Simultaneous surgery for left lung cancer and the aneurysm of an aberrant left subclavian artery in a patient with right aortic arch

A 69-year-old man with right aortic arch was diagnosed as having left lung cancer (cT2aN1M0, cStage IIA) and an aneurysm of an aberrant left subclavian artery. The aneurysm measured 36 mm in diameter and was located 1 cm peripheral from the origin in the area known as "Kommerell's diverticulu Left carotid artery-to-left subclavian artery bypass graft was placed through a left supraclavicular incision prior to thoracotomy. This bypass graft effectively prevented neurological and ischemic complications of the brain and left upper extremity while we safely and successfully performed resection of the aneurysm along with radical surgery for left lung cancer through left thoracotomy. There have been only 10 case reports, including the present case, that have described surgical resection of lung cancer in a patient with right aortic arch. In addition, this is the 1st report to describe simultaneous surgery for both left lung cancer and an aneurysm of an aberrant left subclavian artery in a patient with right aortic arch.     

Completely resected superior sulcus tumor and vascular reconstruction of vertebral and subclavian arteries

A 62-year-old man was pointed out the superior sulcus tumor of the left lung invading to the subclavian artery and the vertebral artery. Bronchoscopic brushing cytology of the tumor showed Class V large cell carcinoma. The patient was diagnosed as clinical stage IIIA(cT4N0M0). After concurrent chemoradiotherapy, we performed left-upper lobectomy and reconstructions of left subclavian and vertebral arteries through modified transmanubrial approach. Surgeons of three different departments took part in the operation. Cooperative works were the key for the complete resection of such an advanced superior sulcus tumor.     

Extended resection of lung cancer invading the left subclavian artery by using cardiopulmonary bypass.

We treated a 54-year-old man with large cell carcinoma of the left upper lobe invading the esophagus and the left subclavian artery (SCA) from its origin. The tumor was completely resected by lobectomy under cardiopulmonary bypass. The left SCA was dissected at the aortic arch and reconstructed with a graft. The muscle layer of the esophagus was resected, followed by patching with an intercostal muscle flap. The pathological tumor stage was T4N0M0. The tumor recurred at two months after surgery in the neck lymph nodes and brain. Both sites were treated with radiation therapy and the patient is now alive without recurrence at 26 months after surgery. Lung cancer invading the great vessels and other mediastinal structures can be cured or long survival can be obtained by extended resection and postoperative adjuvant therapy.     

A successful surgical treatment of ascending aortic aneurysm, left common carotid artery aneurysm and left subclavian artery obstruction due to aortitis syndrome in active phase]

A 24-year-old female was admitted complaining of coldness of left upper extremity and pulsating tumor of the neck. She was diagnosed as ascending aortic aneurysm, left common carotid artery aneurysm and left subclavian artery obstruction due to aortitis syndrome on examinations. Although steroid treatment appeared to be effective in controlling inflammatory reaction, the left common carotid artery aneurysm increased in size and severe neck pain started. The risk of rupture was feared, and surgical intervention was carried out in spite of aortitis in active phase. The patient underwent surgery where aneurysmectomy and graft replacement for ascending aortic aneurysm, aneurysmectomy and graft replacement using autogenous saphenous vein for left common carotid artery aneurysm and bypass grafting for left subclavian artery obstruction were performed. The histology of resected specimens of aortic wall showed active aortitis. The postoperative course was uneventful and the patient was discharged on steroid.     

Long-term survival after resection of giant chondrosarcoma of the chest wall weighing 9.6 kg.

The case of a 43 year old male with giant chest wall tumor weighing 9.6 kg verified as chondrosarcoma is described. The patient was treated by multiple (six times) surgical procedures including left costopleuropneumonectomy and left subclavian artery end-to-end anastomosis between 1998 and 2005. Despite the palliative character of surgery, he achieved long-term survival but finally refused next surgery due to the risk of left upper limb amputation and died a few months later.     

Acute basilar artery occlusion in a patient with left subclavian artery occlusion due to first rib anomaly: case report

A previously healthy 22-year-old man presented with thoracic outlet syndrome manifesting as Raynaud's phenomenon in the left hand and embolic occlusion of the basilar artery. Three-dimensional computed tomography angiography showed that the left subclavian artery was occluded as it passed over the abnormal first rib. Retrograde propagation of the thrombus from the site of arterial occlusion and/or reflux of embolic material was suspected. Medical therapy was started. The patient underwent resection of the anomalous rib. Postoperative angiography demonstrated that the subclavian artery was recanalized with almost normal distal flow. The basilar artery was also recanalized. Thoracic outlet syndrome due to a first rib anomaly may cause stroke.     

An effective and safe surgical approach for a superior sulcus tumor: A case report

IntroductionSuperior sulcus tumors, frequently referred to as Pancoast tumors, are a wide range of tumors invading a section of the apical chest wall called the thoracic inlet. For this reason, a surgical approach and complete resection may be difficult to accomplish. We experienced a locally advanced superior sulcus tumor (SST) located from the anterior to posterior apex thoracic inlet and performed complete resection after definitive chemoradiation.Presentation of caseA 71-year-old Japanese male presented at our hospital due to left back pain and an abnormal chest computed tomography (CT) scan showing 80 × 70 × 60-mm tumor located in the left middle apex thoracic inlet. This tumor was located near the subclavian artery, and the subclavian lymph nodes were swollen. The tumor was found to be an adenocarcinoma (clinical-T3N3M0 stage IIIB). Therefore, we performed definitive chemoradiation therapy. Slight reduction in the tumor size was noted after the treatment, and the subclavian lymph nodes were not swollen. We next performed surgical resection for this SST. Regarding the surgical approaches, the anterior approach was a transmanubrial approach, and the posterior approach was a Paulson’s thoracotomy. In this manner, we were able to perform complete en-bloc resection of this tumor.DiscussionThis surgical approach was effective and safe for treating a SST located from the anterior to posterior apex of the thoracic inlet. The patient remains healthy and recurrence-free at 2.5 years after the operation.ConclusionSurgical approach for SST is difficult. Therefore, this approach is effective and safety.     

Axilloaxillary bypass for the treatment of subclavian artery stenosis complicated by bilateral common carotid artery occlusion: technical case report

OBJECTIVE AND IMPORTANCE: We successfully treated a patient with stenosis of the left subclavian artery, complicated by bilateral common carotid artery occlusion, via axilloaxillary bypass surgery. CLINICAL PRESENTATION: A 67-year-old patient with a history of hypertension and cerebral infarction underwent neck irradiation for treatment of a vocal cord tumor. Three months later, he began to experience transient tetraparesis several times per day. The blood pressure measurements for his right and left arms were different. Supratentorial blood flow was markedly low. The common carotid arteries were bilaterally occluded, and the right vertebral artery was hypoplastic. Therefore, only the left vertebral artery contributed to the patient's cerebral circulation; his left subclavian artery was severely stenotic. INTERVENTION: The patient underwent axilloaxillary bypass surgery because the procedure avoids thoracotomy or sternotomy, manipulation of the carotid artery, and interruption of the vertebral artery blood flow. The patient has been free of symptoms for more than 5 years. CONCLUSION: Neurosurgeons should be aware that extra-anatomic bypass surgery is an effective treatment option for selected patients with cerebral ischemia.     

Report of simultaneous off-pump CABG and modified mastectomy

The patient was a 75-year-old female who had received medical treatment for effort angina. Recently, she noticed a left breast tumor, which was diagnosed as breast cancer with axillary lymph node swelling. Coronary angiography performed prior to the surgery for the breast cancer showed 90% stenosis in segment 6 of the left anterior descending artery (LAD). Coronary intervention was not possible due to anatomical reasons, so she was admitted for simultaneous surgery for the breast cancer and angina. The chest was opened through a median sternotomy and the full-skeletonized right internal thoracic artery was grafted on the LAD without cardiopulmonary bypass. A transverse elliptical incision was made after the median sternotomy was closed, and the breast tumor and lymph nodes around the subclavian and axillary vessels were completely dissected. Even in the case of multiple vessel coronary disease, simultaneous surgery may be possible, but indications should be carefully assessed considering the cardiac function and general condition of the patient.     

Diverticula in association with the proximal left subclavian artery: a cause of mediastinal mass lesions.

The case reports of 5 patients with an aortic arch diverticulum associated with the proximal left subclavian artery are presented. In 3 patients, the left subclavian artery arose from a diverticulum off a right aortic arch and traversed the retroesophageal area to the opposite arm. In 1 patient, the left subclavian artery arose from a diverticulum off a left aortic arch; this represents the second instance of this anomaly to be reported in the literature. In 1 patient, the left subclavian artery was not attached to the aorta, and a diverticulum was present in the expected area of attachment. Confusion of these anomalies with solid mediastinal mass lesions and with aortic aneurysms may occur. Treatment is predicted on symptomatology, and resection is usually not indicated. It is necessary to remain cognizant of aortic diverticula and to differentiate them from other mediastinal mass lesions.     

Median approach for upper lobe lung cancer patients with suspected anterior mediastinal invasion

We report the usefulness of a median approach to the mediastinum for the treatment of lung cancer with possible mediastinal invasion. Patient was a 74-year-old man with left S3 squamous cell carcinoma suspected of anterior mediastinal invasion (cT4N0M0) because of hoarseness before surgery. A median sternotomy with partial collar incision was chosen for surgery. The tumor was widely adherent to the anterior mediastinum, invading the common carotid artery and the origin of the left subclavian artery. Left upper lobectomy with ND2a by incomplete resection of the invading portion followed by postoperative radiotherapy was performed. For upper lobe lung cancer with possible mediastinal invasion, a median approach seems to be useful, because it facilitates both easy approach to the anterior mediastinum and the management of invasion of large vessels.     

Transmanubrial osteomuscular sparing approach for lung cancer invading the anterior part of the thoracic inlet

Standard treatment for lung cancer presenting as a superior sulcus tumor is induction chemoradiotherapy followed by surgery, which yields rates of about 70% complete resection and 50% 5-year survival rate. However, the surgical technique to achieve complete resection for superior sulcus tumor invading major anatomical sites including the subclavian artery is challenging. The anterior transcervical thoracic approach applied by Dartevelle and colleagues provides excellent exposure of the subclavian vessels. Grunenwald and associates have improved on this approach to preserve the clavicle and sternoclavicular joint. We applied the transmanubrial osteomuscular-sparing approach in two patients. In both cases, exposure of the subclavian vessels was excellent. In one case, the subclavian artery was resected and reconstructed with a polytetrafl uoroethylene graft. This patient has continued to show recurrence-free survival for more than 5 years. We outline our experience and review the literature on the surgical approach for superior sulcus tumor invading the anterior part of the thoracic inlet.     

Carotid artery stenting in a patient with right-sided aortic arch with an aberrant left subclavian artery

A right-sided aortic arch with an aberrant left subclavian artery is a rare anatomical variation. We report a case treated with carotid artery stenting (CAS) for a patient with a right-sided aortic arch with an aberrant left subclavian artery. A 72-year-old man presented right hemiparesis due to acute brain infarction. Neck CT angiography showed 70% stenosis in the left internal carotid artery (ICA). We diagnosed acute brain infarction as artery-to-artery embolism due to ICA stenosis and decided to perform carotid artery stenting (CAS) for symptomatic ICA stenosis. CT angiography to evaluate an access route to the lesion incidentally showed the right-sided aortic arch with an aberrant left subclavian artery. An intraoperative aortogram showed a right-sided aortic arch. The guiding catheter was carefully introduced up to the left common carotid artery. CAS was performed with a proximal balloon and distal filter protection. The stenotic area was restored, and the patient was discharged without suffering recurrent attacks. Although a right-sided aortic arch with an aberrant left subclavian artery is a very rare anatomical variation, it can be encountered in neuroendovascular treatment, and therefore knowledge of this anatomical variation is important.     

Surgical repair of a left subclavian artery aneurysm causing stenosis of a left internal mammary graft-a case report

Subclavian artery aneurysms are extremely rare, accounting for approximately 0.1% of peripheral artery aneurysms. We present a case of a proximal left subclavian arterial aneurysm in a patient status post previous coronary artery bypass grafting; the aneurysm was complicated by involvement of the left internal mammary artery that had been previously utilized to revascularize the left anterior descending artery. Ostial stenosis of the internal mammary artery secondary to the aneurysm was present. Simultaneous reoperative coronary bypass surgery and repair of the left subclavian aneurysm was performed, with a good result. This is the second case reported in the literature of concomitant subclavian artery aneurysm repair and coronary revascularization.     

Reimplantation of a non-functioning lung. Report of a case]

The authors present the case of a patient with a carcinoid tumor of the left main bronchus. Conservative surgery by sleeve resection without pulmonary resection was performed. The underlying lung which was considered to be nonfunctioning during pre-operative evaluations, completely recovered within a year following surgery.     

False aneurysm of the axillary artery caused by graft infection: report of a case

A 77-year-old man presented to our hospital following the sudden onset of left subclavicular swelling, 8 years after undergoing subtotal removal of an axillofemoral bypass. Computed tomography revealed a rupture of the left axillary artery with the formation of a false aneurysm. Emergency surgery was performed in the form of an extraanatomic, axillo-axillary bypass with resection of the false aneurysm. Prior to removal of the false aneurysm, the subclavian artery was ligated via a left thoracotomy to minimize blood loss. The pathogen was identified asProteus mirabilis, which is a rare causative organism for prosthetic graft infection. This case report demonstrates that total removal of the graft with revascularization should be performed for graft infections.     

Asymptomatic pseudo-aneurysm of the aortic arch in a patient with aberrant right subclavian artery. A complication of Kommerell's diverticulum?

Kommerell's diverticulum is an aortic arch deformity associated with an aberrant subclavian artery. Symptoms related to compression of adjacent structures, dilatation of the aortic diverticulum or accelerated atherosclerosis leading to increased risks of dissection and rupture represent the indications for surgical treatment. Several surgical strategies have been used for the management of this congenital abnormality. We present the case of a 56-year-old male with a pseudo-aneurysm of a left aortic arch adjacent to a Kommerell's diverticulum at the orifice of a left subclavian artery. The patient also presented an aberrant right subclavian artery originating from the posterior wall of the ecstatic take-off of the left subclavian artery. Our surgical strategy was limited to the resection of the aneurysm without any manipulation of the aortic diverticulum and aberrant right subclavian artery, as the wall of both aorta adjacent to the saccular aneurysm and left subclavian artery was normal, the Kommerell's diverticulum was small and the patient was asymptomatic.     

Staged hybrid treatment of complex ascending aortic and distal aortic arch pseudoaneurysm after repair of aortic coarctation

A 49-year-old operated for aortic coartaction patient presented with thoracic and ascending aortic aneurysm. He was asymptomatic. Angio-magnetic resonance nuclear scan and angiography revealed an ascending aortic aneurysm (5.2 cm), bicuspid aortic valve, 6-cm proximal descending aortic pseudoaneurysm at the site of the previous operation with involvement of the left subclavian artery. Restenosis at the original site of coarctation and aortic arch hypoplasia distally to the brachiocefalic trunk was also found. The operation performed was a "modified Bentall - De Bono". The pseudoaneurysm was not accessible through median sternotomy due to the massive lung adhesions following the previous surgery. The left common carotid artery was explanted from the aortic arch and connected with a graft to the ascending aortic conduit. A proximal neck suitable for landing zone of the endovascular stent-graft was then established. The postoperative course was uneventful. After two weeks, the patient was readmitted. The exclusion of the thoracic descending aortic pseudoaneurysm by endovascular implantation of the stent-graft prosthesis was performed. The left subclavian artery was excluded because left vertebral artery was closed. The patient did not develop hand claudicatio. The procedure was successful.     

Resection of Kommerell's diverticulum and left subclavian artery transfer for recurrent symptoms after vascular ring division.

OBJECTIVES: A Kommerell's diverticulum in patients with a right aortic arch may become aneurysmal and be an independent cause of tracheoesophageal compression, even after ligation and division of a left ligamentum. We review the indications for and results of Kommerell's diverticulum resection and left subclavian artery transfer in children with a right aortic arch who previously underwent vascular ring (ligamentum) division. METHODS: From 1998 through 2001, eight children have been referred with recurrent respiratory symptoms (n=8) and/or recurrent dysphagia (n=4) after vascular ring division. Each child had a right aortic arch with a left ligamentum and had undergone division of the ligamentum elsewhere. All had a Kommerell's diverticulum that was not addressed at the initial operation. All patients had a repeat left thoracotomy with resection of the diverticulum. Five patients had division and reimplantation of the left subclavian artery into the left carotid artery to relieve the sling-like effect of the retroesophageal left subclavian artery on the right aortic arch. One other patient had primary Kommerell's diverticulum resection and transfer of the left subclavian artery to the left carotid artery. RESULTS: The mean age at the initial operation was 1.7+/-0.9 years, and the mean age at reoperation was 8.0+/-3.7 years. In all patients postoperative bronchoscopy confirmed relief of the tracheal compression. There were no complications related to the subclavian artery transfer. Two patients developed postoperative chylothorax, one requiring thoracic duct ligation. The median hospital stay was 5 days. All patients had dramatic resolution of their preoperative symptoms. CONCLUSIONS: Kommerell's diverticulum is an important anatomic structure that can cause recurrent symptoms in patients with a right aortic arch after ligamentum division. In selected patients, reoperation with resection of the Kommerell's diverticulum and transfer of a retroesophageal left subclavian artery results in relief of symptoms. This technique has become our procedure of choice as a primary operation for children with a right aortic arch and a significant Kommerell's diverticulum.     

Dysphagia Lusoria: A Complication Following Gastric Bypass Surgery?

A 23-year-old Caucasian female presented with progressive dysphagia beginning 5 months following laparoscopic gastric bypass for morbid obesity. She was diagnosed with an aberrant right subclavian artery and underwent a combined right supraclavicular approach and left thoracotomy for resection, with reimplantation of the vessel to the ipsilateral carotid artery. The patient had complete resolution of symptoms.