Life-Threatening Postpneumonectomy Syndrome Complicated with Right Aortic Arch after Left Pneumonectomy.

Takahiro Karasaki,Makoto Tanaka

doi:10.1155/2015/768067

Abstract

A 54-year-old man with right aortic arch underwent left lower lobectomy and lingular segmentectomy, followed by complete pneumonectomy, for refractory nontuberculous mycobacterial infection. Three months after the pneumonectomy, he developed acute respiratory distress. Computed tomography showed an excessive mediastinal shift with an extremely narrowed bronchus intermedius and right lower bronchus compressed between the right pulmonary artery and the right descending aorta. Soon after the nearly obstructed bronchus intermedius was observed by bronchoscopy, he began to exhibit frequent hypoxic attacks, perhaps due to mucosal edema. Emergent surgical repositioning of the mediastinum and decompression of the bronchus was indicated. After complete adhesiolysis of the left thoracic cavity was performed, to maintain the proper mediastinal position, considering the emergent setting, an open wound thoracostomy was created and piles of gauze were inserted, mildly compressing the heart and the mediastinum to the right side. Thoracoplasty was performed three months later, and he was eventually discharged without any dressings needed. Mediastinal repositioning under thoracostomy should be avoided in elective cases because of its extremely high invasiveness. However, in the case of life-threatening postpneumonectomy syndrome in an emergent setting, mediastinal repositioning under thoracostomy may be an option to save life, which every thoracic surgeon could attempt.

Highlights

In a patient with right aortic arch, which is a rare congenital malformation that reportedly is found in approximately 0.1% of the population, the right main or intermediate bronchus is subject to compression between the pulmonary artery and the right descending aorta after left pneumonectomy [3, 4]
We report a case with right aortic arch who presented with life-threatening PPS after left pneumonectomy for refractory nontuberculous mycobacterial infection
From 1979 to 2014, a total of 102 adult cases of PPS have been reported in the English literature, 72 after right pneumonectomy and 30 after left pneumonectomy [1, 5,6,7,8,9,10,11]

Summary

Introduction

Postpneumonectomy syndrome (PPS) is a rare complication that occurs in 0.16% to 2% of cases after pneumonectomy [1, 2]. The left main bronchus is compressed between the aortic arch and the pulmonary artery. In a patient with right aortic arch, which is a rare congenital malformation that reportedly is found in approximately 0.1% of the population, the right main or intermediate bronchus is subject to compression between the pulmonary artery and the right descending aorta after left pneumonectomy [3, 4]. We report a case with right aortic arch who presented with life-threatening PPS after left pneumonectomy for refractory nontuberculous mycobacterial infection

Case Presentation

Findings

Discussion