Robotic Ligation Of An Azygos Vein Aneurysm In A Patient With Systemic Lupus Erythematosus And History Of Pulmonary Thromboembolism
Jeffrey Jiang, MD, Neel K. Ranganath, MD, Siyamek Neragi-Miandoab, MD, Ryan J. Potosky, MD, Didier F. Loulmet, MD, Aubrey C. Galloway, MD, Eugene A. Grossi, MD.
NYU Langone Health, New York, NY, USA.
OBJECTIVE: Azygos vein aneurysms are uncommon and usually diagnosed incidentally. Given their rarity, the risk of rupture and thromboembolism is largely unknown and there are no standardized treatment guidelines. Surgical intervention is considered for patients who are symptomatic or at high risk of thromboembolic sequelae, and azygos vein ligation via open thoracotomy has been described previously in published reports. We demonstrate a totally endoscopic robotic-assisted azygos vein ligation in a 55yo woman with systemic lupus erythematosus, history of pulmonary thromboembolism, and recurrent right-sided chest pain between the 2nd and 3rd ribs. Pre-operative MR angiogram demonstrated a 2.9cm aneurysmal azygos arch.
METHODS: The patient was intubated with a double lumen endotracheal tube for right lung exclusion and kept supine. Four ports were placed in the right chest for the da Vinci Xi surgical system. Using a totally endoscopic technique, the cross of the azygos vein was dissected free from surrounding structures. The aneurysm was ligated proximally and distally with two large silk sutures and each suture ligature was reinforced with two large clips. The azygos vein cross was divided to release any tension on surrounding tissue. The right pleural space was irrigated and hemostasis was achieved. Chest ports were closed and a right chest tube was placed.
RESULTS: The patient was extubated in the operation room and was discharged on post-operative day 2. Subsequent CT angiogram performed 2 months postoperatively demonstrated a significant reduction in the size of the azygos arch, though still mildly prominent. On follow-up, patient reported resolution of her chest pain.
CONCLUSIONS: Open thoracotomy and video-assisted thoracoscopic surgery have been reported as modalities to treat azygos vein aneurysm. Here we demonstrate that symptomatic aneurysms can be treated safely and effectively with a totally endoscopic robotic-assisted approach.
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