Life-threatening hemorrhagic shock due to intercostal artery perforation from a protruding staple leg after pulmonary wedge resection with a reinforced stapler: a case report

Pulmonary wedge resection is a lung-sparing procedure, with mechanical staplers enhancing surgical safety. Staple line reinforcement reduces air leakage; however, its effect on preventing mechanical vascular injury remains unclear. Staple-related vascular injuries rarely cause life-threatening complications. Here, we report a rare case of hemorrhagic shock caused by intercostal artery perforation from a protruding staple leg following thoracoscopic wedge resection with a reinforced stapler, which was likely triggered by lung collapse and re-expansion.

A 76-year-old man underwent thoracoscopic wedge resection of right segment 6 for suspected metachronous lung adenocarcinoma using a reinforced stapler with a gold cartridge. The surgery was uneventful. On postoperative day (POD) 1, accidental chest drain removal caused lung collapse. After drain reinsertion and lung re-expansion on POD 2, the patient developed hemorrhagic shock on POD 3. Emergency thoracotomy revealed massive intrathoracic hemorrhage from the eighth intercostal artery due to a staple leg protruding through the reinforcement and perforating the artery during lung inflation. Hemostasis was achieved using electrocautery and artery ligation, followed by removal of the protruding staple and additional staple line reinforcement. The postoperative course was uneventful, and the patient was discharged on POD 10.

Mechanical vascular injury due to staple protrusion can occur despite reinforced staplers. Lung collapse and re-expansion may alter the spatial relationship between the staple line and adjacent chest wall vessels, thereby increasing arterial injury risk. Careful staple line inspection, appropriate cartridge selection based on tissue thickness, and chest drain management are essential for preventing this rare complication.