Non-Operative Management Of Chest Tube Induced Pulmonary Artery Injury

摘要

Chest tube insertion (thoracostomy) is a common procedure performed in the emergency department, the operating theatre and the intensive care unit. Inserting a drain into the pulmonary artery is a rare but life threatening complication. We report a case of successful non-operative management of a pulmonary artery injury after tube thoracostomy insertion. Introduction Chest tube insertion (thoracostomy) is commonly used in the management of thoracic empyema or pneumothorax. Major thoracic vessel injuries are rare but have been reported in literature. We report a case of a pulmonary artery injury caused by chest tube insertion, which has been folded in the pulmonary artery and where the patient was not a candidate for a thoracotomy. We managed this case non-operatively and retracted the drain. Clinical details A 63-year-old female presented to the emergency department with septic shock and somnolence. Six months before, an adenocarcinoma of the upper right lobe had been diagnosed during workup for aortic valve stenosis en mitral valve insufficiency, for which she underwent right upper lobectomy (pT1N0M0 adenocarcinoma) followed by an aortic valve replacement (Edward Magna Fase) five months ago. The mitral valve repair was not feasible because of adhesions after the upper lobe lobectomy. The postoperative cardiac function was still severely impaired. Furthermore the patient had chronic post thrombotic syndrome with ulcers on both legs. The patient required intubation and intensive care unit admission. A chest X ray showed pleural effusion. On needle aspiration pus was drained. No CT or ultrasound was performed in advance of the procedure. A 16 Fr chest-tube was blunt inserted in the forth intercostal space at the place of the diagnostic puncture. Directly after insertion, 2000ml of blood was drained in the drainage system. The chest-tube was immediately clamped. The patient became hypotensive and resuscitation was started with packed red cell and platelet transfusion. Chest X ray showed the tip of the catheter passing across the midline. The drain was retracted a few cm. Subsequently, CT scan showed the catheter to be in the right pulmonary artery and to be double folded (Fig.1, 2) Furthermore the scan showed that the drain was passing through the lower right lobe with widespread pneumonia. Theoretically, the intervention of choice should be a thoracotomy to remove the drain and to treat the empyema. However, the compromised condition of this patient precluded this. Earlier pre-operative lung function test, conducted before the lobectomy, showed the patient could not undergo a pneumonectomy. Because of findings during the aortic valve replacement we believed that central clamping of the pulmonary artery would be a hazardous procedure and surgery therefore would not be an option. We decided on non-operative treatment and to withdraw the catheter 2-3 cm every day, after complete correction of coagulation. On the fourth day the catheter was outside the intra-thoracic cavity without renewed blood loss. The patient was extubated on day five and transferred to the ward after 7 days. Control CT scan showed no embolism or bleedings (Fig. 3). Heparin was restarted 2 days after removal of the chest tube because of the low flow state in the left ventricle and impaired cardiac function inducing a high risk of thromboembolic complications. During the ICU stay the patient was treated with Flucloxacillin combined with Ceftriaxone. These antibiotics started as empirical treatment while the leg ulcers were the expected source of infection. This was confirmed by the microbiological analysis of the aspirated pus from the empyema was positive for Staphylococcus Aureus. The patient was discharged from the hospital by the twenty first day.