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J Thorac Cardiovasc Surg 2008;136:525-527
© 2008 The American Association for Thoracic Surgery

Brief Communication

Superficial femoral vein as substitute for pulmonary artery reconstruction after resection for bronchovascular fistula

^a Division of Thoracic and Vascular Surgery, University Hospital of Lausanne, Lausanne, Switzerland
^b Division of Oto-Rhino-Laryngology, University Hospital of Lausanne, Lausanne, Switzerland
^c Division of Anesthesiology, University Hospital of Lausanne, Lausanne, Switzerland

Received for publication August 15, 2007; accepted for publication October 2, 2007.

^_* Address for reprints: Hans-Beat Ris, MD, Centre Hospitalier Universitaire Vaudois, Service de Chirurgie Thoracique et Vasculaire, Rue du Bugnon 46, 1011 Lausanne, Switzerland.

Post-lobectomy bronchovascular fistula (BVF) associated with massive hemoptysis is a rare but life-threatening complication. Surgical options include completion pneumonectomy or BVF resection with end-to-end anastomosis of the airways and reconstruction of the pulmonary artery (PA) by interposition of an appropriate substitute. We report PA resection and successful reconstruction by interposition of an autologous reversed superficial femoral vein (SFV) segment for this purpose.

Clinical Summary

A 59-year-old man with a history of coronary stenting for coronary artery disease underwent uncomplicated intrapericardial left upper lobectomy after radiochemotherapy (60 Gy) for non–small cell lung cancer. Two months later, cataclysmal hemoptysis developed in the patient, requiring cardiopulmonary reanimation, bedside rigid bronchoscopy, selective intubation, and stabilization in the intensive care unit. Bronchoscopy and computed tomography scan revealed a BVF between the PA and the bronchial stump ( Figure 1), and surgical reintervention was considered. Posterolateral left thoracotomy was performed, and the left PA was clamped proximally and distally. Exploration confirmed the localization of the fistula between the left PA and the bronchial stump. Pneumonectomy seemed prohibitive considering the history of coronary artery disease, and segmental resection of the main stem bronchus and the PA was performed. The airway conduit was reconstructed by end-to-end anastomosis between the left main bronchus and the left lower lobe bronchus with separated suture of 5-0 polydioxanone. The PA was reconstructed by interposition of a reversed SFV segment. An interrupted suture with 5-0 Prolene was applied for both end-to-end anastomoses. The reconstructed airway and PA were separated by interposition of an intrathoracically transposed serratus anterior muscle flap ( Figure 2, A). Postoperative angio-computed tomography imaging at 3 and 9 months showed a patent PA reconstruction and appropriate perfusion of the residual lobe (Figure 2, B). The patient is alive and tumor-free 24 months after the operation.

View larger version (162K): [in this window] [in a new window]   Figure 1. CT scan reveals a postlobectomy residual space containing a hematoma with an air-fluid level and air bubbles surrounding the bronchial stump which is in close contact with the pulmonary artery, suggesting a bronchovascular fistula between the bronchial stump and the pulmonary artery.

View larger version (90K): [in this window] [in a new window]   Figure 2. SFV, superficial femoral vein; PA, pulmonary artery. A, Intraoperative documentation of the pulmonary artery (PA) reconstruction by end-to-end superficial femoral vein (SFV) interposition. The distal anastomosis is shown with the lung on the right side of the picture. The proximal anastomosis is covered by a serratus anterior muscle flap transposed intrathoracically (left side of the picture). B, CT-angiography reconstructions 3 months after the operation revealing a patent reconstruction without caliber mismatch of the pulmonary artery (PA) by end-to-end superficial femoral vein (SFV) interposition.

BVF is usually associated with pathologic conditions of the descending thoracic aorta, including atherosclerotic aneurysms, para-anastomotic pseudoaneurysms secondary to previous open surgical repair, and mycotic aneurysms.^1,2 Massive hemoptysis caused by BVF occurring after lung surgery and involving the pulmonary arteria is a rare life-threatening event that requires urgent diagnosis and treatment. In the management of massive hemoptysis, maintenance of airway permeability is of utmost importance. The patient must be placed immediately on the involved side to prevent contralateral lung compromise. Rigid bronchoscopy should be realized without delay to achieve clot evacuation and selective intubation of the involved airway. Surgical intervention after hemodynamic and respiratory stabilization is required.^3,4 Surgical options in BFV after lobectomy include completion pneumonectomy. Bronchovascular resection followed by end-to-end anastomosis of the airways and reconstruction of the PA by interposition of an appropriate substitute may be an alternative in patients unable to undergo an urgent completion pneumonectomy. Because sleeve resection with reconstruction of the PA has progressively gained acceptance as an alternative to pneumonectomy in lung cancer surgery, several PA reconstructive techniques have been proposed depending on the vascular involvement and the surgeon's attitude.^2,3,5 Revascularization can be realized by patch closure or end-to-end suture when the defect is small. For extended circumferential defects in which end-to-end anastomosis is not feasible, interposition of a synthetic prosthesis (Dacron, polytetrafluoroethylene) or biologic substitute (pericardium, azygos vein) has been described.^2,3,5 Biologic substitutes have a number of advantages, such as availability and biocompatibility with a reduced risk of infection and graft thrombosis, compared with synthetic substitutes. Direct contact between the reconstructed airway and PA should be avoided to prevent further erosive damage and recurrence of BVA by use of muscle flap interposition.¹ Because BVF with severe hemorrhage after lung resection is rare, there are no guidelines concerning the adequate surgical treatment in such an emergency situation. In the present case, completion pneumonectomy was considered inappropriate given the cardiopulmonary reanimation and history of coronary artery disease. Therefore, we performed a segmental resection of the main stem bronchus followed by end-to-end airway suture. The PA was reconstructed by the interposition of a reversed SFV segment. The 2 reconstructed structures were separated by the interposition of an intrathoracically transposed serratus anterior muscle flap. Postoperative angio-computed tomography imaging at 3 and 18 months showed a patent PA reconstruction and appropriate perfusion of the residual lobe.

Conclusions

In emergency situations, segmental defects of the PA can be rapidly and elegantly reconstructed by interposition of an autologous reversed SFV when pericardium is not available (prior intrapericardial resections) or synthetic substitutes are avoided because of an increased risk of infections.

References

1. Piciche M, De Paulis R, Fabbri A, Chiariello L. Postoperative aortic fistulas into the airways: etiology, pathogenesis, presentation, diagnosis, and management. Ann Thorac Surg 2003;75:1998-2006.[Abstract/Free Full Text]
   
2. Venuta F, Ciccone AM. Reconstruction of the pulmonary artery. Semin Thorac Cardiovasc Surg 2006;18:104-108.[Medline]
   
3. Rendina EO, De Giacomo T, Venuta F, Ciccone AM, Coloni GF. Lung conservation techniques: Bronchial sleeve resection and reconstruction of the pulmonary artery. Semin Surg Oncol 2000;18:165-172.[Medline]
   
4. Pinet C, Palka W, Metras D, Thomas P, Méric B, Dumon JF. Management of an intrabronchial rupture of right main pulmonary artery. Chest 2002;121:988-990.[Medline]
   
5. Galetta D, Veronesi G, Leo F, Spaggieri L. Pulmonary artery reconstruction by a custom-made heterologous pericardial conduit in the treatment of lung cancer. Lung Cancer 2006;53:241-243.[Medline]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hans-Beat Ris Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kotzampassaki, N. Articles by Ris, H.-B. Search for Related Content PubMed Articles by Kotzampassaki, N. Articles by Ris, H.-B. Related Collections Lung - other Trachea and bronchi Great vessels