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Year : 2022  |  Volume : 25  |  Issue : 2  |  Page : 200-201
Pulmonary thromboendarterectomy and pulmonary haemorrhage


Department of Anaesthesiology, Singapore General Hospital; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore

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Date of Submission27-Sep-2020
Date of Acceptance06-Jan-2021
Date of Web Publication11-Apr-2022
 

   Abstract 


Pulmonary thromboendarterectomy surgery is the recommended treatment for patients with chronic thromboembolic pulmonary hypertension. Massive intraoperative pulmonary haemorrhage with bleeding into the airway is a rare complication, and it typically presents as cardiopulmonary bypass flow is reduced and blood begins to flow through the pulmonary circulation. Immediate management includes maintaining extracorporeal circulation to reduce blood flow through the pulmonary circulation, isolation of the affected lung, while the surgeon identifies and repairs the site of haemorrhage.

Keywords: Communication, double-lumen endobronchial tube, endobronchial blocker, extracorporeal membrane oxygenation, reperfusion injury

How to cite this article:
Roscoe AJ, Hwang NC. Pulmonary thromboendarterectomy and pulmonary haemorrhage. Ann Card Anaesth 2022;25:200-1

How to cite this URL:
Roscoe AJ, Hwang NC. Pulmonary thromboendarterectomy and pulmonary haemorrhage. Ann Card Anaesth [serial online] 2022 [cited 2022 May 21];25:200-1. Available from: https://www.annals.in/text.asp?2022/25/2/200/342847




Pulmonary thromboendarterectomy (PTE) surgery is the recommended treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH), with a perioperative mortality now less than 2% reported by major centres.[1] However, devastating complications may occur, including pulmonary haemorrhage, reperfusion injury and right ventricular failure.[2] Kanchi et al had presented three different management approaches to intrapulmonary haemorrhage and reperfusion injury during PTE surgery.[3]

Massive intraoperative pulmonary haemorrhage with bleeding into the airway is a rare, but life-threatening complication of PTE surgery, with a reported incidence of 1-2%.[4],[5] It typically presents as cardiopulmonary bypass (CPB) flow is reduced and blood begins to flow through the pulmonary circulation. Immediate management includes restoration of full CPB to reduce blood flow through the pulmonary circulation. Prompt detection is essential to prevent contamination of the contralateral airway. Anaesthetic management involves lung isolation, which may be achieved with either a double-lumen endobronchial tube (DLT) or an endobronchial blocker (EBB). Weaning from CPB with a DLT and one-lung ventilation is challenging. Ventilation-perfusion mismatch and subsequent hypoxaemia result in an increase in pulmonary vascular resistance, creating a higher afterload for the impaired right ventricle. A DLT allows for suctioning of blood and potential differential lung ventilation but is suboptimal to promote tamponade of the bleeding bronchial segment. The advantage of an EBB is the ability to provide selective lobar blockade, which may better facilitate subsequent weaning from CPB, and assist in tamponade of the haemorrhage.[6] The successful use of a DLT in combination with an EBB has been reported.[7] Early identification of the site of haemorrhage is also critical. Using the “bubble” technique, during gentle ventilation, bubbles can be visualised arising from distal pulmonary branches to help identify the location of the breach.[8] This may then allow surgical application of a haemostatic agent to control the bleeding. If surgical haemostasis is not possible, then short-term venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is often employed to decrease blood flow through the pulmonary circulation. Weaning from VA-ECMO occurs after bleeding into the airway has resolved.

Intrapulmonary haemorrhage from a bronchial collateral vessel presents a different challenge. Systemic-to-pulmonary arterial collaterals are common in CTEPH[9] and bleeding from one or more of these bronchial collaterals may not be sufficiently reduced by maintaining extracorporeal circulation alone. Management options are limited. Lung isolation is again critical to prevent contralateral lung involvement and weaning from CPB with reversal of heparinisation may prove successful. However, continued haemorrhage into the airway requires further intervention: urgent pulmonary angiography and coil embolisation of the culprit collateral vessel can provide the solution.

Post-PTE reperfusion pulmonary oedema may occur in up to 20% of cases.[10] It can occur immediately after weaning from CPB, but typically presents 24 – 48 hours after surgery. In its most severe form, veno-venous (VV) ECMO is warranted to provide adequate oxygenation for the patient. Weaning from VV-ECMO support is frequently successful and acceptable patient outcomes are reported by major centres.[10]

In approaching the management of PTE pulmonary haemorrhage teamwork is key. Good communication between surgeon, anaesthetist and perfusionist during weaning from CPB is essential. Prompt diagnosis and early institution of the appropriate treatment pathway can be enhanced by management algorithms,[3] potentially yielding successful patient outcomes.



 
   References Top

1.
Ali J, Kaul P, Osman M, Bartnik A, Taghavi J, Tsui S, et al. Pulmonary endarterectomy: Improving outcomes over time with increased institutional experience. J Heart Lung Transplant 2020;39:S31-2.  Back to cited text no. 1
    
2.
Ng CY, Roscoe A. Surgery for pulmonary vascular disease. In: Arrowsmith J, Roscoe A, Mackay J, editors. Core Topics in Cardiac Anaesthesia. 3rd ed.. Cambridge: Cambridge University Press; 2020. p. 113-7.  Back to cited text no. 2
    
3.
Kanchi M, Nair HC, Natarajan P, Punnen J, Shetty V, Patangi SO, et al. Management of intrapulmonary hemorrhage in patients undergoing pulmonary thrombo-endarterectomy. Ann Card Anaesth 2021;24:384-8.  Back to cited text no. 3
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4.
Guth S, Wiedenroth CB, Wollenschlager M, Richter MJ, Ghofrani HA, Arlt M, et al. Short-term venoarterial extracorporeal membrane oxygenation for massive endobronchial hemorrhage after pulmonary endarterectomy. J Thorac Cardiovasc Surg 2018;155:643-9.  Back to cited text no. 4
    
5.
Mayer E, Klepetko W. Techniques and outcomes of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Proc Am Thorac Soc 2006;3:589-93.  Back to cited text no. 5
    
6.
Dalia AA, Streckenbach S, Andrawes M, Channick R, Wright C, Fitzsimons M. Management of pulmonary hemorrhage complicating pulmonary thromboendarterectomy. Front Med (Lausanne) 2018;5:326.  Back to cited text no. 6
    
7.
Yildizeli B, Arslan O, Tas S, Eldem B, Aksoy E, Koçak T, et al. Management of massive pulmonary hemorrhage following pulmonary endarterectomy. Thorac Cardiovasc Surg 2014;62:89-91.  Back to cited text no. 7
    
8.
Morsolini M, Azzaretti A, Orlandoni G, D'Armini AM. Airway bleeding during pulmonary endarterectomy: The “bubbles” technique. J Thorac Cardiovasc Surg 2013;145:1409-10.  Back to cited text no. 8
    
9.
Remy-Jardin M, Duhamel A, Deken V, Bouaziz N, Dumont P, Remy J. Systemic collateral supply in patients with chronic thromboembolic and primary pulmonary hypertension: Assessment with multi-detector row helical CT angiography. Radiology 2005;235:274-81.  Back to cited text no. 9
    
10.
Martin-Suarez S, Gliozzi G, Fiorentino M, Loforte A, Ghigi V, Di Camillo M, et al. Role and management of extracorporeal life support after surgery of chronic thromboembolic pulmonary hypertension. Ann Cardiothorac Surg 2019;8:84-92.  Back to cited text no. 10
    

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Correspondence Address:
Nian Chih Hwang
Department of Anaesthesiology, Singapore General Hospital, 1 Hospital Drive, 169608
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.aca_247_20

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