カテーテルに起因した仮性肺動脈瘤に対する術中肺区域動脈塞栓術

Intraoperative Subsegmental Pulmonary Artery Embolization for Catheter Induced Pulmonary Pseudoaneurysm

肺動脈カテーテルによる肺動脈損傷は致死率の高い合併症であり，2021年に報告された日本心臓血管外科学会のアンケート調査では，開心術の0.05％に発生している1）．われわれは，体外循環終了直後の大量喀血に対して術中に分離換気，選択的肺動脈造影・塞栓術，経皮的静脈脱血-動脈送血の体外式膜型人工肺（VA-ECMO）により救命することができたので，治療法を中心に報告する．

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.