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J Thorac Cardiovasc Surg 2003;126:900-902
© 2003 The American Association for Thoracic Surgery
Brief communications |
a Department of Cardiac Surgery, University of Bologna, Bologna, Italy
b Department of Surgery, University of Bologna, Bologna, Italy
c Department of Cardiac Anaesthesia, University of Bologna, Bologna, Italy
Received for publication January 22, 2003; accepted for publication February 14, 2003.
* Address for reprints: Dr Davide Pacini, c/o Unità Operativa di Cardiochirurgia, Università degli studi di Bologna, Policlinico S. Orsola, Via Massarenti, 9, Bologna 40138, Italy
dpacini{at}hotmail.com
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Tracheomalacia, often secondary to congenital aortic arch abnormalities, can be caused by external compression of mediastinal mass, but its association with chronic aneurysms has not been previously reported.1 We present a case of severe respiratory insufficiency due to tracheomalacia. Main airway obstruction occurred immediately after aortic arch repair for luetic aneurysm and was treated successfully with temporary tracheobronchial stenting.
Clinical summary
A 58-year-old man was referred to our hospital because of hoarseness, dysphagia, and dyspnea on exertion. He was a past heavy smoker and had no significant medical history except for a venereal infection in youth.
Chest radiography revealed a large superior mediastinal mass extending posteriorly, with dislocation and compression of the trachea and both main bronchi (Figure 1, A). On computed tomography (CT) scan, the mass was recognized as a saccular aortic arch aneurysm and measured 7.0 cm in maximal diameter (Figure 1, B). Respiratory function tests revealed moderate chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 1.91 L, 64%; and vital capacity 3.3 L, 88%). Serologic testing for syphilis (enzyme immunoassay) was positive.
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The microscopic examination of the aneurismal wall revealed the characteristic changes of syphilis: medial necrosis with inflammatory infiltration, consisting of lymphocytes and plasma cells, and severe atherosclerotic degeneration.
After 6 months, the T-Y tube was successfully removed and the trachea and main bronchi were well stabilized as shown by tracheobroncoscopy and CT scan (Figure 2, A and B). The patient had granulation tissue in the main left bronchus causing partial obstruction, which was successfully treated by laser therapy.
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Cardiovascular syphilis, once a relatively common disorder, has declined in incidence with the advent of antibiotic therapy,2 although in some countries recently there has been a rapid increase of this infective disease.3
Luetic aortitis is the most prevalent form of cardiovascular syphilis and produces severe destructive changes in the aortic wall. Aortic aneurysms are a common manifestation of aortitis and are typically saccular, although fusiform dilatations occur as well. Approximately 50% of aneurysms occur in the ascending aorta, whereas the transverse aortic arch is involved in almost 30% to 40% of the cases.2 The aneurysm in our patient involved the back wall of the transverse arch with a posterior expansion and direct compression of the trachea and both bronchi.
Tracheomalacia can be congenital and sometime is associated with congenital (or acquired) aortic arch abnormalities. The acquired form of tracheomalacia may be secondary to chronic external compression by mediastinal mass, but no case of chronic aortic arch aneurysm has been reported in the English literature.1
We believe that the particular location of the aneurysm, with a posterior expansion and the direct long-standing compression (more than 30 years) of the trachea, was the cause of the severe tracheomalacia that occurred in the reported case.
The treatment of such tracheal lesions includes direct or staged repair and reconstruction. However, sometimes these methods are unavailing, such in the case of postoperative tracheomalacia, which is a life-threatening condition. In these cases the silicon T or T-Y tube may be used as a safe alternative.4 Moreover, silicon has been found to be a relatively nonirritating substance and it can be used long term in the human body.5
In cases of limited granulation tissue formation, which in the past always required removal of the tube, laser treatment now provides a good resolution.
In conclusion, we point out that tracheomalacia can occur in cases of aortic arch aneurysm with a posterior expansion and a long-standing compression of the tracheobronchial tree. Even though suggestive, a relationship between tracheomalacia and luetic etiology of the aneurysm cannot be established. The endoscopic treatment with a silicon T or T-Y tube can be effective in resolving this lesion.
References
This article has been cited by other articles:
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  D. Pacini, O. Leone, S. Turci, N. Camurri, F. Giunchi, G. N. Martinelli, and R. Di Bartolomeo Incidence, Etiology, Histologic Findings, and Course of Thoracic Inflammatory Aortopathies Ann. Thorac. Surg., November 1, 2008; 86(5): 1518 - 1523. [Abstract] [Full Text] [PDF]
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H. Sakamoto, T. Hattori, Y. Watanabe, and Y. Sakakibara Chronic post-traumatic pseudoaneurysm of the brachiocephalic artery with tracheal obstruction resulting in repeated pneumonia. Ann. Thorac. Surg., September 1, 2006; 82(3): 1101 - 1103. [Abstract] [Full Text] [PDF]
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