INTRODUCTION: Pulmonary artery (PA) rupture is a rare (0.03%) but commonly fatal complication of right heart catheterization (RHC) that carries a mortality risk of 50–70%. Pulmonary hypertension (PH) appears to be a risk factor for rupture. Proposed management includes resuscitation procedures and specific medical or surgical management. We report a case of PA rupture caused by a PA catheter (PAC) in a patient with severe pulmonary arterial hypertension (PAH).
CASE PRESENTATION: This is a 51 yo woman with scleroderma who experienced progressive deterioration while on oral agents for PAH. She underwent a followup RHC under fluoroscopic guidance (right internal jugular vein access). Based on her severe PAH (80/30/mean 48 mmHg) she was admitted to the intensive care unit (ICU) to initiate inotropic agents, intravenous diuretics, and a continuous prostanoid infusion. PAC was left in place to monitor hemodynamic response for 48–72 hours. A wedge measurement was obtained by the ICU nurse about 40 hours after PAC placement (uneventful previous wedge measurements). Immediately after, she developed massive hemoptysis (400cc). Her physician was called to the bedside, the PAC balloon was deflated, pulled back 2 cm and reinflated again, immediately stopping the hemoptysis. She was taken emergently to the interventional radiology suite where fluoroscopy confirmed the presence of the PAC tip in the left lower lobe PA. Under fluoroscopic guidance, the PAC balloon was deflated (balloon had been up for about 20 minutes) and withdrawn into the main left PA. A limited left pulmonary angiography revealed a rounded pseudoaneurysm in the left PA lateral basal segmental branch. A pulmonary angiogram catheter was inserted via the right femoral vein and a selective angiogram confirmed the pseudoaneurysm. A 5 French vertebral catheter was advanced and the pseudoaneurysm was packed with four, 4 mm Nester coils. Post embolization angiogram confirmed the pseudoaneurysm and its trunk to be completely occluded and well packed with coils. She went back to ICU for further observation and was discharged home after 48 hours. She is doing well 8 months later.
DISCUSSIONS: While the use of PAC in the ICU setting has significantly declined, its use in the diagnosis and management of patients with PH remains high. PH has been found to be a risk factor for PA rupture during PAC placement. Therefore, our fortunate clinical outcome has significant clinical relevance in this population. We suspect that her right ventricular dilatation and PAC coiling in the right ventricle led to unexpected catheter migration in between wedge measurements. Balloon inflation likely led to PA rupture given her diseased vessels and her severe PA pressures then led to massive hemoptysis. A few years earlier, one of our PAH patients succumbed to PA rupture after a RHC. This made us review the available interventions and steps to be followed if another case were to occur. This prior experience prompted our team to rapidly pull the catheter back and do a proximal balloon inflation which completely stopped the bleeding. Identification of the pseudoaneurysm and subsequent coiling controlled this complication and saved our patient's life.
CONCLUSION: While rare, PA rupture is a dreaded complication of PAC placement. We believe ours is the first reported case of a PAH patient who suffered this complication and survived with a radiological therapeutic intervention. Our patient underwent rapid balloon occlusion of the vessel at its proximal level with subsequent emergency intra-arterial coil embolization. Establishing a similar algorithm in specialized PH centers might be life-saving given the high mortality risk expected in these cases.
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