Intraoperative Management of Pulmonary Artery Bleeding with Hemostatic Agents

Small defects in the pulmonary artery can be managed with compression and usually do not require aggressive intervention (1-3). Major injury to the pulmonary artery, however, can lead to large volume blood loss and rapid hemodynamic collapse if not addressed appropriately (1-3). In this case, we encountered significant pulmonary artery bleeding during VATS lingula sparing left upper lobectomy in a patient treated with neoadjuvant EGFR and MEK targeted therapy for lung adenocarcinoma.

To initially obtain control, we used the suction irrigator to laterally compress the arterial defect as temporary hemostasis; a technique previously described by Lui et al (1,2). Although our operating room was prepared to convert to thoracotomy, there was evidence throughout the case that tissue integrity was an issue and there was concern the arterial tissues would not support further manipulation. For this reason, we applied a hemostatic fibrin sealant patch (EVARREST®, Ethicon, Inc., Somerville, NJ) directly on the artery to prevent catastrophic bleeding. With sufficient time and compression, the injury was sealed and no sutures were needed to obtain hemostasis. The durability of the fibrin sealant patch was tested intraoperatively with administration of intravenous phenylephrine and lung inflation; neither maneuver exacerbated bleeding. The patient did not require any additional intervention and was discharged home on postoperative day 3.

While this approach is not yet generalizable, we think it provides an example of the potential for topical coagulants in pulmonary surgery.

References

1. Xiao ZL, Mei JD, Pu Q, et al. Technical strategy for dealing with bleeding during thoracoscopic lung surgery. Ann Cardiothorac Surg. 2014;3(2):213-215.

2. Mei JD, Pu Q, Liao H, et al. A novel method for troubleshooting vascular injury during anatomic thoracoscopic pulmonary resection without conversion to thoracotomy. Surg Endosc. 2013;27:530-537.

3. Demmy TL, James TA, Swanson SJ, et al. Troubleshooting video-assisted thoracic surgery lobectomy. Ann Thorac Surg. 2005;79:1744-53.