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

Investigating the predictive factors of thoracic aortic invasion and surgical outcomes in patients with primary lung cancer: A retrospective study

BACKGROUND

This study aimed to investigate predictors of thoracic aortic invasion in lung cancer patients using preoperative clinical and imaging characteristics and elucidate surgical outcomes in cases of aortic invasion.

METHODS

Of the 4751 lung cancer patients who underwent surgery at our hospital, we included 126 (6.8%) who underwent left-sided surgery and in whom tumor appeared to be in contact with the thoracic aorta on preoperative imaging. The patients were divided into two groups: group A, 23 patients (18%) who underwent combined aortic resection (+); group B, 103 patients (82%) who did not undergo combined aortic resection (-).

RESULTS

The percentage of aortic invasion for tumor diameter <3 cm, 3-4 cm, 4-5 cm, 5-7 cm, and >7 cm was 0%, 13%, 23%, 16%, and 35%, respectively. The percentages of aortic invasion were 27%, 16%, and 0% for tumor localization in the upper division, S6, and S10, respectively. Multivariate analysis revealed that aortic depression due to tumor or loss of fatty tissue between tumor and mediastinum in the chest CT significantly predicted aortic invasion (odds ratio = 23.83, 16.66). Group A demonstrated significantly more blood loss, longer operative time, prolonged hospital stay, and increased percentage of recurrent nerve palsy (13%) compared to group B. The 1-, 3-, and 5-year survival rates for patients in group A were 53.4%, 24.3%, and 24.3%, respectively.

CONCLUSION

If the chest CT of a patient demonstrates aortic depression due to tumor or loss of fatty tissue between tumor and mediastinum, aortic complications should be considered when planning surgery.

Combined resection of lung cancer and thoracic aortic wall with simultaneous thoracic aortic endografting: a case report

BACKGROUND

Combined resection of lung cancer and the thoracic aortic wall with thoracic aortic endografting has been reported. However, whether the resection and endografting should be performed simultaneously or in two steps remains controversial.

CASE PRESENTATION

A 68-year-old man was referred to our hospital because of left chest pain. Chest contrast-enhanced computed tomography revealed a huge tumor of the left lower lung lobe, and invasion to the aortic wall was suspected. Bronchoscopic examination was performed, revealing squamous cell carcinoma with a programmed death ligand 1 expression level of 90%. The clinical stage was T4N0M0 stage 3A. After neoadjuvant chemotherapy and radiotherapy, we performed one-stage surgery with the patient in the right lateral decubitus position and the left inguinal region exposed for femoral vessel isolation. Posterolateral thoracotomy was performed with making a latissimus dorsi muscle flap. The pulmonary artery, vein, and left lower bronchus were cut with a stapler. After hilar isolation, we evaluated the involvement of the descending aorta and marked the area of the involved aortic wall by a surgical clip. Using the left femoral artery approach, a GORE TAG conformable thoracic stent graft was delivered to the descending aorta. After thoracic aortic endografting, the involved aortic wall was resected and the left lower lobe of the lung and resected aortic wall were resected en bloc. The adventitial defect was covered by the latissimus dorsi muscle flap. The operating time was 474 min, and the blood loss volume was 330 mL. The postoperative pathological diagnosis was adenocarcinoma with an epidermal growth factor receptor mutation of exon 19 deletion. The residual viable tumor was 7 mm in diameter and close to the resected aortic wall. The patient's postoperative course was uneventful. Five days after surgery, chest contrast-enhanced computed tomography revealed no endoleak or stent migration. Three months after surgery, he was alive with neither recurrence nor stent graft-related complications.

CONCLUSIONS

One-stage surgery involving combined resection of lung cancer and the thoracic aortic wall with simultaneous thoracic aortic endografting in the right lateral decubitus position with the left inguinal region exposed is safe and acceptable.

Primary Thoracic Endografting for T4 Lung Cancer Aortic Involvement

PURPOSE

The aim of the study was to present the results in patients with a T4 thoracic tumor with aortic involvement who were treated with a thoracic endograft before surgical resection.

DESCRIPTION

All consecutive patients undergoing a thoracic endograft procedure before an oncologic resection between January 2012 and December 2019 were reviewed in a single-center retrospective study. Included patients had either a T4 lung tumor or a mediastinal tumor invading the thoracic aorta.

EVALUATION

Nine patients were included: 7 with T4 lung cancer, 1 with sarcoma, and 1 patient with thymoma. Median follow-up was 25 months (range, 22-47 months). There were no endograft-related complications. All but 1 patient had an R0 oncologic resection. Eight patients were alive and free from recurrence at the last follow-up.

CONCLUSIONS

Use of thoracic stent grafting before surgical resection for patients with a thoracic tumor invading the aorta is a feasible option that obviates the need for extracorporeal circulation and its associated morbidity. This technique could be an alternative strategy in the treatment of tumors invading the thoracic aorta.

Intraoperative aortic endograft placement for an unexpected plaque rupture during lung surgery

BACKGROUND

Surgical resection of tumors invading the aorta is a challenging procedure. More recently, the use of thoracic aortic endografts has been reported to facilitate en bloc resection of tumors invading the aortic wall. The best treatment option is to keep the procedure separated before lung resection to reduce the risks of bleeding, therefore avoiding adverse consequences for the patient. However, an aortic stent placement before surgery is not mandatory with no clear signs of tumor or atherosclerotic plaque infiltrating the entire aortic wall.

CASE PRESENTATION

A 72-year-old man came to our Department for a persistent cough. Computed tomography (CT) scan with enhancement showed a mass located in the left upper lobe of the lung with no clear sign of infiltration or calcified plaques along the entire vascular wall. A positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-d-glucose integrated with computed tomography (PET/CT with 18F-FDG) was positive for hypermetabolic mass with negative lymph node stations bilaterally. Patient was undergone surgery for major lung resection by left thoracotomy. For an unexpected intraoperative bleeding due to the rupture of a calcified plaque, a stent was placed before proceeding with lung surgery. Patient was persistently stable, discharged after six days from surgery with no morbidities.

CONCLUSIONS

In our case, no signs of the atherosclerotic plaque infiltration as well as no tumor infiltration were shown. In these situations, the aortic stent placement is possible in emergency, even during another operation. Nevertheless, surgeon experience and the good coordination among specialists is mandatory to yield a satisfying solution.

Massive Hemorrhage From the Aorta on Removal of an Anterior Mediastinal Tumor in Spite of Using an Endovascular Stent Graft: A Case Report

A 68-year-old man was scheduled for mediastinal tumor resection. Aortic invasion was unclear on preoperative computed tomography. Transesophageal echocardiography showed a smooth endothelial border, but the tumor was contiguous with the distal arch, and the adventitial border was unclear. After median sternotomy, the tumor was found to be adherent to the aorta. An endovascular stent graft was placed in the distal arch to protect the aorta, but excessive bleeding occurred from the aortic defect on tumor removal. This case shows that massive hemorrhage can occur during the resection of an aorta-invading tumor despite the use of an endovascular stent graft.

Paraneoplatic Obstruction of Descending Thoracic Aorta: A New Indication for Endovascular Surgery?

We describe the rare case of a 61-year-old man admitted to our emergency department with visceral-organ and lower-limb malperfusion because of an unknown retroperitoneal high-grade undifferentiated pleomorphic sarcoma and a severe paraneoplastic obstruction of the descending thoracic aorta, treated with thoracic endovascular aortic repair. The postoperative period was uneventful, and the patient was discharged within 4 days. At 6-month follow-up, computed tomography showed complete patency of the descending thoracic aorta. This single case experience shows that thoracic endovascular aortic repair can be a less invasive and effective off-label alternative to exclude infiltrated or obstructed descending thoracic aorta, thus avoiding conventional surgery.

Early and mid-term outcomes of simultaneous thoracic endovascular stent grafting and combined resection of thoracic malignancies and the aortic wall

Objectives

To aim of this study was to clarify the safety of simultaneous thoracic aortic endografting and combined resection of the aortic wall and thoracic malignancy in a one-stage procedure over the early and mid-term periods.

Methods

From March 2013 to December 2017, 6 patients underwent aortic endografting followed by one-stage en bloc resection of the tumor and aortic wall. Thoracic surgeons and cardiovascular surgeons discussed predicted tumor invasion range and resection site, stent placement position, stent length and size, and the surgical procedure, taking into account the safe margin.

Results

The proximal site of aortic endografting was the: aortic arch in 2 cases (subclavian artery (SCA) occlusion in one, and SCA fenestration in one); distal arch just beneath the SCA in 2; descending aorta in 2. Pulmonary resection involved lobectomy in 2 patients, pneumonectomy in 2, and completion pneumonectomy in 1. Aortic resection was limited to the adventitia in 2 cases, extended to the media in 3, and extended to the intima in 1. An endograft-related complication, external iliac artery intimal damage requiring vessel repair, was observed in one case. No complications associated with aortic resection were observed. Two postoperative complications of atrial fibrillation and chylothorax developed. There were no surgery-related deaths. During follow-up, no late endograft-related complications such as migration or endoleaks occurred.

Conclusions

Early and mid-term outcomes of stent graft-related complications are acceptable. Simultaneous thoracic aortic endografting and combined resection of the aortic wall and thoracic malignancies are feasible in one stage on the same day.