Pneumothorax after left pneumonectomy: implantation of an intrapleural prosthesis

Postpneumonectomy syndrome is defined as an airway obstruction due to mediastinal shift and rotation after pneumonectomy. A patient who had undergone a left pneumonectomy for bronchial carcinoma 13 years before presented with tension pneumothorax of her remaining lung. Although all factors relevant to the development of postpneumonectomy syndrome were ascertained, the patient had a pneumothorax rather than an airway obstruction. This pneumothorax was treated surgically. The goal of this operation was to reduce the right pleural cavity volume by implanting an intrapleural prosthesis in the pneumonectomy cavity. This treatment is identical to that used for postpneumonectomy syndrome, which allows the right lung to be rejoined with the thoracic wall.     

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.     

Extension of the “Elephant Trunk” Technique in Complex Aortic Pathology: The “Bidirectional” Option

Background. The “elephant trunk” technique, using a free-floating vascular prosthesis, was originally described to facilitate a subsequent operation on the downstream aorta. We developed an additional refinement of this technique, called the “bidirectional elephant trunk.” This option may represent an interesting tool in more complex aortic operations, especially when the descending aorta has to be replaced first in patients with concomitant pathology of the ascending aorta or of the aortic arch.

Methods. The initial operation is performed through a left thoracotomy. The proximal elephant trunk is created by invaginating the future aortic arch graft into the descending aortic graft. The proximal anastomosis between the doubled graft and the proximal descending aorta is performed first. During construction of the distal anastomosis, a distal elephant trunk may be inserted likewise. If the aortic arch and ascending aorta have to be replaced later, this second step is performed through a median sternotomy. The free-floating arch graft is pulled out of the proximal descending aorta with a nerve hook, unfolded, and used for total arch replacement.

Results. This technique was used successfully in 3 patients without mortality. No major complications were observed excepted persistent hoarseness in a patient with preoperative paresis of the recurrent nerve. No perfusion problems due to the unfolding of the free-floating graft occurred during the second operation.

Conclusions. The bidirectional elephant trunk technique is an interesting option that may be suitable for patients presenting with a complex pathology of the whole thoracic aorta when the descending segment has to be replaced first.     

Right aortic arch, right ligamentum, absent left pulmonary artery: a rare vascular ring.

A 5-month-old infant presented with respiratory failure secondary to severe right bronchial compression. Diagnostic imaging revealed a right aortic arch and absent left pulmonary artery. Surgical relief was obtained via median sternotomy by dividing a right ligamentum and pexing the enlarged right pulmonary artery to the ascending aorta.     

Cervical aortic arch with retroesophageal aortic obstruction: report of a case with successful surgical intervention

The clinical, roentgenographic, hemodynamic, and angiographic features of a patient with a right cervical aortic arch and retroesophageal aortic obstruction associated with a ventricular septal defect are presented. Surgical relief of the aortic obstruction was successfully achieved by placement of a bypass graft between the left common carotid artery and the descending thoracic aorta.     

Tracheal compression by the aortic arch following right pneumonectomy in infancy

Uneventful pneumonectomy was carrried out in a 10-month-old infant for hypoplastic right lung associated with esophageal origin of the right main bronchus. Eight months after operation, symptoms of tracheal compression began. This compression was due to the aortic arch, which was stretched across the lower trachea following the displacement of the heart to the posterior right chest after pneumonectomy. Successful relief of the airway obstruction was achieved by inserting a 20 mm woven Dacron graft between the ascending and the descending aorta, with division of the aortic arch between the left carotid and the left subclavian arteries. An aortogram performed two years after operation confirmed good patency of the graft and normal flow through the descending aorta. The child remains well two years after operation but continues to have mild residual tracheomalacia and limited exercise tolerance, compatible with the presence of only one lung.     

Correction of postpneumonectomy syndrome in infants with saline-filled expandable prosthesis

We report two infants who underwent right pneumonectomy in infancy and developed postpneumonectomy syndrome with obstruction of the left main bronchus causing severe airway obstruction in one patient and gastrointestinal reflux due to a displaced and grossly dilated oesophagus in the other patient. Both patients were operated with implantation of an expandable breast prosthesis.     

Postpneumonectomy syndrome in children: advantages and long-term follow-up of expandable prosthesis

BACKGROUND/PURPOSE: Pneumonectomy in children can be complicated by a severe mediastinal shift, which leads to bronchial stretching resulting in severe respiratory failure. This postpneumonectomy syndrome can be corrected by inserting a prosthesis in the empty side of the chest. METHODS: Forty-two children, from 6 months to 15 years old, underwent a pneumonectomy. Seven of these patients were treated surgically for severe manifestations of postpneumonectomy syndrome. First insertion of an expandable prosthesis was followed up in 5 cases by its replacement with a breast prosthesis in adolescence. The expandable prosthesis was injected periodically with saline solution to maintain the mediastinum in a midline position as the children grew. RESULTS: The mean delay between pneumonectomy and first prosthesis implantation was 5 years (range, 11 months to 8 years). Pulmonary function tests showed a substantial improvement in the obstructive syndrome in all patients except one, in whom the functional improvement was moderate. The mean follow-up after the expandable prosthesis implantation was 6 years (range, 6 months to 10 years) and all patients are doing well. CONCLUSIONS: The insertion of an intrathoracic prosthesis can dramatically improve the clinical symptoms and reduce the functional obstructive syndrome. The expandable prosthesis allowed for progressive, well-tolerated recentering of the mediastinum and adjustment for growth.     

Extensive aortic reconstruction for aortic aneurysms in Marfan syndrome

Background. Marfan syndrome patients frequently develop aneurysms or dissections involving multiple segments of the aorta, and occasionally require staged replacement of the entire aorta. This study reviews the surgical outcome of patients with Marfan syndrome who underwent extensive aortic reconstruction. Extensive reconstruction is defined as reconstruction of more than two segments of the ascending, arch, descending thoracic, or abdominal aorta.

Methods. From March 1973 to December 1997, 101 patients with Marfan syndrome underwent aortic operation. Twenty-six patients (25.7%) had extensive aortic reconstruction. All 26 patients suffered from aortic dissection: 13 patients had Stanford type A and 13 had type B dissection. Twenty-three patients (88.4%) had annuloaortic ectasia and aortic regurgitation. Surgical procedures included composite valve graft replacement (n = 23, 88.4%), aortic arch reconstruction (n = 15, 57.7%), graft replacement of the descending thoracic aorta (n = 6, 23.1%), and graft replacement of the thoracoabdominal aorta (n = 16, 61.5%). Five patients (19.2%) had total thoracoabdominal aortic replacement, and three patients (11.5%) had replacement of the entire aorta. Twenty-one patients (80.8%) required multiple operations.

Results. Follow-up was complete in all patients. The 30-day survival rate was 88.5%. None of the survivors had paraplegia or paraparesis. The overall long-term survival rate was 88.5 ± 6% at 1 year, and 81.7 ± 9% at 9 years.

Conclusions. Aortic surgery prolongs survival in patients with Marfan syndrome, and currently there is a relatively low associated morbidity and mortality even for aggressive surgical treatment.     

Postpneumonectomy syndrome after left pneumonectomy

Postpneumonectomy syndrome, a late complication of pneumonectomy, is secondary to shift of the mediastinum and remaining lung toward the pneumonectomy side, leading to tracheobronchial compression between the vertebral body and the aorta or pulmonary artery. Obstructive airway symptoms are usually due to tracheobronchial tree compression, however, secondary airway malacia may develop. We report herein a case of postpneumonectomy syndrome with secondary bronchomalacia after left pneumonectomy in a patient with normal mediastinal vascular anatomy.     

Distal arch aneurysm repair using stent-grafting and ascending aorto-left axillary bypass

Background. Transcatheter application of a stent-graft to the angulated aortic segments with critical side branches poses some problems. We report our technique of distal arch aneurysm repairs using stent-grafts inserted through the aortic arch and ascending aorto-axillary bypass.

Patients and Results. Three patients underwent successful distal arch aneurysm repair using a homemade semiflexible stent-graft placed under hypothermic circulatory arrest. The left subclavian artery was reconstructed by an extraanatomic bypass grafting between the ascending aorta and left axillary artery. Postoperative imaging demonstrated reduction of aneurysm size and no endoleaks from an intercostal artery.

Conclusions. Our technique seems to be useful for repair of distal arch aneurysms and is a less invasive procedure.     

Postpneumonectomy aortic arch mycotic aneurysm

A 31-year-old woman who had undergone left pneumonectomy for a tuberculosis-destroyed left lung 3 years previously presented in respiratory distress after a pregnancy complicated by preeclampsia and aspiration pneumonia. Investigation revealed a large aortic arch aneurysm as well as a filling defect in the descending thoracic aortic lumen. Emergency aortic arch reconstruction was performed for a massive pseudoaneurysm or contained rupture filling the entire postpneumonectomy space. Pathologic and microbiological examination demonstrated Aspergillus fumigatus and active inflammation.     

Simultaneous multi-vessel coronary artery bypass grafting, ischemic mitral regurgitation repair and descending aortic aneurysm replacement: analysis of technical points

The combination of coronary artery disease and its complications (ischemic mitral regurgitation etc.) with the aneurysm of the descending thoracic aorta is not a rare case. The single-stage correction of coronary/intracardiac/aortic lesions may be considered as a way of managing the combined patients. Simultaneous multi-vessel coronary artery bypass grafting, suture mitral annuloplasty and descending aortic aneurysm replacement with synthetic prosthesis is described. The operation was performed through the left thoracotomy with cardiopulmonary bypass established by the cannulation of the ascending aorta and of the right atrial appendage. Ventricular fibrillation and no clamping of the ascending aorta were used. The circulatory arrest was induced for the construction of the proximal anastomosis between the descending aorta and the synthetic prosthesis. No complications related to the operation were diagnosed for the 14-month follow-up. Several technical points seem optimal for the combined procedure: (1) Minimization of manipulations on the ascending aorta (using of pedicled left internal thoracic artery; construction of the proximal anastomoses with synthetic aortic prosthesis; unclamped ascending aorta). (2) Revascularization of all coronary areas and correction of intracardiac lesions through the left thoracotomy. Individual planning of the procedural technical points for every patient may provide a safe feasibility of the combined procedure.     

Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection

A 40-year-old man with Stanford type B dissection underwent his first endovascular repair (EVAR) in April 2004 by Talent thoracic stent graft. He had an uncomplicated recovery and maintained good blood pressure control. However, a new retrograde dissection appeared in September 2004. The new dissection involved his aortic arch and ascending thoracic aorta to the opening of the coronary arteries. To reconstruct the aortic arch, bypasses between the right common carotid artery (RCCA), left common carotid artery and left subclavian artery were performed before endovascular repair. A modified bifurcated Talent stent graft was deployed from the RCCA to the ascending thoracic aorta with a long limb in the innominate artery and a short limb in the aortic arch. A further two pieces of graft were deployed via the common femoral artery. The ascending thoracic aorta and aortic arch were reconstructed completely by the bifurcated stent graft. The final angiography confirmed that there was good stent graft configuration, normal blood flow, and stable haemodynamics. No endoleak or other major complications were encountered. This result indicated that it is possible to reconstruct the aortic arch with a bifurcated stent graft and could be a new endovascular repair model for complex thoracic aortic aneurysm and dissection.     

Acute intraoperative aortic dissection following axillary artery cannulation

We describe a 75-year-old woman who underwent right axillary artery cannulation in preparation for reconstruction of the aortic arch and the proximal descending aorta for athesosclerotic aortic aneurysm via a 'clamshell' incision. As soon as cardiopulmonary bypass was established, the ascending aorta and the aortic arch was dissected. The innominate artery was dissected including one-third of its circumferance anteriorly. Arterial perfusion was stopped immediately and the left femoral artery was cannulated to resume CPB. We proceeded with replacement of the ascending aorta, the aortic arch and the proximal descending thoracic aorta with a Dacron branched aortic graft. The patient recovered uneventfully. Arterial blood pressure was equal bilaterally.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Emergent thoracic endovascular aortic repair in a patient with hemoptysis due to bronchial fistula: a case for airway management

Bronchial fistula due to bronchial compression is a rare complication following both open surgical and endovascular repair of thoracic aortic aneurysms. We report on the airway management for a case of emergent thoracic endovascular aortic repair (TEVAR) in a patient with left bronchial obstruction due to hemoptysis. A 68-year-old man had undergone total arch replacement 8 years before, and was preoperatively diagnosed with aortobronchial fistula in the left lung. To prevent obstruction of the right lung by rebleeding in the left bronchus, we planned to exchange the single lumen endotracheal tube placed following hemoptysis to a double lumen tube prior to the operation. With assisted spontaneous breathing, bronchoscopy performed before replacing of the endotracheal tube showed obstruction of the left bronchus with many clots. With bronchoscopic assistance, clots were removed from the left bronchus and oxygenation improved significantly. We found a blue nylon suture penetrating the bronchial wall, most likely from a previous operation. However, bronchoscopy did not disclose aortobronchial fistula. Following TEVAR, the patient was diagnosed with bronchopleural fistula induced by bronchial compression due to blood vessel prosthesis and surrounding felt strips. Cooperation from surgeons and careful airway management were required to prevent life-threatening oxygenation insufficiency.     

A successful surgical treatment of chronic traumatic mid-descending thoracic aortic aneurysm]

A 48-year-old woman with chronic mid-descending thoracic aortic aneurysm was successfully repaired. She received a blunt chest trauma due to automobile accident at July in 1988. Left upper lobectomy was performed for her lung contusion. March 1990, she admitted our hospital with abnormal shadow revealed by a chest roentgenogram. A computed tomogram of the chest and an aortogram revealed two false aneurysms. One of them was located at mid-descending thoracic aorta and another was aortic isthmus. Under a partial femoral veno-arterial bypass, a Dacron graft replacement of mid-descending thoracic aorta was performed and aneurysm of isthmus was wrapped by Teflon mesh after the left pneumonectomy. 2 months after the operation, bronchopulmonary fistula occurred at the left bronchial stump. The fistula was successfully covered with major omentum. The mid-descending thoracic aortic aneurysm due to blunt chest trauma is rare. The traumatic aortic aneurysms commonly occur aortic isthmus or ascending aorta. Initial diagnosis of traumatic mid-descending thoracic aortic aneurysm is often missed or delayed. Careful follow up is need and when an abnormality is revealed by chest roentgenogram, computed tomogram and aortogram should be obtained to make diagnosis of chronic traumatic aneurysm.     

Extended operation for lung cancer invading the aortic arch and superior vena cava

Extended operation for lung cancer and mediastinal carcinoma involving the aortic arch or superior vena cava was performed in six patients. In three patients with lung cancer invading the right side of the mediastinum, sleeve pneumonectomy (two patients) or sleeve lobectomy was followed by resection and reconstruction of the superior vena cava with ringed polytetrafluoroethylene grafts. One patient with squamous cell carcinoma and T4 N1 M0 disease was alive and free of disease more than 34 months after the operation. The other patients with adenocarcinoma (T4 N1 M0) and adenosquamous cell carcinoma (T4 N2 M0) died 18 and 5 months after the operation of systemic metastases. In two patients with invasion of lung cancer into the left side of the mediastinum, resection and reconstruction of the aortic arch and left common carotid artery were performed by a femoro-femoral bypass. These patients had adenocarcinoma (T4 N2 M0) and large cell carcinoma (T4 N1 M0) and died of systemic metastases and bleeding during reoperation 12 and 4 months after the initial operation. In one patient with mediastinal squamous cell carcinoma, resection and reconstruction of the aortic arch and left subclavian artery were performed by application of a temporary bypass graft between the ascending and descending aorta. This patient was alive and free of disease more than 17 months after the operation.     

Aortic arch repair with right brachial artery perfusion

Background. To determine the effectiveness of unilateral selective cerebral perfusion for aortic arch repair and to discuss possible modifications to enhance technical simplicity.

Methods. In the period between January 1996 and April 2001, 104 patients underwent aortic arch repair with the use of right brachial artery low flow (8 to 10 mL/kg per minute) antegrade selective cerebral perfusion under moderate hypothermia (26°C). Mean patient age was 52 ± 12 years. Sixty-four patients presented with Stanford type A aortic dissection, including 12 with acute dissection; 38 patients had aneurysmal dilatation of the ascending aorta and aortic arch; and 2 patients had isolated arch aneurysm. Ascending and partial arch replacement was performed in 50 patients; ascending and total arch replacement in 33 patients; ascending and descending arch replacement in 19 patients; and isolated arch replacement in 2 patients.

Results. Mean antegrade cerebral perfusion time was 39 ± 22 minutes. One patient with acute proximal dissection died because of cerebral complications. One other patient developed right hemiparesis, which resolved during the second postoperative month without sequela. Other than these 2 cases (1.9%), no other neurologic event was observed.

Conclusions. The technique of low flow antegrade selective cerebral perfusion through the right brachial artery may be used for a vast majority of aortic aneurysms and dissections requiring arch repair. This technique does not necessitate deep hypothermia, requires shorter cardiopulmonary bypass and operation times, has the advantage of simplicity, provides optimal vascular repair without time restraints and, in terms of clinical results, is as safe as other techniques for cerebral protection.