Ann Thorac Surg 2009;88:2011-2013. doi:10.1016/j.athoracsur.2009.04.082
© 2009 The Society of Thoracic Surgeons
Case Reports
Unusual Presentation of a Complication After Pulmonary Wedge Resection for Coccidioma
François Leduc, BSc PTa,
Seng Thipphavong, MDa,b,
Fred Matzinger, MDa,b,*,
Carole Dennie, MDa,b,
Sudhir Sundaresan, MDa,c
a Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
b Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
c Department of Thoracic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
Accepted for publication April 15, 2009.
* Address correspondence to Dr Matzinger, Department of Diagnostic Imaging, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, Ontario, K1H 8L6, Canada (Email: fmatzinger{at}ottawahospital.on.ca).
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Abstract
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We report an unusual presentation of a complication after pulmonary wedge resection. A patient with a history of pulmonary wedge resection for coccidioma presented postoperatively with dyspnea and severe hypoxemia. Cerebral infarctions were diagnosed less than 1 year later. Cardiac magnetic resonance imaging and pulmonary angiogram revealed a pulmonary arteriovenous fistula. Surgical resection of the pulmonary arteriovenous fistula led to improved oxygen saturation and discontinuation of home oxygen.
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Introduction
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Pulmonary wedge resection is a common surgical procedure for diagnosis or treatment of lung nodules, or both. Major postoperative complications may include fistulae, such as bronchopleural, bronchial artery to bronchial vein, and pulmonary artery to pulmonary vein [1–3]. The pulmonary arteriovenous fistula (AVF) is a rare, acquired vascular lesion that may follow penetrating trauma, necrotizing pneumonia, or lung resection. Clinical presentation may include dyspnea, hypoxia, and paradoxical embolism leading to stroke or brain abscess. We report a case of a pulmonary AVF as a rare complication of pulmonary wedge resection.
A 52-year-old woman, who is a smoker, underwent a wedge resection of a right lower lobe lung nodule in April 2004. The lesion was located centrally within the anterobasal segment. Pathology and fungal stains were diagnostic of coccidioma. Postoperatively, she complained of pleuritic chest pain and shortness of breath with minimal exertion. She was given fluconazole for 2.5 months with no improvement. Pulmonary function tests showed moderate airflow obstruction and oxygen saturation of 80% on room air. She was diagnosed with chronic obstructive pulmonary disease and was put on home oxygen. In early 2005, she was admitted to the hospital for investigation of medullary and parietal strokes. A transesophageal bubble echocardiogram did not identify a patent foramen ovale. A cardiac magnetic resonance image revealed an AVF in the right lower lobe of the lung. A pulmonary angiogram confirmed an AVF between the interlobar branch of the right pulmonary artery and one of the pulmonary veins (Fig 1). In retrospect, a computed tomographic angiogram, performed previously for exclusion of pulmonary embolism, also depicted the AVF (Fig 2). It was deemed that the AVF was a complication of the wedge resection performed in 2004. Because the AVF was too central and large to safely embolize, a completion right lower lobectomy was performed. At surgery, the combined suture and staple-line from the previous wedge resection of the anterobasal segment was noted to course near the inferior pulmonary vein and interlobar pulmonary artery, causing significant distortion of the structures. At pathology, a dense fibrous scar was identified in the lung parenchyma leading to the hilum and the AVF, and surgical staples and suture material were identified within the scar. Postoperatively, the patient improved significantly, with oxygen saturation at rest of 95%. She was weaned off oxygen therapy.
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Fig 1. Selective pulmonary angiogram of the right pulmonary artery demonstrates an abnormal connection between the interlobar artery (arrow) and a vein (arrowhead) that drains into the left atrium.
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Fig 2. Computed tomographic volume-rendered image of the pulmonary vessels demonstrates the fistula between the interlobar pulmonary artery and pulmonary vein (arrow).
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Comment
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An AVF is an abnormal connection between an artery and a vein [4]. The AVF can be differentiated from an arteriovenous malformations (AVM), which is a congenital lesion resulting from improper development of arteries or veins. However, both the AVF and the AVM share similar physiologic as well as clinical and radiological features. The pulmonary AVF is very rare, occurs twice as often in women as men, and presents most often during the fifth and sixth decades. Most times the pulmonary AVF is single, abuts the pleura, and is found in the lower lungs. Classified as either simple or complex, up to 90% are the former, with all feeding arteries arising from a single subsegmental artery. Causes include hepatopulmonary syndrome, metastatic thyroid carcinoma, schistosomiasis, actinomycosis, necrotizing pneumonias, mitral stenosis, systemic amyloidosis, penetrating chest trauma, and surgery for lung resection or congenital cardiac conditions [5].
Pulmonary AVFs do not usually affect cardiac hemodynamics. The degree of right-to-left shunt and the potential for paradoxical embolism dictate the clinical manifestations [5]. Patients may present with an asymptomatic lung nodule on a chest roentgenogram or with one or more of a broad spectrum of symptoms, including epistaxis, dyspnea, and hemoptysis. Physical examination may reveal cyanosis, digital clubbing, or pulmonary vascular bruits. Complications are often neurologic, secondary to paradoxical emboli. These include transient ischemic attacks, strokes, brain abscesses, migraine headaches, and seizures. Other complications include hemothorax resulting from transpleural rupture, hemoptysis, polycythemia, anemia, and pulmonary hypertension.
The diagnostic evaluation is centered on identifying its presence as well as determining treatment. Oxygen saturation studies nearly always demonstrate hypoxemia and an elevated shunt fraction (>5%) [5]. The chest roentgenogram is usually abnormal in symptomatic patients, and it may reveal single or multiple round or oval masses of uniform density, occasional lobulation, sharply defined borders, and tubular opacities representing feeding vessels [5]. Contrast-enhanced computed tomography is useful for diagnosis, and pulmonary angiography provides further anatomical detail for consideration of embolization. Contrast echocardiography, radionuclide perfusion lung scanning, and magnetic resonance imaging can also be helpful. Contrast echocardiography can detect a right-to-left shunt, but it does not provide anatomical detail. Perfusion lung scanning may reveal decreased pulmonary arterial perfusion of the involved lobe and unexpected radionuclide activity in the brain and kidneys. The pulmonary AVF can be seen on a magnetic resonance image, but computed tomographic angiography is preferred, due to its higher spatial resolution.
Treatment of the pulmonary AVF encompasses either surgery or embolotherapy. An untreated pulmonary AVF may lead to considerable morbidity and mortality. Treatment is indicated when it is symptomatic, greater than 2 cm in diameter, or has feeding arteries at least 3 mm in diameter [5]. Surgical resection was the mainstay of treatment until the late 1970s. Percutaneous embolization using coils or balloons (when feasible) is now the treatment of choice, because it preserves lung parenchyma, is less invasive, and can be repeated if necessary [6]. A large or central AVF may not be suitable for embolization due to the high risk of distal embolization to the left-sided circulation.
In our patient, we postulate that a fistula was created between the right interlobar pulmonary artery and an adjacent branch of the inferior pulmonary vein by the automated stapling device used during wedge resection of the coccidioma. This complication gave rise to exertional dyspnea, hypoxemia, and paradoxical embolism, and the fistula was identified on cardiac magnetic resonance imaging and computed tomographic angiography, and as it was too large to treat safely with embolization, so it was surgically resected. There are no other reports of an AVF after wedge resection of a lung lesion with a stapling device.
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References
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- Kim EA, Lee KS, Shim YM, et al. Radiographic and CT findings in complications following pulmonary resection Radiographics 2002;22:67-86.[Abstract/Free Full Text]
- McHugh K, Hedge V, Brock P, Elliott MJ. Bronchial artery to bronchial vein fistula secondary to lung nodule resection Arch Dis Child 2005;90:384.[Free Full Text]
- Riehl G, Chaffanjon P, Frey G, Sessa C, Brichon PY. Postoperative systemic artery to pulmonary vessel fistula: analysis of three cases Ann Thorac Surg 2003;76:1873-1877.[Abstract/Free Full Text]
- Stedman's Medical Dictionary27th edit.. Baltimore, MD: Lippincott, Williams & Wilkins; 2000. pp. 679.
- Gossage JR, Kanj G. Pulmonary arteriovenous malformations: A state of the art review Am J Respir Crit Care Med 1998;158:643-661.[Free Full Text]
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Abstract
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