Injury of the Pulmonary Artery and Its

Branches due to Penetrating Chest Trauma

Michel Deneuville, MD, Pointe-à-Pitre, France

This study describes the treatment of seven wounds involving the pulmonary artery or its main
branches in six men (36 ± 12 years). Injury was associated with hemoptysis or massive hemo-
thorax in four patients, three of whom had arrest on the way to the operating room. The mean
interval between injury and admittance and between injury and surgery was 18 ± 8 min and 39
± 14 min, respectively. Wounds were located on the left pulmonary artery in two cases, right
pulmonary artery in two cases, intermediate branch of the pulmonary artery in one case and right
upper mediastinal branch of the pulmonary artery in two cases. Injuries involved penetration of
only one side of the vessel in three cases, transfixion of two sides of the vessel in one case, and
complete disruption of the vessel in three cases. Treatment required pneumonectomy in two
cases presenting complex lesions involving both vessels and lung structures. In the remaining
five cases, arterial repair was achieved by resection-anastomosis (n = 2) and lateral suture (n =
3). Our results show that isolated injuries of the pulmonary artery are amenable to surgical repair
and have a good prognosis. Mortality appears to be high in patients presenting complex lesions
involving vascular and pulmonary structures that require pneumonectomy to achieve hemosta-
sis and in patients presenting associated cardiovascular lesions. (Ann Vasc Surg 2000;14:463-
467.)
DOI: 10.1007/s100169910089

INTRODUCTION military2-4 or civilian5 series. Pulmonary artery in-

juries were specifically mentioned in only one ci-
The main causes of death after penetrating chest vilian series.1 Most descriptions are found in iso-
trauma are exsanguination, mediastinal compres- lated case reports.6-9 Based on existing data, pen-
sion, or cardiac tamponade due to injury of large etrating pulmonary artery trauma seems to be
mediastinal vessels. Since most patients die before associated with high immediate mortality1,10 and
arrival at the hospital, series describing manage- often requires pneumonectomy to control bleed-
ment of these lesions at nonmilitary institutions ing.11
have been small. In the largest consecutive series,1-5 Our institution receives all patients requiring
most wounds involved the heart or supraaortic ves- emergency treatment for vascular and thoracic
sels. Injury of the pulmonary artery is uncommon trauma in Guadeloupe. The present study describes
and has not been singled out for study in either a series of consecutive cases involving injuries of
the pulmonary artery or its main branches. Our
From the Department of Thoracic and Vascular Surgery, findings are different from those previously re-
Guadeloupe University Hospital, Pointe-à-Pitre, Guadeloupe, ported in the literature regarding the incidence,
France. mortality, and efficacy of conservative treatment
Correspondence to: M. Deneuville, MD, Service de Chirurgie using standard arterial repair techniques. The pur-
Thoracique et Vasculaire, CHU de Guadeloupe, Pointe-à-Pitre-
pose of this retrospective study was to describe our
Abymes, F-97159 Cedex, Guadeloupe, France.
experience in the management of patients with in-

463
464 Deneuville Annals of Vascular Surgery

Table I. Clinical presentation of 6 patients upon arrival at hospital

Systolic
Age Instrument arterial
(years) of injury pressure Clinical findings Radiological findings
32 Knife 80 PNOX, SCE Tension PNOX, PDV: 500 mL
37 Shotgun 75 Large open HTOX, PTOX, ME >8 cm
wound
24 Knife 80 SCE Moderate HTOX, PDV: 800 mL
22 Shotgun 60 SCE, CA Massive HTOX, ME >8 cm
55 Bull horn 45 Hemoptysis, CA Not available
44 Knife 65 SCE Massive HTOX
CA, cardiac arrest; HTOX, hemothorax; ME, mediastinal enlargement; PDV, pleural drain vol-
ume; PNOX, pneumothorax; SCE, subcutaneous emphysema.

juries of the pulmonary artery or its main branches immediately presented cardiac arrest either upon
due to penetrating chest trauma. arrival (n = 2) or during the procedure (n = 1). The
surgical procedure used in all four cases consisted of
median or transverse sternotomy, promptly fol-
PATIENTS AND METHODS
lowed by exposure of the intrapericardial portion of
Between December 1992 and February 1996, 88 pulmonary artery responsible for hemothorax.
patients were admitted to our department for pen- After control of bleeding, the pleural space was
etrating chest trauma. A total of seven injuries of opened and blood was recovered for autotransfu-
the pulmonary artery and/or its main branches sion. In two patients with complex lesions involving
were observed in six men (mean age 36 ± 12 years). structures in the region of the hilus, pneumonecto-
The instrument of injury, hemodynamic status, and my was required with vascular and bronchial stap-
initial clinical and radiological findings are listed in ping. In the other two patients, only repair of the
Table I. In five out of six patients, penetrating pulmonary artery or its branches was required.
trauma occurred during attempted homicide. “Pep- Three of the four patients who underwent imme-
pering” of the lung parenchyma with retained diate surgery presented associated extrapulmonary
buckshot was observed in two patients with shot- cardiovascular lesions involving the right ventricle
gun wounds. treated by suture, the superior vena cava treated by
All patients received emergency care at the scene lateral suture, and the internal mammary artery
of injury and were transported directly to the op- treated by ligation. In the two patients who pre-
erating room within a mean delay of 18 ± 8 min. sented persistent hemorrhage from the pleural
Endotracheal intubation by the oral route was per- drain, control of the pulmonary artery was
formed immediately in two patients with massive achieved prior to exposure of lesion in mediastinum
hemoptysis and a large open wound. In four pa- or scissura. Control was achieved by intrapericardial
tients, arterial pressure was successfully stabilized dissection between the aorta and vena cava in one
by intravenous fluid resuscitation (systolic pressure case and by extrapericardial dissection behind the
between 60 and 80 mmHg). Two patients failed to vena cava in one case.
respond to fluid resuscitation and were in hypovo- A total of seven wounds involving the pulmo-
lemic shock. nary artery were observed. The anatomic location
In four patients, surgery was performed imme- of these lesions was the right pulmonary artery in
diately on arrival and the mean interval between two cases, the left pulmonary artery in two cases,
injury and surgery was 39 ± 14 min. In two pa- the intermediate branch of the pulmonary artery in
tients, initially treated for tension pneumothorax one case, and the right upper mediastinal branch of
and hemothorax by placement of a pleural drain, the pulmonary artery in two cases. The injury in-
surgery was delayed to allow evacuation of blood volved penetration of one side of the vessel in three
(blood loss 500 and 800 mL in 30 min). Table II cases, transfixation of two sides of the vessel in one
summarizes the exposure route, location of lesion, case, laceration of the vessel in two cases, and dis-
and type of pulmonary artery injury. ruption of the vessel with formation of a false an-
Three of the four patients who were operated on eurysm in one case. Arterial repair was performed
Vol. 14, No. 5, 2000 Pulmonary artery injury from chest trauma 465

Table II. Clinical data for 6 patients presenting injuries of the pulmonary artery and its branches due to
penetrating chest trauma
Repair Associated Intraoperative Immediate
Description of lesions Exposure route technique lesions blood loss outcome
One side of right PA Lateral suture PLT Upper lobe 700 mL Survived
of lung
Transfixation of MSPA, Suture, RA S Sternum, 1200 mL Survived
false aneurysm of the IPA 3 lobes
of lung
One side of MSPA Lateral suture S Upper lobe 3200 mL Survived
of lung
Disruption of right PA Pneumonectomy S SVC, PV, 3200 mL Died
3 lobes
of lung
Disruption of left PA Pneumonectomy S MSB, PV, 6000 mL Died
heart
One side of left PA Lateral suture AT/S MA, lobe 3500 mL Survived
of lung
AT/S, anterior thoracotomy/sternotomy; IPA, intermediate branch of pulmonary artery; MSB, main stem bronchus; MSPA, medias-
tinal pulmonary artery; PA, pulmonary artery; PLT, posterolateral thoracotomy; PV, pulmonary vein; RA, resection anastomosis; S,
sternotomy; SVC, superior vena cava.

after clamp placement in four patients either by di- convulsive manifestations suggestive of air embo-
rect suture (n = 3) or by resection-anastomosis lism (not confirmed by autopsy). Immediate mor-
(n = 1). tality attributable to associated lesions, surgical
Mean intraoperative blood loss was 2970 ± 1900 techniques, and blood loss is listed in Table II.
mL. Unclotted blood was recovered for autotrans- The four surviving patients were extubated
fusion (Cell-saver, Haemonetics Corp., Braintree, within 24 hr. The duration of intensive care ranged
MA). In three patients, associated lesions of lung from 2 to 4 days and the duration of hospitalization
structures were treated by debridement using a GIA ranged from 7 to 22 days. Postoperative recovery
stapler and elective vascular and bronchial suture was uneventful in three out of four survivors. The
with 5-0 polydiaxanone suture. In the fourth pa- remaining patient who presented an open fracture
tient, left upper lobectomy was required because of of the manubrium with extensive loss of soft tissue
an extensive transfixing wound. developed sepsis on the sternotomy with mild me-
diastinitis. He was successfully treated by surgical
RESULTS debridement and myoplasty using the pectoralis
major muscle.
Two patients died. Both were in deep cardiovascu- Follow-up in the four surviving patients was 27 ±
lar shock upon arrival, presented cardiac arrest ei- 14 months. Respiratory function was normal in all
ther on arrival or during the procedure, required four patients. Plain chest films show minimal pleu-
pneumonectomy to control bleeding due to mul- ral sequelae in three patients and ascension of the
tiple injury of vessels in the hilus region, and had diaphragm due to paralysis of the phrenic nerve in
associated cardiovascular lesions. The cause of one patient. Function tests (Table III) demonstrated
death in one patient who was gored by a bull was nearly normal values in two patients and were con-
exsanguination due to an extensive lesion involv- sistent with lobectomy in one patient and section of
ing the right ventricle, the left pulmonary, and the phrenic nerve in one patient. Arterial blood gas
main stem bronchus. In this patient, death occurred measurements and mean pulmonary artery pres-
despite control of bleeding, pulmonary resection, sure determined by ultrasonography were normal
and closure of the heart wound. The second death in all four patients (Table III).
occurred in an intensive care patient who under-
went resection of the right lung, which had been DISCUSSION
“peppered” with buckshot. This patient presented Injury of the pulmonary artery and its main
irreversible hypovolemic shock associated with branches due to penetrating chest trauma is consid-
466 Deneuville Annals of Vascular Surgery

Table III. Function test data in four Thus, in this series, injury of the pulmonary ar-
surviving patients tery was associated with massive bleeding in only
two patients (33%) presenting either massive he-
PaO2 MPAP Follow-up
Repair technique VC (kpa) (mgHG) (months) moptysis due to associated disruption of the bron-
chus in one case or a transfixing wound in the
Suture of side of
other. In the other four patients (66%), surgical or
left PA 82 12.8 26 42
Suture of side of radiological findings showing the presence of a false
MSPA; RA of IPA 61a 10.9 28 29 aneurysm in the scissura and of mediastinal hema-
Lateral suture of toma suggested that bleeding may have been lim-
MSPA 91 13.1 19 28 ited by various mechanisms of tamponade. Devel-
Lateral suture of opment of false aneurysms or arteriovenous fistulas
right PA 76b 11.5 32 8 has been previously reported8,9 at various time in-
IPA, intermediate branch of the pulmonary artery; MPAP, mean
tervals after initially undetected injuries of the pul-
pulmonary artery pressure; MSPA, mediastinal pulmonary ar- monary artery. Our findings suggest that trauma
tery; PA; pulmonary artery; PaO2, arterial partial pressure of O2; surgeons should bear in mind the possibility of a
RA, resection-anastomosis; VC, vital capacity (% of theoretical pulmonary artery injury in patients in whom clini-
VC). cal and radiological findings demonstrate small le-
a
Paralysis of the diaphragm due to damage of the phrenic nerve.
b
Left upper lobectomy.
sions of the lung parenchyma. Further risk factors
for pulmonary artery lesions in these patients are
hematoma in the hilus region, recurrent bleeding,
ered an uncommon lesion, accounting for only 2 to and increase in the volume of blood from the pleu-
3% of massive hemothorax cases and 3% of cardiac ral drain after hemodynamic resuscitation. Similar
tamponade cases.10 In the only nonmilitary series observations have been reported in patients with
specifically mentioning injury of the pulmonary ar- closed chest trauma.12,13
tery,1 the incidence in 117 patients admitted to The main problem in surgical treatment of inju-
the hospital for cervicothoracic wounds with life- ries of the pulmonary artery is management of mas-
threatening manifestations was 7%. sive hemothorax with hemodynamic shock. In our
The lesions in the present series, which, to our opinion, prompt surgery is necessary to avoid life-
knowledge, is the largest yet published, accounted threatening cardiovascular complications. Avoid-
for 7% of the intrathoracic lesions identified in 88 ance of lateral decubitus and insertion of a pleural
patients who underwent thoracotomy for penetrat- drain is an important management issue. The man-
ing chest trauma and for 36% of intrathoracic vas- datory route of exposure for patients in dorsal de-
cular lesions treated in our department. This higher cubitus is either median sternotomy or anterior
incidence than that in previous reports1,5,10 could thoracotomy with enlargement by transverse ster-
be related to the short interval between injury and notomy. Preoperative pleural drainage is a predis-
admittance to the hospital, which is located in close posing factor for hemodynamic decompensation
proximity to an urban zone with a high crime rate. and exsanguination. Early selective intubation
The influence of transport time on prognosis is sug- should be performed especially in cases involving
gested by the findings of a recent series showing tension pneumothorax or massive hemoptysis.
that 41% of patients admitted with cervicothoracic Surgical procedure should begin as follows: (1)
wounds without life-threatening injury presented prompt control of the intrapericardial segment of
injuries of the pulmonary artery. the pulmonary artery (prior to opening of the pleu-
In our series, the most common presenting ral cavity involved by hemothorax); (2) opening of
manifestation of pulmonary artery injuries was he- the pleural cavity with recovery of blood for auto-
modynamic shock in association with either mas- transfusion; and (3) tamponade and/or digital con-
sive hemothorax or hemoptysis. However, in two trol of the bleeding lesion. The rest of the proce-
cases, bleeding was due to injury of another intra- dure, in particular the decision to perform conser-
thoracic vessel (superior vena cava or internal vative treatment, depends on visual inspection of
mammary artery) rather than the pulmonary artery surrounding structures in the hilus region and lung.
lesion. In these two cases, the main presenting find- Like other practioners,5,11 we perform routine pul-
ing was a wound involving the lung parenchyma monary resection for all lesions with deep paren-
with only mild symptoms (pneumothorax or mod- chymal or bronchial involvement. In our opinion,
erate hemothorax). The decision to perform throra- sutures should be made using a stapler to shorten
cotomy was based on the conventional criteria of procedure time. In patients presenting lesions with-
persistence of blood in the pleural drain.11 out parenchymal or bronchial involvement, repair
Vol. 14, No. 5, 2000 Pulmonary artery injury from chest trauma 467

can be achieved using conventional vascular suture the pulmonary artery are amenable to surgical
techniques or resection anastomosis as during con- treatment using conventional arterial repair tech-
servative pulmonary resection.14 Although involve- niques with a good immediate and mid-term prog-
ment of the main pulmonary artery was not en- nosis. Conversely, mortality is high in patients with
countered in the present series, one previous au- complex lesions involving the bronchial structures
thor reported that exposure and repair are easy requiring pneumonectomy and in patients with as-
under extracorporeal circulation.9 sociated lesions of the heart and other mediastinal
Vascular and thoracic surgeons should be famil- vessels.
iar with techniques allowing prompt control of the
intrapericardial segment of pulmonary artery. In
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