Successful lung lobectomy for a lung cancer following thoracic endovascular aortic repair for a thoracic aortic aneurysm: report of a case

Off-label use of thoracic aortic endovascular stent grafts to simplify difficult resections and procedures in general thoracic surgery

OBJECTIVES

Tumour infiltration, or gross infectious involvement of the thoracic aortic wall, poses a significant intraoperative risk for fatal bleeding and therefore could compromise adequate resection or efficient surgical management of pleural infection in a considerable amount of cases. We present 3 successful cases of off-label thoracic aortic endografting to safeguard thoracic aortic wall integrity.

METHODS

After all patients received thoracic stent grafts through femoral access into the descending aorta, the first patient underwent a resection of a locally advanced squamous cell carcinoma of the left inferior lobe cT4cN0-1cM0 after neoadjuvant chemoradiation, which had infiltrated the descending aortic wall. The second case was video-assisted thoracoscopic bilateral pleural decortication for empyema with aortic ulcers of the distal thoracic aorta in a patient with pancreatic intrathoracic fistula in a necrotizing pancreatitis. The third patient was operated for a locally advanced squamous cell carcinoma of the left inferior lobe initial stage cT4 cN1-2 cM0 after neoadjuvant chemoradiation, which had broad contact to the descending aorta at the level of thoracic vertebrae 7 and 8 on a circumference of circa 180°. Regional ethics committee approval according the Swiss Federal Human Research Act was obtained according to regulations.

RESULTS

Preventive stent graft placement resulted in complication-free resection and significantly minimized the risk of fatal intraoperative bleeding. Patients were thus not exposed to complications associated with aortic cross-clamping, possible prosthetic replacement and extracorporeal circulation techniques.

CONCLUSIONS

In carefully selected patient populations, the resection of locally advanced tumours or infectious processes involving the aortic wall can be facilitated by thoracic endovascular aortic repair prior to resection.

Incidental extravascular findings in computed tomographic angiography for planning or monitoring endovascular aortic aneurysm repair: Smoker patients, increased lung cancer prevalence?

AIM

To validate the feasibility of high resolution computed tomography (HRCT) of the lung prior to computed tomography angiography (CTA) in assessing incidental thoracic findings during endovascular aortic aneurysm repair (EVAR) planning or follow-up.

METHODS

We conducted a retrospective study among 181 patients (143 men, mean age 71 years, range 50-94) referred to our centre for CTA EVAR planning or follow-up. HRCT and CTA were performed before or after 1 or 12 mo respectively to EVAR in all patients. All HRCT examinations were reviewed by two radiologists with 15 and 8 years’ experience in thoracic imaging. The results were compared with histology, bronchoscopy or follow-up HRCT in 12, 8 and 82 nodules respectively.

RESULTS

There were a total of 102 suspected nodules in 92 HRCT examinations, with a mean of 1.79 nodules per patient and an average diameter of 9.2 mm (range 4-56 mm). Eighty-nine out of 181 HRCTs resulted negative for the presence of suspected nodules with a mean smoking history of 10 pack-years (p-y, range 5-18 p-y). Eighty-two out of 102 (76.4%) of the nodules met criteria for computed tomography follow-up, to exclude the malignant evolution. Of the remaining 20 nodules, 10 out of 20 (50%) nodules, suspected for malignancy, underwent biopsy and then surgical intervention that confirmed the neoplastic nature: 4 (20%) adenocarcinomas, 4 (20%) squamous cell carcinomas, 1 (5%) small cell lung cancer and 1 (5%) breast cancer metastasis); 8 out of 20 (40%) underwent bronchoscopy (8 pneumonia) and 2 out of 20 (10%) underwent biopsy with the diagnosis of sarcoidosis.

CONCLUSION

HRCT in EVAR planning and follow-up allows to correctly identify patients requiring additional treatments, especially in case of lung cancer.

One-stage operation for thoracic aortic arch aneurysm and left lung carcinoma: a case report

Background

The simultaneous surgical treatment of thoracic aortic arch aneurysm (TAA) and lung carcinoma is extremely rare.

Case presentation

We report the simultaneous surgical treatment of TAA and squamous cell carcinoma of the lung in a 72-year-old Japanese man. We performed a one-stage operation that consisted of aortic arch replacement for aortic arch aneurysm with a 3-branched artificial vessel under separate cerebral and systemic extracorporeal circulation, and left upper lobectomy for lung cancer via a left lateral thoracotomy.

Conclusions

Although patients should be carefully selected for this procedure, the simultaneous surgical treatment of TAA and lung carcinoma can be performed safely.

Video-assisted thoracic surgery for cancer after thoracic aortic aneurysm repair

Video-assisted thoracoscopic surgery is increasingly accepted as an alternative to open thoracotomy and has established efficacy in the management of non-small-cell lung cancer, but the presence of extensive intrapleural adhesions has been considered a deterrent to a minimally invasive approach. We report the successful use of video-assisted thoracoscopic surgery in 3 patients with history of open thoracic aortic aneurysm repair who presented with left lower lobe stage I non-small-cell lung cancer. While this approach is feasible, it is technically demanding and thus, at the present time, we recommend that its use be limited to high-volume video-assisted thoracoscopic surgery centers.