthetist hand ventilates is a reliable method of testing the integrity of the vessel wall while the PA is open, enabling us to attempt to seal the rent. Before adopting this technique, torrential bleeding into the bronchi would occur when the PA was perfused, leading to severely compromised gas exchange, hypoxia, and hemodynamic instability. The volume of blood flooding the endotracheal tube would be profuse, and attempts to either contain it with protamine or ventilate the lungs would fail. In these three cases, it was immediately apparent to us that the quantity of bleeding into the bronchi was significantly less. Whereas previously bleeding was measured in liters, now it was only 5 to 10 mL at a time and could be cleared on suctioning. The total bleeding was never more than a few hundred milliliters, which stopped after protamine. However, detecting the source of bleeding early enough to intervene is the invaluable worth of this technique.
References 1. Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg 2003;76:1457–64. 2. Thistlethwaite PA, Kaneko K, Madani MM, Jamieson SW. Technique and outcomes of pulmonary endarterectomy surgery. Ann Thorac Cardiovasc Surg 2008;14:274–82. 3. Manecke GR Jr, Kotzur A, Atkins G, et al. Massive pulmonary hemorrhage after pulmonary thromboendarterectomy. Anesth Analg 2004;99:672–5; table of contents. 4. Pretorius V, Alayadhi W, Modry D. Extracorporeal life support for the control of life-threatening pulmonary hemorrhage. Ann Thorac Surg 2009;88:649–50. 5. Yildizeli B, Arslan O, Tas S, et al. Management of massive pulmonary hemorrhage following pulmonary endarterectomy. Thorac Cardiovasc Surg 2014;62:89–91. 6. Reddy S, Rajanbabu BB, Kumar NK, Rajani I. Temporary clamping of branch pulmonary artery for pulmonary hemorrhage after endarterectomy. Ann Thorac Surg 2013;96:1459–61.
Injury to the pulmonary artery during thromboendarterectomy is a rare but potentially fatal complication with no reported surgical techniques to combat it. Treatment is only supportive and morbidity is high. We report the intraoperative diagnosis and surgical management
of pulmonary hemorrhage in 3 patients after pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. (Ann Thorac Surg 2015;99:e77–8) Ó 2015 by The Society of Thoracic Surgeons
P
circulation was then stopped for better visualization, and that particular branch of the PA was sealed with a hemostatic agent (Surgicel wick; Ethicon LLC, San Lorenzo, Puerto Rico). The key here is to not block the branch by rolling the Surgicel like a ball; rather a forceps is used to introduce a rolled up wick that fills the PA branch gradually. A ball of Surgicel cannot reach the segmental branch; however, a long strip can reach the segmental or subsegmental branch and will be held in position by the forward flow of the pulmonary circulation and the wind sock–like shape of the PA radicals. Placed thus, it will not require anything to tether it in place. Because this was the first case, and faced with the prospect of torrential bleeding into the airways as witnessed earlier, the patient was also connected to an extracorporeal membrane oxygenator circuit, and a double-lumen endotracheal tube (DLT) was inserted. When weaning off cardiopulmonary bypass commenced, the bleeding from the right endobronchial tube appeared moderate enough to be stemmed by reversing the heparin. As a result of protamine administration, anticoagulation was reduced to levels not compatible with extracorporeal membrane oxygenation and so it was discontinued. The patient had blood staining from the right side of the DLT that improved with repeated bronchoalveolar lavage and suctioning. He was extubated after 48 hours of elective ventilation when he showed improvement in both gas exchange and PA pressures. The second patient was a 41-year-old man who presented with grade III dyspnea. He had deep vein thrombosis and an inferior vena caval filter put in previously. He exhibited an air leak from the right lower lobe after endarterectomy that was plugged with Surgicel in the manner described. Before weaning off cardiopulmonary bypass, both lumens of the DLT were cleared with saline solution and suction. Initially approximately 100 mL of blood was suctioned out of the right PA, but once weaning was begun, the bleeding was reduced and completely stopped with protamine. The DLT was retained overnight and then changed to a single-lumen
ulmonary thromboendarterectomy is the definitive treatment for chronic thromboembolic pulmonary hypertension in patients far advanced into the natural course of the illness and manifesting with severe debilitating dyspnea and sometimes cyanosis [1]. During surgery, an endarterectomy of the pulmonary artery (PA) is performed from the branch PA onward extending into the segmental and subsegmental branches. Respecting the tissue plane and dissecting in the right plane will prevent injury to the PA, but injury can still occur in rare cases when the PA wall is breached [2]. Left untreated, this results in massive bleeding into the bronchus when the heart starts ejecting. Detecting this breach has hitherto been deemed impossible at this stage of the surgery because the circulation is stopped and the PA is open [3]. In this report we describe the techniques we used in 3 patients to detect injury sustained to the PA soon after performing the endarterectomy and its treatment.
Technique A 58-year-old man with grade IV dyspnea, cyanosis, and right heart failure underwent pulmonary thromboendarterectomy under cardiopulmonary bypass and deep hypothermic circulatory arrest in the standard fashion [2]. After endarterectomy was completed in the right lung and circulation reestablished, the PA lumen slowly filled up with blood. At this time, gentle positive pressure was delivered to the airway through the anesthetic circuit, and bubbling was noticed in the PA lumen. The area was then flooded with saline solution and rechecked with hand ventilation, much like finding a hole in a punctured tire (Fig 1). The site of the leak was ascertained by visualising the air bubbles streaming in from the affected ostia. The Accepted for publication Nov 24, 2014. Address correspondence to Dr Nair, Department of Anesthesia and Critical Care Services, Institute of Cardiac Sciences, Narayana Health City, Anekal Taluk, Hosur Rd, Bangalore, India 560099; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.060
e78
HOW TO DO IT SHETTY ET AL TREATING PULMONARY ARTERY HEMORRHAGE
Fig 1. Pulmonary artery after the endarterectomy showing back bleeding and air bubbles collecting within its lumen during lung inflation by ventilation. The persistent bubbling alerts the surgeon to the possibility of injury to the pulmonary artery branch, which can then be sealed. (RPA ¼ right pulmonary artery; SVC ¼ superior vena cava.)
tube for 36 more hours before extubation. His arterial partial pressure of oxygen was less than 100 mm Hg for 6 hours, but then it steadily improved during the next 48 hours, enabling extubation on the second postoperative day. The third patient was a 50-year-old man with a longstanding history of exercise intolerance and no history of deep vein thrombosis, but who was diagnosed as having chronic thromboembolic pulmonary hypertension on extensive investigation. Surgery proceeded uneventfully until the right lower lobe air leak was detected after endarterectomy by means of the ventilating technique that we now routinely follow in our institute. After sealing the branch of the PA with Surgicel, the PA was once again tested under water. This time no air bubbles were seen and the seal appeared to be working. As is protocol now, a DLT was placed before starting pulmonary perfusion. A total of 150 mL of blood was suctioned out from the right lumen of the DLT while in the operating room. This slowed down to a trickle after protamine and then stopped by the time of chest closure. In the critical care unit, suction from the right side only yielded bloodstained secretions. Gas exchange improved overnight, the DLT was changed in the morning to a single-lumen tube, and he was extubated after 48 hours of ventilation.
Comment Pulmonary hemorrhage after pulmonary thromboendarterectomy is a rare but life-threatening complication in
Ann Thorac Surg 2015;99:e77–8
which it is imperative to prevent exsanguination and allow for adequate gas exchange. Several techniques have been described to deal with this complication, including isolating the affected lung and controlling the bleed with vasoconstrictors and procoagulants and use of a Fogarty catheter and clamp to occlude the injured PA [3–6]. If the bleeding persists, then gas exchange can be maintained with venoarterial or venovenous extracorporeal membrane oxygenation [4, 5]. In the past we had to resort to the above methods, but none have been as successful as our current technique. For the hemostatic plug, we used Surgicel because the fiber it contains gives it a tenacity, enabling it to be fashioned into a filiform wick that can be placed deep into the PA radicals. Some authors have described their inability to test the integrity of the PA while on deep hypothermic circulatory arrest [1, 3, 6]. We have found that irrigating the PA with normal saline solution while the anesthetist hand ventilates is a reliable method of testing the integrity of the vessel wall while the PA is open, enabling us to attempt to seal the rent. Before adopting this technique, torrential bleeding into the bronchi would occur when the PA was perfused, leading to severely compromised gas exchange, hypoxia, and hemodynamic instability. The volume of blood flooding the endotracheal tube would be profuse, and attempts to either contain it with protamine or ventilate the lungs would fail. In these three cases, it was immediately apparent to us that the quantity of bleeding into the bronchi was significantly less. Whereas previously bleeding was measured in liters, now it was only 5 to 10 mL at a time and could be cleared on suctioning. The total bleeding was never more than a few hundred milliliters, which stopped after protamine. However, detecting the source of bleeding early enough to intervene is the invaluable worth of this technique.
References 1. Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg 2003;76:1457–64. 2. Thistlethwaite PA, Kaneko K, Madani MM, Jamieson SW. Technique and outcomes of pulmonary endarterectomy surgery. Ann Thorac Cardiovasc Surg 2008;14:274–82. 3. Manecke GR Jr, Kotzur A, Atkins G, et al. Massive pulmonary hemorrhage after pulmonary thromboendarterectomy. Anesth Analg 2004;99:672–5; table of contents. 4. Pretorius V, Alayadhi W, Modry D. Extracorporeal life support for the control of life-threatening pulmonary hemorrhage. Ann Thorac Surg 2009;88:649–50. 5. Yildizeli B, Arslan O, Tas S, et al. Management of massive pulmonary hemorrhage following pulmonary endarterectomy. Thorac Cardiovasc Surg 2014;62:89–91. 6. Reddy S, Rajanbabu BB, Kumar NK, Rajani I. Temporary clamping of branch pulmonary artery for pulmonary hemorrhage after endarterectomy. Ann Thorac Surg 2013;96:1459–61.
