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© 2004 European Association of Cardio-Thoracic Surgery
Interposition grafting of the lower lobe pulmonary artery with a cuff of azygous vein, following its accidental ligation and divisionCardiothoracic Unit, Victoria Hospital, Whinney Heys Road, Blackpool FY3 8NR, UK
* Corresponding author. Tel.: +44-1253-303-668; fax: +44-1253-303-853 Received July 29, 2003; received in revised form October 30, 2003; accepted November 11, 2003
A patient with a mass lesion suggestive of a bronchial carcinoma in the right upper lobe was taken to theatre for a right upper lobectomy. The lower lobe artery, which was smaller than usual, was inadvertently divided. The arterial blood supply to the lower lobe was repaired with azygous vein as an interposition graft between the stump of the right apical segment arteries and the lower lobe artery. There were no signs of reperfusion injury post-operatively. We report a method that can be safely and relatively easily performed in these rare circumstances.
Key Words: Azygous vein; Lung resection; Vessel reconstruction
A 58-year-old male who had been complaining of shortness of breath, haemoptysis and coughing for 2 months, was referred to a chest physician for further investigation of his symptoms. He was a smoker until recently with 25 pack-years. A chest radiograph revealed a large cavitating opacification in the region of the right upper lobe. Flexible bronchoscopy was performed, which did not show any visible endobronchial abnormality, nor did the cytology of the bronchial aspirate yield any diagnostic material. The computer tomogram of his chest revealed a large mass lesion in the right upper lobe with some cavitation, without any lymph node enlargement. Appearances were suggestive of a bronchial carcinoma. Spirometry revealed a forced expiratory volume in 1 s (FEV1) of 2.97 l (3.66 predicted) and a forced vital capacity (FVC) of 5.12 l (4.49 predicted). It was jointly decided at the multidisciplinary team meeting that he should undergo a right upper lobectomy for both diagnostic and therapeutic reasons. The patient underwent a standard postero-lateral thoracotomy through the fifth intercostal space. On opening, the upper lobe was adherent to the parietal pleura and the fissures appeared only partially developed. The lung was mobilised by blunt dissection and the apical segmental branches of the pulmonary artery doubly ligated and divided. Attention was then turned to the major fissure but there were very dense adhesions and anthracotic nodes, which made exposure of the pulmonary artery very difficult. The upper lobe pulmonary vein was exposed, ligated and divided. At this point it was noted that the lower lobe artery, which was smaller than usual, had been inadvertently included in the ligature and also divided. Right upper lobectomy was completed and the bronchial stump was stapled. It was decided to attempt to repair the arterial blood supply to the lower lobe. The azygous vein was resected between its vertical portion and the superior vena cava and used as an interposition graft between the stump of the right apical segmental arteries and the lower lobe artery as illustrated in Fig. 1. The middle lobe was sacrificed, as its artery was damaged by the ligature that had been placed inadvertently. The total ischemic time to the lower lobe was around 90 min.
Following the procedure there were no signs of reperfusion injury. A persistent airleak was eventually treated by video-assisted thoracoscopic talc pleurodesis 3 weeks after the initial procedure. Histological examination of the removed lung tissue revealed a 6 cm cavitating abscess with surrounding organising pneumonia. Outpatient follow-up 6 weeks after discharge from hospital confirmed that the patient was doing well, without any respiratory symptoms. A chest radiograph revealed normal appearances compatible with right upper and middle lobectomy. Spirometry performed at this stage revealed a FEV1 of 2.73 l (3.24 predicted) and an FVC of 3.87 l (4.08 predicted).
The above-described surgical problem is fortunately a rare occurrence, but is a scenario in which many surgeons might have performed a pneumonectomy. We report here a method that can be safely employed and is also in practice relatively easy to perform. The additional warm ischaemic time to the lower lobe did not seem to cause any measurable functional detriment, and clearly offers better long-term respiratory function than a pneumonectomy. At this stage we can assume that the azygous vein conduit is patent, otherwise infarction and gangrene of the lower lobe would have occurred with the resultant local thoracic and systemic findings of infection. We consider it unlikely that the conduit will become aneurysmal due to the low pressures in the pulmonary artery system. He will be regularly followed up in the outpatient clinic with serial chest radiographs, and further imaging will be obtained if any suspicious changes occur. Using the azygous vein for interposition grafting has been described before in operations for congenital heart disease, most notably cavo-pulmonary connections [1], unifocalisation of pulmonary blood supply [2] and systemic-to-pulmonary arterial shunt formation [3,4]. It has also been evaluated in a dog model as to its quality when using it as a replacement of pulmonary artery branches [5]. In these settings the azygous vein was used either to elongate an anastomosis, create an interposition tube or use it as an alternative conduit to a native artery. Neither of the specific methods seems to report any difficulties in either harvesting or using the vein for these indications, nor were there any reported long-term problems associated with its use. As it is easy to access and able to grow if necessary, it is ideal for use in situations as described above. We therefore recommend the use of the azygous vein as a replacement or interposition graft in situations where the arterial or venous blood supply to the right lung has been injured or a piece of it has been resected and there would be too much tension on the anastomosis. doi:10.1016/S1569-9293(03)00276-7
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Abstract
1. Case
