Surgical Treatment of a Superior Sulcus Tumor in a Patient with Idiopathic Thrombocytopenic Purpura: Report of a Case

We herein report a resection of a superior sulcus tumor in a patient with idiopathic thrombocytopenic purpura. A resection of the left upper lobe of the lung, left subclavian artery, and left first to third ribs, as well as a reconstruction of the left subclavian artery, were performed. Postoperative hemorrhaging was controlled due to preoperative high-dose intravenous immunoglobulin therapy and a platelet transfusion both during and following surgery. The resected tumor was diagnosed to be a pulmonary pleomorphic carcinoma, which was pathologically determined to be T3N0M0-Stage 2B. The patient remained in good condition for 20 months following the surgery; however, he eventually died due to bone metastases.     

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.     

A case of chondrosarcoma arising from the left first rib

A 46-year-old female was admitted to our hospital because of a left supraclavicular tumor. The chest CT scan and MR imaging revealed that the tumor arose from the left first rib and developed into the supraclavicular region. In this case, we tried to resect the tumor using the so-called "trap-door" thoracotomy. Although removal of subclavian vessels and brachial plexus from the tumor was easily performed, we could not enough treat the vertebral side of the first rib through this thoracotomy without the T1 nerves injury. In cases of superior sulcus tumors developing into the posterior chest wall, a posterior incision combined with an anterior one will be useful to remove these tumors safely.     

Surgical Treatment of Superior Sulcus Tumors

Purpose To access the clinical outcome of patients with superior sulcus tumor.Methods We reviewed the records of 16 patients who underwent surgery for a superior sulcus tumor between 1988 and 2003, focusing on the type of surgery.Results All 16 patients underwent en bloc lung and chest wall resection, which was done as pneumonectomy in 1 patient and lobectomy in 15. Complete resection was achieved in 11 patients, but incomplete resection was done in 5 patients because microscopic examination revealed positive surgical margins. Eight patients underwent partial vertebrectomy and 1 patient had combined resection of the subclavian artery. There was no postoperative mortality. All patients received pre- or postoperative adjuvant therapy, or both. The overall 5-year survival rate was 31.0%. The 5-year survival rate was higher after complete resection than after incomplete resection (59.3% vs 0%, P = 0.08). Patients who underwent complete resection for vertebral invasion and those who did not had 5-year survival rates of 66.7% and 0%, respectively (P = 0.17). Patients who underwent preoperative induction therapy followed by complete resection and those who did not had 5-year survival rates of 80% and 0%, respectively (P = 0.009).Conclusion Although superior sulcus tumors are still complex, preoperative induction therapy followed by complete resection seemed effective for prolonging survival.     

Total vertebrectomy (Th2) and dissection of the subclavian artery for a superior sulcus tumor invading the spine: A case report

IntroductionSurgery for primary lung cancer invading the spine remains challenging. Here, we present a case of superior sulcus tumor (SST) with vertebral invasion, successfully resected with total vertebrectomy (Th2) and dissection of involved apical chest wall and the subclavian artery (SCA).Presentation of caseA 62-year-old man was referred with the diagnosis of lung squamous cell carcinoma originating from left upper lobe (clinical stage IIIA/T4N0M0) involving the thoracic vertebrae (Th2) as well as the apical chest wall including three ribs (1st, 2nd and 3rd) and SCA. After induction concurrent chemo-radiotherapy, we achieved complete resection by three-step surgical procedures as follows: first, the anterior portion of involved chest wall including SCA was dissected through the trans-manubrial approach (TMA); next, the posterior portion of involved chest wall including ribs was dissected and left upper lobectomy with nodal dissection was performed through posterolateral thoracotomy; finally, total vertebrectomy (Th2) was performed through posterior mid-line approach.DiscussionThis tumor was existence of anterior and posterior position in pulmonary apex region. So that, it is very important for complete resecting this complicated tumor to work out operation’s strategy.ConclusionSurgery may be indicated for SST invading the spine, when complete resection is expected.     

Anterior approach for tumor of the superior sulcus.

A new approach for the resection of tumors of the superior sulcus is described. The exposure is gained through a proximal median sternotomy extended into the anterior fourth intercostal space as well as to the base of the neck on the appropriate side. This approach guarantees excellent exposure of the tumor, subclavian artery, and brachial plexus as well as access to the ribs posteriorly and the border of the vertebral bodies. Hilar dissection is readily accomplished without change of the patient's position. Disadvantages relate to depth of exposure, especially in large individuals, and the complicated wound closure.     

Vertebral artery embolic protection via ipsilateral brachial approach during left subclavian artery angioplasty and stenting--a case report

The purpose of this report is to explore angioplasty and stenting with cerebral embolic protection as a salvage procedure for a compromised carotid-subclavian bypass in the presence of antegrade vertebral artery flow. A 76-year-old woman with a carotid-subclavian bypass presented with graft infection. Failure of medical therapy to treat the infection prompted surgical removal of the graft. The native subclavian artery was still patent, but a severe complex proximal stenosis was present with antegrade flow into the left vertebral artery. Angioplasty and stenting of the subclavian artery was performed with cerebral protection achieved by positioning a FilterWire EX in the left vertebral artery via the left brachial artery approach. Deployment of a filter device in the vertebral artery via the brachial or radial approach can provide embolic protection without interfering with the subclavian artery stenting. The successful treatment of the subclavian artery enabled the complete removal of the infected graft without need for major vascular reconstruction.     

Review of the surgical treatment in superior sulcus tumor

The rarity of the superior sulcus tumor has led to varying treatment techniques. Generally, radiation therapy followed by surgery has been used. En bloc resection combined with lobectomy and nodal dissection remains standard therapy. The unique location of this tumor, surgical approach thought to be important. Involvement of the anterior areas such as subclavian vessels can be resected by anterior transcervical approach, and vertebral body or brachial plexus through the classic Shaw Paulson approach. Preoperative computed tomography (CT) or magnetic resonance imaging (MRI) is beneficial to the evaluation of the vessels, nerves, and surgical planning. Recent studies showed that induction concurrent chemoradiation therapy improved the resectability and curability. This article reviews the treatment of superior sulcus tumor.     

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.     

A case of traumatic subclavian steal syndrome

A 44-year-old man who had sustained injuries to the chest and left upper extremity was admitted to our hospital. The radial pulse was not palpated at the left wrist. Angiography showed occlusion of the left subclavian artery with mediastinal hematoma. The left vertebral artery filled in a retrograde direction and the distal left subclavian artery could be visualized by filling from the left vertebral artery. He had no ischemic neurological symptom but was immediately operated on to prevent hemorrhage. Through a median sternotomy the injured portion of the left subclavian artery was removed and replaced by a dacron prosthesis. The specimen represented that the artery was completely divided and occluded with thrombus. Recovery was uneventful. This was the seventh case of traumatic subclavian steal syndrome. Vascular repair should be made soon in traumatic subclavian steal syndrome because collateral circulation is poor compared with that in arteriosclerotic obstruction.     

Common trunks of the subclavian and the vertebral arteries: presentation of a new aortic arch anomaly

Information about the variations of the origins of subclavian and vertebral arteries and their course is of great importance for head and neck surgery. The normal vertebral arteries arise as the first branches of the corresponding subclavian arteries. In a minority of cases, the left vertebral artery could arise directly from the aortic arch between the left common carotid and the left subclavian arteries. An aberrant right subclavian artery arising as the last branch of the aortic arch is also a frequently seen aortic arch anomaly. Here, we present a case with common trunks of the subclavian and vertebral arteries, demonstrated by cardiac catheterization.     

Anomalous Origins of the right vertebral, subclavian, and common carotid arteries in a patient with a four-vessel aortic arch

Many anomalies of the aortic arch and great vessels are uncovered as serendipitous findings on imaging studies, in the anatomy laboratory, or at surgery. A 56-year-old man had an arch angiogram as part of an evaluation for cerebrovascular disease. A four-vessel left aortic arch was identified consisting of the right carotid, left carotid, right subclavian, and left subclavian arteries. The right common carotid gave rise to the right vertebral artery in the chest while the normally located left vertebral arose from the left subclavian artery. No aneurysm or aortic diverticulum was identified.     

Techniques for preserving vertebral artery perfusion during thoracic aortic stent grafting requiring aortic arch landing.

Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.     

Carcinoma of the superior pulmonary sulcus. Results of irradiation and radical resection.

Fifty-six patients with superior sulcus syndrome were evaluated at the First Surgical Department of the University of Padua between 1981 and 1990. Forty-two patients with the characteristic of Pancoast's tumor received preoperative irradiation and then en bloc resection of the tumor, chest wall, and adjacent structures. Seven lobectomies and 35 segmentectomies or wedge resections were performed. There was one early postoperative death. Median survival was 14 months, and actuarial survival was 25% at 5 years. Patients with pain relief had better 5-year survival (36.4%) than patients without pain relief (9%). We have no patients with vertebral invasion who survived more than 1 year. Of the five patients with subclavian artery invasion, only one survived more than 1 year. Of five patients with N2 disease, only one survived more than 1 year. Our results suggest that pain relief after irradiation is a good prognostic factor, whereas N2 involvement and vertebral body and great vessel invasion are ominous factors. Another ominous prognostic factor is the Claude Bernard-Horner syndrome even if it is not a contraindication to resection.     

Effect of subclavian flap angioplasty on growth and circulation of the left front leg in pigs

The effect of subclavian flap angioplasty on the growth of the left front limb and on its collateral circulation was studied in 11 pigs. The left subclavian artery and its first branch, the costocervical trunk, were divided while the remaining three branches--the deep cervical, the vertebral and the internal thoracic artery--were preserved. Postoperative angiographies (5 pigs) showed that the blood supply to the left front limb was maintained through these three branches, which acted as collaterals, supplying blood in retrograde fashion. The left vertebral artery was seen to be the predominant collateral already on postoperative day 1. Four months later the diameter of the left vertebral artery had increased more than that of the contralateral (right) vertebral artery. Eight months postoperatively the size of both front legs (6 pigs) was the same. No signs of cerebral disturbance were seen. The clinical implications of the findings are discussed.     

Emergent ascending and arch replacement for acute type A aortic dissection with anomalies of the aortic arch

We experienced 4 cases that had to be performed emergent ascending and arch replacement for acute type A aortic dissection with anomalies of the aortic arch (aberrant right subclavian artery in 2 case and isolated left vertebral artery in 2 cases). As for the aberrant right subclavian artery, preoperative diagnosis is possible by CT scan. We must not overlook aberrant right subclavian artery in order to prevent brain complication in emergency arch replacement for acute type A aortic dissection. For the isolated left vertebral artery, incision of the aortic arch is recommended for its reconstruction.     

Subclavian steal syndrome associated with the right aortic arch in a patient with Peutz-Jeghers syndrome: case report

We report an adult case who presented vertigo attacks due to subclavian steal syndrome associated with the right aortic arch in a patient with Peutz-Jeghers syndrome. A 29-year-old male diagnosed as having Peutz-Jeghers syndrome developed frequent vertigo attacks and was admitted to our hospital. Blood pressure of the left arm was 20 mmHg lower than that of the right arm. Aortagraphy showed that he had a right aortic arch and isolation of the left subclavian artery. Right vertebral angiography opacified the left vertebral artery and the subclavian artery in retrograde fashion, suggesting subclavian steal phenomenon. Blood flow studies disclosed impaired reactivity to acetazolamide in the bilateral cerebellar hemispheres. We successfully carried out left common carotid artery-transverse cervical artery bypass. Postoperative angiography confirmed the patency of the graft and the disappearance of subclavian steal phenomenon. Vasoreactivity to acetazolamide normalized in the cerebellum. Vertigo attacks were not noted during the one-year follow-up period.     

Pancoast's tumor: multi-disciplinary treatment and combined cervico-thoracic approach

Five patients were treated from May 1987 to April 1988 in CHUV, Lausanne, for a superior sulcus tumor (3 epidermoid, 2 undifferentiated carcinomas). Treatment consisted of preoperative radiotherapy (3000 cGy)-surgery-postoperative radiotherapy (1500-2500 cGy). Two patients died from metastases. Only one patient presented with a local recurrence. Surgical resection was carried out by combined cervical and thoracic exposure. The cervical approach allows separation of the tumor from the subclavian artery, brachial plexus and vertebrae. Then, by thoracotomy, the superior lobe with tumor and thoracic wall is removed. Technical aspects of the procedure are described.     

Coronary-subclavian steal corrected with percutaneous transluminal angioplasty

We describe a case of coronary-subclavian steal syndrome treated with percutaneous transluminal angioplasty. A 58-year-old female who had her first coronary bypass operation 6 years previously and a second operation 3 years previously involving the left internal mammary artery and right gastroepiploic artery, developed unusual angina on effort characterized by left precordial pain, pain in the left shoulder and arm, tinnitus and dizziness. Angiography revealed retrograde flow to the left subclavian artery via the left vertebral artery and left internal mammary artery. Severe stenosis of the left subclavian artery was demonstrated at its ostium. Restoration of antegrade flow to the vertebral artery and left internal mammary artery by transluminal angioplasty resulted in complete resolution of these symptoms.