Ann Thorac Surg CASE REPORT COHEN ET AL 1257 1996;61:1257-9 PA RECONSTRUCTION FOR TUBERCULOSIS

used to prevent nar rowing of the entrance of the inferior vena cava after the removal of a margin of normal atrium.

The operat ion enabled the pat ient to avoid an impend- ing cardiac catastrophe and has improved the quali ty of her remain ing life. Comple te resection of cardiac metas- tasis of a me lanoma may be indica ted and achievable in se lected cases, especial ly if the pat ient (as in this case) has a Karnofsky performance status greater than 80% preoperat ively.

References

1. Glancy DL, Roberts WC. The heart in malignant melanoma: a study of 70 autopsy cases. Am J Cardiol 1968;21:555-71.

2. Klatt EC, Heitz DR. Cardiac metastases. Cancer 1990;65: 1456-9.

3. MacGee W. Metastatic and invasive tumours involving the heart in a geriatric population: a necropsy study. Virchows Arch [A] 1991;419:183-9.

4. Thomas JH, Panoussopoulos DG, Jewell WR, Pierce GE. Tricuspid stenosis secondary to metastatic melanoma. Cancer 1977;39:1732-7.

5. Emmot WW, Vacek JL, Agee K, Moran J, Dunn MI. Metastatic malignant melanoma presenting clinically as obstruction of the right ventricular inflow and outflow tracts. Characteriza- tion by magnetic resonance imaging. Chest 1987;92:362-4.

6. Canver CC, Lajos TZ, Bernstein Z, DuBois DP, Mentzer RM Jr. Intracavitary melanoma of the left atrium. Ann Thorac Surg 1990;49:312-3.

7. Vetto JT, Heelan RT, Burt M. Malignant melanoma metastatic to the right atrium: an asymptomatic solitary metastasis diagnosed incidentally by magnetic resonance imaging [Let- ter]. J Thorac Cardiovasc Surg 1992;104:843-4.

8. Merer DM, Dutcher JP, Mercando A, et al. Case report: Clinical findings and successful resection of melanoma met- astatic to the right atrium. Cancer Invest 1994;12:409-13.

Pulmonary Artery Reconstruction for Tuberculosis Andrew S. Cohen, FRCS, Tina Beaconsfield, FRCR, Aghiad A1-Kutoubi, FRCR, Clive E. Handler , MRCP, and Brian E. Glenville, MS

Department of Cardiothoracic Surgery, St Mary's Hospital, London, England

A 35-year-old woman underwent reconstruction of her fight pulmonary artery for treatment of acquired right pulmonary artery stenosis. The stenosis was secondary to tuberculosis causing both an extrinsic and an intrinsic obstructive component. After her reconstruction, the pa- tient made an uneventful recovery, and perfusion to the right lung was subsequently restored.

(Ann Thorac Surg 1996;61:1257-9)

external compress ion include medias t ina l tera toma [1], Hodgkin ' s disease [1], aneurysm of the ascending aorta [1, 2], bronchial carcinoma [1[, sarcoidosis [3], hyda t id cyst [4], bronchogenic cyst [5], cystic thymoma [6[, and his toplasmosis [7]. Gough and associates [1], in their review of acquired pu lmonary stenosis and pu lmonary ar tery compression, descr ibed an addi t ional case in which the probable diagnosis was thought to be tuber- culosis. However, spu tum cultures for tubercle bacilli were negative and, thus, the diagnosis of sarcoidosis is b rought into question. We repor t a case of tuberculosis causing acquired right pu lmonary artery stenosis sec- ondary to both external compress ion and intrinsic ob- struction.

A 35-year-old woman presen ted with a 4-week history of rapidly increasing shortness of breath on exertion and vague retrosternal chest pain. Examination revealed her to be in sinus tachycardia with normal hear t sounds. She was hypoxic on room air with an oxygen tension of 72 m m Hg. Chest r ad iography revealed a general ized decrease in pu lmonary vascular markings on the right. A perfusion-vent i la t ion scan revealed normal venti lat ion to both lungs and no perfusion to the right lung with a p resumpt ive diagnosis of pu lmonary embolism. A pul- monary angiogram was performed, which revealed pul- monary ar tery stenosis on the right with no evidence of pu lmonary embol ism (Fig 1). A right pu lmonary angio- plasty was a t tempted, but there was no significant radio- logic improvement . A computed tomogram was per- formed, which showed a tight stenosis of the right pu lmonary ar tery at the origin with abnormal t issue sur rounding the point of stenosis and abnormal tissue in the region of the right hilum. A Mantoux test proved negative, and bronchoscopy was normal.

A cquired pu lmonary stenosis secondary to extrinsic compress ion of the pu lmonary ar tery is rare [1]. Of

the cases repor ted in the l i terature, the causes of the

Accepted for publication Oct 25, 1995.

Address reprint requests to Mr Cohen, Department of Cardiothoracic Surgery, St Mary's Hospital London, W2 1NY, England.

Fig 1. Pulmonary angiogram showing right pulmonary artery steno- sis.

© 1996 by The Society of Thoracic Surgeons 0003-4975[96/$15.00 Published by Elsevier Science Inc SSDI 0003-4975(95)01063-7

1258 CASE REPORT COHEN ET AL Ann Thorac Surg PA RECONSTRUCTION FOR TUBERCULOSIS 1996;61:1257-9

Fig 2. Intraoperative photograph showing right pulmonary artery reconstruction with a polytetrafluoroethylene-reinforced graft, with the ascending aorta slung and retracted laterally.

The patient was prepared for surgical reconstruction of her right pulmonary artery. Through a median sternot- omy a stenosed right pulmonary artery was found with a fibrous reaction surrounding it and enlarged glands. The area of stenosis was from the origin of the right pulmo- nary artery distally over a length of 2.5 cm. Distal to this the right pulmonary artery was normal. The surrounding glands were debulked, and the patient was placed on cardiopulmonary bypass to facilitate the reconstruction of her pulmonary artery. A vascular clamp was placed distally on the normal right pulmonary artery, and an- other clamp was placed over the main pulmonary trunk. The stenosis was opened along its length. The vessel was fibrotic, with less than 15% of its circumference repre- senting normal artery. Pericardial patch repair was, therefore, inappropriate. Formal reconstruction from the main pulmonary trunk to the normal distal right pulmo- nary artery was performed using a 12-mm reinforced polytetrafluoroethylene graft (Fig 2). Once distal and proximal anastomoses were performed, the patient was weaned from cardiopulmonary bypass with ease. Post- operatively the patient made an uneventful recovery and was given oral anticoagulants to achieve a target Inter- national Normalized Ratio of 2.5. Histologic examination of the excised pulmonary artery segment revealed inti- mal proliferation and granulomatous inflammation with granulomata showing central caseous necrosis and Lang- han's multinucleate giant cells. Acid-fast bacilli were seen on Ziehl-Neelsen staining. The patient received standard anti-tuberculosis triple therapy.

Postoperatively a perfusion-ventilation scan demon- strated perfusion to the right lung. The patient 's symp- toms of shortness of breath were abolished, and she was discharged on the tenth postoperative day.

At follow-up she remained in excellent condition at 2 months. A repeat pulmonary angiogram at 6 months postoperatively showed a patent graft with normal per- fusion to the right lung (Fig 3).

C o m m e n t

Pulmonary tuberculosis is known to cause acute respira- tory distress resulting from major airway compression caused by enlarged tuberculosis mediastinal lymph nodes and dysphagia from compression of the esopha- gus. As Gough and associates [1] reported, external compression of the main pulmonary artery is rare; com- pression of the right or left branch, however, is more common. As in their cases in which the main pulmonary trunk was not involved, no clinical evidence of pulmo- nary stenosis or of pulmonary artery branch stenosis was present [1]. In our patient the heart sounds were normal and the electrocardiogram showed no evidence of right ventricular hypertrophy.

Gough and associates advocated the use of cardiac catheterization and selective angiography in patients who had evidence of right ventricular outflow obstruc- tion to determine the site and severity of the obstruction and to differentiate extrinsic compression and intrinsic stenosis. In our case, before pulmonary angiography, the presumptive diagnosis was one of pulmonary embolism, ie, pathology within the lumen of the artery. Subsequent to pulmonary angiography, pulmonary embolism was excluded, and the combination of pulmonary angiogra- phy and computed tomography suggested that the ste- nosis was largely due to external compression. At oper- ation external compression from tuberculosis lymph glands was certainly part of the problem, but it was

Fig 3. Six months postoperative pulmonary angiogram showing a patent graft with normal perJ~sion to the right lung.

Ann Thorac Surg CASE REPORT BASTOUNIS ET AL 1259 1996;61:1259-61 BRACHIOCEPHALIC OCCLUSIVE DISEASE

intrinsic involvement of the right pu lmonary artery itself, with only about 15% of normal ar tery circumference remaining, that was responsible for the stenosis.

References

1. Gough JH, Gold RG, Gibson RV. Acquired pulmonary steno- sis and pulmonary artery compression. Thorax 1967;22: 358-67.

2. Nasrallah A, Goussous Y, El-Said G, Garcia E, Hall RJ. Pulmonary artery compression due to acute dissecting aortic aneurysm: clinical and angiographic diagnosis. Chest 1975;67: 228-30.

3. Faunce HF, Ramsay GC, Sy W. Protracted yet variable major pulmonary artery compression in sarcoidosis. Radiology 1976; 119:313-4.

4. Mercante A, Colome JA, Diaz Fernandez AJ, Gallardo J, Saiz F. Acquired pulmonary stenosis. A case of pulmonary artery compression caused by hydatid cyst. Rev Clin Esp 1974;135: 289-93.

5. Watts WJ, Rotman HH, Patten GA. Pulmonary artery com- pression by a bronchogenic cyst simulating congenital pul- monary artery stenosis. Am J Cardiol 1984;53:347-8.

6. Soorae AS, Stevenson HM. Cystic thymoma simulating pul- monary stenosis. B J Dis Chest 1988;74:193-7.

7. Lloyd JE, Tillman BF, Atkinson JB, DesPrez RM. Mediastinal fibrosis complicating histoplasmosis. Medicine 1988;67:295- 310.

Circulatory Arrest in a Reoperation for Brachiocephalic Arterial Occlusive Disease Elias A. Bastounis, MD, Leonidas K. Hadjinikolaou, MD, David P. Taggart, MD(Hons), Constant ine A. Gouvas, MD, Attiya S. Khan, MD, and Demitr io G. Boulafendis, MD

Department of Cardiovascular Surgery, Spring Branch Medical Center, Houston, Texas

We report a patient with multiple brachiocephalic arte- rial occlusive disease who suffered failure of a bifurcated aorto-carotid artery graft. Profound hypothermic circu- latory arrest provided adequate cerebral protection dur- ing redo aorto-brachiocephalic arterial grafting.

(Ann Thorac Surg 1996;61:1259-61)

R eoperat ion for recurrent mult iple brachiocephal ic arterial occlusions and stenoses has been consid-

ered a rare condition. It is general ly recognized that such redo procedures are technically more difficult and are associated with a h igher risk of embol ism than operat ion for p r imary disease. Hypothermic circulatory arrest may offer significant surgical advantages in these cases, but there has been l imited experience of its use in pat ients

Accepted for publication Sep 27, 1995.

Address reprint requests to Dr Hadjinikolaou, Salton House, St Mary's Hospital, Praed St, London W2 1NY, England.

with severely compromised cerebral b lood flow. This article reports the appl icat ion of p rofound hypothermic circulatory arrest in a complex reopera t ion in a pat ient with recurrent mul t ip le brachiocephal ic arterial occlusive disease.

A 66-year-old woman was admi t ted due to f requent episodes of dizzy spells (8 to 12 per day) associated with numbness of left arm and face for the last 6 months. Eleven years before admission, a bifurcated bypass graft from the ascending aorta to both common carotid arteries had been placed, due to severe atherosclerotic disease of the innominate and both common carotid arteries. That procedure was carried out via a median sternotomy. She was a heavy smoker with a posit ive family history of atherosclerotic disease. Physical examinat ion revealed bruits in both carotid arteries.

Aor tography showed graft failure with occlusion of the right l imb and 90% stenosis of the left l imb. The innom- inate, the right subclavian, and both common carotid arteries were occluded. There was also a 75% stenosis in the origin of the left subclavian artery, 95% stenosis of the right coronary artery, and diffuse aortoiliac disease.

The operat ion was per formed through a med ian ster- notomy. The femoral artery was exposed in the right groin and cannula ted with an 18F arterial perfusion cannula (Research Medical, lnc, Midvale, UT). After dissection of the adhes ions a round the right atr ium, ca rd iopulmonary bypass was es tabl ished be tween a 34F two-stage venous cannula (DLP, Inc, Grand Rapids, MI) in the right a t r ium and arterial re turn to the right femoral artery. Systemic cooling was ini t iated immediate ly . Dur- ing the per iod of cooling, the hear t was freed from the per icardial adhesions. After 35 minutes of cooling and when the t empera tu re reached 23°C, the heart went into ventr icular fibrillation. When the nasopharyngea l tem- pera ture reached 15°C, circulatory arrest was es tabl ished and the brachiocephal ic vessels with the old grafts were identif ied and carefully dissected free. The old graft was excised and the brachiocephal ic vessels were d iv ided at their takeoff from the aorta. After debris and atheroscle- rotic mater ial were removed from the lumen of the vessels, an aor to - innomina te artery s ide- to-end Gore- Tex (W. L. Gore & Associates, Flagstaff, AZ) No. 8 graft and an aorto- lef t subclavian/left carotid s ide- to-end bi- furcated Gore-Tex No. 16 graft were placed. The proxi- mal s tump of the old graft was used for the proximal anastomosis of the latter. The left brachiocephal ic vein was reconstructed with a Gore-Tex No. 10 interposi t ion graft (Fig 1). Aor tocoronary bypass grafting to the right coronary ar tery with reversed saphenous vein graft was per formed dur ing rewarming. The cooling lasted 43 min- utes, the circulatory arrest lasted 70 minutes, and the ca rd iopulmonary bypass t ime was 120 minutes. The mean aortic pressure ranged from 50 to 85 m m Hg throughout the procedure.

The pat ient was extubated 24 hours after operat ion and, after an uncompl ica ted recovery, she was dis- charged from the hospital on the 8th postoperat ive day.

© 1996 by The Society of Thoracic Surgeons 0003-4975/96/$15.00 Published by Elsevier Science Inc SSDI 0003-4975(95)00979-5