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© 2004 European Association of Cardio-Thoracic Surgery
Reconstruction of a tracheobronchial tree disruption with bovine pericardium
a Department of Otolaryngology and Communicative Disorders, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA
* Corresponding author. Address: Department of Thoracic and Cardiothoracic Surgery-Desk F24, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA. Tel.: +1-216-444-5640; fax: +1-216-445-6876 Received March 22, 2004; received in revised form June 1, 2004; accepted June 7, 2004
Iatrogenic tracheobronchial disruption is a rare, life-threatening condition. Depending upon the extent of the injury, its location, and the condition of the patient, repair/reconstruction options may be limited. The natural history of bovine pericardium used to repair one such tracheal injury has been documented.
Key Words: Bronchoscopy; Pericardium; Tracheal injury; Rupture; Tracheal stenosis
Transmural tracheobronchial disruption is a rare, life-threatening emergency. Diagnosis is often delayed and treatment is dependent upon the severity of the injury and the underlying health of the patient. Little is known regarding repair of tracheobronchial rupture with bovine pericardium.
A 72-year-old female with multiple co-morbidities (hypertension, insulin-dependent diabetes, dialysis-dependent renal failure, hypothyroidism and anticoagulation for atrial fibrillation) was admitted for recurrent pneumonia with respiratory failure and ultimately required tracheotomy. The patient was decannulated shortly after hospital discharge. Six weeks later, the patient was presented with expiratory stridor. Bronchoscopy revealed a high-grade stenosis at the level of the tracheal stoma. Balloon dilation was partially effective and uncomplicated. The patient continued to experience some obstructive symptoms and re-establishment of the tracheotomy was considered. A second trial of dilation was eventually undertaken. For this procedure, the patient underwent manometrically monitored dilation with a 20 Fr FogartyTM balloon catheter (Baxter, Minneapolis, MN) placed across the residual stenosis. Some bleeding was noted immediately after balloon removal and bronchoscopy revealed a 1.5 cm mucosal rent of the membranous trachea beginning at the stenosis and extending inferiorly. The adventitia appeared intact. Conservative management was pursued and a 7.0 Fr BivonaTM Air-Cuff tracheostomy tube (Smith's Medical, London, UK) was placed through the original stoma. Ventilation became difficult shortly thereafter, and the patient began developing subcutaneous emphysema. Bronchoscopy demonstrated dehiscence of the membranous tracheal wall extending to the right mainstem. The tracheostomy tube was in the posterior mediastinum. An emergency right posterolateral thoracotomy was performed. With the airway exposed, an avulsion injury of the membranous trachea was noted. A 7.0 Fr endotracheal tube (ETT) was passed cross-table through the defect into the left mainstem. There was insufficient posterior wall remaining for primary repair (Fig. 1A) and the deficit was closed with glutaraldehyde-fixed bovine pericardium (Fig. 1B). The repair was buttressed with an epicardial fat pad. Right and left 4.0 Fr MLT ETTs were passed transorally beyond the repair and the patient was successfully ventilated.
After 4 days, the MLTs were exchanged for an #8 ETT with the cuff-positioned directly under the cricoid arch. One week later, the tracheal stoma was revised and cannulated. Bronchoscopy demonstrated excellent graft position without evidence of dehiscence (Fig. 2A). The patient recovered uneventfully. Outpatient bronchoscopy performed in the first, second and third post-operative months revealed good graft position.
In the fourth post-operative month, the patient experienced worsening biphasic stridor. Bronchoscopy demonstrated significant tracheal compromise from the sloughed pericardial patch (Fig. 2B). The patient underwent rigid bronchoscopy, and the extruded graft was extracted. Surprisingly, the airway appeared completely healed and of normal caliber after the patch was removed. The patient expired 2 years later of unrelated causes and had no sequelae from her airway injury.
Pressure-monitored balloon dilation is a well-understood and accepted treatment of benign tracheobronchial tree stenoses [1]. If successful, balloon dilation avoids the morbidity of trans-thoracic primary repair. Minor mucosal rents are common (25%) but major complications are rare [2]. This approach is well adapted to combination therapy with endobronchial laser therapy and stent placement for endoluminal masses [2]. Tracheal ruptures are most commonly encountered in the setting of difficult intubation or high velocity, blunt thoracic trauma. Reported risk factors for tracheal rupture include advanced age, chronic obstructive pulmonary disease, prior tracheotomy, chronic inflammatory conditions, and long-term steroid use [3]. Diagnosis is usually delayed, unless bronchoscopy is performed promptly. Management can be observational or surgical, depending on the extent and complexity of the injury, and the general condition of the patient. When surgical therapy is necessary, reconstructive options are limited. The injury occurs almost uniformly in the membranous tracheal wall. In the setting of trauma, primary suture closure is performed when possible. Post-operative sequelae include a high incidence of stenosis. Fibrin glue and expandable metallic stents have been used with success in the repair of tracheal tears [4,5]. For complex injuries, segmental tracheal resection with primary anastomosis may be considered. Little is known about the use of bovine pericardium for airway reconstruction. In the current case, gluteraldehyde-fixed bovine pericardium was used to close an extended tracheal wall rupture. It provided an effective structural scaffold, enabling re-epithelialization of the defect. The repair showed no evidence of wound breakdown, despite the trauma of intermediate-term positive pressure ventilation, serial therapeutic bronchoscopies, and multiple surveillance endoscopies carried out over a 4-month period. The graft spontaneously sloughed by the fourth post-operative month. No evidence of graft instability or rejection was observed until then. The wound bed appeared well healed. There was no evidence of post-operative stenosis or weakness in the posterior tracheal wall.
Although balloon dilation of tracheal stenoses has been shown to be a safe procedure, the authors recommend the use of low volume, high-pressure balloons. The integrity of the tracheal wall should be verified after the completion of the procedure. Bovine pericardium served as an effective temporary surrogate for the membranous trachea in this case. It does not last indefinitely, but may promote the autologous ingrowth of mucosa. Careful follow-up is required as sloughed pericardium may obstruct the airway.
ICVTS on-line discussion Author: Dr. Christophoros Foroulis, Larissa University Hospital, Department of Cardio-thoracic Surgery, 35 Ioustinianou Street, Larissa, 41223 Greece Date: 16-Sep-2004 Message: An extensive rupture of the membranous trachea could be repaired using an autologous patch, such as pericardium. Succesful tracheal patching with autologous pericardium has been reported by Moghissi and Hasse (Pericardial patch reinforced by Marlex mesh or PTFE, J Thorac Cardiovasc Surg 1975; 69: 499-506 and Eur J Cardiothorac Surg 1990; 4: 412-6 respectively), by Gorenstein et al. (Simple pericardial patch, Ann Thorac Surg 1992; 54: 784-6) and by Foroulis et al. (Pericardial patch reinforced by pedicled thoracic muscle flap, Interactive Cardiovascular and Thoracic Surgery 2003; 2: 595-7). Bovine pericardium was sloughed into the tracheal lumen and its use as a tracheal substitute should be limited. Indeed, we keep in mind that bovine pericardium could be an alternative to autologous pericardium patch for tracheal repair. Author: Dr. Mark Hazekamp, Leiden University Medical Center, Department of Cardiothoracic Surgery D6-26, LUMC, PO Box 9600, 2300 RC Leiden, Netherlands Date: 27-Sep-2004 Message: It is important to emphasize again that (untreated) autologous pericardium is excellent material for tracheal reconstruction. When used for repair of defects in the membranous part of the trachea, external support is not needed as long as the cartilaginous part of the trachea has remained intact. Contrary to xenopericardium, autologous pericardium will remain in place and does not carry the risk of patch material infection in a potentially contaminated environment.In our experience, extrusion of an autologous pericardial patch has not been observed after tracheal repair. doi:10.1016/j.icvts.2004.06.002
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Abstract
1. Introduction
