Sir: We read the report by Jaillard et al. [1] concerning the placement of a chest tube into the pulmonary artery and the subsequent discussion [2, 3]. This potentially fatal complication may be associated with the use of a trocar and, according to Jaillard et al., requires emergency thoracotomy. In addition to the Jaillard et al. [1] report, we report a patient with this complication although the trocar was not used, and where emergency thoracotomy was not needed. We discuss the potential role of the chest-tube material in the occurrence of this "fausse route."

A 73-year-old man with chronic obstructive pulmonary disease was admitted because of progressive dyspnea and collapse. Chest radiography showed pulmonary edema and an infiltrate in the left lower lobe. He was intubated for severe congestive heart failure with acute renal failure. In addition, a left-sided testicular mass was found. Diagnostic hemicastration was performed. On that day massive pleural fluid was found leading to shunting and hypoxia. A polyurethane chest tube was inserted at the bedside on the left side. After a skin incision an opening in the pleural cavity was made manually. The chest tube was inserted, guided by the finger while the trocar was withdrawn. During insertion of the tube further into the thorax no resistance was noticeable. Immediately thereafter blood flowed easily out of the tube, which was clamped off. Chest radiography suggested a fausse route (Fig. 1). We measured a pulmonary artery pressure curve at the tube end (Fig. 2) and inserted contrast (Fig. 3, provided as Electronic Supplementary Material). The patient was hemodynamically stable with acceptable ventilator settings. The thoracic surgeon decided to postpone surgical intervention for 12 h until the next morning. During the night the situation remained unchanged. A left-sided thoracotomy revealed the chest tube in the left pulmonary artery. The tube was removed with reconstruction of the pulmonary artery. The testicular mass appeared to be a pneumococcal abscess. After several weeks the patient died because of irreversible multiple organ failure.

Fig. 1.
figure 1

Chest tube entering left lateral into the thorax. The tip ends in the median line, suggesting a fausse route

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Fig. 2.
figure 2

Pulmonary artery pressure curve, recorded at the chest tube

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Chest tube placement is frequently associated with complications [4]. Pulmonary artery cannulation is extremely rare but was recently reported by Jaillard et al. [1]. Surgical removal and repair are obligatory. However, our report shows that in a stable condition surgical intervention can be postponed to allow necessary preparations to be made. The second point that we want to address is the tube material. We changed chest tubes (from polyvinylchloride to polyurethane) and experienced two major complications shortly thereafter, whereas no complications had been observed in previous years. One complication is described here; the other complication was chest tube placement in the lung itself leading to intrapulmonary bleeding. In both patients the tube was inserted without trocar. This suggests that the chest tube material and its characteristics, such as stiffness and design of the tip, may play a role. Figure 4 (Electronic Supplementary Material) shows that the polyvinylchloride tube is more flexible than the polyurethane tube.

In conclusion, we confirm the pulmonary artery cannulation as a complication of chest tube placement. However, emergency operation is not always necessary. Furthermore, the chest tube material may be an additional risk factor for a fausse route even when a trocar is not used.