Eur J Cardiothorac Surg 2002;21:946-947
© 2002 Elsevier Science NL
Tracheal stenosis caused by false aneurysm of the right subclavian artery
M. Hohlsa*,
N. Ghanemb,
M. Wilhelmc,
E. Stoelbena
a Department of Thoracic Surgery, Freiburg University Hospital, Hugstetter Strasse 55, 79106 Freiburg, Germany
b Department of Radiology, Freiburg University Hospital, Hugstetter Strasse 55, 79106 Freiburg, Germany
c Department of Cardiovascular Surgery, Freiburg University Hospital, Hugstetter Strasse 55, 79106 Freiburg, Germany
Received 7 January 2002;
received in revised form 8 February 2002;
accepted 12 February 2002.
* Corresponding author. Tel.: +49-761-270-2457; fax: +49-761-270-2499
e-mail: docmaho{at}gmx.de
 |
Abstract
|
|---|
The development of tracheal stenosis following insertion of a central venous catheter is a rare complication of this procedure. We present the case of an 81-year-old woman, who suffered acute onset of dyspnea, stridor and dysphagia 4 weeks after coronary artery bypass surgery. Investigations revealed a false aneurysm of the right subclavian artery, compressing the trachea and the oesophagus. The iatrogenic lesion was caused by the insertion of a central venous catheter via the right subclavian route. By the time symptoms developed the catheter had already been removed.
Key Words: Tracheal stenosis • False aneurysm • Central venous catheter
|
1. Introduction
|
|---|
Acute postoperative tracheal stenosis must be diagnosed and treated swiftly to avoid respiratory failure. This case report describes a false subclavian artery aneurysm, following insertion of a central venous catheter via the right subclavian route. As in this patient, who was afflicted with acute dyspnea, stridor and dysphagia 3 weeks after the removal of the central venous cannula, symptoms can develop with a considerable delay from the time of the insulting event.
|
2. Case report
|
|---|
Following triple coronary artery bypass surgery in a peripheral hospital, an 81-year-old woman required 7 days of ventilation postoperatively due to respiratory failure. Three weeks after extubation and removal of the right subclavian venous catheter she developed acute progressive stridor in combination with dysphagia to solid food as well as fluids. For diagnostic purposes she was transferred to our unit. On admission she had marked in- and expiratory stridor and a pulsating thyroid gland without bruit. Chest X-ray revealed a widened upper mediastinum, a rather unspecific finding following median sternotomy and coronary artery bypass grafting. Flexible bronchoscopy showed a distorted and severely stenosed trachea, the pars membranacea being compressed by a pulsatile mass (Fig. 1
). Contrast enhanced computed tomography (CT) (Fig. 2b
) depicted a large false aneurysm obstructing the trachea and the oesophagus. Digital subtraction angiography (DSA) located the origin of the aneurysm within an elongated and kinked right subclavian artery (Fig. 2a). The patient was transferred to the cardiovascular surgical theatre the same night. Using a right supraclavicular approach, the haematoma was evacuated and the neck of the aneurysm oversown. She made an uneventful recovery and was discharged back to her home hospital 8 days after operation, without any further signs of tracheal stenosis or dysphagia, respectively.
View larger version (118K):
[in this window]
[in a new window]
|
Fig. 1. Flexible bronchoscopy demonstrates subtotal stenosis and distortion of the trachea caused by extrinsic compression of the pars membranacea.
|
|
View larger version (83K):
[in this window]
[in a new window]
|
Fig. 2. (a) Intraarterial DSA locates the origin of the aneurysm within the elongated and kinked right subclavian artery (black arrow). (b) Contrast enhanced CT-scan depicts a 3x4x5 cm false aneurysm (white arrow), shifting the trachea as well as the oesophagus.
|
|
|
3. Discussion
|
|---|
Tracheal stenosis can occur with acute or chronic onset [1]. If an acute stenosis develops in the postoperative setting, the level of suspicion for a possible complication of the preceding procedure must be high. Arterial injuries following subclavian central venous catheter insertion have been described before. Sznajder et al. [2] investigated 261 central venous catheter attempts via this route and found an arterial puncture rate of 3.0% in experienced hands and 3.1% in inexperienced hands. However, tracheal stenosis caused by a false subclavian artery aneurysm after inserting the catheter via the subclavian route is a rare complication. We only found one case reported in the literature, describing pressure necrosis of the membranous trachea by such an aneurysm, which was surgically repaired via right posterolateral thoracotomy. The patient made a slow recovery [3]. Differential diagnosis of a postoperative pulsatile mass following coronary artery bypass grafting must include pseudoaneurysm of the ascending aorta [4,5].
This case illustrates the need for swift diagnosis and treatment of a tracheal stenosis to avoid respiratory failure, especially in a patient who postoperatively had been dependent on respiratory support due to a low cardio-respiratory reserve.
|
Footnotes
|
|---|
This case report was presented as a poster at the 10th meeting of the German Society for Thoracic Surgery (Deutsche Gesellschaft für Thoraxchirurgie), Berlin, June 8, 2001.
|
References
|
|---|
-
Grillo H.C. Management of nonneoplastic diseases of the trachea. In: Shields T.W., LoCicero J., III, Ponn R.B., eds. General thoracic surgery. Philadelphia, PA: Lippincott Williams and Wilkins, 2000:885-897.
-
Sznajder J.I., Zveibil F.R., Bitterman H., Weiner P., Bursztein S. Central vein catheterization: failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259-261.[Abstract/Free Full Text]
-
Baldwin R.T., Kieta D.R., Gallagher M.W. Complicated right subclavian artery pseudoaneurysm after central venipuncture. Ann Thorac Surg 1996;62(2):581-582.[Abstract/Free Full Text]
-
Acosta A.R., Valle D.E., Calimano M.T., Kaakaji Y., Diethelm L. Aortic pseudoaneurysm after coronary artery bypass. Am J Roentgenol 1998;171:842-843.
-
Gilkeson R.C., Clampitt M.S., Stewart R.M., Laden N.S. Pseudoaneurysm of aortic cannulation site after coronary artery bypass grafting: evaluation with gadolinium-enhanced MR angiography. Am J Roentgenol 1999;172:843-844.[Medline]
Top
Abstract
1. Introduction
