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A novel approach to the management of tracheoinnominate artery fistula
1424
CASE REPORT GASPARRI ET AL TRACHEOINNOMINATE FISTULA
A Novel Approach to the Management of Tracheoinnominate Artery Fistula Mario G. Gasparri, MD, Alfred C. Nicolosi, MD, and G. Hossein Almassi, MD Division of Cardiothoracic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin
A 75-year-old gentleman with tracheoinnominate fistula is reported. The issues regarding the surgical approach to this problem are reviewed and a creation of an aortoaxillary bypass graft described. (Ann Thorac Surg 2004;77:1424 – 6) © 2004 by The Society of Thoracic Surgeons CASE REPORTS
T
racheoinnominate fistula (TIF) is a devastating complication of tracheostomy. Although the advent of low-pressure cuffs has made this a rare complication, mortality associated with TIF remains high [1]. The outcome following TIF is largely dependent upon its timely diagnosis and prompt management with most authors advocating simple ligation or resection due to high reported rates of rebleeding associated with vascular reconstruction [1– 4]. The following case report describes a novel approach to the management of TIF, which restores vascular continuity while protecting against the risk of rebleeding. A 75-year-old gentleman was treated for in situ laryngeal cancer with radiation therapy. Six-months later he developed laryngeal edema and stridor requiring tracheostomy. One-week later, he presented with bright red blood through and around the tracheostomy. He was evaluated by removal of the tracheostomy and flexible bronchoscopy to assess the airway. An erosion in the anterior wall of the trachea with pulsations and oozing was noted. The airway was secured by oral intubation and the patient transferred to our institution. On arrival he was hemodynamically stable. Examination revealed the tracheostome to be foul smelling with obvious necrotic, infected tissue throughout its tract. Manual palpation of the tract revealed the innominate artery palpable at the base of the infected tracheostome. The patient was taken urgently to the operating room. A partial upper sternotomy was T’d off at the third intercostal space. The ascending aorta and innominate artery were isolated. A right infraclavicular incision was used to isolate the axillary artery in the deltopectoral groove. After administration of 5000 U of heparin, a side-biting clamp was placed on the ascending aorta and Accepted for publication May 29, 2003. Address reprint requests to Dr Gasparri, Division of Cardiothoracic Surgery, 9200 W Wisconsin Ave, Milwaukee, WI 53226; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2004;77:1424 – 6
an ascending aorta-to-axillary artery bypass performed using a 10-mm Dacron graft (DuPont Pharmaceuticals, Wilmington, DE) tunneled extrapleurally along the chest wall (Fig 1). The aortic and axillary artery anastomoses were constructed using running 4-0 and 5-0 Prolene (Ethicon, Somerville, NJ), respectively. Once perfusion was established, the innominate artery was divided proximal and distal to the area of fistulization and this segment, found at roughly the fourth tracheal ring, resected. Care was taken to preserve the right subclavian–right common carotid junction. At that point, the sternotomy was closed and the tracheostomy site explored. A portion of pectoralis muscle was placed between the innominate artery stump and the previous tracheostomy site and a new tracheostomy created at the second tracheal ring. The patient did well postoperatively. He was neurologically intact with brisk upper extremity pulses and equal blood pressures bilaterally. He continues to do well 24 months postoperatively.
Comment The currently advocated management strategy in dealing with TIF is one of prompt diagnosis, emergency management, and definitive operative repair. The first two steps, prompt diagnosis and emergency management, have attained general consensus and are well described in the literature [1–3]. What remains controversial, however, involves the optimum surgical correction for TIF. In general, the two basic strategies include those approaches that maintain flow and those that interrupt flow through the innominate artery. Maintenance of flow can be accomplished either with direct repair of the defect or by interposition grafting. Interruption of flow is accomplished by simple ligation or resection of the innominate artery, while attempting to preserve the right carotid– right subclavian junction. Most authors currently advocate interruption of flow [1– 4]. This recommendation is based on case reports and retrospective reviews. Two reviews in particular have been frequently cited. The first is by Gelman and coworkers [3], in which cases of 71 survivors of TIF from 1962 to 1994 were reviewed. Of the 71 initial survivors, only 40 survived “long-term” (⬎2 months). Maintenance of flow resulted in 15.8% “long-term” survival, whereas interruption of flow resulted in 71.2% “long-term” survival. Most deaths in the maintenance of flow group were due to suture repair or graft failure with subsequent rebleeding. Also noted was minimal neurologic sequelae in the interruption of flow group with only 2 cases of transient right arm weakness reported. Based on this, it was concluded that interruption of flow is the procedure of choice as it is well tolerated neurologically and is accompanied by a much lower mortality rate. Similarly, Yang and coworkers [4] reported data on 24 survivors of TIF from 1975 to 1984 and found comparable results. They drew similar conclusions to Gelman and associates [3]. Based on these data the majority of authors believe that ligation of the innominate artery is the treatment of 0003-4975/04/$30.00 doi:10.1016/S0003-4975(03)01000-2
Ann Thorac Surg 2004;77:1424 – 6
CASE REPORT GASPARRI ET AL TRACHEOINNOMINATE FISTULA
1425
choice due to decreased rebleeding rates and decreased mortality. Additionally, as there have been no reports of significant neurologic sequelae or vascular complications associated with innominate artery ligation, it is felt that restoration of flow is not crucial. A more detailed review of each case in these articles as well as other case reports, however, reveals many points worth noting. In terms of the neurologic safety of procedures interrupting flow through the innominate, there have been 6 reported early survivors of innominate artery ligation who remained comatose postoperatively and ultimately expired. In all cases, it was felt that preoperative hypotension or cardiac arrest rather than innominate artery ligation accounted for the postoperative neurologic status. Additionally, in reported survivors of interruption of flow in which postoperative neurologic status was specifically noted to be normal, the average age was 24.5 years old (range 11 to 76 years old) with only 1 patient greater than 35 years of age. It may be suggested that in these young patients, in which there is most likely an absence of significant atherosclerotic disease, ligation of the innominate artery may be “safer.” The potential danger of innominate artery ligation was well illustrated in a case report by Black and coworkers [5] in which a 70-year-old male was found to have a TIF. He underwent cerebral angiogram before operative repair and was found to have occlusion of the left internal carotid artery as well as significant stenoses of the right internal carotid and vertebral arteries. He underwent construction of an axillofemoral graft with division of the TIF and did well postoperatively. Finally, in the cases in which innominate artery flow is maintained, it is done either through direct repair or construction of an “in situ” bypass conduit. The rebleeding episodes in these patients are predictable as it is well known that suture repair of an infected artery or graft placement in an infected field is doomed to failure and,
by definition, the area of a TIF is infected. If, on the other hand, vascular continuity and antegrade flow are reestablished using “clean” inflow and outflow targets, as six case reports have described (two aorta-right carotid, two axillary-axillary, and two axillary-femoral), graft failure and rebleeding has not been reported. Accordingly, we elected to perform an extraanatomic bypass to ensure antegrade flow followed by resection of the innominate artery. The bypass created, aorta-axillary artery (Fig 1), is a simple one to construct and has many advantages over the previously described extraanatomic bypasses performed (aorta-right carotid, axillary-axillary, axillary-femoral). The aorta is already exposed and a “clean” area proximal to the innominate artery can easily be isolated with a side-biting clamp, therefore avoiding a separate incision for inflow access (as opposed to axillary-femoral or axillary-axillary). The axillary artery is easy to expose in the deltopectoral groove with minimal dissection. Also, its location allows for a relatively short graft that is easy to tunnel in a straight fashion along the chest wall (as opposed to aorta-right carotid). This operation avoids a long-segment bypass that can lead to graft failure, and also avoids a groin incision that has its own attendant complications (as opposed to axillary-femoral). Finally, the construction of an aorta-to-axillary artery bypass avoids constructing a graft whose tunnel either crosses across the sternotomy incision or near the area of previous tracheostomy (as opposed to axillary-axillary). Tracheoinnominate fistula, although more rare since the advent of low-pressure tracheostomy tubes, remains a highly lethal complication of tracheostomy. Successful management relies on early diagnosis and prompt management. Although reports have commented on the relative safety of innominate artery ligation, the aorta–axillary artery bypass allows an easy method to restore vascular continuity while protecting against the risk of rebleeding.
CASE REPORTS
Fig 1. Resection of the innominate artery with construction of an aorta-to-axillary artery bypass graft. (SVC ⫽ superior vena cava.)
1426
CASE REPORT LOSCERTALES ET AL ARTERIAL EMBOLISM IN LUNG CANCER
References 1. Wright CD. Management of tracheoinnominate artery fistula. Chest Surg Clin N Am 1996;6:865–73. 2. Jones JW, Reynolds M, Hewitt RL, Drapanas T. Tracheoinnominate artery erosion: successful surgical management of a devastating complication. Ann Surg 1976;184:194 –204. 3. Gelman JJ, Aro M, Weiss SM. Tracheo-innominate artery fistula. J Am Coll Surg 1994;179:626 –34. 4. Yang FY, Criado E, Schwartz JA, Keagy BA, Wilcox BR. Trachea-innominate artery fistula: retrospective comparison of treatment methods. South Med J 1988;81:701–6. 5. Black MD, Shamji FM, Todd TR. Trachea-innominate artery fistula and concomitant critical cerebrovascular disease. Ann Thorac Surg 1996;62:286 –8.
Peripheral Arterial Embolism Arising From Pulmonary Adenocarcinoma CASE REPORTS
Jesus Loscertales, MD, PhD, Miguel Congregado, MD, PhD, Carlos Arenas, MD, PhD, Andres Arroyo, MD, Juan Carlos Giron, MD, Javier Ayarra, MD, PhD, and Rafael Jimenez-Merchan, MD, PhD Department of General and Thoracic Surgery, Virgen Macarena University Hospital, Seville, Spain
Bronchogenic carcinoma is a rare source of peripheral arterial embolism. We present the case of a 28-year-old female nonsmoker with an adenocarcinoma of the left main bronchus involving the pulmonary veins. While the patient was hospitalized awaiting operation, she presented embolization in her legs; embolectomy and fasciotomy were necessary to treat compartment syndrome. Echocardiography disclosed floating tumoral masses in the left atrium. Seven days later, an operation was performed with cardiopulmonary bypass to remove the tumor masses from the atrial lumen; pulmonary veins were sutured from within the atrium, and pneumonectomy was performed. Fulminant infection of the lower limbs developed that led to gangrene and multiple organ failure, and the patient died 8 days after the operation. (Ann Thorac Surg 2004;77:1426 – 8) © 2004 by The Society of Thoracic Surgeons
C
oagulation disorders are a frequent complication of cancer. Hypercoagulation has been reported to cause thromboembolism in lung cancer patients. However, peripheral arterial embolism of tumoral origin is relatively uncommon [1]; in a 1996 review of the literature, Zurcher and colleagues [2] found 38 reported cases. Accepted for publication April 11, 2003. Address reprint requests to Dr Loscertales, Hospital Universitario Virgen Macarena, Av Dr Fedriani No. 3, 41071 Seville, Spain; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2004;77:1426 – 8
Primary pulmonary tumor is thus a rare cause of arterial occlusion in the distal portion of the limbs. In 1998, Fernandez and colleagues [3] reported a case of bronchogenic carcinoma that presented as an intracardiac mass with simultaneous popliteal artery embolization, for which the authors recommended echocardiography as the best means for achieving a precise diagnosis. Similarly, 1 year earlier, Jobic and colleagues [4] had reported on a 45-year-old female renal transplant patient in whom echocardiography disclosed the presence of bronchial carcinoma with intracardiac invasion; echocardiography was found to be the best diagnostic tool. Thus, although it is a rare occurrence, lung carcinoma should be considered as a possible source of peripheral arterial embolism if the atrium or pulmonary veins are invaded. A 28-year-old female nonsmoker with no relevant history, presenting only nonspecific pain in the left hemithorax over the previous month, was referred to our department for surgical treatment. The referring hospital had diagnosed carcinoma of the left main bronchus, because radiography had disclosed complete atelectasis of the left lung and minimal ipsilateral hemoptysis. Fiberoptic bronchoscopy confirmed complete occlusion of the left main bronchus by a very poorly differentiated large-cell carcinoma, with a mass growing 3 cm from the carina. Computerized tomography scan (Fig 1) findings were similar, showing a hilar mass apparently adhering to or invading the atrium, together with subcarinal and hilar adenopathies. The day after admission, while preoperative tests were being finalized, acute arterial ischemia developed in both legs that was caused by arterial embolism; coagulation tests yielded normal results, and electrocardiography showed no alterations. An emergency bilateral embolectomy was performed by using a Fogarty catheter with a perfect backflow; an epidural catheter was placed for postoperative analgesia. Subsequent echocardiography (Fig 2) disclosed a hyperechoic tumoral mass within the left atrium; it did not adhere to the septum and infiltrated the pulmonary veins. Twenty-four hours later, fasciotomy was required on both legs because of postrevascularization compartment syndrome. One week later, the patient underwent pneumonectomy by means of median sternotomy with cardiopulmonary bypass to avoid possible embolization due to the release of emboli during routine surgical handling at dissection of pulmonary veins. The left atrium was opened, and 2 tumoral masses growing from the pulmonary veins and floating in the atrial lumen, without atrial invasion, were removed; the mass in the upper pulmonary vein was the larger of the 2 (Fig 3). This was followed, closing the atrium from inside and a pneumonectomy with partial resection of the left atrium from outside, in view of invasion of the veins just to the atrium. The intrabronchial tumor mass disclosed by fiberoptic bronchoscopy arose more than 3 cm from the carina; it was growing into the lumen but did not involve the bronchial wall. During the operation, the border of the 0003-4975/04/$30.00 doi:10.1016/S0003-4975(03)00143-3
CASE REPORT GASPARRI ET AL TRACHEOINNOMINATE FISTULA
A Novel Approach to the Management of Tracheoinnominate Artery Fistula Mario G. Gasparri, MD, Alfred C. Nicolosi, MD, and G. Hossein Almassi, MD Division of Cardiothoracic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin
A 75-year-old gentleman with tracheoinnominate fistula is reported. The issues regarding the surgical approach to this problem are reviewed and a creation of an aortoaxillary bypass graft described. (Ann Thorac Surg 2004;77:1424 – 6) © 2004 by The Society of Thoracic Surgeons CASE REPORTS
T
racheoinnominate fistula (TIF) is a devastating complication of tracheostomy. Although the advent of low-pressure cuffs has made this a rare complication, mortality associated with TIF remains high [1]. The outcome following TIF is largely dependent upon its timely diagnosis and prompt management with most authors advocating simple ligation or resection due to high reported rates of rebleeding associated with vascular reconstruction [1– 4]. The following case report describes a novel approach to the management of TIF, which restores vascular continuity while protecting against the risk of rebleeding. A 75-year-old gentleman was treated for in situ laryngeal cancer with radiation therapy. Six-months later he developed laryngeal edema and stridor requiring tracheostomy. One-week later, he presented with bright red blood through and around the tracheostomy. He was evaluated by removal of the tracheostomy and flexible bronchoscopy to assess the airway. An erosion in the anterior wall of the trachea with pulsations and oozing was noted. The airway was secured by oral intubation and the patient transferred to our institution. On arrival he was hemodynamically stable. Examination revealed the tracheostome to be foul smelling with obvious necrotic, infected tissue throughout its tract. Manual palpation of the tract revealed the innominate artery palpable at the base of the infected tracheostome. The patient was taken urgently to the operating room. A partial upper sternotomy was T’d off at the third intercostal space. The ascending aorta and innominate artery were isolated. A right infraclavicular incision was used to isolate the axillary artery in the deltopectoral groove. After administration of 5000 U of heparin, a side-biting clamp was placed on the ascending aorta and Accepted for publication May 29, 2003. Address reprint requests to Dr Gasparri, Division of Cardiothoracic Surgery, 9200 W Wisconsin Ave, Milwaukee, WI 53226; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2004;77:1424 – 6
an ascending aorta-to-axillary artery bypass performed using a 10-mm Dacron graft (DuPont Pharmaceuticals, Wilmington, DE) tunneled extrapleurally along the chest wall (Fig 1). The aortic and axillary artery anastomoses were constructed using running 4-0 and 5-0 Prolene (Ethicon, Somerville, NJ), respectively. Once perfusion was established, the innominate artery was divided proximal and distal to the area of fistulization and this segment, found at roughly the fourth tracheal ring, resected. Care was taken to preserve the right subclavian–right common carotid junction. At that point, the sternotomy was closed and the tracheostomy site explored. A portion of pectoralis muscle was placed between the innominate artery stump and the previous tracheostomy site and a new tracheostomy created at the second tracheal ring. The patient did well postoperatively. He was neurologically intact with brisk upper extremity pulses and equal blood pressures bilaterally. He continues to do well 24 months postoperatively.
Comment The currently advocated management strategy in dealing with TIF is one of prompt diagnosis, emergency management, and definitive operative repair. The first two steps, prompt diagnosis and emergency management, have attained general consensus and are well described in the literature [1–3]. What remains controversial, however, involves the optimum surgical correction for TIF. In general, the two basic strategies include those approaches that maintain flow and those that interrupt flow through the innominate artery. Maintenance of flow can be accomplished either with direct repair of the defect or by interposition grafting. Interruption of flow is accomplished by simple ligation or resection of the innominate artery, while attempting to preserve the right carotid– right subclavian junction. Most authors currently advocate interruption of flow [1– 4]. This recommendation is based on case reports and retrospective reviews. Two reviews in particular have been frequently cited. The first is by Gelman and coworkers [3], in which cases of 71 survivors of TIF from 1962 to 1994 were reviewed. Of the 71 initial survivors, only 40 survived “long-term” (⬎2 months). Maintenance of flow resulted in 15.8% “long-term” survival, whereas interruption of flow resulted in 71.2% “long-term” survival. Most deaths in the maintenance of flow group were due to suture repair or graft failure with subsequent rebleeding. Also noted was minimal neurologic sequelae in the interruption of flow group with only 2 cases of transient right arm weakness reported. Based on this, it was concluded that interruption of flow is the procedure of choice as it is well tolerated neurologically and is accompanied by a much lower mortality rate. Similarly, Yang and coworkers [4] reported data on 24 survivors of TIF from 1975 to 1984 and found comparable results. They drew similar conclusions to Gelman and associates [3]. Based on these data the majority of authors believe that ligation of the innominate artery is the treatment of 0003-4975/04/$30.00 doi:10.1016/S0003-4975(03)01000-2
Ann Thorac Surg 2004;77:1424 – 6
CASE REPORT GASPARRI ET AL TRACHEOINNOMINATE FISTULA
1425
choice due to decreased rebleeding rates and decreased mortality. Additionally, as there have been no reports of significant neurologic sequelae or vascular complications associated with innominate artery ligation, it is felt that restoration of flow is not crucial. A more detailed review of each case in these articles as well as other case reports, however, reveals many points worth noting. In terms of the neurologic safety of procedures interrupting flow through the innominate, there have been 6 reported early survivors of innominate artery ligation who remained comatose postoperatively and ultimately expired. In all cases, it was felt that preoperative hypotension or cardiac arrest rather than innominate artery ligation accounted for the postoperative neurologic status. Additionally, in reported survivors of interruption of flow in which postoperative neurologic status was specifically noted to be normal, the average age was 24.5 years old (range 11 to 76 years old) with only 1 patient greater than 35 years of age. It may be suggested that in these young patients, in which there is most likely an absence of significant atherosclerotic disease, ligation of the innominate artery may be “safer.” The potential danger of innominate artery ligation was well illustrated in a case report by Black and coworkers [5] in which a 70-year-old male was found to have a TIF. He underwent cerebral angiogram before operative repair and was found to have occlusion of the left internal carotid artery as well as significant stenoses of the right internal carotid and vertebral arteries. He underwent construction of an axillofemoral graft with division of the TIF and did well postoperatively. Finally, in the cases in which innominate artery flow is maintained, it is done either through direct repair or construction of an “in situ” bypass conduit. The rebleeding episodes in these patients are predictable as it is well known that suture repair of an infected artery or graft placement in an infected field is doomed to failure and,
by definition, the area of a TIF is infected. If, on the other hand, vascular continuity and antegrade flow are reestablished using “clean” inflow and outflow targets, as six case reports have described (two aorta-right carotid, two axillary-axillary, and two axillary-femoral), graft failure and rebleeding has not been reported. Accordingly, we elected to perform an extraanatomic bypass to ensure antegrade flow followed by resection of the innominate artery. The bypass created, aorta-axillary artery (Fig 1), is a simple one to construct and has many advantages over the previously described extraanatomic bypasses performed (aorta-right carotid, axillary-axillary, axillary-femoral). The aorta is already exposed and a “clean” area proximal to the innominate artery can easily be isolated with a side-biting clamp, therefore avoiding a separate incision for inflow access (as opposed to axillary-femoral or axillary-axillary). The axillary artery is easy to expose in the deltopectoral groove with minimal dissection. Also, its location allows for a relatively short graft that is easy to tunnel in a straight fashion along the chest wall (as opposed to aorta-right carotid). This operation avoids a long-segment bypass that can lead to graft failure, and also avoids a groin incision that has its own attendant complications (as opposed to axillary-femoral). Finally, the construction of an aorta-to-axillary artery bypass avoids constructing a graft whose tunnel either crosses across the sternotomy incision or near the area of previous tracheostomy (as opposed to axillary-axillary). Tracheoinnominate fistula, although more rare since the advent of low-pressure tracheostomy tubes, remains a highly lethal complication of tracheostomy. Successful management relies on early diagnosis and prompt management. Although reports have commented on the relative safety of innominate artery ligation, the aorta–axillary artery bypass allows an easy method to restore vascular continuity while protecting against the risk of rebleeding.
CASE REPORTS
Fig 1. Resection of the innominate artery with construction of an aorta-to-axillary artery bypass graft. (SVC ⫽ superior vena cava.)
1426
CASE REPORT LOSCERTALES ET AL ARTERIAL EMBOLISM IN LUNG CANCER
References 1. Wright CD. Management of tracheoinnominate artery fistula. Chest Surg Clin N Am 1996;6:865–73. 2. Jones JW, Reynolds M, Hewitt RL, Drapanas T. Tracheoinnominate artery erosion: successful surgical management of a devastating complication. Ann Surg 1976;184:194 –204. 3. Gelman JJ, Aro M, Weiss SM. Tracheo-innominate artery fistula. J Am Coll Surg 1994;179:626 –34. 4. Yang FY, Criado E, Schwartz JA, Keagy BA, Wilcox BR. Trachea-innominate artery fistula: retrospective comparison of treatment methods. South Med J 1988;81:701–6. 5. Black MD, Shamji FM, Todd TR. Trachea-innominate artery fistula and concomitant critical cerebrovascular disease. Ann Thorac Surg 1996;62:286 –8.
Peripheral Arterial Embolism Arising From Pulmonary Adenocarcinoma CASE REPORTS
Jesus Loscertales, MD, PhD, Miguel Congregado, MD, PhD, Carlos Arenas, MD, PhD, Andres Arroyo, MD, Juan Carlos Giron, MD, Javier Ayarra, MD, PhD, and Rafael Jimenez-Merchan, MD, PhD Department of General and Thoracic Surgery, Virgen Macarena University Hospital, Seville, Spain
Bronchogenic carcinoma is a rare source of peripheral arterial embolism. We present the case of a 28-year-old female nonsmoker with an adenocarcinoma of the left main bronchus involving the pulmonary veins. While the patient was hospitalized awaiting operation, she presented embolization in her legs; embolectomy and fasciotomy were necessary to treat compartment syndrome. Echocardiography disclosed floating tumoral masses in the left atrium. Seven days later, an operation was performed with cardiopulmonary bypass to remove the tumor masses from the atrial lumen; pulmonary veins were sutured from within the atrium, and pneumonectomy was performed. Fulminant infection of the lower limbs developed that led to gangrene and multiple organ failure, and the patient died 8 days after the operation. (Ann Thorac Surg 2004;77:1426 – 8) © 2004 by The Society of Thoracic Surgeons
C
oagulation disorders are a frequent complication of cancer. Hypercoagulation has been reported to cause thromboembolism in lung cancer patients. However, peripheral arterial embolism of tumoral origin is relatively uncommon [1]; in a 1996 review of the literature, Zurcher and colleagues [2] found 38 reported cases. Accepted for publication April 11, 2003. Address reprint requests to Dr Loscertales, Hospital Universitario Virgen Macarena, Av Dr Fedriani No. 3, 41071 Seville, Spain; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2004;77:1426 – 8
Primary pulmonary tumor is thus a rare cause of arterial occlusion in the distal portion of the limbs. In 1998, Fernandez and colleagues [3] reported a case of bronchogenic carcinoma that presented as an intracardiac mass with simultaneous popliteal artery embolization, for which the authors recommended echocardiography as the best means for achieving a precise diagnosis. Similarly, 1 year earlier, Jobic and colleagues [4] had reported on a 45-year-old female renal transplant patient in whom echocardiography disclosed the presence of bronchial carcinoma with intracardiac invasion; echocardiography was found to be the best diagnostic tool. Thus, although it is a rare occurrence, lung carcinoma should be considered as a possible source of peripheral arterial embolism if the atrium or pulmonary veins are invaded. A 28-year-old female nonsmoker with no relevant history, presenting only nonspecific pain in the left hemithorax over the previous month, was referred to our department for surgical treatment. The referring hospital had diagnosed carcinoma of the left main bronchus, because radiography had disclosed complete atelectasis of the left lung and minimal ipsilateral hemoptysis. Fiberoptic bronchoscopy confirmed complete occlusion of the left main bronchus by a very poorly differentiated large-cell carcinoma, with a mass growing 3 cm from the carina. Computerized tomography scan (Fig 1) findings were similar, showing a hilar mass apparently adhering to or invading the atrium, together with subcarinal and hilar adenopathies. The day after admission, while preoperative tests were being finalized, acute arterial ischemia developed in both legs that was caused by arterial embolism; coagulation tests yielded normal results, and electrocardiography showed no alterations. An emergency bilateral embolectomy was performed by using a Fogarty catheter with a perfect backflow; an epidural catheter was placed for postoperative analgesia. Subsequent echocardiography (Fig 2) disclosed a hyperechoic tumoral mass within the left atrium; it did not adhere to the septum and infiltrated the pulmonary veins. Twenty-four hours later, fasciotomy was required on both legs because of postrevascularization compartment syndrome. One week later, the patient underwent pneumonectomy by means of median sternotomy with cardiopulmonary bypass to avoid possible embolization due to the release of emboli during routine surgical handling at dissection of pulmonary veins. The left atrium was opened, and 2 tumoral masses growing from the pulmonary veins and floating in the atrial lumen, without atrial invasion, were removed; the mass in the upper pulmonary vein was the larger of the 2 (Fig 3). This was followed, closing the atrium from inside and a pneumonectomy with partial resection of the left atrium from outside, in view of invasion of the veins just to the atrium. The intrabronchial tumor mass disclosed by fiberoptic bronchoscopy arose more than 3 cm from the carina; it was growing into the lumen but did not involve the bronchial wall. During the operation, the border of the 0003-4975/04/$30.00 doi:10.1016/S0003-4975(03)00143-3