Hemoptysis is a common symptom in bronchiectasis patients. However, other causes of hemoptysis include tuberculosis, mycetomas, necrotizing pneumonia, and bronchogenic carcinomas [1, 2]. Treatments for massive hemoptysis include cold saline lavage, epinephrine, endobronchial stent tamponade, bronchial artery embolization, and invasive surgical intervention. The standard surgical procedure for the treatment of hemoptysis is anatomic lung resection (pneumonectomy, lobectomy, segmentectomy). Nonanatomic (wedge) resection should be avoided due to greater risk of failure to control the bleeding [3, 4].
In our initial purpose, anatomic resection of lung (left lower lobe lobectomy) was planned to do. Due to severe bronchiecstasis and inflammation, there’s much extremely tortuous and engorged collateral arteries around. We therefore decided to resect the pulmonary vein first and then the bronchus and pulmonary artery sequentially. But the severe adhesion fissure and tortuous vessels made the dissection of pulmonary artery unachievable after the bronchus resected. What’s more, the border of left upper and lower lobe also got severe inflammation and adhesion. Pneumonectomy seems the only way to get anatomic resection of lung in this patient. However, high risk and postoperative mortality was concerned and we decided to leave the pulmonary artery alone and perform a large wedge resection with both pulmonary vein and bronchus resected.
Both infection and bleeding are major concerns in this patient postoperatively. As for infection, we elongated the use of antibiotics to 4 weeks. And for bleeding, there’s no hemoptysis after the procedure or at further outpatient clinics follow-up. This patient can tolerate daily activity and some light works after discharge. The chest plain film also revealed no obvious progression ten months after the operation (Figure 3).
On searching related articles, we found no similar case reports. The only related procedure we found was resection of the pulmonary artery and bronchus whereas leave the pulmonary vein [5]. In that procedure, the isolated lung continues to receive a blood supply from the vessels between the lung surface and the chest wall, which keeps the lung parenchyma viable. Moreover, the intact pulmonary veins drain the blood, and therefore no necrosis of the lung parenchyma occurs [5]. In our case, the pulmonary artery was kept intact, and the pulmonary vein was resected. The bronchus of the left lower lobe was transected to control the hemoptysis. We considered that pneumonectomy for this patient was technical feasible to control the hemoptysis, but the associated risk of mortality was high. We wanted to preserve the lung function of left upper lobe, and therefore we resected the inferior pulmonary vein and bronchus and left the pulmonary artery. In follow-up imaging studies asymptomatic local lung consolidation with deficits in ventilation and perfusion were noted.