Ann Thorac Surg 2001;72:274-276
© 2001 The Society of Thoracic Surgeons
Case report
Contralateral pulmonary artery stenosis after left pneumonectomy
Raja M. Flores, MDa,
Sudish Murthy, MD, PhDa,
Malcolm M. DeCamp, Jr, MDa
a Division of Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
Accepted for publication May 15, 2000.
Address reprint requests to Dr DeCamp, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Desk F25, 9500 Euclid Ave, Cleveland, OH 44195
e-mail: decampm{at}ccf.org
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Abstract
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Contralateral pulmonary artery stenosis is a rare complication following pneumonectomy. When extensive intrapericardial dissection is warranted, one must be wary of this potential complication and take measures to avoid it. Postoperatively, a high index of suspicion must be maintained in a patient with a new onset of right-sided heart failure after intrapericardial pneumonectomy. We discuss intraoperative risk factors, postoperative clinical findings, and our strategy for repair.
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Introduction
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Contralateral pulmonary artery stenosis is a potential complication when an aggressive resection is performed for a patient with a very medial pulmonary tumor abutting the pulmonary artery. Preoperative anticipation of this potential complication is essential in formulating an optimal operative plan. Cardiopulmonary bypass should be available at the time of operation so that adequate pulmonary artery reconstruction can be performed if necessary. We describe a case in which we did not anticipate this potential complication and describe our subsequent management postoperatively and our reoperative approach.
60-year-old woman presented with a obstructing left-upper-lobe lung cancer. A computed tomographic scan (Fig 1) showed an obstructing left-upper-lobe lesion encroaching on the left main pulmonary artery. Cervical and anterior mediastinoscopy excluded N2 and N3 disease. Remote metastatic disease was excluded by means of head and abdominal computed tomographic scans and a bone scan. The patient was taken to the operating room for a left pneumonectomy.
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Fig 1. Computed tomographic scan demonstrating encroachment on the left pulmonary artery by an obstructing large left-upper-lobe tumor. Arrow indicates bifurcation of the main pulmonary artery.
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A left posterolateral thoracotomy was performed. Extensive dissection was required to obtain adequate mobilization of the left lung and hilar structures secondary to marked inflammation from chronic obstruction. The pericardium was opened and the ligamentum arteriosum divided in order to obtain greater length on the left pulmonary artery. A TLV-30 vascular stapler (Ethicon, Somerville, NJ) was then advanced across the left pulmonary artery origin. However, as the clamp was tightened, the patient became profoundly hypotensive, suggestive of critical compression of the right ventricular outflow tract. The stapler was therefore removed. A less bulky DeBakey cross-clamp (Codman, Piscataway, NJ) was then used to clamp the origin of the left main pulmonary artery, and hemodynamics remained acceptable. However, proximal to the clamp, bleeding was noted from the pulmonary artery. Because there was little additional length to obtain proximal control, cardiopulmonary bypass was initiated. The main pulmonary artery was cannulated with a 36F cannula passed retrograde into the right ventricle, and the descending aorta was cannulated with a 20F cannula. With the heart decompressed, an atraumatic Fogarty hydrogrip clamp (V. Mueller, Deerfield, IL) was placed across the main pulmonary artery, and the previously placed DeBakey clamp was removed. The origin of the left main pulmonary artery was then oversewn with a lower layer of running mattress 4-0 Prolene (Ethicon) and an upper layer of simple sutures. After adequate hemostasis was obtained, cardiopulmonary bypass was weaned. During the postbypass period, adequate oxygenation was obtained, but significant inotropic support was required.
Postoperatively, the patient demonstrated right-sided heart failure. The patient also experienced significant cardiac arrhythmias warranting multiple cardioversions. A transesophageal echocardiogram demonstrated severely depressed right ventricular systolic function, a narrowed right pulmonary artery (diameter of 0.5 cm), and 2+ tricuspid regurgitation.
The patient was taken back to the operating room on the second postoperative day to undergo repair of this lesion. The patient was placed in the right lateral decubitus position. Cardiopulmonary bypass was initiated through the femoral vessels. The main pulmonary artery was separated from the aorta by sharp dissection to facilitate exposure. A large Fogarty hydrogrip clamp was then placed across the main pulmonary artery. The previous suture line was removed. A patch of autologous pericardium was sewn over the pulmonary arterial defect, augmenting the right pulmonary artery as it coursed behind the aorta. The patient was weaned from cardiopulmonary bypass, and she demonstrated normal hemodynamics without pressor requirement. A transesophageal echocardiogram showed greatly improved right ventricular systolic function, no evidence of tricuspid regurgitation, and a right pulmonary artery diameter of 1.2 cm. Pathology revealed a 6.5-cm poorly differentiated large-cell anaplastic carcinoma with tumor involving one of four level 10L lymph nodes from direct extension rather than metastasis and negative subcarinal lymph nodes. A full course of adjuvant radiotherapy was administered to the ipsilateral hilum and mediastinum. The patient is doing well, without evidence of disease, 18 months after her resection.
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Comment
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Several factors predisposed the patient to this uncommon complication: the presence of marked inflammation from chronic obstruction, medial tumor location, extensive left intrapericardial dissection requiring division of the ligamentum arteriosum, and the failure to recognize the potential for this complication at the time of the initial operation.
The presence of inflammation and a medially located tumor may obscure the normal hilar anatomy. The right pulmonary artery normally courses behind the aorta and superior vena cava after its origin at the main pulmonary artery and travels approximately 6 cm before entering the right hemithorax. Therefore, stenosis after a right intrapericardial pneumonectomy would appear to be unlikely because of the abundant length of the right pulmonary artery. However, the left main pulmonary artery exits the pericardium and enters immediately into the left hemithorax after it originates from the main pulmonary artery. Therefore, when performing a left intrapericardial pneumonectomy, especially if the ligamentum arteriosum requires division, there is a risk of stenosing the flow from the main pulmonary trunk as it bifurcates into the right and left pulmonary arteries. In addition, the main pulmonary artery trunk may be tented up with the left pulmonary artery from extensive retraction on the left lung, thus increasing the likelihood of stenosing the outflow to the right pulmonary artery.
Factors that should increase one’s index of suspicion of this complication after pneumonectomy include: significant pressor support, arrhythmias refractory to conventional treatments, and new onset of right-sided heart failure. Intraoperative transesophageal echocardiography was a valuable tool in identifying the presence of this lesion and documenting adequate repair [1].
Identification of the potential for this complication during the initial operative procedure would have allowed proper planning. A tumor encroaching on the hilar structures on preoperative computed tomography or upon intraoperative inspection should heighten one’s suspicion on this potential complication. Elective cardiopulmonary bypass and planned pulmonary artery reconstruction with autologous pericardium in one procedure would have been the preferred procedure, as described by Ricci and colleagues [2]. When approaching patients with bulky left hilar tumors warranting intrapericardial dissection, anticipation of this rare complication should allow for immediate recognition and concurrent repair.
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References
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Michel-Cherqui M., Brusset A., Liu N., et al. Intraoperative transesophageal echocardiographic assessment of vascular anastomosis in lung transplantation: a report on 18 cases. Chest 1997;111:1229-1235.[Abstract/Free Full Text]
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Ricci C., Rendina E.A., Venuta F., Ciriaco P.P., DeGiacomo T., Fadda G.F. Reconstruction of the pulmonary artery in patients with lung cancer. Ann Thorac Surg 1994;57:627-633.[Abstract]
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Abstract
Introduction
