Ann Thorac Surg 2003;75:573-575
© 2003 The Society of Thoracic Surgeons
Case report
Tracheal erosion by an innominate artery graft: presentation and surgical repair
Lori D. Conklin, MDa,b,
Scott A. LeMaire, MDa,b,
Gregorio J. Casar, MDa,b,
Joseph S. Coselli, MDa,b*
a The Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA
b The Methodist DeBakey Heart Center, Houston, Texas, USA
Accepted for publication August 22, 2002.
* Address reprint requests to Dr Coselli, 6560 Fannin St, Suite 1100, Houston, TX 77030, USA
e-mail: jcoselli{at}bcm.tmc.edu
 |
Abstract
|
|---|
This report illustrates the presentation, diagnosis, and successful surgical management of a unique case involving erosion of a prosthetic innominate artery graft into the trachea.
|
Introduction
|
|---|
Although erosion of prosthetic grafts into adjacent structures is well described, graft erosion into the trachea is uncommon. For example, tracheal erosion was not reported among the complications in several recent series of innominate artery (IA) reconstructions [1–4]. The purpose of this report is to illustrate the presentation, diagnosis, and surgical management of a unique case involving a prosthetic IA graft that eroded into the trachea.A 60-year-old man with non-Hodgkin’s lymphoma, noninsulin dependent diabetes mellitus, and previous coronary artery bypass had recently completed six cycles of chemotherapy. He presented with a 3 week history of increasing dyspnea, nonproductive cough, hoarseness, generalized malaise, pharyngitis, and fever. His white blood cell count was 8.5 x 103. A chest radiograph confirmed a right upper mediastinal mass with rightward tracheal deviation. Review of a prior computed tomographic scan of the chest (obtained 5 weeks earlier) revealed only right axillary lymphadenopathy. A repeat computed tomographic scan demonstrated a newly formed 5.2 cm IA pseudoaneurysm causing compression of the upper airway (Fig 1).
Aortography confirmed the diagnosis and the patient was transferred to our institution for operative repair.
View larger version (105K):
[in this window]
[in a new window]
|
Fig 1. The arch aortogram (A), drawing (B), and computed tomographic scans (C) demonstrate the innominate artery pseudoaneurysm and severe upper airway obstruction.
|
|
Shortly after arrival, progressive airway obstruction caused severe respiratory distress requiring emergent intubation. Because of the rapidly expanding pseudoaneurysm, the patient underwent immediate operation. Cardiopulmonary bypass was initiated after femoral-femoral cannulation. Under profound hypothermic circulatory arrest, a right supraclavicular incision and an upper "J" partial sternotomy were performed. The pseudoaneurysm arose from the posterior aspect of the proximal IA and appeared mycotic. Gram stain of the contents confirmed the presence of bacteria. The IA was replaced with a 12-mm gelatin impregnated polyester graft (Gelweave, Sulzer Medica, Austin, TX) that had been soaked in rifampin and vancomycin. Two drains were placed adjacent to the graft, which allowed a 10 day course of antibiotic irrigation. He was extubated on postoperative day 5 and discharged home on postoperative day 12. Culture of the pseudoaneurysm grew coagulase negative Staphylococcus. He received a 6 week course of outpatient vancomycin therapy followed by a long-term suppressive oral antibiotic regimen.
Although he did well initially, 5 months later he presented with increasing dyspnea on exertion, a worsening nonproductive cough, and difficulty breathing when supine. Fiberoptic bronchoscopy revealed erosion of the IA graft through the anterolateral tracheal wall, resulting in 70% stenosis of the lumen (Fig 2)
and necessitating a two-stage repair. During the first operation, a right femoral to right axillary artery bypass was performed with a 10-mm ringed polytetrafluoroethylene graft (Fig 3A).
Five days later, the IA graft was removed via a supraclavicular incision; the trachea was primarily repaired and covered with a pedicled left sternocleidomastoid muscle flap (Fig 3B). He tolerated both procedures well, had no neurologic sequelae, and was discharged home with oral antibiotics on postoperative day 12. At follow-up 8 months after the operation, he was doing well and had no recurrence of respiratory symptoms. Two months later he succumbed to complications related to his lymphoma.
View larger version (166K):
[in this window]
[in a new window]
|
Fig 2. Fiberoptic bronchoscopy revealed erosion of the innominate artery graft through the anterolateral wall of the trachea. (L = left; R = right.)
|
|
View larger version (67K):
[in this window]
[in a new window]
|
Fig 3. (A) During the first stage of repair, a right femoral to right axillary artery bypass was performed to preserve flow (arrows) to the right subclavian and right carotid arteries. (B) The second stage involved removal of the innominate artery graft, primary tracheal repair, and placement of a pedicled left sternocleidomastoid (SCM) muscle flap over the tracheal repair.
|
|
|
Comment
|
|---|
This case report highlights several important considerations when repairing a ruptured mycotic IA pseudoaneurysm, including selection of the appropriate conduit, surgical approach, and tissue interposition. Conduit options were limited in this particular patient because of time constraints related to emergent hypothermic circulatory arrest and the uncertain size and quality of his remaining saphenous vein. Although allograft tissue would have been the ideal conduit in this setting, a homograft was not immediately available [5]. Other options, including extra-anatomic bypass, transposition of the right common carotid artery onto the left common carotid artery [4], and the use of autologous internal jugular or superficial femoral vein [3, 6], were also impractical in this case. Under these conditions, an antibiotic-soaked polyester graft was the most practical option. In retrospect, tissue interposition at this time would have prevented subsequent tracheal erosion.
This complication was managed using a two-staged approach. The first stage was performed to ensure adequate cerebral perfusion after the subsequent graft removal. Our approach was chosen based on several factors: (1) the prior median sternotomies; (2) the potential need for future mediastinal radiation for lymphoma; and (3) the chronic contamination of the upper mediastinum and thoracic inlet from the prior infection and tracheal opening. The right femoral to right axillary artery graft assured cerebral perfusion, while avoiding crossing the mediastinum (as with a left axillary to right axillary artery graft) and an extensive neck dissection (as with a left carotid to right axillary artery graft).
During the second stage, after graft removal and tracheal repair, viable tissue was interposed between the trachea and adjacent structures. Pedicled tissue flaps used to cover tracheal repairs have included strap muscles, intercostal muscles, omentum, and thymus. In this patient, the thymus and omentum were not practical options because of his past surgical history. Therefore the left sternocleidomastoid muscle was harvested as a pedicled flap based on branches of the transverse scapular artery.
In conclusion, tracheal erosion is a rare complication that can present with recurrent respiratory symptoms and is diagnosed with fiberoptic bronchoscopy. In order to prevent this complication, autologous tissue grafts or homografts should be used whenever possible when repairing mycotic aneurysms involving the brachiocephalic arteries. Primary tissue interposition also should be considered, especially when a synthetic graft is required.
|
Acknowledgments
|
|---|
The authors gratefully acknowledge Scott Weldon for his illustrations.
|
References
|
|---|
- Reul G.J., Jacobs M.J., Gregoric I.D., et al. Innominate artery occlusive disease: surgical approach and long-term results. J Vasc Surg 1991;14:405-412.[Medline]
- Berguer R., Morasch M.D., Kline R.A. Transthoracic repair of innominate and common carotid artery disease: immediate and long-term outcome for 100 consecutive surgical reconstructions. J Vasc Surg 1998;27:34-42.[Medline]
- Rhodes J.M., Cherry K.J., Jr, Clark R.C., et al. Aortic-origin reconstruction of the great vessels: risk factors of early and late complications. J Vasc Surg 2000;31:260-269.[Medline]
- Kieffer E., Chiche L., Koskas F., Bahnini A. Aneurysms of the innominate artery: surgical treatment of 27 patients. J Vasc Surg 2001;34:222-228.[Medline]
- Schuch D., Wolff L. Repair of mycotic aneurysm of the innominate artery with homograft tissue. Ann Thorac Surg 1991;52:863-864.[Abstract/Free Full Text]
- Hardin C.A., Thompson R. Mycotic aneurysm of the innominate artery with a supraclavicular aortic stenosis. J Cardiovasc Surg 1976;7:489-492.
This article has been cited by other articles:
|
|
|
|
 
E. M. Marone, G. Esposito, A. Kahlberg, Y. Tshomba, C. Brioschi, P. Zannini, and R. Chiesa
Surgical treatment of tracheoinnominate fistula after stent-graft implantation
J. Thorac. Cardiovasc. Surg.,
June 1, 2007;
133(6):
1641 - 1643.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Kaneko, J. Kobayashi, A. Masuzawa, H. Yoda, A. Inage, and K. Tsuchiya
Bronchial migration of a systemic-pulmonary shunt conduit.
Ann. Thorac. Surg.,
May 1, 2006;
81(5):
1892 - 1893.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
