Repair of Pulmonary Vein Injury in Trauma
Pulmonary vein injuries from trauma require immediate surgical repair via thoracotomy with direct suturing under cardiopulmonary bypass support, as these injuries are life-threatening and cannot be managed conservatively. 1, 2, 3
Immediate Recognition and Resuscitation
Suspect pulmonary vein injury in blunt or penetrating chest trauma patients presenting with hemopericardium, cardiac tamponade, or hemodynamic instability despite initial resuscitation. 1, 2, 3
Transthoracic echocardiography is essential to identify pericardial effusion and guide the decision for emergency surgery. 1, 2
Patients with identified bleeding sources and hemodynamic instability require immediate surgical bleeding control rather than prolonged resuscitation attempts. 4
During initial resuscitation, maintain normoventilation (PaCO2 5.0-5.5 kPa) and avoid hyperventilation, which worsens outcomes in trauma patients through decreased cerebral perfusion and cardiovascular collapse. 4
Surgical Approach and Technique
Establish cardiopulmonary bypass before attempting definitive repair, as this provides hemodynamic stability and optimal visualization of all injuries. 1, 3
The medial approach to thoracotomy allows adequate exposure for inspection and repair of pulmonary vein injuries. 1
Direct repair using 4-0 or 5-0 polypropylene running sutures is the standard technique for pulmonary vein lacerations. 1, 2
Catastrophic hemorrhage commonly occurs when releasing pericardial clot; cardiopulmonary bypass must be established before complete evacuation to prevent exsanguination. 1
Carefully inspect for concomitant injuries including cardiac chamber ruptures, inferior vena cava lacerations, and pericardial tears, as these frequently occur together. 1, 2
Postoperative Management
Initiate lung-protective ventilation with low tidal volumes (<6 mL/kg predicted body weight) and moderate PEEP immediately postoperatively to prevent acute lung injury. 4, 5
Begin mechanical thromboprophylaxis immediately in all patients without absolute contraindications. 4
Start LMWH-based pharmacologic thromboprophylaxis within 48-72 hours of injury once hemostasis is secured, as delays beyond 72 hours increase VTE risk over fourfold. 4
For patients with massive pulmonary vein trauma causing treatment-refractory hypoxemia, inhaled nitric oxide may reverse hypoxemia when conventional ventilation fails. 6
Early enteral feeding should begin within 72 hours when hemodynamically stable and not requiring vasopressor support. 4
Critical Pitfalls to Avoid
Never attempt repair without cardiopulmonary bypass capability, as uncontrolled hemorrhage during repair is uniformly fatal. 1, 3
Do not delay surgical intervention for additional imaging once hemopericardium with hemodynamic instability is identified—this represents a surgical emergency. 1, 2
Avoid hyperventilation during resuscitation, as PaCO2 <27 mmHg causes neuronal injury, cerebral vasoconstriction, and impaired venous return leading to cardiovascular collapse. 4
Do not use high tidal volumes (>6 mL/kg), as even short-term ventilation with 12 mL/kg promotes pulmonary inflammation and coagulation abnormalities. 4
Prognosis
Survival is possible with prompt recognition and surgical repair under cardiopulmonary bypass, with patients achieving ambulatory discharge within 2-3 weeks. 1, 2
Isolated pulmonary vein ruptures are extremely rare; most cases involve multiple cardiac and great vessel injuries requiring comprehensive repair. 1, 2, 3