An Approach to Intraoperative Accidental Pulmonary Artery Transection and Role of Mid-Point to Transverse Process Interfascial Plane Block
Year: 2025
Type: article
Abstract: The Editor One of the major and catastrophic intraoperative complications associated with lung resection involves the transection of broncho-vascular structures. The incidence of vascular injury is reported to be 2.2–4.1% in video-assisted thoracoscopic surgery (VATS).[1] Through our case, we want to share our experience of successful anesthesia management after the transection of the interlobular pulmonary artery and an effective method of postoperative pain control. A 49-year-old female presented with complaints of shortness of breath and cough with expectoration of sputum associated with multiple episodes of hemoptysis for 2 months. She had a history of tuberculosis 10 years ago. HRCT chest showed a thick cavitatory lesion on the right upper lobe with a lobulated wall and surrounding fibrotic changes suggestive of aspergilloma [Figure 1a and b]. Preoperative vitals and laboratory investigations of the patient were normal. Postoperative predicted forced expiratory volume in one second (PPo FEV1 76) showed a low risk for postoperative ventilation. The patient was taken up for the VATS procedure and two wide bore cannulas (16 G and 18 G) were secured along with left radial arterial cannulation. Intravenous fluids were given through hotline fluid warmer and patient was covered with forced air patient warming blanket to prevent hypothermia. General anesthesia was induced with an injection fentanyl, propofol and vecuronium. The airway was secured with 35-Fr left-sided double-lumen tube for intraoperative one lung ventilation after induction with general anesthesia. The patient remained hemodynamically stable until a rent developed in the right interlobar pulmonary artery. The procedure was converted into open thoracotomy with patient remaining in lateral position. Uncontrolled bleeding led to patient becoming hemodynamically unstable with severe hypotension and a peri-arrest situation developed. Inhalational agent were stopped, patient ventilated with 100% FiO2 oxygen. Bypass machine was prepared as bleeding was profuse and difficult to control. Autotransfusion system (cell saver) was attached. Expeditious resuscitation during next one and half hour by anesthesia team involved blood transfusion with 3 units of PRBC, FFP, and platelets in the ratio of 1:1:1 along with noradrenaline and adrenaline IV infusions. Once artery got repaired, inotropes were tapered and stopped. At the end of surgery, blood gas analysis was normal and bilateral pupils were normal size and reacting to light. A mid- point transverse to pleura block (MTPB) using 25ml of 0.5% ropivacaine with dexamethasone 8mg as adjuvant was performed at T4–T5 level, on ipsilateral side for postoperative analgesia. The patient was extubated and shifted to ICU on venture mask at 0.4% FiO2. After 4 hours of surgery the patient was allowed orally and was having a Numerical rating scale (NRS) scoring for pain 0/10 for next 24 hours. The patient was discharged from ICU on postoperative day 1 with no oxygen requirement.Figure 1: (a and b) showing CT scan suggestive of Aspergilloma (c) showing ultrasound view to perform midpoint transverse to pleura block. TM: Trapezius muscle, RMM: Rhomboid muscle, ESM: Erector spinae muscle, SCTl: Superior costotransverse ligamentThe MTPB is a modification of thoracic paravertebral block, also called as paravertebral block by proxy. The MTPB was performed using high frequency linear probe and by placing the needle in craniocaudal direction at T4–T5 level as shown in Figure 1c. The LA was injected into retro-superior costotransverse ligament (SCTL) space or intertransverse tissue complex (ITTC), between two transverse processes, without piercing the SCTL. This block is associated with lesser complication and can be used in any thoracic surgeries. Adequate analgesia can also be achieved by single injection MTPB and doesn’t require a catheter, additional IVPCA, and other IV analgesic drugs. As the needle tip is placed far away from the pleura, it lowers the possibility of risk of pneumothorax, damage to the neurovascular structures in the paravertebral space, and also avoids the damage to the dorsal rami as the needle point is superior to the course. The plane of block is avascular and away from central neuraxial space; therefore, MTPB is a safer option compared to epidural analgesia in patients suspected or proven coagulopathy. Spread of drug to the thoracic spinal nerve, epidural space, sympathetic chain, and the intercostal space and posteriorly to the adjoining fat-filled intermuscular fascial compartments is probably the mechanism to provide analgesia.[2,3] This case constitutes an unusual scenario of intraoperative accidental pulmonary artery transection in lobectomy surgery. Previous reports on pulmonary artery rupture have been linked to spontaneous rupture due to prolonged use of steroids,[4] trauma, pulmonary artery catheter,[5] pulmonary artery aneurysm, and pulmonary artery hypertension. The anesthesia team should be well prepared to handle such crisis. Since the procedure was started as VATS, neuraxial analgesia was not performed. The MTPB is very useful for providing postoperative analgesia superior to PVB with less expertise and lesser complication and can also be used in conditions in which deeper blocks are contraindicated. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Annals of Cardiac Anaesthesia
Authors: Ankita Suri, Swati Jindal, Deepika Gupta, Varna Madhu, Naini Sood
Institution: Government Medical College and Hospital
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4412112853