Pulmonary vessel pseudo-aneurysm after blunt traumatic injury: A report of two cases

Abstract

Pulmonaryarterypseudo-aneurysm(PAPA)resultingfromchesttrauma is uncommon. Seventeen cases have been described in theliterature [1–17]: 12 of these resulted from penetrating injuries[1,2,4,5,7,8,12,13,15–17], 4 from blunt injuries [3,9,11,14],and1case that involved penetrating chest trauma with simultaneouspulmonary artery and pulmonary vein pseudo-aneurysm [10].In 2006, Reade et al. first described the case of blunt traumaticmain PAPA, detected on initial computed tomography (CT) scan,that was treated non-operatively [14]. In every reported case, thetraumatic PAPA was repaired operatively by means of localresection (aneurysectomy), ligation of vessels, lobectomy orembolisation [5,15].The development and improvement of imaging techniques,especiallymultisliceCT scan,havepermittedthediagnosis of‘newinjuries’ in trauma patients. These injuries identified with moderndiagnostic technology may represent a challenge to the surgeon,who has to determine or characterise their nature and apply theappropriate management.Here,wereporttwocasesofpulmonaryvesselpseudo-aneurysmin blunt-trauma patients who were admitted to our emergencysurgical service (ESS) and were successful treated non-operatively.1. Case 1A 37-year-old man was involved in a collision with a car whileriding a bicycle and arrived at our ESS without any additionalinformation. The patient was not alert upon his admission to theemergency room. An orotracheal intubation was performed. Thechest physical examination showed multiple thoraco-abdominalexcoriations, and bilateral vesicular murmur was present withdiffuse bruises. The cardiocirculatory system was normal onphysical examination, and the focussed assessment with sono-graphy for trauma (FAST) showed fluid in hepatorenal and pelvicfields.Pelvicandrectalexaminationwasnormal,andtheurinewasclear. The Glasgow Coma Scale (GCS) score was 8 before sedation.Right tibia and fibula fractures (Gustilo grade IIIa) were observed.Acranial/thoracicCTscanshowedmultiplefacialfractures(nasal,maxillary, right zygomatic and bilateral orbital), as well as a smallright haemo-pneumothorax, a right PAPA measuring 24 mm 21mm 23mm (23-mm extension) and a right inferior pulmonaryvein pseudo-aneurysm measuring 10 mm (Fig. 1). An abdominal/pelvicCTshowedasmallrighthepaticlobelaceration,arightadrenalhaematomaand smallliquid collectionsinhepatic andpelvic fields.The patient underwent external fixation of tibia and fibulafractures performed by the orthopaedic surgery group. Facialfractures as well as the thoracic and abdominal lesions weremanaged non-operatively. The patient received care in the traumaintensive care unit (ICU), where he required continuous nora-drenalininfusionfor3days.Eightdaysafteradmission,thepatienthad internal fixation of tibia and fibula fractures. No specifictreatmentforthepseudo-aneurysmwasperformed.A repeatedCTscan performed 22 days after admission showed no evidence ofpseudo-aneurysm of pulmonary artery or vein. The patient’scondition improved rapidly, and the patient was discharged fromthe hospital 23 days after admission.2. Case 2A70-year-oldmanwasinvolvedinvehiclecrashwithapole.Theaccidentsiteassessmentrevealedthathewasnotwearingaseatbelt.Hislevelofconsciousnesswasunknown.Intheemergencyroom,hepresented with wheezing; chest examination showed paradoxicalmovementsoftherighthemithoraxwithinstabilityofchestwallandreducedhomolateralvesicularmurmurs.Orotrachealintubationandright chest drainage were performed. His heart rate was 74 beats/min,hisbloodpressurewas116/78 mmHgandhisheartsoundswerenormal on auscultation. His GCS score was 15 and no additionalinjurieswereobserved.TheFASTshowednofluidaccumulation.TheCTscanexaminationwithcontrastshowednosignofinjurytoheador