Successful Management of a Patient with Pulmonary Artery Rupture in a Catheterization Suite

The patient was a 73-year-old woman with a complicated past medical history significant for orthotopic liver transplant, pulmonary hypertension, atrial fibrillation, and end-stage renal disease. She presented for routine right- and left-heart catheterization as part of an evaluation for renal transplantation. The patient received no sedation during the initial part of the procedure. Femoral artery and vein access were obtained without any complications. A 7-French introducer sheath was placed in the femoral vein, and a PAC was directed into the pulmonary artery. Pulmonary artery pressure was measured as 61/19 mmHg. Upon advancement of the PAC to the “wedge” position, the patient developed severe hemoptysis and an acute decrease in oxygenation. The anesthesia code team was called immediately for airway management. The PAC balloon was inflated by the cardiologist to prevent further hemorrhage. Cardiopulmonary resuscitation was initiated for pulseless bradycardia before the arrival of the code team. An anesthesiologist from the code team performed tracheal intubation with an 8.0 single-lumen ETT with direct laryngoscopy despite a copious amount of hemoptysis. The patient regained spontaneous circulation shortly after tracheal intubation. However, she continued to hemorrhage through the endotracheal tube, and ventilation with a bag-valvemask device (AirLife self-inflating resuscitation device, CareFusion, Yorba Linda, CA) became extremely difficult. To further control bleeding and to protect the left lung from spillage of blood, an Arndt endobronchial blocker (Cook Critical Care, Bloomington, IN) was placed blindly. Position of the bronchial blocker in the right mainstem bronchus was confirmed and adjusted with fluoroscopy (Figs 1 and 2). After placement of the bronchial blocker and inflation of the cuff with 3 mL of air, tracheal suctioning yielded no further evidence of active bleeding, and the peripheral oxygen saturation improved. The location of the bronchial blocker within the right mainstem bronchus, between the carina and the take-off of the right upper lobe, was confirmed later via fiberoptic bronchoscopy. Despite successful intubation and one-lung ventilation, the patient’s blood pressure remained labile. The cardiothoracic surgery team was called to initiate extracorporeal membrane oxygenation (ECMO). Femoral venoarterial (VA) ECMO was initiated without complication. With the initiation of ECMO, her vital signs stabilized, and the interventional cardiology team was able to localize the perforation to a distal pulmonary artery. Hemostasis then was achieved by advancing a second intravascular catheter within the pulmonary artery to coil the damaged branch. Subsequent bronchoscopy confirmed placement of the bronchial blocker in an optimal position and further demonstrated a resolution of bleeding. The patient was then transferred to the cardiothoracic intensive care unit for continued monitoring. The patient remained stable in the intensive care unit and was weaned from ECMO on postoperative day one. Although the patient’s ventilation and oxygenation had improved, she subsequently passed away as a result of multisystem organ failure.