1. Catheter Induced PA Perforation

2. Case II  55 female non smoker  POD#7 CABG & mitral valve annuloplasty  Chest medicine consult because of Recurrent hemoptysis Recurrent hemoptysis  No previous hemoptysis

3. History  Initial presentation of NSTEMI & CHF  NO fever, CP, leg pain or SOB  POD#1 frank blood from ETT without hemodynamic consequence Coagulopathy corrected INR 1.5 & Plt 70 Coagulopathy corrected INR 1.5 & Plt 70  POD#3 thick clotted blood

4. History  PMH No CAP, TB  No travel, contact, pets  No occupational risk  Rx : ASA, Metoprolol, Ramipril

5. Examination  Stable RR 14 Sat 91% RA 96% 3 l O2 BP 120/80 HR 70 afebrile BP 120/80 HR 70 afebrile  Chest : decreased BS anteriorly  CVS : S1+S2+O  Abd & LL  NAD

6. Investigation  WBC 11 HB 70  55  70 POD#1 No further drop No further drop  Renal function N  Minimal sputum for study  CXR & CT chest

7. Course  Bronchoscopy  N airway  N airway Thick blood clot LUL Thick blood clot LUL

8. Catheter Induced PA Perforation  Injury can be intimal tear full thickness rupture full thickness rupture retrograde dissection retrograde dissection  contralateral pulmonary artery  contralateral pulmonary artery   As result pulmonary hemorrhage and hematomas extend into the airways rupture through visceral pleura  hemothorax   The parenchymal hemorrhage self-limited if a defect in the arterial wall seals or forms a pulmonary artery pseudoaneurysm  high potential for rupture Ann Of thoracic Sx 2001 Ann Of thoracic Sx 2001

9. Catheter Induced PA Perforation  Retrospective study 1985-1998  850 Swan Ganz line Cardiac Sx CABG, Valve, Aortic Aneurysm Cardiac Sx CABG, Valve, Aortic Aneurysm  12 case of perforation 0.1%  Mean age 70 Female : Male 2:1 Ann Of thoracic Sx 2001 Ann Of thoracic Sx 2001

10. Catheter Induced PA Perforation Intraoperative Dx 5 cases  Brisk blood from ETT during  Brisk blood from ETT during weaning CPB or immediately after weaning CPB or immediately after Postoperative Dx 7 cases 3 Pts  brisk blood ETT with inflating balloon 3 Pts  brisk blood ETT with inflating balloon 1 Pt  Cardiac arrest 1 Pt  Cardiac arrest discovered during chest exploration discovered during chest exploration 3 Pts  Mild hemoptysis Ann Of thoracic Sx 2001 Ann Of thoracic Sx 2001

11. Catheter Induced PA Perforation  Brisk Blood ETT (300-400) was managed with Bronchial blocker in 6 Pts with Double lumen ETT in 2 Pts with Double lumen ETT in 2 Pts  Intraoperative cases All had injury to branches of lobar artery All had injury to branches of lobar artery 1 in addition had injury to Lt main 1 in addition had injury to Lt main 3 lobectomies & 1 pneumonectomy 3 lobectomies & 1 pneumonectomy Ann Of thoracic Sx 2001 Ann Of thoracic Sx 2001

12. Catheter Induced PA Perforation  2 postop major bleeding Initially stable Initially stable  1 died of extensive lobar hemorrhage  1 died of extensive lobar hemorrhage  3 postop minor hemoptysis 1 complete recovery 1 complete recovery 1 died after recurrent hemoptysis from 1 died after recurrent hemoptysis from rupture pesudoaneurysm POD#15 rupture pesudoaneurysm POD#15 1 recurrent hemoptysis  embolization 1 recurrent hemoptysis  embolization Ann Of thoracic Sx 2001 Ann Of thoracic Sx 2001

13. Catheter Induced PA Perforation  73% of injuries were Rt sided mainly lobar artery branches  RLL 43% > RML 27% > RUL 7%  Mortality 42% Higher in old age, female Higher in old age, female & in surgically treated group & in surgically treated group Ann Of thoracic Sx 2001 Ann Of thoracic Sx 2001