Mediastinitis and pseudoaneurysm of brachiocephalic artery long after the resection of invasive thymoma and postoperative irradiation

A blunt traumatic giant pseudoaneurysm of the brachiocephalic artery: A case report from Somalia

INTRODUCTION

Pseudoaneurysm of the brachiocephalic artery is a rare condition that can occur as a result of various causes, including trauma, iatrogenic injury, and infection. The clinical presentation of brachiocephalic artery pseudoaneurysms can vary depending on the size and location of the pseudoaneurysm. The treatment options for innominate artery pseudoaneurysms include both surgical and endovascular approaches. Our goal of the study is to increase awareness and early detection of blunt injuries in the chest, clavicle, or sternoclavicular joint that may cause a vascular injury.

CASE PRESENTATION

We present here A 24-year-old male came to present with an acute onset of dyspnea, stridor (an abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway), a worsening cough, and chest pain that had been worsening over several months. His medical history was significant for blunt chest trauma secondary to a bicycle fall 3 months earlier.

DISCUSSION

A traumatic giant pseudoaneurysm of the innominate artery is a rare but potentially life-threatening condition. Treatment options for brachiocephalic artery pseudoaneurysm include both endovascular and surgical approaches. This case report contributes to the current literature when any patient has a blunt injury in the chest, clavicle, or sternoclavicular joint and is highly suspect of a vascular injury. To increase awareness, we first need to exclude if there is any vascular injury, which helps to detect it early and intervene.

CONCLUSION

Brachiocephalic artery traumatic large pseudoaneurysm is an uncommon but potentially fatal disorder that can arise from a number of different sources. Achieving favorable results requires prompt diagnosis and proper care, which may include open surgical repair and endovascular procedures. To better comprehend the condition and optimize its management approaches, more investigation and case studies are required.

Superior vena cava graft infection in thoracic surgery: a retrospective study of the French EPITHOR database

 

OBJECTIVES

To report our experience on the management of superior vena cava graft infection.

METHODS

Between 2001 and 2018, patients with superior vena cava synthetic graft or patch reconstruction after resection of intrathoracic tumours or benign disease were selected retrospectively from the French EPITHOR database and participating thoracic centres. Our study population includes patients with superior vena cava graft infection, defined according to the MAGIC consensus. Superior vena cava synthetic grafts in an empyema or mediastinitis were considered as infected.

RESULTS

Of 111 eligible patients, superior vena cava graft infection occurred in 12 (11.9%) patients with a polytetrafluoroethylene graft secondary to contiguous contamination. Management consisted of either conservative treatment with chest tube drainage and antibiotics (n = 3) or a surgical graft-sparing strategy (n = 9). Recurrence of infection appears in 6 patients. Graft removal was performed in 2 patients among the 5 reoperated patients. The operative mortality rate was 25%.

CONCLUSIONS

Superior vena cava graft infection may develop as a surgical site infection secondary to early mediastinitis or empyema. Graft removal is not always mandatory but should be considered in late or recurrent graft infection or in infections caused by aggressive microorganisms (virulent or multidrug resistant bacteria or fungi).

Endovascular stenting and coil embolization for management of radiation-induced pseudoaneurysms of the peripheral arteries

Objective

This study was performed to evaluate the safety and efficacy of endovascular stenting and embolization for the management of radiation-induced peripheral arterial pseudoaneurysms.

Methods

Twelve consecutive patients with radiation-induced peripheral arterial pseudoaneurysms (diameter of 10–30 mm and mean size of 20.42 mm) were admitted to our hospital from 1 January 2015 to 31 October 2019. The patients’ baseline characteristics, perioperative parameters, device characteristics, and curative effects were systematically recorded and analyzed.

Results

The 12 patients comprised 3 men and 9 women with a mean age of 62.90 ± 13.97 years. The iliac artery was the most commonly involved artery, followed by the subclavian artery. In all patients, the pseudoaneurysms were detected by enhanced computed tomography. Twelve covered stents were deployed (7 or 8 mm in diameter and 50 mm in length). Additional coil embolization was performed in three patients (Patients 8, 9, and 10). The primary and secondary technical success rate was 91.7% and 100%, respectively. Apart from one death caused by rebleeding, no patients developed rebleeding during follow-up.

Conclusion

Endovascular stenting and coil embolization are feasible and effective for the management of radiation-induced peripheral arterial pseudoaneurysms in highly selected patients.

Traumatic pseudoaneurysm of the brachiocephalic artery obstructing the airways

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Pseudoaneurysm of the brachiocephalic artery is a very rare condition, with the majority occurring post chest trauma.

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The delayed presentations are usually nonspecific and may vary from mild to very severe and potentially life threating symptoms.

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CT angiogram is the most accurate diagnostic tool that sets the pathway for a well-planned surgical intervention.

This is a case report of a young patient referred to our ER as a case of mediastinal tumor compressing the airways. On presentation, the patient had severe stridor and tachypnea, with oxygen saturation less than 60%. As the patient presented alone to the ER, obtaining any history was not possible. Chest x-ray showed a huge right paratracheal mediastinal mass compressing the airway. The patient was not able to lie supine and was taken to the OR for intubation under fiberoptic bronchoscopy guidance. Bronchoscopic evaluation showed significant compression of the trachea from the right side. A small endotracheal tube (size 5) was successfully inserted. Then, the patient was taken for a chest CT with IV contrast. Chest CT showed a huge vascular mass compressing the trachea, the right mainstem bronchus, and the superior vena cava. The study showed the proximal innominate artery, followed by a pseudoaneurysm. There was an interruption of the right subclavian artery at its origin. Collaterals were seen supplying the right upper limb. Surgical resection was done. Postoperatively the patient gave a history of chest-penetrating injury in the right infraclavicular area, 15 years prior to presentation. The pseudoaneurysm of the innominate artery is a rare delayed complication of chest trauma.

Aortic pseudoaneurysm due to graft infection after invasive thymoma resection

A 69-year-old woman with invasive thymoma underwent chemoradiotherapy followed by surgical resection, including extended thymectomy, right upper lobectomy, and innominate vein and superior vena cava reconstruction with a polytetrafluoroethylene graft. Computed tomography on the 27th postoperative day revealed mediastinitis and right hemothorax; open debridement and evacuation were performed. Vacuum-assisted closure was initiated to heal the median incision. The wound gradually cleared, and the vacuum was terminated on the 150th postoperative day. On the 155th postoperative day, the patient suffered a sudden hemorrhage from the anterior thoracic wall. Computed tomography revealed a ruptured ascending aortic pseudoaneurysm surrounding the graft.

Pseudoaneurysm of brachiocephalic artery mimicking the mediastinal tumor

58 year-old male admitted to the Hospital of Lithuanian University of Health Sciences due to suspicion of mediastinal tumor for diagnostic endobronchial ultrasound procedure (EBUS). The main patient's complain was progressive dyspnea. Objective investigation revealed no major findings: normal breath sounds, heart rate – 96 bpm, blood pressure – 120/80 mmHg. Chest CT scan showed the mediastinal tumor of 3.8 × 3.5 cm. During bronchoscopy smooth intratracheal nodule of 5 mm was found. Superficial biopsy showed normal airway mucosa. During EBUS procedure no clear lymph node structure or blood flow was detected. It was decided to observe the patient clinically. One month later massive hemoptysis started. Urgent bronchoscopy revealed large right-sided mass and intratracheal wall dislocation due to the possible mediastinal tumor in the same location as the polyp in the previous investigation. Repeated chest CT scan showed increasing tumor of size 4.0 × 3.2 × 4.0 cm in the mediastinum and pseudoaneurysm of brachiocephalic artery was suspected. The diagnosis was later confirmed by aortography. The patient underwent successful aneurysmectomy.