Management of pulmonary artery perforation during balloon angioplasty
Management of perforation of a pulmonary vessel is on the same lines as that of any other vessel like coronary perforation during percutaneous coronary intervention.
Prevention of perforation of pulmonary artery during angioplasty
First and foremost is to prevent a rupture before it actually occurs! Proper wire positioning within the lumen and avoiding a segment with total occlusion and no distal flow are two important aspects of prevention. But if the total occlusion is involving a large segment, we may have to proceed with special precautions.
In the knuckle wire technique, a loop is formed at the distal end of the wire while trying to cross a total occlusion. This loop will prevent the occurrence of a perforation, though it is negotiating the sub intimal space.
But if a rupture does occur, it is managed similar to a coronary perforation by:
- Balloon tamponade (inflating the balloon to keep the perforation closed)
- Reversal of anticoagulation
- Use of a covered stent to close off the perforation
- Coil embolization or embolization with gelfoam particles
Supportive management of consequent lung injury can be with non invasive ventilation and oxygen supplementation in milder cases. More severe cases would require invasive ventilation and in the worst case scenario extracorporeal membrane oxygenator (ECMO) to bail out . ECMO can take care of both hypoxia and hypotension while invasive ventilation can only take care of hypoxia. In fact positive pressure ventilation can bring down the blood pressure when higher levels of positive end expiratory pressures (PEEP) are used in an attempt to maintain oxygenation.
- Hosokawa K, Abe K, Oi K, Mukai Y, Hirooka Y, Sunagawa K. Balloon pulmonary angioplasty-related complications and therapeutic strategy in patients with chronic thromboembolic pulmonary hypertension. Int J Cardiol. 2015 Oct 15;197:224-6.