Ann Thorac Surg 2001;71:1028-1030
© 2001 The Society of Thoracic Surgeons
Case report
Innominate artery rupture after transcervical drainage for descending necrotizing mediastinitis
Hideo Ichimura, MDa,
Shigemi Ishikawa, MDa,
Yuji Hiramatsu, MDa,
Yuzuru Sakakibara, MDa,
Masataka Onizuka, MDa
a Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
Accepted for publication September 17, 2000.
Address reprint requests to Dr Ishikawa, Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8575, Japan
e-mail: ishikawa{at}md.tsukuba.ac.jp
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Abstract
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We present a case of innominate artery rupture after descending necrotizing mediastinitis (DNM) on day 36 of cervicomediastinal drainage. The patient recovered after aortosubclavian arterial bypass grafting followed by resection of the eroded artery. Because mechanical pressure caused by drains in addition to the inflammatory process can cause major vessel erosion, prolonged transcervical tube drainage for treating descending necrotizing mediastinitis should be avoided even if the drains applied are soft and thin.
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Introduction
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Descending necrotizing mediastinitis (DNM) is a fatal infection that can complicate various clinicopathologic conditions if not treated properly [1]. As described in the case of deep cervical infection [2] and cuff injury due to tracheostomy tube [3], severe vessel erosion caused by the inflammatory process and mechanical pressure can be a lethal complication of DNM. We describe here a case of innominate artery rupture after DNM on day 36 of cervicomediastinal tube drainage.
A 63-year-old Japanese man who had previously undergone aortocoronary bypass grafting through a full median sternotomy was referred to our hospital with a 6-day history of sore throat. On admission the patient complained of hoarseness and shortness of breath. The swelling of the left side of the neck extended to the upper anterior chest wall and the right side of the neck. A contrast medium swallow examination did not reveal any abnormalities. A cervicothoracic computed tomography (CT) scan (Fig 1) demonstrated soft tissue infiltration with air bubbles in the retropharyngeal and left carotid space extending downward above the level of the tracheal carina in the upper mediastinum. Cervicomediastinal debridement and drainage was performed through a left transverse cervical skin incision 5 cm in length within several hours of admission. Soft, thin-walled silicone drains with an 8-mm outer diameter and 0.7-mm wall thickness (Fujisystems, Tokyo, Japan) were placed through a cervical incision into the retropharyngeal space, and through the right paratracheal and left paraesophageal space into the superior mediastinum (Fig 2). Group F Streptococcus and Hemophilus influenzae were cultured from the pus. A combination of carbapenum and clindamycin were administered intravenously for 7 days. A tracheostomy was not performed. However supraglottis swelling was noticed with flexible laryngoscopy, so the patient remained intubated endotracheally for 9 days postoperatively.
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Fig 1. Contrast-enhanced CT scan at the level of the oropharynx showing diffuse thickening with air bubbles in the retropharynx and the left carotid space (arrows).
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Fig 2. Illustration showing the route of the transcervical tube drainage. (SVC = superior vena cava; PA = pulmonary artery.)
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Cervicothoracic CT performed 5, 14, and 24 days after operation showed no residual abscess requiring additional drainage. However the drains were kept in position since neck swelling recurred and serum C-reactive protein showed reelevated values of 4.0 mg/dL on day 22 after admission. A grayish exudate was continuously discharged from the tube inserted in the upper mediastinum although the culture was negative. The drains were not mobilized, put on suction, or irrigated, and the cervical wound was left open during the postoperative period.
On hospital day 36 intermittent but massive hemorrhaging occurred suddenly from the cervical wound. The patient was immediately brought to the operating room, and a median resternotomy was performed. An eroded and disrupted area 5 mm in diameter was found at the posterior wall of the innominate artery and the drain just behind it in the right paratracheal tissue. Bleeding was controlled by finger pressure. The right subclavian artery was exposed through a subclavian incision. A partial occluding clamp was placed on the ascending aorta and a vascular prosthesis (Hemashield, Meadox Medicals, Inc, Oakland, NJ), 8 mm in diameter, was sutured in place. End-to-side anastomosis was accomplished to the exposed right subclavian artery. The route of the ascending aorto-right subclavian artery bypass was determined with special care given to avoid contaminated areas. The disrupted innominate artery was then resected and a monofilament suture line was placed to close both ends (Fig 3).
The patient recovered uneventfully without any neurologic deficit and was discharged on hospital day 67. Cervicothoracic CT performed 6 months after innominate artery rupture showed no recurrent abscess or graft infection, and the patient was in good condition 18 months after discharge.
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Comment
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Fundamentally the treatment of DNM consists of intravenous antibiotics, surgical debridement and drainage, and airway management. As for surgical drainage, a controversy exists as to whether transthoracic drainage is universally required and as to what the optimal surgical approach should be. Although a majority recommend extensive transthoracic drainage [4, 5], transcervical mediastinal drainage may be effective enough in the treatment of DNM when the inflammatory and necrotizing processes do not extend below the level of the tracheal bifurcation anteriorly or the fourth thoracic vertebra posteriorly [6]. Whichever the approach, tube drainage should be considered for deep positioned abscesses and sometimes for irrigation. It is surely important to choose a soft tube, avoiding possible damage to intrathoracic organs. In the present case open drainage was thought to be insufficient for a deep position infection and therefore soft, thin tubes were positioned through the cervical wound. It was then decided to keep them in place for another 2 weeks because of neck swelling and elevated C-reactive protein 3 weeks after the initial drainage.
Cervicothoracic CT scan is undoubtedly a useful means of assessing the extent of the inflammatory process. Moreover surveillance CT is recommended to ensure the adequacy of drainage and to identify unsuspected progression of DNM. Repetitive operative drainage is required if adequate drainage is to be achieved [1]. Even without any clinical deterioration, surveillance CT will provide important information regarding whether the tube is compressing major vessels. A slight change in tube position along with the withdrawal of inflammation and a decrease in the thickness of the mediastinal soft tissue may result in compression of the innominate artery.
With regard to the treatment of innominate artery rupture, division of the innominate artery may result in cerebral ischemia and stroke [3]. It is our policy to restore blood flow by bypass grafting before ligation of the innominate artery, as described for treating innominate artery trauma [7]. No shunt or cardiopulmonary bypass is used for this repair. When the operative field is infected an extrathoracic bypass procedure should be considered.
Finally, we conclude that prolonged tube drainage of the upper mediastinum through a cervical wound should be avoided because even soft, thin tubes may cause large vessel erosion. These drainage tubes should not be kept in position for more than 3 weeks. If clinical deterioration (including CT findings) developed after withdrawal of the transcervical drainage tube, transthoracic drainage should be performed instead of prolonged transcervical tube drainage. Surveillance CT should be done not only to confirm the adequacy of the drainage but also to check the tube position.
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References
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Abstract
Introduction
