Inouchi Mikito, Nasu Michihiro, Tanaka Jin
Department of Thoracic and Cardiovascular Surgery, Toyooka Hospital, Toyooka, Japan.
Kyobu Geka. 2023 Aug;76(8):608-612.
An 82-year-old female patient with severe aortic stenosis underwent aortic valve replacement. After weaning from cardiopulmonary bypass, it was noticed that Swan-Ganz( SG) catheter tip was located 50 cm distally to the right neck. After the catheter was pulled back, massive hemoptysis occurred. Fiberoptic bronchoscopy revealed bleeding from the left main bronchus. The tracheal tube was exchanged to a left selective bronchial tube and protamine sulfate was administered. However, massive hemorrhage continued. Intraoperative selective pulmonary angiography identified a pseudoaneurysm in A10. Efferent arteries, A10a, A10b, A10c, and an afferent artery, A10, were successfully embolized to obtain hemostasis. The patient remained hypoxemic despite inhalation with 100% oxygen and high positive end-expiratory pressure, so veno-arterial extracorporeal membrance oxygenation (VA-ECMO) was initiated. The patient was then transferred to intensive care unit (ICU) with VA-ECMO and the sternum was left open. Strenuous bronchial lavage was performed and VA-ECMO was discontinued at 2 days later. The patient was weaned from ventilator 14 days and discharged 63 days postoperatively.
一名82岁患有严重主动脉瓣狭窄的女性患者接受了主动脉瓣置换术。在脱离体外循环后，发现 Swan-Ganz（SG）导管尖端位于右颈部远端50厘米处。将导管撤回后，发生了大量咯血。纤维支气管镜检查显示左主支气管出血。将气管导管更换为左选择性支气管导管并给予硫酸鱼精蛋白。然而，大出血仍在继续。术中选择性肺血管造影发现A10处有假性动脉瘤。成功栓塞了传出动脉A10a、A10b、A10c和一条传入动脉A10以实现止血。尽管吸入100%氧气并采用高呼气末正压通气，患者仍存在低氧血症，因此启动了静脉-动脉体外膜肺氧合（VA-ECMO）。然后患者带着VA-ECMO被转至重症监护病房（ICU），胸骨保持开放。进行了强力支气管灌洗，2天后停用VA-ECMO。患者在术后14天脱机，并于术后63天出院。
