A new surgical approach to the management of symptomatic aberrant right subclavian artery

Aberrant right subclavian artery is a rare congenital anomaly that usually does not produce symptoms. Symptomatic patients require surgical intervention. Ligation of the aberrant artery through a left thoracotomy has been advocated as the operation of choice. If development of vertebrobasilar insufficiency is anticipated, division and ligation of the aberrant artery and its anastomosis to the right common carotid artery or aortic arch are performed at a second operation. In the procedure advocated here, both ligation and anastomosis of the aberrant artery are performed simultaneously through midsternotomy. Normal blood flow is thereby established to the right upper extremity, which obviates any early or late complications.     

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.     

Endovascular repair of cervical aortic arch aneurysm

Cervical aortic arch (CAA) is a rare congenital anomaly of the aortic arch. Rarely, CAA is associated with aneurysm of the arch and great vessels. A 32-year-old male patient, previously in good health, presented with 2 weeks of severe chest pain. Radiographic evaluation revealed a CAA with aneurysmal dilation of the distal aortic arch. The aneurysm extended into the left subclavian artery. There was also marked angulation just distal to the aneurysmal portion. The aneurysmal arch and subclavian artery were repaired using a thoracic aortic endograft. An open axillary-to-axillary bypass was performed, and the left axillary artery was ligated proximally. This restored perfusion to the left upper extremity and effectively excluded the aneurysm sac. Immediately postoperatively, the patient's chest pain resolved, and he has remained symptom free. To the authors' knowledge, this is the first reported repair of a cervical arch aneurysm by endovascular technique.     

Left renal vein reconstruction after right nephrectomy and inadvertent left renal vein ligation: a case report and review of the literature.

Left renal vein ligation has been used as a technical aid to gain exposure to the perirenal aorta and to control bleeding in abdominal aortic operations. Left renal vein ligation is considered to be well tolerated in patients with 2 functioning kidneys, but has rarely been described in the setting of concomitant right nephrectomy and presents a management challenge. Some reports suggest recovery of renal function may be possible after left renal vein ligation during right nephrectomy, but other suggest that a delay in revascularizing the left renal venous drainage may result in irreversible nephropathy. This article reports the inadvertent division of the left renal vein during right nephrectomy. Renal failure ensued postoperatively. The left renal vein was reconstructed, and renal function was recovered. The inability to reliably predict which patients will have adverse outcome after left renal vein ligation in the setting of a right nephrectomy may necessitate preemptive intervention.     

A case of left lung cancer associated with an aneurysm of the thoracic aorta

A 61-year-old man was admitted to our hospital because of a left lung cancer. The chest x-ray film showed an irregular mass in the left upper lung field and the ill-defined left upper mediastinal border. A large portion of the aorta seen in the CT section above the aortic arch was understood to be aortic elongation. When a left pneumonectomy was performed, a saccular aneurysm of the distal aortic arch was found and resected under partial aortic clamping. Following the aneurysmectomy mediastinal dissection was performed in the normal way. The patient recovered uneventfully. The pathological specimens showed a pT2N1M0 squamous cell carcinoma with obstructive pneumonia and an arteriosclerotic aneurysm. There was no report of lung cancer associated with aneurysm of the thoracic aorta. In a patient with left lung cancer obliterating the left upper mediastinal border (the "silhouette sign") the aortic arch should be closely examined by MRI and/or angiography.     

Ligation of the renal vein during resection of abdominal aortic aneurysm

In resection of abdominal aortic aneurysm, ligation and division of the left renal vein may be necessary in order to expose the perirenal aorta. This manoeuvre is possible, with conservation of the left kidney function, because of the extensive venous collateral circulation of the left kidney. It is of crucial importance however, that ligation of the vein is performed close to the inferior vena cava. A case is presented where ligation of the left renal vein was performed in relation to an operation for a ruptured abdominal aortic aneurysm. After the operation there was initially dysfunction of the left kidney, and later on sepsis-induced uraemia. The renal function stabilized at a moderately reduced level. No permanent kidney damage related to the venous ligation could be demonstrated. In the literature serious renal damage has been reported in 10 cases out of 89 reported ligations of the left renal vein. Ligation of the left renal vein is thus a reasonably safe and acceptable procedure for surgical exposure in difficult aortic procedures.     

Massive upper extremity edema following vascular access surgery

We recently treated three patients with chronic renal failure who required subclavian vein cannulation with Uldall catheters following thrombosis of their arteriovenous fistulae. New arteriovenous fistulae were created in each patient following removal of the Uldall catheters. The patients were seen subsequently with massive, painful edema in the ipsilateral upper extremities from one to 10 weeks following creation of the arteriovenous fistulae. Radiographic studies documented stenosis or occlusion of the ipsilateral proximal subclavian vein. The arteriovenous fistula was ultimately ligated in each patient, which promptly resolved the pain and edema. Because subclavian vein thrombosis following temporary hemodialysis through an indwelling catheter is frequently asymptomatic until an arteriovenous fistula is constructed, venography should be considered in patients requiring upper extremity vascular access procedures. Demonstration of subclavian vein stenosis or occlusion would either preclude use of the upper extremity for an arteriovenous fistula or would require a concomitant procedure to relieve the venous obstruction.     

Video-assisted thoracic surgery for left lung cancer in a patient with a right aortic arch

We report a rare case of left lung cancer in a patient with a right aortic arch. A 65-year-old woman was diagnosed to have an adenocarcinoma in the left upper lobe (S3) in addition to a right aortic arch (type II), with the left subclavian artery originating from the descending aorta. Left upper lobectomy and lymph node dissection was performed by video-assisted thoracic surgery (VATS). For the mediastinal dissection, the upper mediastinal lymph nodes were easily resected after verifying the location of the arterial ligament and the recurrent laryngeal nerve (RLN). This is the first report of using VATS to remove a lung cancer from a patient with a right aortic arch.     

Lung cancer with an extrapericardial single trunk as the left pulmonary vein; report of a case

A left lower lobectomy was successfully performed in a lung cancer patient with anatomical variation in which the left superior and inferior pulmonary veins were connected to the left atrium after forming an extrapericardial single trunk. This variation is surgically important because ligation and division of the left inferior pulmonary vein may result in blockage of upper lobe vein drainage at the time of a left lower lobectomy. The ligation of the pulmonary vein leads to severe lung edema, which may cause infection, respiratory distress, or postoperative complications that could be life-threatening. Surgeons must always pay attention to this variation when performing a left lower lobectomy.     

Venous injury: to repair or ligate, the dilemma

Surgical management of major venous injuries remains controversial. The medical records of 184 patients with major venous injury were reviewed. Forty-three patients had isolated venous injury; 31 of 43 patients (72%) underwent ligation to treat their vein injury. Another 141 patients had combined arterial and venous injury; 117 of these patients (83%) had ligation. Injured were the inferior vena cava, iliac, femoral, popliteal, distal leg, and arm veins; all patients underwent surgical exploration. Arterial injuries were repaired by standard techniques and venous injuries were either ligated or repaired by end-to-end or lateral phleborrhaphy. Adjunctive fasciotomy was used when clinically indicated. The patients were followed up for 1 month to 9 years. No permanent sequelae of venous ligation were identified. Transient extremity edema developed in up to 32% of patients, regardless of whether vein ligation or repair was performed. This edema resolved completely within 12 weeks of the injury. No extremity was lost after ligation of a venous injury. Although it may be ideal to repair all venous vascular injuries, selective management reflecting mechanism of injury, blood loss, anesthesia requirements, associated organ injury, and other concerns may mitigate against extensive venous repair.     

Combined mediastinal node assessment by lymphadenectomy and intraoperative mediastinoscopy

The purpose of this study was to determine the importance of combined mediastinal node assessment by lymphadenectomy and intraoperative mediastinoscopy to patients with left lung cancer. Forty-one patients with left lung cancer were divided into a group of 13 and a group of 28: in the first group, the aortic arch was mobilized, while in the second group the aortic arch was not mobilized. The mediastinal nodes of both groups were then dissected and mediastinoscopes were inserted into the operation field with an approach through thoracotomy to biopsy each mediastinal node. We compared nodal pathological assessment in these two groups. In the group with mobilized aortic arches, pathological assessment of lymphadenectomy at Naruke's station 3 was 11/13 (85%) and combined with intraoperative mediastinoscopy was 12/13 (92%). In the group without mobilized aortic arches, pathological assessment of lymphadenectomy of station 3 was 14/28 (50%) and combined use of intraoperative mediastinoscopy significantly improved the diagnoses to 24/28 (86%) (P=0.004). Combined use of lymphadenectomy and intraoperative mediastinoscopy could improve the assessment of station 3 in left lung cancer without mobilizing aortic arch.     

Hybrid endovascular pseudoaneurysm and pulmonary stenosis repair in bovine arch

This case report details the endovascular management of a large aortic pseudoaneurysm in a high-risk patient with a complicated history using a multi-disciplinary, hybrid approach. The pseudoaneurysm compressed the main pulmonary artery to 5 mm with near complete obstruction of the left main pulmonary artery, while also compromising the lumens of the left superior pulmonary vein and left main bronchus. Furthermore, the patient's left upper extremity arteriovenous dialysis fistula and bovine arch anatomy required a hybrid approach of repair that preserved the fistula while treating the aortic, pulmonary, and bronchial pathology.     

Prognosis of completely resected pN2 non-small cell lung carcinomas: What is the significant node that affects survival?

OBJECTIVE: We analyzed the effect of the station of mediastinal metastasis with regard to the location of the primary tumor on the prognosis in patients with non-small cell lung cancer. METHODS: Of 956 consecutive patients who underwent operation for primary lung carcinoma between 1986 and 1996, 760 patients (79.5%) were diagnosed as having non- small cell carcinoma and were subjected to complete removal of hilar and mediastinal lymph nodes together with the primary tumor. RESULTS: The status of lymph node involvement was N0 in 480 patients (63.2%), N1 in 139 patients (18.3%), and N2 in 141 patients (18.6%). The 5- and 10-year survival of patients with N2 disease were 26% and 17%, respectively. Neither cell type nor the extent of procedure was a significant survival determinant. Patients having involvement of subcarinal nodes from upper-lobe tumors had a significantly worse prognosis than those patients with metastases only to the upper mediastinal or aortic nodes (P =.003). Patients with nodal involvement of the upper mediastinum from lower-lobe tumors had a significantly worse survival than those patients with metastases limited to the lower mediastinum (P =.039). Furthermore, patients with involvement of the aortic nodes alone from left upper-lobe tumors had a significantly better survival than those patients with metastasis to the upper or lower mediastinum beyond the aortic region (P =.044). CONCLUSIONS: When mediastinal metastasis is limited to upper nodes from upper-lobe tumor, to lower nodes from lower-lobe tumor, or to aortic nodes from left upper-lobe tumor, acceptable survival could be expected after radical resection.     

Total aortic arch replacement through the L-incision approach

BACKGROUND: Even though the median sternotomy is the standard approach for surgery involving the aortic arch, access to the site of distal anastomosis is problematic when the aortic pathology involves the distal arch. We recently developed an "L-incision" approach (a combination of a left anterior thoracotomy and upper half median sternotomy) for total arch replacement. METHODS: We reviewed our surgical technique and operative results for 11 patients who underwent total aortic arch replacement through the L-incision between July 1999 and July 2000. With a patient in a left anterolateral position, a left anterior thoracotomy was performed through the fourth to sixth intercostal space. An upper half median sternotomy followed. Operative exposure was enhanced with spring retractors. The proximal anastomosis (between the four branched graft and ascending aorta) was accomplished first. Upon completion of the proximal anastomosis, the heart was reperfused from one branch of the graft. The three arch vessels were subsequently reconstructed under deep hypothermia and retrograde cerebral perfusion. Antegrade cerebral perfusion was accomplished through the graft as the distal anastomosis (between the graft and descending thoracic aorta) was performed. RESULTS: No early operative deaths were observed. One patient sustained a permanent neurologic deficit. A transient recurrent laryngeal nerve palsy lasting 1 month occurred in 1 patient. No patient required reoperations for bleeding, nor did any patient develop a postoperative phrenic nerve palsy, aspiration pneumonia, or renal dysfunction. CONCLUSIONS: The L-incision allows extensive replacement of the aortic arch and is associated with a low incidence of postoperative bleeding and respiratory insufficiency.     

Division of the left renal vein. Guidelines and consequences.

Ligation and division of the left renal vein is a reasonable safe procedure in selected patients when exposure of the perirenal aorta is crucial. This manipulation is possible because of extensive venous collateralization from the left kidney in man. Measurement of the venous stump pressure before ligation is recommended to assess the degree of collateralization, and the upper limit within which the vein may be divided safely is probably in the neighborhood of 60 cm of water. Reanastomosis of the vein is not necessary for preservation of renal function, although transient left renal dysfunction may occur. Examination of the urine and careful monitoring of renal function should be routine in the postoperative period. Intravenous urography and left spermatic venography later in the postoperative course can indicate the ultimate degree of function of the left kidney and the pathways of venous collateralization. Preservation of normal function and venous architecture at the renal hilum should be the rule.     

The anterior jugular venous system: variability and clinical impact

The anterior jugular venous system, with its interconnections to the subclavian and deep jugular veins, provides a collateral venous network across the midline of the neck area, which is especially important in unilateral occlusion of an innominate vein. We illustrate the variability of this system and its clinical impact on catheterization by three cases of landmark-guided central venous cannulation. Case 1: Cannulation of the left internal jugular vein with a central venous catheter and of the left innominate vein (LIV) with a pulmonary artery catheter resulted in correctly positioned catheter tips. However, these catheters were actually not placed in the innominate vein but coursed through the jugular venous arch. Case 2: Cannulation of the left subclavian vein was complicated by resistance of guidewire advancement at 13 cm. Occlusion of the LIV and enlargement of the jugular venous arch were present. Case 3: Insertion of a pulmonary artery catheter and a central venous catheter through the LIV. The pulmonary artery catheter was correctly placed. The tip of the central venous catheter was mistakenly positioned in the left anterior jugular vein. We describe the normal anatomy of the anterior jugular venous system and its role as a major collateral. Correct placement of central venous catheters may be possible via the anterior jugular venous system. Conversely, central venous catheters malpositioned in the anterior jugular vein can increase the risk for complications and should be removed.     

Postpneumonectomy syndrome: diagnosis, management, and results.

Airway obstruction may be caused by extreme mediastinal shift and rotation after right pneumonectomy or after left pneumonectomy in the presence of a right aortic arch. Eleven adults (aged 18 to 58 years) with severe symptoms were treated surgically between 5 months to 17 years after pneumonectomy (7 right, 4 left). An initial patient with only one functional lobe was treated unsuccessfully by aortic division and bypass graft. Ten underwent mediastinal repositioning. After two recurrences prostheses were used to maintain mediastinal position. Five patients who underwent such repositioning are doing well from 5 months to more than 5 years later. One died 1 month after operation probably of pulmonary embolism. One who showed residual airway collapse after operation has some recurrent obstruction. Three other patients who showed severe malacic obstruction of the airway after mediastinal repositioning variously underwent aortic division with bypass graft and tracheal and bronchial resection. One is well almost 6 years later. Two died postoperatively. Occurrence of the syndrome is unpredictable. Where malacic changes have not occurred, mediastinal repositioning may reasonably be expected to correct obstruction. Optimal treatment for concurrent severely malacic airways is unclear.     

Absent left pulmonary artery and double aortic arch in tetralogy of Fallot: reconstruction using homograft saphenous vein or iliac artery

Two cases of tetralogy of Fallot (TOF) with double aortic arch and absent left pulmonary artery are reported. Single-stage repair was performed using a left thoracotomy for division of the non-dominant arch followed by complete repair through a median sternotomy. In both patients, the left pulmonary artery was reconstructed using either a homograft saphenous vein or a homograft common iliac artery.     

血管重建在原发性纵隔肿瘤中的临床应用

目的总结血管重建在原发性纵隔肿瘤中的应用经验和疗效。方法经外科手术治疗并血管重建的原发性纵隔肿瘤76例,22例（28.9%）单纯侵及上腔静脉;16例（21.1%）侵及单纯左或右无名静脉;34例（44.7%）侵及上腔静脉和左或右无名静脉;有4例（5.3%）单纯侵及主动脉外膜。行完整切除70例,部分切除6例;行血管置换46例,血管成形30例。结果全组病人无一例围术期死亡。上腔静脉阻断时间为（10-30）min,平均（18.0±5.3）min。左或右无名静脉单侧阻断时间为（11-25）min,平均（16.5±4.2）min。全组病人均获随访,时间为12-26个月,术后生活质量满意。结论纵隔肿瘤侵及上腔静脉及其属支大血管的病人,如全身无系统功能严重受损应积极手术治疗,可选用血管置换或血管成形术。     

Division of the left renal vein during aortic surgery

Perirenal aortic exposure and control can be facilitated by division of the left renal vein (LRV), but only if adequate collateral venous drainage is present. When incremental elevations in LRV pressure were produced in nine dogs, we noted that left renal glomerular and tubular function (creatinine clearance, sodium retention, urine osmolality, and urine output) were virtually lost at pressures greater than 50 to 60 cm water. Between January 1967 and December 1989, 64 patients underwent LRV division during the performance of abdominal aortic aneurysm surgery (57 of 589 = 10%) or reconstruction for aortoiliac occlusive disease (7 of 506 = 1%). LRV stump pressures (LRVSPs) were measured in 44 of these patients and were less than or equal to 60 cm water in all but one instance. Ten of the 64 patients died, but none as a consequence of this maneuver. Post-operatively, all survivors had serial serum creatinine levels measured and either an intravenous pyelogram, renal scan, or arteriogram. One case of a non-functioning left kidney was identified. This occurred in the only patient who underwent re-anastomosis after LRV division. A LRVSP equal to or greater than 50 cm water and extreme venous distention after test clamping served as a contraindication to LRV division in seven other patients. We conclude that a LRVSP less than or equal to 50 to 60 cm water indicates that the LRV may be safely divided during juxtarenal aortic exposure. However, a pressure greater than or equal to 50 to 60 cm water suggests that LRV division should not be carried out unless absolutely essential and then only if right kidney function is known to be adequate.