eComment: Management options of tube thoracostomy-induced pulmonary artery injury.

Fig. 1. Axial CT-scan image showing intercostal catheter located in the right pulmonary artery. Fig. 2. CT-scan image six weeks post removal of the catheter showing the sealed tract. used is by no means innocuous. Bleeding complications have been seen in patients with dense adhesions in the pleural space and in the post-pneumonectomy state. In the latter situation pulmonary vascular injury has been suspected if the tip of the catheter lies beyond midline w3x. In our case the catheter had traversed the trapped and diseased lung probably at the site of pleural adhesion into the right pulmonary artery in spite of using blunt dissection to introduce the catheter. The patient was fortunate to have this complication recognised early and resuscitation was rapid as he was already in the ICU. The non-operative approach to management of this situation was chosen owing to the trapped lung making a surgical approach quite hazardous and likely to result in further bleeding and lung injury. We anticipated that the dense pleural adhesions around the entire lung and positive pressure ventilation would assist in limiting the spread of any intra-pulmonary haematoma. We were pleased that gradual catheter removal over several days allowed progressive clot formation and sealing of the catheter tract. Pulmonary artery injury is very rare but a serious complication of tube thoracostomy. The literature has reported few cases, but all have required surgical intervention. Because of our patient's underlying lung disease he was managed by a trial of catheter removal with a backup plan for surgical intervention should that be required. He was fortunate not to require surgical intervention. This case once again emphasises the importance of determining the location of the pleural space and the lung edge prior to insertion of a thoracostomy tube. References w1x Singh KJ, Newman MAJ. Pulmonary artery catheterisation: an unusual complication of chest tube insertion. Sundaramurthy et al. w1x describe an interesting mode of treatment of tube thoracostomy-induced pulmonary artery perforation. It is generally recognized that the blunt dissection method of chest tube insertion is safer but certainly not innocuous as their report shows. Pulmonary artery injury in such a setting is uncommon but appears to occur more frequently in the presence of pleural adhesions w2, 3x; the tube penetrates the lung parenchy-ma and perforates a branch pulmonary artery as it is advanced medially. Immediate return of frank blood via the tube leads to a suspicion of major …