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Yanagawa et al. Vessel Plus 2018;2:1 I http://dx.doi.org/10.20517/2574-1209.2017.37 Page 3 of 8

[2]
it is usually secondary to asphyxia rather than hypovolemia . The initial presentation may be as obvious as
massive pulmonary hemorrhaging or as subtle as a cough associated with minimal hemoptysis, or it may
[30]
even be totally asymptomatic .
When catheter-induced PAI happens during insertion of a fluoroscope, it is relatively easy to retract the PA
catheter a few centimeters and re-inflate the balloon under direct vision. It may therefore be possible to stop
[2]
the bleeding . Additional diagnostic angiography and embolization also can be easily performed at that
point.

In addition to treatments for PAI, the patient may need selective intubation to obtain lung isolation in
accordance with clinical symptoms. Lung isolation can be performed with different techniques, including
selective intubation with a standard endotracheal tube, bronchial blocker or double-lumen tube (DLT) .
[2]
A bronchial blocker can be used for lung separation when a DLT is not immediately available or when
it is difficult to insert the DLT. Bronchial blockers can be used to tamponade the bleeding side while
waiting for diagnostic and therapeutic interventions. The most important aspects of treatment are lung
isolation using selective intubation, bronchial blockers, or DLT as a temporary measure; rapid movement is
important for more definitive therapy as it can avoid clotting of the entire lung on one side, which effectively
causes pneumonectomy. Surgery, including pulmonary artery ligature, segmentectomy, lobectomy or
pneumonectomy, is reserved for extreme cases, since these procedures are technically challenging and entail
high morbidity .
[2]

NON-IATROGENIC PAI
A majority of non-iatrogenic PAI cases occur due to chest trauma; however, most chest trauma cases do not involve
PAI. PAI accounts for a small percentage of thoracic trauma cases. Epidemiologically, Kulshrestha et al. reported
[31]
102 patients sustaining cardiac injuries over a 4-year period. There were 45 blunt trauma, 36 stab injuries,
and 21 gunshot injuries . The injury involved the ventricle in 85 patients, atrium in 7 and the PA in 5 (5%)
[31]
and resulted in crush injury to the heart in the remaining 5 cases. Thirty-three patients (32.3%) died at the
scene, and 58 (56.9%) died during transportation. Only 11 patients (10.8%) reached the hospital alive, and
10 of these survived following thoracotomy and repair of the cardiac injury. The patients with ventricular
injuries had a greater prehospital mortality than those with atrial or PA injuries.

Deneuville reported 88 cases of penetrating chest trauma, focusing on non-iatrogenic PAIs. Of these 88 cases,
[32]
[32]
6 with PAI reached the hospital alive . All cases underwent urgent operation, and 4 survived. The mortality
appears to be high in patients presenting with complex lesions involving vascular and pulmonary structures.
As a result, they concluded that isolated injuries of the PA were amenable to surgical repair and had a good
prognosis if the patients arrived at the hospital alive.

We summarized the cases of non-iatrogenic PAI in Tables 1 and 2. Most cases were reported as case reports,
[32]
except for the findings of Deneuville . Penetrating injuries were more frequent than blunt ones. Similar
to Deneuville , 46/50 (92%) cases survived. The diagnosis was made based on intraoperative findings,
[32]
enhanced CT or pulmonary arteriography. The main treatment method was surgery or an interventional
approach. These findings suggest that if hemorrhaging is not noted and the vital signs are stable, conservative
treatment can be selected. There are no strict guidelines concerning the management of PAI, and the
preferred approach depends on the lesion, patient and institution .
[1]

CONCLUSION
PAI is a rare, lethal clinical entity; most vital emergencies involve proximal PAI. Anatomically, traumatic
PAI is classified into transection/rupture/laceration, pseudoaneurysm, dissection and fistula. Iatrogenic