Bronchopleural fistula after lower lobectomy of the right lung following thoracic endovascular aortic repair

Abstract

A 77-year old male patient was admitted for the treatment of a thoracic aortic aneurysm (TAA) and primary lung cancer. A saccular aneurysm, 4.8 cm in diameter, located in the proximal segment of the descending thoracic aorta and a pulmonary tumour, 3 cm in diameter, located at the right lower lobe, with lymph node swelling, were detected simultaneously. First, a thoracic endovascular aortic repair (TEVAR) was performed for TAA, and then 45 days later, a lobectomy and radical lymph node dissection by open thoracotomy were performed safely for primary lung cancer. The postoperative course was complicated by a bronchopleural fistula (BPF). Massive necrotic changes to the bronchial stump and the intercostal muscle flap were observed during an open window thoracotomy. Both the chronic use of corticosteroids and TEVAR may have been among the predisposing factors for the occurrence of the fistula. The patient died as a result of respiratory failure 68 days after the lobectomy. This is a first case report of a BPF after a staged operation of TEVAR and major lung surgery. We reviewed and discussed the surgical strategy and timing for both the primary lung cancer and the thoracic aortic aneurysm.

The Rationale for Treatment of Postresectional Bronchopleural Fistula: Analysis of 52 Patients

“…The 1.4% rate of BPF reported in the present study is similar to other recent series [3][4][5][13][14][15][16][17] (Table 9). …”

“…Local factors include technique of stump closure, disruption of bronchial blood supply, a long bronchial stump, residual carcinoma at the bronchial margin, presence of empyema, extended resection, and preoperative radiotherapy, even if no single factor has been clearly identified [3,4]. Systemic factors include the patient's nutritional status, diabetes, presence of sepsis, and preoperative chemotherapy [5].…”

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

“…It is noteworthy, however, that Hino et al [1] reported the occurrence of a bronchial fistula after a post-TEVAR lung lobectomy. In this case study, impairment of the arterial supply to the bronchial stump and the intercostal muscle flap was stated to be a possible cause of the complication.…”

“…A previous case was reported in which, subsequent to performing TEVAR to treat a TAA, a bronchial fistula occurred after a right lower lobectomy for a primary lung cancer; loss of blood flow to the bronchial stump and the pedicled intercostal muscle flap from the aorta due to the TEVAR procedure was stated as a possible reason for the complication [1]. In response to this article, we evaluated the blood flow of the branches of the descending aorta using CT angiography before undertaking the lung resection, and confirmed that the blood supply was preserved for both the right bronchial artery and the fifth intercostal artery The definitive lung tumor diagnosis in this case was a moderately differentiated squamous cell carcinoma with a hilar lymph node metastasis (pT2aN1M0).…”