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

Abstract

Pulmonary artery pseudo-aneurysm (PAPA) resulting from chest trauma is uncommon. Seventeen cases have been described in the literature [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17]: 12 of these resulted from penetrating injuries [1,2,4,5,7,8,12,13,[15][16][17], 4 from blunt injuries [3,9,11,14], and 1 case that involved penetrating chest trauma with simultaneous pulmonary artery and pulmonary vein pseudo-aneurysm [10].In 2006, Reade et al. first described the case of blunt traumatic main PAPA, detected on initial computed tomography (CT) scan, that was treated non-operatively [14]. In every reported case, the traumatic PAPA was repaired operatively by means of local resection (aneurysectomy), ligation of vessels, lobectomy or embolisation [5,15].The development and improvement of imaging techniques, especially multislice CT scan, have permitted the diagnosis of 'new injuries' in trauma patients. These injuries identified with modern diagnostic technology may represent a challenge to the surgeon, who has to determine or characterise their nature and apply the appropriate management.Here, we report two cases of pulmonary vessel pseudo-aneurysm in blunt-trauma patients who were admitted to our emergency surgical service (ESS) and were successful treated non-operatively. Case 1A 37-year-old man was involved in a collision with a car while riding a bicycle and arrived at our ESS without any additional information. The patient was not alert upon his admission to the emergency room. An orotracheal intubation was performed. The chest physical examination showed multiple thoraco-abdominal excoriations, and bilateral vesicular murmur was present with diffuse bruises. The cardiocirculatory system was normal on physical examination, and the focussed assessment with sonography for trauma (FAST) showed fluid in hepatorenal and pelvic fields. Pelvic and rectal examination was normal, and the urine was clear. The Glasgow Coma Scale (GCS) score was 8 before sedation. Right tibia and fibula fractures (Gustilo grade IIIa) were observed.A cranial/thoracic CT scan showed multiple facial fractures (nasal, maxillary, right zygomatic and bilateral orbital), as well as a small right haemo-pneumothorax, a right PAPA measuring 24 mm  21 mm  23 mm (23-mm extension) and a right inferior pulmonary vein pseudo-aneurysm measuring 10 mm (Fig. 1). An abdominal/ pelvic CT showed a small right hepatic lobe laceration, a right adrenal haematoma and small liquid collections in hepatic and pelvic fields.The patient underwent external fixation of tibia and fibula fractures performed by the orthopaedic surgery group. Facial fractures as well as the thoracic and abdominal lesions were managed non-operatively. The patient received care in the trauma intensive care unit (ICU), where he required continuous noradrenalin infusion for 3 days. Eight days after admission, the patient had internal fixation of tibia and fibula fractures. No specific treatment for the pseudo-aneurysm was performed. A repeated CT scan performed 22 days after admissio...