Ann Thorac Surg 2005;79:1038-1040
© 2005 The Society of Thoracic Surgeons
Case report
Compression of Trachea and Left Main Bronchus by Arch Aneurysm
Hiroshi Kumeda, MDa,
Yukihiro Tomita, MDa,*,
Shigeki Morita, MDa,
Hisataka Yasui, MDa
a Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University, Fukuoka, Japan
Accepted for publication September 15, 2003.
* Address reprint requests to Dr Tomita, Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University, 3-1-1, Maidashi, Higashi-Ku, Fukuoka 812-8582, Japan
tomita{at}heart.med.kyushu-u.ac.jp
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Abstract
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We report on the case of a 70-year-old woman who presented dyspnea. Contrast-enhanced computed tomography of the chest revealed the compression of the lower part of the trachea and left main bronchus by an aneurysm of the ascending aorta and aortic arch. Although we performed a replacement of the ascending aorta and aortic arch, we were unable to relieve the stenosis of the trachea and bronchus. By the suspension of the posterior wall of the native aneurysm, we were able to successfully relieve the compression and alleviate the respiratory insufficiency.
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Introduction
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Most patients with thoracic aortic aneurysms do not show any symptoms, although on occasion, dyspnea will be present. Some patients experience respiratory insufficiency owing to the compression of the airway by thoracic aneurysms. Total arch replacement relieves this symptom. We report the case of a patient in whom the suspension of the posterior wall of the native aneurysm together with total arch replacement relieved the condition.
A 70-year-old woman had been suffering from dyspnea and wheezing for 2 months. She had no history of asthma, nor had she shown symptoms of chronic obstructive lung disease. She was of small build, 148 cm in height and 38 kg in weight. Laboratory findings were unremarkable. Chest roentgenograms showed no sign of thoracic aortic aneurysm. On physical examination, the left respiratory sound was almost inaudible compared with the right one, and tachypnea was found (30 times/min). A chest computed tomographic (CT) scan revealed an aneurysm of the ascending aorta and aortic arch, which was causing the compression of the lower part of the trachea and left main bronchus (Fig 1a). Its maximum diameter was 6 cm at the carina level. We assumed that simply cutting and replacing the aneurysm would relieve these stenotic lesions. According to the method of Ueda and colleagues [1], we used a median sternotomy and retrograde cerebral perfusion through the superior vena cava during deep hypothermic circulatory arrest. Although we cut the aneurysm and performed a replacement of the ascending aorta and aortic arch, intraoperative bronchoscopy demonstrated no remarkable change to the tracheal stenosis. We therefore raised the posterior wall of the native aneurysm, which was not dissected and left untouched. Under bronchoscopy, this seemed to relieve the compression of the trachea and left main bronchus. We suspended the posterior aneurysmal wall to the sternum using a 3-0 pledgeted suture. Then, the second needle of the suture was placed in the same way (Fig 2). After closure of the sternotomy, the suture was tied down slowly and carefully to broaden the airway under the bronchoscopy. The postoperative period was uneventful, and the patient was extubated 2 days after the operation. The left respiratory sound showed a significant improvement. PaCO2 of 49.1 mm Hg before the procedure decreased to 39.0 mm Hg after the procedure. Three weeks after the operation, an enhanced chest CT scan demonstrated a satisfactory dilatation of the trachea and left main bronchus (Fig 1b). The patient was discharged with no symptoms of respiratory insufficiency. She continued to do well 20 months on.
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Fig 1. Preoperative and postoperative enhanced chest computed tomographic (CT) scans. (a) Preoperative CT scan showed a large aneurysm of the aortic arch, which compressed the left main bronchus (arrowhead). (b) Postoperative CT scan demonstrated relief of the stenosis of the left main bronchus (arrowhead).
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Fig 2. Operative procedures to relieve the stenosis of the trachea and bronchus. (a) Two sutures were placed on the posterior wall of the aneurysm sticking to the trachea. (b) The 2 sutures through the sternum were tied each other to lift the aneurysmal wall. (A = aneurysmal wall; G = graft; T = trachea.)
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Comment
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Symptoms of aortic aneurysm usually occur because of pressure or the obstruction of adjacent structures. Aneurysms of the ascending aorta cause symptoms less frequently, and there may be none until the aneurysm actually erodes through the ribs and the sternum. Tracheal or bronchial obstructions caused by aneurysms of the arch often lead to a wheeze, the characteristic brassy cough, and pneumonitis secondary to the obstruction. The recurrent and even the phrenic nerves may be paralyzed because of pressure from an expanding aneurysm [2].
It is rare to show dyspnea, as in our patient, although Gothe and Harris [3] reported a case of severe dyspnea caused by a thoracic aortic aneurysm. Our patient was of small stature (148 cm, 38 kg), and the distance between the thoracic wall and vertebra was small; therefore, the aneurysm, measuring 6 cm in diameter, which was not so large, caused severe compression of both of the trachea and left main bronchus.
Compressed by aneurysms for a long period, the tracheobronchial wall may become thin, and the destruction of cartilage, namely, tracheomalacia, may cause structural weakness [4]. We think that compression results in inflammatory changes of the trachea and strong adhesion between the aneurysm and the trachea. The condition cannot be remedied immediately, even if the ascending aorta and aortic arch are successfully replaced. In our case, it was indeed useful to suspend the posterior wall of the native aneurysm sticking to the left main bronchus. Gentle and careful manipulation relieved the compression without any injury to the airway.
Endotracheal stenting is another option for airway stenosis. It is inserted at the narrow site and expands the condition [5]. However, we should note that it can cause restenosis and should be removed if the respiratory condition stabilizes after the operation. A rigid stent in the trachea may cause an aneurysmal rupture itself. Special techniques and skills are required for this kind of operation.
In conclusion, total arch replacement in itself was insufficient to relieve the stenosis of the airway, and suspension of the aneurysm was required to relieve the condition. We believe that a combination of the replacement of a thoracic aneurysm and the suspension of the posterior wall of a native aneurysm is useful to improve tracheobronchial compression by a thoracic aortic aneurysm.
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Acknowledgments
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We thank Alisdair Montgomery for the English version of this paper.
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References
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- Ueda Y, Miki S, Kusuhara K, Okita Y, Tahata T, Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg. 1990;31:553–558[Medline]
- Bahnson HT. Thoracic aneurysms. Sabiston DC, Spencer FC. Gibbon's surgery of the chest. 4th ed. Philadelphia, Pa: W. B. Saunders; 1983. p. 967–976
- Gothe B, Harris L. Thoracic aortic aneurysm causing acute bronchospasm. Crit Care Med. 1981;9:496–497[Medline]
- Tominaga R, Tanaka J, Kawachi Y, et al. Surgical treatment of respiratory insufficiency due to tracheobronchial compression by aneurysms of the ascending aorta and innominate artery. J Cardiovasc Surg. 1988;29:413–417[Medline]
- Watanabe S, Toyohira H, Yamaoka A, et al. Usefulness of Dumon type endotracheal stent for left main bronchial obstruction caused by thoracic aortic aneurysm. J Jpn Assn Thorac Surg. 1996;44:1776–1780
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Abstract
Introduction
