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J Thorac Cardiovasc Surg 2003;126:864-866
© 2003 The American Association for Thoracic Surgery
Brief communications |
a Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo, USA
b Division of Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo, USA
Received for publication December 7, 2002; accepted for publication January 22, 2003.
* Address for reprints: Seth D. Force, MD, 3108 Queeny Tower, One Barnes Hospital Plaza, St Louis, MO 63110, USA-1013
sethforce{at}earthlink.net
Aneurysms of the pulmonary artery are a rare entity. In a review in 1947, Deterling and Clagett documented only 8 cases in more than 100,000 autopsies. Similarly, there were only 6 cases of pulmonary artery aneurysms in 4000 patients documented from 1785 to 1946.1 These aneurysms are most commonly found with congenital heart anomalies, but acquired aneurysms may be associated with atherosclerosis, cystic medial necrosis, trauma, infections such as syphilis and endocarditis, or inflammatory processes such as giant cell arteritis. Although many patients with pulmonary artery aneurysms demonstrate pulmonary hypertension, this has not been proven to be a causative factor. In fact, most patients with pulmonary hypertension never have aneurysms. Symptoms are usually vague and may represent manifestations of the primary disease process or may be related to local compression. The disease process leads to rupture and death in approximately 30% of patients, with other deaths resulting from right-sided heart failure or pulmonary embolus.2
Clinical summary
A 64-year-old man with a history of chronic obstructive pulmonary disease and pulmonary hypertension with giant pulmonary artery aneurysms came to our lung transplant center for evaluation. The pulmonary history was significant for tuberculosis treated at 8 months of age and an open lung biopsy performed in 1965 that showed pulmonary fibrosis.
Preoperative pulmonary function tests revealed a forced expiratory volume in 1 second of 0.650 L (20% of predicted) and a diffusing capacity of lung for carbon monoxide of 28.9 (23% of predicted). Lung volumes were consistent with emphysema with a total lung capacity of 139% of predicted and a residual volume of 338% of predicted. Arterial blood gas analysis demonstrated a PaO2 of 53 mm Hg and a PaCO2 of 46 mm Hg on 21% inspired oxygen. The chest radiograph revealed enlarged bilateral pulmonary hila (Figure 1), and a computed tomographic (CT) scan of the chest performed in August 2000 showed a 6.2-cm main pulmonary artery with eccentric thrombus extending to the aneurysmal right and left pulmonary arteries (Figure 2). The lung parenchyma showed evidence of emphysema but no evidence of pulmonary fibrosis. Pretransplant cardiac blood pool imaging revealed decreased right and left ventricular ejection fractions at 29% and 39%, respectively. Cardiac catheterization showed pulmonary hypertension with a pulmonary artery pressure of 58/26 mm Hg, a cardiac index of 2.9 L/min, and no evidence of an intracardiac shunt.
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The patient was placed in the supine position, and the right and left sides of the chest were exposed through the fourth intercostal space using bilateral anterior thoracotomies and transverse division of the sternum. The lungs were then mobilized, and the aneurysm was seen extending from the origin of the main pulmonary artery into both pulmonary hila. The pericardium was opened, and the patient was placed on cardiopulmonary bypass with bicaval and ascending aortic cannulation. After this, both lungs were excised. When the pulmonary arteries were opened, a large amount of fibrinous clot was seen.
The left lung was implanted first. The bronchial anastomosis was performed first, by our previously described technique.3 The pericardium was then opened circumferentially around the pulmonary vein stumps, and the pulmonary vein anastomosis was performed using an everting, running 4-0 polypropylene suture. The lung was then inflated, the atrial clamp was removed, and the atrium was de-aired. Retrograde flow through the donor left pulmonary artery was controlled with a bulldog clamp. After this, the sequence was repeated on the right side with the right donor lung.
The recipient main pulmonary artery was then opened, and the neck of the aneurysm was isolated just distal to the pulmonic valve (Figure 3). The proximal donor ascending aorta was then anastomosed to the pulmonary outflow tract, with a running 4-0 polypropylene suture, with the donor descending aorta oriented toward the right side of the patient's chest. The intercostal arteries and bronchial arteries on the donor aorta were ligated. A common orifice was then made by connecting the orifices of the donor innominate and left carotid arteries, and the orifice of the donor left subclavian artery was sealed with a vascular stapler. After this, the pulmonary artery of the left donor lung was anastomosed to this common orifice with a running 5-0 polypropylene suture. The descending donor aorta was then placed within the aneurysm lumen, posterior to the recipient aorta and vena cava. The donor right pulmonary artery and descending aorta were trimmed to an appropriate length, and an end-to-end anastomosis was created with a running 5-0 polypropylene suture (Figure 4). The lungs were reinflated and perfused, and the patient was weaned from cardiopulmonary bypass. Chest drains were then placed, the chest was closed, and the bronchial anastomoses were inspected with a bronchoscope. The patient was then transferred to the intensive care unit.
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Treatment of pulmonary artery aneurysms has been recommended and includes angioplasty and plication, prosthetic graft reconstruction, autologous tissue reconstruction, and homograft reconstruction.4-6 These techniques are only suitable for patients who have adequate lung function. Patients with pulmonary artery aneurysms and end-stage lung disease, as in our patient, require repair of the aneurysm and transplantation of the diseased lungs. Lung transplantation for this disease has been reported for a patient with a giant pulmonary artery aneurysm and pulmonary hypertension. In this case, the donor pulmonary arteries were anastomosed directly to the recipient's main pulmonary artery.7 This was not an option in our patient, because the aneurysm extended to the proximal main pulmonary artery that, in turn, required resection. The donor pulmonary arteries lacked adequate length to reach to the recipient's main pulmonary artery orifice. Combined heart-lung transplantation was considered in our patient, and although this was technically feasible, we believed that it was impractical because of the lack of available heart-lung donors and the absence of a specific indication for replacing the recipient's normal heart. In addition, because the donor heart was not being harvested for transplant, the entire donor thoracic aorta was available as a conduit. We were thus able to avoid the use of any prosthetic graft material. The donor aorta conduit provided a good technical and functional result in our patient and should be considered as an option for patients with pulmonary artery aneurysms who require lung transplantation.
References
This article has been cited by other articles:
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  H. Shayan, B. Sareyyupoglu, N. Shigemura, J. Thacker, C. Bermudez, and Y. Toyoda Lung Transplant, Double Valve Repair, and Pulmonary Artery Aneurysm Resection Ann. Thorac. Surg., January 1, 2012; 93(1): e3 - e5. [Abstract] [Full Text] [PDF]
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S. D. Force, B. Kogon, A. Pelaez, D. C. Neujahr, A. M. Ramirez, D. L. Miller, and E. C. Lawrence Bilateral Lung Transplant With Pulmonary Thromboendarterectomy for Eisenmenger's Syndrome Ann. Thorac. Surg., March 1, 2008; 85(3): 1097 - 1099. [Abstract] [Full Text] [PDF]
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