Asian Cardiovasc Thorac Ann 2002;10:191-193
© 2002 Asia Publishing EXchange Pte Ltd
Bronchial Artery Dissection and Fatal Hemothorax Following Pneumonectomy
Augustine TM Tang, FRCSEd,
Theodore J Velissaris, FRCSEd,
Geoffrey Tsang, FRCS(CTh),
William Roche, FRCPath1
Department of Thoracic Surgery
1 Department of Clinical Pathology Wessex Cardiothoracic Centre Southampton General Hospital Southampton, Hampshire, England, UK
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Augustine TM Tang, FRCSEd Tel: 44 23 8077 7222 Fax: 44 23 8079 8508 email: gus{at}tang-family.org Department of Thoracic Surgery, Wessex Cardiothoracic Centre, Southampton General Hospital, Tremona Road, Southampton, Hampshire, England SO16 6YD, UK.
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ABSTRACT
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A 59-year-old man died suddenly and unexpectedly two days after an uncomplicated pneumonectomy for bronchogenic adenocarcinoma. In addition to a distal pulmonary thromboembolism found at postmortem, there was significant hemorrhaging into the pneumonectomy space, which was associated with rupture of a dissecting aneurysm in the calcified bronchial artery stump. The pathology and surgical implications of bronchial artery disease are discussed.
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INTRODUCTION
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Hemorrhagic complications are reported to occur in up to 5% of all pulmonary resections, and they can be fatal.1 A case of massive hemothorax after pneumonectomy, caused by acute dissection of an arteriopathic bronchial artery (BA) stump, is described.
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CASE REPORT
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A 59-year-old man was admitted with a 2-month history of hemoptysis and night sweats. He was an ex-smoker with previous exposure to asbestos. Finger clubbing was found in an otherwise unremarkable clinical examination. Radiological investigations revealed a mass in the middle lobe of the right lung with no evidence of metastatic disease. Bronchoscopic appearances were normal, but brushings from the right middle lobe showed nonsmall cell bronchial carcinoma. Pulmonary function, as demon-strated by spirometry, was adequate for lung resection (forced expiratory volume in 1 second, 2.89 L; forced vital capacity, 4.74 L). The patient was not given any neoadjuvant radiotherapy or chemotherapy.
At thoracotomy, a large (5 x 5 x 8 cm) central tumor was seen in the right middle lobe, extending into the upper and lower lobes. The distal lung parenchyma was consolidated with reactive hilar lymphadenopathy. The tumor was resected by pneumonectomy: the pulmonary artery and vein were ligated and divided, and their proximal ends were oversewn; the right main bronchus was transected using a TL 30 stapling device (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA), and the stump was tested for air leak to a pressure of 40 mm Hg. Routine closure was performed without insertion of chest drain. The patient progressed well with no complication in the first 2 postoperative days. Clinical monitoring of vital signs (pulse rate, noninvasive brachial blood pressure, and core temperature), transcutaneous pulse oximetry, and daily fluid balance (bladder catheter on the first postoperative day) revealed no abnormality. Routine chest radiography carried out within 24 hours of the procedure showed no evidence of hemorrhage into the pneumo-nectomy space. On the 3rd postoperative day, the patient experienced acute dyspnea at rest and suffered cardiorespiratory arrest. Attempts at resuscitation were unsuccessful.
Histological examination of the resected right lung revealed a poorly differentiated adenocarcinoma in the middle lobe, invading the oblique and horizontal fissures. The bronchial margins as well as the hilar and bronchial lymph nodes were free of tumor. These findings confirmed a pathological stage of T2N0 (stage IB) disease. Post-mortem examination showed scattered peripheral thrombi in the left pulmonary vasculature, occupying the segmental pulmonary arteries, which was considered to be the immediate cause of death. There was associated deep venous thrombosis in the left calf. Furthermore, over 1 L of blood in addition to fresh clots were found in the pneumonectomy space. Extensive fresh hematoma and blood clots surrounded the stump of the right main bronchus. Histology confirmed that the bronchial stump was free of tumor. The BA showed dystrophic calcification in the vessel wall and a ruptured dissecting aneurysm just proximal to the surgical staples (Figures 1 and 2
). There was associated nonocclusive thrombosis and acute inflammation. The coronary arteries were patent and the aorta displayed only mild atherosclerosis.
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Figure 1. Bronchial neurovascular bundle showing bronchial artery (A) and nerve (N). There is calcification of the internal elastic lamina of the bronchial artery (arrows). (Hematoxylin and eosin stain, original magnification x55).
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Figure 2. Bronchial artery at the resection margin showing a dissection (arrow) extending from the lumen (L) to form a dissecting aneurysm (D) between the inner two-thirds and outer one-third of the arterial wall (hematoxylin and eosin stain, original magnification x27.5).
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DISCUSSION
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This was a very unusual case of postoperative hemorrhage from an acute dissecting aneurysm arising in the BA stump. Although it might not have been the immediate cause of death, it undoubtedly contributed to the hemo-dynamic compromise created by the distal pulmonary thromboembolism. Hemorrhagic complications are not uncommon following pulmonary resection. Peterffy and Henze1 reviewed a series of 1,428 pulmonary resections and found a 5% incidence of significant intraoperative vascular injuries and a 2.6% incidence of postoperative bleeding necessitating emergency repeat thoracotomy. The prime cause of catastrophic postoperative hemorrhage is slipping of ligatures or sutures from the stumps of divided major vessels (pulmonary artery, pulmonary vein, azygos vein). Transfixion sutures of the main vascular stumps are generally recommended, although some authors have proposed a pursestring suture between double ligatures as a safer alternative.1 Other causes of hemorrhage reported after pulmonary resection include bleeding from systemic arteries (bronchial, mediastinal, and intercostal), coagu-lopathy, and pulmonary artery erosion by a bronchopleural fistula.
Vascular disease of the BAs is uncommon and usually manifests as nondissecting aneurysms.2–6 These can be either intrapulmonary or mediastinal and may remain asymptomatic or present with hemoptysis, hematemesis, superior vena cava obstruction, or symptoms mimicking aortic dissection.2–5 Routine preoperative evaluation of patients referred for resection of bronchogenic carcinoma in our unit, including clinical examination, spirometry, bronchoscopy, plain radiographs, and axial computed tomography would not reveal localized bronchial vasculopathy. It could be argued that selective angiography with or without digital enhancement might secure the diagnosis. However, as hemoptysis is one of the most common presenting symptoms of lung cancer, bearing in mind the rarity of bronchial vasculopathy, the costs and potential complications of angiography, routine screening of all surgical candidates using this procedure, in the absence of specific indications, would be hard to justify.
BA aneurysms have been associated with bronchiectasis, atherosclerosis, mycotic arteritis, and hereditary hemor-rhagic telangiectasia (Rendu-Osler-Weber disease).6 Treatment may be surgical or by transcatheter emboli-zation. The arteriopathic nature of the right BA with extensive mural calcification in our patient was not macroscopically evident at surgery. The bronchial stump was transected using a stapling device that also achieved closure of the BA by mass compression, and no bleeding was seen after the maneuver. However, the pathological arterial wall resulted in an acute dissecting aneurysm that led to postoperative intrathoracic hemorrhage. This unusual complication (believed to be the first reported case of dissection of the BA) seems to have been the consequence of an abnormal vessel responding to a common surgical maneuver.
Although one can only speculate whether oversewing of the divided bronchial stump might have prevented this complication, this along with other reported cases of BA aneurysm indicate that vascular disease and complications involving the BAs are entities that every thoracic surgeon should be aware of. Oversewing of the bronchial stump or individual ligation of an arteriopathic BA may prevent complications similar to those we encountered. In particular, when significant calcified vasculopathy is identified in the BA, identification and control of a disease-free segment proximal to the site of subsequent division should help to minimize dissection and rupture. However, it remains vitally important that direct visual confirmation of secure hemostasis is obtained prior to chest closure, regardless of the technical maneuver chosen to deal with the BA stump.
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REFERENCES
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Peterffy Á, Henze A. Haemorrhagic complications during pulmonary resection. A retrospective review of 1428 resections with 113 haemorrhagic episodes. Scand J Thorac Cardiovasc Surg
1983;17:283–7.[Medline]
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Yanagihara K, Ueno Y, Kobayashi T, Isobe J, Itoh M. Bronchial artery aneurysm. Ann Thorac Surg
1999;67: 854–5.[Abstract/Free Full Text]
-
Shaer AH, Bashist B. Computed tomography of bronchial artery aneurysm with erosion into the esophagus. J Comput Assist Tomogr
1989;13:1069–71.[Medline]
-
Hoffmann V, Ysebaert D, De Schepper A, Colpaert C, Jorens P. Acute superior vena cava obstruction after rupture of a bronchial artery aneurysm. Chest
1996;110:1356–8.[Abstract/Free Full Text]
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Hall RJ, Miller GA, Kerr IH. Ruptured bronchial artery aneurysm mimicking aortic dissection. Br Heart J
1977;39:909–10.[Abstract/Free Full Text]
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Ishizaki N, Shimokawa S, Tanaka K, Taira A, Onohara S, Tabata M, et al. Ruptured bronchial artery aneurysm associated with pleural telangiectasis and tortuous portal obstruction: report of a case. Surg Today
1995;25:852–4.[Medline]
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ABSTRACT
INTRODUCTION
