Emergency donor pericardial conduit for ruptured pulmonary artery in lung transplantation for severe PH: a case report

Intraoperative pulmonary artery (PA) rupture is a rare but catastrophic complication during lung transplantation, particularly in patients with severe pulmonary hypertension (PH). Effective salvage strategies in this setting are not well described. This case report details the successful emergency application of a readily available donor pericardial conduit to manage an uncontrollable PA rupture during lung transplantation for end-stage idiopathic pulmonary fibrosis (IPF) with severe PH. A 58-year-old woman with end-stage IPF and severe PH (preoperative pulmonary artery systolic pressure 105 mmHg) underwent bilateral lung transplantation. Immediately upon reperfusion of the left lung, an acute longitudinal dissection and rupture of the recipient’s left main PA occurred, causing massive hemorrhage unresponsive to re-clamping due to extreme vessel friability. After emergent conversion from peripheral veno-arterial extracorporeal membrane oxygenation to full cardiopulmonary bypass, the damaged PA segment was resected. A 24-mm tubular conduit was fashioned intraoperatively from donor pericardium and anastomosed end-to-end to restore vascular continuity. The patient survived the procedure. Her postoperative course was complicated by a resistant Burkholderia cepacia infection, requiring prolonged treatment and tracheostomy. She was discharged on postoperative day 86. The follow-up CTA two months later showed that the catheter was widely patent and that the anastomosis had mild stenosis, which did not affect blood flow. Emergency reconstruction of a ruptured PA using an on-site fabricated donor pericardial conduit is a feasible and life-saving salvage technique in the setting of severe PH. Although the technique itself is not novel, its application in this extreme scenario—where the native PA is exceptionally friable and direct repair is impossible—offers a practical, biocompatible, and infection-resistant solution. We highlight the critical decision-making, technical execution, and lessons learned for perioperative preparedness in high-risk transplant recipients.