A large pseudoaneurysm caused by extrapleural plastic ball plombage.

Clinical History: The patient was a 32-year-old man who had been diagnosed as having a tuberculous lesion in his left upper lobe in 1949 and underwent collapse surgery using several plastic balls of larger size at the University Hospital on December 27, 1949. He had not noticed subjective symptoms until July 20, 1956, when he felt a sudden pain and pressure inside his left chest wall after elevation of his left arm. Slight fever, and coughing, without expectoration, lasted for a few days but no pulmonary hemorrhage, or blood-streaked sputum, was noticed. He visited our hospital asking for removal of the plastic balls. We hesitated to operate on him immediately and watched him carefully, for the fever between 99 and 101#{176} F. persisted for a long period. While we were still pondering on the indication of removal of plastic balls in this condition, hemoptysis started on August 8, 1956 and within a few days it changed into a profuse hemorrhage exceeding 500 cc. on the night of August 25th. The hemorrhage reached 1,000 cc. the next night and he complained of a severe chest pain which was hardly controlable by injection of large doses of demerol, and he requested immediate thoracotomy and removal of the balls. Operation: He was subjected to thoracotomy on August 31, 1956. To combat the pulmonary hemorrhage during operation, he was placed in the face-down position, using the table specially built for this purpose. For the same reason regional anesthesia was preferred to general anesthesia, in which preservation of tracheal reflex and maintainance of air-way is a hazardous problem. The regional anesthesia was reinforced by intramuscular administration of M1 cocktail consisting of Chlorpromazine 50 mg., Demeral 105 mg. and Prometazine 50 mg. one hour prior to operation. Three ribs, third, fourth and fifth, were resected following skin incision and division of muscles. Then the thorax was entered through the 5th periosteal bed. Adhesion of the lung to the wall was so severe that detachment required a meticulous manipulation. The lower, lobe was almost intact but the upper lobe was compressed to the wall by the pressure from inside. When the hematoma at the lateral edge of the upper lobe was partly removed oozing of blood was met and a gauze pack was placed to control the oozing. The medial-posterior approach was taken next and the thick white pleura at the upper end of the compact upper lobe was incised. Before long a part of a ball surface was disclosed and the ball was extracted with a large clamp. No sooner than the removal, a torrent of arterial blood filled the chest. The operator quickly probed the upper space and floating balls were all extracted in a moment. A large amount of gauze packing was placed in the chest to control the bleeding, and the wound was closed in layers with interrupted silk sutures without delay. The blood loss was at this time 2,000 cc., systolic pressure around 40 mg. Hg., and the patient was unconscious. Treatment with generous transfusion of bank blood and fresh blood, and administration of vasospastics and other drugs helped the patient to overcome the shock stage, and he survived. The second operation was undertaken a week later. This time the patient was put under general anesthesia with intratracheal intubation, for absence of pulmonary hemorrhage during operation and postoperative days convinced the anesthetist of the safety of this method. We presumed that the bleeding point was in the upper pulmonary vessels. The chest was reopened through the old wound and without removing the gauze pack the lower lobe was mobilized to ease the intrathoracic