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International Society For Minimally Invasive Cardiothoracic Surgery

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Left Bronchial Compression After Endovascular Repair Of Contained Rupture Of Descending Thoracic Aortic Dissection
Nikola Dobrilovic1, Karl Karlson1, Jaishankar Raman2, Peter Soukas3, Immad Sadiq3, Lidia Vognar3, Arun Singh3.
1Boston University, Boston, MA, USA, 2Oregon Health Sciences, Portland, OR, USA, 3Brown Univeristy, Providence, RI, USA.

OBJECTIVE:
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RESULTS:
CONCLUSIONS: INTRODUCTION • Descending thoracic aortic dissection with subsequent rupture is almost uniformly fatal • If such an aortic rupture is contained, survival is possible, though, prognosis still remains poor • We describe a patient who survived descending thoracic aortic dissection after rupture was contained within the mediastinum • The patient developed profound left bronchial compression secondary to the rupture (mediastinal hematoma) • We believe that bronchial compression was further exacerbated by our endovascular repair • Postoperatively the patient developed significant pulmonary complications including complete lung collapse, persistent pneumonia, and prolonged ventilator requirement • The patient improved only after re-expansion of the left bronchus using a covered, removable airway stent • To our knowledge, such a case has not previously been reported CASE DETAILS • 57 yo female • PMH: RA - steroids • Known descending thoracic aortic dissection • Routine, outpatient f/u chest CT demonstrated significant proximal progression of dissection and contained rupture • Patient sent to hospital emergency department • Patient was thought to be a poor candidate for either standard TEVAR or open surgical repair of descending dissection/contained rupture • Patient was treated using hybrid approach Sternotomy debranching (innominate, L carotid, L subclavian) TEVAR (antegrade deployment) • Immediately post-op - left lung collapse • Difficulty maintaining left lung expansion resulted in a post-operative course complicated by multiple pulmonary issues Pulmonary toilet was extremely difficult Patient developed pneumonia Failed extubation Required tracheostomy • Patient’s overall progress was limited by pulmonary system • A removable, covered airway stent was placed within the left mainstem bronchus resulting in an immediate improvement trend Left lung was re-expansion was significantly facilitated Pneumonia and pulmonary complications resolved Patient was discharged and weaned from ventilator shortly thereafter LESSONS LEARNED • Mediastinal hematoma from contained aortic rupture can cause airway compression, lung collapse, and severe pulmonary complications • Aortic endovascular stent deployment can increase pressure on the hematoma and further exacerbate airway compression • Intervention with a covered, removable airway stent was successful • Treatment with a covered, removable airway stent should be considered EARLY


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