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CLINICAL STUDY

Pulmonary artery trauma due to balloon dilation: recognition, avoidance and management

Charles M. Baker, MD^a, Francis X. McGowan, Jr., MD, John F. Keane, MD, FACC^a and James E. Lock, MD, FACC^a

^a Cardiology, The Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
Anesthesiology, The Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

Manuscript received September 20, 1999; revised manuscript received April 20, 2000, accepted June 16, 2000.

Reprint requests and correspondence: Dr. James E. Lock, Department of Cardiology, The Children’s Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115

OBJECTIVES

We reviewed the management and outcome of patients experiencing pulmonary artery (PA) trauma during balloon dilation (BD).

BACKGROUND

Balloon dilation of the PA is important in the management of peripheral pulmonary stenosis. Successful BD requires a controlled tear of the PA; excessive tearing can produce complications ranging from pseudoaneurysms to rupture and death. The incidence and optimum management for such complications are unreported.

METHODS

All records of patients who underwent branch PA dilation between June 1984 and October 1997 were reviewed; those with a significant complication were analyzed.

RESULTS

Of 1,286 catheterizations in 782 patients, PA trauma (excluding isolated pulmonary edema and PA aneurysms) was identified in 29 catheterizations in 26 patients. Tears occurred distal to the area of stenosis in most cases (62%). Intensive medical management, with and without catheter directed therapy, was employed. The damaged PA was successfully coil embolized in five patients, four of whom survived; temporary balloon occlusion did not prevent death in two patients. There were six deaths from pulmonary hemorrhage. A case control analysis demonstrated that PA trauma was significantly associated with pulmonary hypertension.

CONCLUSIONS

Pulmonary artery trauma associated with BD occurs mostly distal to the site of narrowing, is associated with underlying pulmonary hypertension and is frequently (5/12 or 42%) fatal in those with unconfined tears. Intensive management strategies as well as attention to distal balloon position may reduce incidence and mortality. Coil occlusion of the damaged PA appears to be a valuable strategy to prevent fatal hemorrhage.

Abbreviations and Acronyms   BD = balloon dilation   CICU = cardiac intensive care unit   CT = confined tear   ECMO = extracorporeal membrane oxygenation   PA = pulmonary artery   PPS = peripheral pulmonary stenosis   TOF/PA = Tetralogy of Fallot with pulmonary atresia   UT = unconfined tears

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