140 likes | 281 Views
Catheter Induced PA Perforation. Case II. 55 female non smoker POD#7 CABG & mitral valve annuloplasty Chest medicine consult because of Recurrent hemoptysis No previous hemoptysis. History. Initial presentation of NSTEMI & CHF NO fever , CP , leg pain or SOB
E N D
Case II • 55 female non smoker • POD#7 CABG & mitral valve annuloplasty • Chest medicine consult because of Recurrent hemoptysis • No previous hemoptysis
History • Initial presentation of NSTEMI & CHF • NO fever , CP , leg pain or SOB • POD#1 frank blood from ETT without hemodynamic consequence Coagulopathy corrected INR 1.5 & Plt 70 • POD#3 thick clotted blood
History • PMH No CAP , TB • No travel , contact , pets • No occupational risk • Rx : ASA , Metoprolol , Ramipril
Examination • Stable RR 14 Sat 91% RA 96% 3 l O2 BP 120/80 HR 70 afebrile • Chest : decreased BS anteriorly • CVS : S1+S2+O • Abd & LL NAD
Investigation • WBC 11 HB 70 55 70 POD#1 No further drop • Renal function N • Minimal sputum for study • CXR & CT chest
Course • Bronchoscopy N airway Thick blood clot LUL
Catheter Induced PA Perforation • Injury can be intimal tear full thickness rupture retrograde dissection contralateral pulmonary artery • As result pulmonary hemorrhage and hematomas extend into the airways rupture through visceral pleura hemothorax • The parenchymal hemorrhage self-limited if a defect in the arterial wall seals or forms a pulmonary artery pseudoaneurysm high potential for rupture Ann Of thoracic Sx 2001
Catheter Induced PA Perforation • Retrospective study 1985-1998 • 850 Swan Ganz line Cardiac Sx CABG , Valve , Aortic Aneurysm • 12 case of perforation 0.1% • Mean age 70 Female : Male 2:1 Ann Of thoracic Sx 2001
Catheter Induced PA Perforation Intraoperative Dx 5 cases Brisk blood from ETT during weaning CPB or immediately after Postoperative Dx 7 cases 3 Pts brisk blood ETT with inflating balloon 1 Pt Cardiac arrest discovered during chest exploration 3 Pts Mild hemoptysis Ann Of thoracic Sx 2001
Catheter Induced PA Perforation • Brisk Blood ETT (300-400) was managed with Bronchial blocker in 6 Pts with Double lumen ETT in 2 Pts • Intraoperative cases All had injury to branches of lobar artery 1 in addition had injury to Lt main 3 lobectomies & 1 pneumonectomy Ann Of thoracic Sx 2001
Catheter Induced PA Perforation • 2 postop major bleeding Initially stable 1 died of extensive lobar hemorrhage • 3 postop minor hemoptysis 1 complete recovery 1 died after recurrent hemoptysis from rupture pesudoaneurysm POD#15 1 recurrent hemoptysis embolization Ann Of thoracic Sx 2001
Catheter Induced PA Perforation • 73% of injuries were Rt sided mainly lobar artery branches • RLL 43% > RML 27% > RUL 7% • Mortality 42% Higher in old age , female & in surgically treated group Ann Of thoracic Sx 2001