Ann Thorac Surg 2006;82:1101-1103
© 2006 The Society of Thoracic Surgeons
Case report
Chronic Post-Traumatic Pseudoaneurysm of the Brachiocephalic Artery With Tracheal Obstruction Resulting in Repeated Pneumonia
Hiroaki Sakamoto, MDa,*,
Takashi Hattori, MDa,
Yasunori Watanabe, MD, PhDa,
Yuzuru Sakakibara, MD, PhDb
a Department of Cardiovascular Surgery, Hitachi General Hospital, Hitachi, Ibaraki, Japan
b Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
Accepted for publication January 18, 2006.
* Address correspondence to Dr Sakamoto, Department of Cardiovascular Surgery, Hitachi General Hospital, 2-1-1, Jonan, Hitachi, Ibaraki, 317-0077 Japan (Email: sakamotoh{at}aol.com).
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Abstract
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Posttraumatic pseudoaneurysms of the brachiocephalic artery are relatively rare. We report the case of a 64-year-old man who presented with a large posttraumatic brachiocephalic aneurysm and recurrent pneumonia. Further examination revealed tracheal obstruction by the aneurysm. The patient underwent aneurysmectomy and ascending aorta-right subclavian artery bypass with retrograde cerebral perfusion under circulatory arrest. The patient's postoperative course was uneventful and his respiratory symptoms resolved. The interesting feature of this case is the presenting symptom of recurrent pneumonia, which is an uncommon complication of this type of aneurysm.
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Introduction
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Pseudoaneurysms of the brachiocephalic artery secondary to trauma are relatively rare. Occasionally aneurysms in this location can cause respiratory symptoms including dyspnea, cough, and hypoxia. In this article, we report the case of a patient with a chronic posttraumatic pseudoaneurysm of the brachiocephalic artery causing impingement of the trachea, and resulting in recurrent episodes of pneumonia.
A 64-year-old man was referred to our hospital due to dyspnea, cough, and fever. The dyspnea worsened when the patient was supine, but improved when sitting upright. He had a history of a motor vehicle accident 34 years prior to admission, and had suffered from several episodes of pneumonia since the age of 51. Chest roentgenogram revealed right lower lobe pneumonia and an abnormal shadow in the upper mediastinum. White blood cell count was elevated to 22,800/L and C-reactive protein level was 24.7 mg/dL. The pneumonia improved with oral antibiotics, and a computed tomographic (CT) scan of the chest was ordered for further evaluation of the abnormal mediastinal shadow. The chest CT scan revealed a 70-mm aneurysm of the brachiocephalic artery with mural thrombus that was causing impingement of the trachea and right main stem bronchus (Fig 1). Angiography showed a saccular aneurysm of the brachiocephalic artery and diffuse stenosis of the right common carotid artery. Bronchoscopy showed significant compression of the trachea anteriorly.
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Fig 1. Computed tomographic scans of the chest showed an aneurysm of the brachiocephalic artery and compression of the trachea (thin arrow, top) and bronchus (thick arrow, bottom) by the large aneurysm.
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The patient was taken to the operating room. The aneurysm of the brachiocephalic artery and the right subclavian artery were exposed through a median sternotomy and right subclavian incision. Cardiopulmonary bypass was established with the ascending aorta and bi-caval cannulation. An ascending aorta to right subclavian artery bypass was performed using an 8-mm prosthetic graft with side-clamp forceps, which was tunneled through the first intercostals space. Then the patient was cooled to 20°C, and circulatory arrest with retrograde cerebral perfusion was initiated. After opening the aneurysm, the mural thrombus and calcified aneurysmal wall were removed from the sac to relieve compression of the trachea and bronchus. The proximal and distal aspects of the brachiocephalic artery were oversewn with pledgetted sutures.
The patient was extubated on the first postoperative day without difficulty. Postoperative CT scan showed complete re-expansion of the trachea and bronchus and a patent aorto-subclavian bypass graft (Fig 2). The final pathology of the aneurysm was pseudoaneurysm of the brachiocephalic artery. The patient was discharged to home after an uneventful 3 weeks postoperative course with complete resolution of his respiratory symptoms.
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Fig 2. Postoperative computed tomography showed the trachea (top) and bronchus (bottom) were fully expanded, the prosthetic graft was patent (arrow, bottom).
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Comment
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Pseudoaneurysms of the brachiocephalic artery are typically due to blunt chest trauma, infection, or an iatrogenic event [1]. Although thoracic arterial injury from blunt trauma most commonly occurs at the aortic isthmus, about 10% of these occur in the brachiocephalic artery [2].
The interesting feature of this case was the patient's history of recurrent pneumonia. Respiratory problems are not uncommon in patients with large thoracic aneurysms; however, usually the presenting symptom is dyspnea [3]. In the present case, the patient suffered from dyspnea and recurrent pneumonia. Aneurysmal compression of the trachea and right main stem bronchus was compromising the patient's natural defense mechanism of coughing. Therefore his ability to clear his tracheobronchial tree was inhibited, making him prone to recurrent episodes of pneumonia. The interval between the trauma and the treatment was 34 years, a lengthy time period compared with previous reports [1, 3–5]. However, the patient's history of recurrent pneumonia began 13 years prior to admission, which was probably the time at which the aneurysm had reached a significant size to cause tracheobronchial compression.
With regard to treatment options, recent advances in endovascular covered stent grafts have enabled application of this technology to more complex cases [4]. Endovascular repair was not an option in this case, because the aneurysm was located in the brachiocephalic artery at the take-off of the right common carotid artery. Thus there was not a sufficient landing zone for placement of a stent graft. Another option would be aneurysmectomy with placement of an interposition graft. However, due to the diffuse stenosis in the proximal segment of the right common carotid artery, we believed that the risk of causing complete occlusion of the carotid artery with the distal anastomosis of an interposition graft was high. Therefore we performed an extra-anatomical bypass from the ascending aorta to the right subclavian artery.
Although we considered replacing the stenotic portion of the right common carotid with a prosthetic graft, we decided against this option. We believed that if the patient's proximal carotid stenosis became worse postoperatively, he would benefit from a percutaneous transluminal angioplasty rather than subjecting him to the concomitant additional operative stress associated with this procedure.
Our management of the circulation in this case involved cardiopulmonary bypass and circulatory arrest because we were unable to place a cross clamp at the origin of the brachiocephalic artery due to significant adherence of the aneurysm to the surrounding tissues. If a cross clamp could have been placed at the origin of the brachiocephalic artery, we would have done this repair without the use of cardiopulmonary bypass.
After revascularization we removed the calcified aneurysmal wall and mural thrombus. Previous reports have described the importance of aneurysmectomy and thrombus removal in relieving the compression of the tracheobronchial tree [3]. In this case the trachea and bronchus were completely re-expanded by these procedures. However, if the obstructive symptom of the tracheobronchial tree had not resolved postoperatively, we would have considered placing a stent in the tracheobronchial tree. Tracheomalacia has also been reported as an infrequent complication of thoracic aortic aneurysms due to longstanding compression of the trachea. In that article the patient was successfully treated with temporary tracheobronchial stenting [5]. Fortunately stenting was not needed in our case because our patient's respiratory symptoms resolved completely.
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References
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- Sakakibara Y, Gomi S, Mihara W, Jikuya T, Onizuka M, Mitsui T. Pulmonary atelectasis from a posttraumatic pseudoaneurysm of the thoracic aortaa case report and review of the literature. Vasc Surg 1999;33:317-321.
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Abstract
Introduction
