812 - Bilateral Upper Extremity Hematomas with Left Brachial Artery Pseudoaneurysm following Bilateral Orthotropic Lung Transplant

Case Diagnosis: Bilateral Upper Extremity Hematomas with Left Brachial Artery Pseudoaneurysm following Bilateral Orthotropic Lung Transplant

Case Description: A 64 y/o female with a 40 pack-year smoking history with combined pulmonary fibrosis and emphysema was admitted to inpatient rehabilitation(IPR) after a bilateral orthotropic lung transplant. On initial examination, she was found to have new bilateral upper extremity hematomas. She denied any trauma to the area. She was on aspirin and subcutaneous heparin for DVT prophylaxis. Non-vascular duplex ultrasounds of bilateral upper extremities confirmed presence of hematomas. Vascular duplex demonstrated a pseudoaneurysm off the left brachial artery. After consultation with Vascular Surgery, she underwent pseudoaneurysm repair. She additionally required a tunneled line placement by Interventional Radiology due to subsequent complications with obtaining intravenous access in the setting of frequent lab monitoring. She ultimately was able to return to IPR to complete her post-transplant rehabilitation.

Discussions: Post-lung transplant patients benefit from rehabilitation in an IPR setting for several reasons including maximizing their functional independence, close monitoring of labs while immunosuppressed, monitoring for signs of infection or rejection, and helping with post-op pain management. In this case, unexplained bruising of the patient’s arms was quickly recognized by the rehabilitation medical team and appropriately addressed to prevent further complications. Unfortunately, this interrupted her IPR stay. Although she had significant risk factors for vascular disease, the exact cause of the pseudoaneurysm and hematomas is not clear.  Per the transplant OP report, she was in a supine position with arms tucked and monitoring lines only included and radial arterial line and pulmonary artery catheter without lines directly into the brachial artery.

Conclusions: Post-lung transplant patients may present with unique complications in IPR. Performing thorough physical examinations and maintaining a high level of suspicion for complications can allow for early identification and treatment.