Intraoperative aortic endograft placement for an unexpected plaque rupture during lung surgery

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InternationalJournalofSurgeryCaseReports60(2019)161–163

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

j o u r n al ho m e p a g e :w w w . c a s e r e p o r t s . c o m

Intraoperative

aortic

endograft

placement

for

an

unexpected

plaque

rupture

during

lung

surgery

Wei

Huang

a

_,

_Beatrice

_Aramini

a,b

_,

_Jiang

_Fan

a,∗

a_Department_of_Thoracic_Surgery,_Tongji_University_Shanghai_Pulmonary_Hospital,_Postal_address:_No.₅₀₇_Zheng_Ming_Road,_Shanghai_200433,_PR_China b_Department_of_Medical_and_Surgical_Sciences_for_Children_and_Adults,_University_of_Modena_and_Reggio_Emilia,₄₁₁₂₄_Modena,_Italy

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r

t

i

c

l

e

i

n

f

o

Articlehistory: Received12May2019 Accepted3June2019 Availableonline8June2019 Keywords:

Aorticendograft Aorticbleeding Lungtumorinvasion Challengingprocedure Teamwork

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BACKGROUND:Surgicalresectionoftumorsinvadingtheaortaisachallengingprocedure.Morerecently,

theuseofthoracicaorticendograftshasbeenreportedtofacilitateenblocresectionoftumorsinvading

theaorticwall.Thebesttreatmentoptionistokeeptheprocedureseparatedbeforelungresectionto

reducetherisksofbleeding,thereforeavoidingadverseconsequencesforthepatient.However,anaortic

stentplacementbeforesurgeryisnotmandatorywithnoclearsignsoftumororatheroscleroticplaque

inﬁltratingtheentireaorticwall.

CASEPRESENTATION:A72-year-oldmancametoourDepartmentforapersistentcough.Computed

tomography(CT)scanwithenhancementshowedamasslocatedintheleftupperlobeofthelungwithno

clearsignofinﬁltrationorcalciﬁedplaquesalongtheentirevascularwall.Apositronemission

tomogra-phywith2-deoxy-2-[ﬂuorine-18]ﬂuoro-d-glucoseintegratedwithcomputedtomography(PET/CTwith

18F-FDG)waspositiveforhypermetabolicmasswithnegativelymphnodestationsbilaterally.Patient

wasundergonesurgeryformajorlungresectionbyleftthoracotomy.Foranunexpectedintraoperative

bleedingduetotheruptureofacalciﬁedplaque,astentwasplacedbeforeproceedingwithlungsurgery.

Patientwaspersistentlystable,dischargedaftersixdaysfromsurgerywithnomorbidities.

CONCLUSIONS:Inourcase,nosignsoftheatheroscleroticplaqueinﬁltrationaswellasnotumor

inﬁltra-tionwereshown.Inthesesituations,theaorticstentplacementispossibleinemergency,evenduring

anotheroperation.Nevertheless,surgeonexperienceandthegoodcoordinationamongspecialistsis

mandatorytoyieldasatisfyingsolution.

accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

1. Introduction

Locallyadvancedlungcancerinvadingtheaorticwallrepresents amajorchallengeforthoracicsurgeons.Preoperativeendovascular stentgraftplacementhasbeennormallyusedtofacilitate section-ingoftumorsinfiltratingtheaorta[1–4].However,thepresenceof anaorticcalcifiedplaqueinthetumorareaisnota“redflag”for possiblebleedingduringsurgery,aswellasastentplacementis notmandatorywheneveraplaqueisshownclosedtothetumor, especiallyintheabsenceofclearsignsofinfiltrationoftheentire vascularwall. We describeacase ofbleedingfrominjury ofan adventitialplaqueduringmassmobilizationbeforethelungtumor

Abbreviations: CT,computedtomography;PET/CT18_F-FDG,_positron_emission

tomographywith2-deoxy-2-[ﬂuorine-18]ﬂuoro-d-glucoseintegratedwith com-putedtomography;SUV,maxstandardizeduptakevaluemaximum;FEV1,forced expiratoryvolumeinthe1stsecond;FVC,forcedvolumevitalcapacity;EBUS, endo-bronchialultrasound;MAP,meanarterialpressure;ICU,intensivecareunit.

∗ Correspondingauthor.

E-mailaddresses:jxnchw@yeah.net(W.Huang),beatrice.aramini@unimore.it

(B.Aramini),drjiangfan@yahoo.com(J.Fan).

resection.Intraoperativepositioningofanaorticendograftresolved thebleedingwiththepossibilitytoproceedwiththeoperation[5]. TheworkhasbeenreportedinlinewithSCAREcriteriahasbeen reportedinlinewiththeSCAREcriteria[6].

2. Casepresentation

A72-year-oldmancametoourThoracicSurgeryDepartment inMarch2018forapersistentcoughthatwasresistantto ther-apy.HeunderwentchestX-rayandaCTscanwithenhancement, whichshowedamassof34×32mmlocatedintheleftupperlobe ofthelung,infiltratingtheleftmainpulmonaryarteryandtheleft bronchus(Fig.1).Nosignsofanatheroscleroticplaqueortumor infiltrationinvolvingtheentireaorticwallweredetected.Invasion ofacalcifiedplaquewasslightandappearedtoinvolveonlythe adventitia.APET/CTwith18_F-FDG_was_positive_(Standard_Uptake

Value,SUVmax=15)forhypermetabolicmasswithnegativelymph nodestationsbilaterally.Thepatienthadasmokinghistory(one pack/50pack-years),withnootherpreviousmalignancies,and20 yearsofcomorbidities,includingdiabetesmellitustype2, hyper-tensionandhypercholesterolemiatreatedwithmedicaltherapy.

https://doi.org/10.1016/j.ijscr.2019.06.001

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162 W.Huangetal./InternationalJournalofSurgeryCaseReports60(2019)161–163

Fig.1. AandB.CTscanshowingtheleftupperlobetumormassinﬁltratingthemainleftpulmonaryarteryandthebronchus.Fig.1C.Redarrowshighlightingtheposition oftheatheroscleroticplaque.Fig.1DandE.Revealingtheendograftstentplacedintheaortabytheinterventionalradiologistthroughthefemoralartery.CT:computer tomography.

Fig.2.A.ThechestX-rayonthedayofdischargefromthehospital(sixthpostoperativeday),atonemonth(2B)andfourmonthsaftersurgery(2C).

Pulmonaryfunctiontestsbeforesurgeryshowedaforced expira-toryvolumeinthe1stsecond(FEV1)of1.7,equalto80%predicted, andaforcedvolumevitalcapacity(FVC)of2.4,equalto82% pre-dicted.Theendobronchialultrasound(EBUS)showednoN2lymph nodeinﬁltration,althoughthepercutaneouslungmassbiopsywas highlysuspectforadenocarcinomaofthelung.Aftersigningthe consent,thepatientunderwentadouble-sleeveleftupper lobec-tomyplusenblocresectionoftheaorticwalladventitiafor4_×2 cm2 _through _a _left_posterior _thoracotomy._At _the _beginning _of

theoperation,duringthemobilizationofthemass,a5-mm aor-ticruptureoccurredintheadventitiaduetothepresenceofan atheroscleroticcalciﬁedplaqueatthislevel(Fig.1C).Atﬁrst, man-ualpressurewasappliedonthebleedingsite,thenthesurgeon triedtoplacea sutureonthebleedingsite, butthehardnessof theplaquehinderedthemaneuvering.Inthesametime,the anes-thesiologistmaintainedlowmeanarterialpressure(MAP).Patient conditionsstayedpersistentlystableandafter15minthe bleed-ingwasundercontrolled,however,forthehighriskofananother

unexpectedbleeding,thethoracicwallwasclosedandthepatient intubatedwastransferredurgentlytotheinterventional operat-ingroomwhereanendovascularstentwasplacedfromtheleft subclavianarterytothedescendingaortausingpercutaneous ret-rogradecommonfemoralarteryaccess(Fig.1DandE).Afterthe vascularprocedure,thepatientwasretransferredtotheoperative room,thechestwasre-openedforinspectionandforproceeding withthelungresection.

Intraoperativebloodlosswastotally800ml.Clinicalparameters werestableduringandaftertheprocedure.Thepatienttolerated the endovascular stent placement and the subsequent double-sleeveleftupperlobectomywithinsixtotal hoursofoperation. Thepatientwasplacedin theintensivecareunit(ICU) for48h aftersurgeryforoptimalstabilizationofhisclinicalcondition.Chest tubeswereremovedonthethirdpostoperativeday,andthepatient wasdischarged aftersixdaysfromsurgerywithnomorbidities (Fig. 2A).No stent-related complications were noted. Histology conﬁrmedthediagnosisofadenocarcinomaofthelung,stagepT2

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W.Huangetal./InternationalJournalofSurgeryCaseReports60(2019)161–163 163

pN1pM0(TNM8th),andanoncologicevaluationwasrequested forthenexttreatmentoptions.ChestX-rays atone-monthand four-monthfollow-upfromsurgery(Fig.2B–C)revealedno com-plications.

3. Conclusions

Theresectionoftheinvadedadventitiaoftheaortaisacommon procedureinthoracicsurgeryandthepresenceofatherosclerotic plaques isfairlycommon.In ourcase,aftermobilizationofthe tumormass,acalciﬁedplaquelostthesupportinducingruptureof theadventitiaoftheaortawithconsequentbleeding.Insummary, evenifitispossibletocontrolandsolvetheaorticbleedingwith anintraoperativestentplacementandagoodcoordinationamong specialists,wheneveritispossibletostudyanddeﬁneaccurately beforetheoperationthecharacteristicsofanatheroscleroticaortic plaque[5],especiallythelargeones,astentshouldbeplacedprior tosurgery.

Conﬂictsofinterest

TheAuthorshavenoﬁnancialandpersonalrelationshipsto dis-close.

Sourcesoffunding

Nofunding.

Ethicalapproval

ForsinglecasereportNOethicalapprovalneeds.Patientsigned aconsentforpublishingthecasereport.

Consent

Patientsignedaconsentforthepublicationofthiscasereport.

Authorcontribution

W.H.andB.A.wrotethecasereport.J.F.revisedthecasereport.

Registrationofresearchstudies

EthicalBoardapprovalisnotrequiredforcasereportsinour Center.

Guarantor

Prof.JiangFanistheGuarantorofthiscasereport.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

Acknowledgements

Notapplicable.

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