An unexpected complication of titanium rib clips

(1)

after the surgery. Postsurgical control echocardiogram revealed that pulmonary artery pressure was decreased to 30 mm Hg. The postoperative period of the patient was uneventful, and she was discharged on the seventh postoperative day. The patient’s latest follow-up visit was 6 months after the operation, and no signs or symptoms were found.

Comment

A ﬁstula between the systemic artery or vein and the pulmonary vessel is rare abnormal communication. A small number of cases were described in the literature before. They are usually congenital, but can be iatrogenic or traumatic or occur because of tumors or inﬂammatory diseases [3]. As our patient had no previous history of trauma, tumor or placement of a central venous catheter, this case was considered congenital.

The feeding arteries of a fistula can originate from abnormal aortic branches or subclavian, axillary, dia-phragmatic, mediastinal, or coronary arteries. Outflow of afistula can be through the pulmonary artery, pulmonary vein, or both [4]. As stated earlier, this type of communication between the pulmonary artery and innominate vein is rare. According to the literature search performed during the preparation of this manuscript, only one similar case was reported[2].

The possibility of enlargement of the untreatedfistula leading to high-output congestive heart failure and presenting with acute pulmonary symptoms owing to increased preload must be kept in mind in the man-agement of the fistula [5, 6]. Treatment options should include surgical ligation and intravascular coil emboli-zation with interventional techniques. In this case, the fistula between the left pulmonary artery and innominate vein was causing dyspnea, pulmonary hypertension, and mild right heart dilatation secondary to a shortcut be-tween cardiac chambers creating volume overload.

CT images should be investigated carefully, because preaortic round lesions can be confused with lymph nodes, which can lead to misdiagnosis, as occurred in our case during an earlier CT evaluation by another radiolo-gist. The continuity of this tubular structure in the consecutive images of the scan directs the physician to diagnosis. Axial images of the chest with MRI may show similarﬁndings, but consecutively repeated angiographic sequences help to reconstruct the three-dimensional im-ages. Moreover, coronal images of the chest may reveal the abnormal vascular communication. MRI angiography is as helpful as CT, but with the beneﬁt of non-ionizing radiation[5].

Interstitial lung disease was suspected clinically and could not be ruled out as an etiology of the patient’s symptoms. Even if imaging studies were revealed the nature of anatomic and functional details of anomalous vascular structure connecting the pulmonary artery with innominate vein, the expectation of an alternative diag-nosis directed us to perform a lung biopsy in addition to surgical ligation.

In conclusion, mediastinal arteriovenous ﬁstula is a rare, congenital malformation of high variability. In this report, we describe an adult patient with chronic dyspnea owing to aﬁstula from the left pulmonary artery to the innominate vein. She recovered completely from her symptoms after the surgical ligation.

References

1. Iqbal M, Rossoff LJ, Steinberg HN, Marzouk KA, Siegel DN. Pulmonary arteriovenous malformations: a clinical review. Postgrad Med J 2000;76:390–4.

2. Aydogdu S, Ozdemir M, Diker E, Korkmaz S, K€ut€uk E, G€oksel S. Fistulous connection between the left pulmonary artery and the innominate vein. Cathet Cardiovasc Diagn 1996;39:80–1.

3. Hadjimiltiades S, Antonitsis P, Kaitzis D, Klimatsidas M, Mantelas M, Moros I. Endovascular repair of a left axillary-left pulmonary arteryﬁstula: report of a case. Surg Today 2007;37: 980–3.

4. Riehl G, Chaffanjon P, Frey G, Sessa C, Brichon PY. Post-operative systemic artery to pulmonary vesselﬁstula: analysis of three cases. Ann Thorac Surg 2003;76:1873–7.

5. Prasad SK, Soukias N, Hornung T, et al. Role of magnetic resonance angiography in the diagnosis of major aortopulmo-nary collateral arteries and partial anomalous pulmoaortopulmo-nary venous drainage. Circulation 2004;109:207–14.

6. Sears E, Aliotta JM, Klinger JR. Partial anomalous pulmonary venous return presenting with adult-onset pulmonary hypertension. Pulm Circ 2012;2:250–5.

An Unexpected Complication of

Titanium Rib Clips

Tevﬁk Kaplan, MD, Gultekin Gulbahar, MD,

Ahmet Gokhan Gundogdu, MD, and Serdar Han, MD

Department of Thoracic Surgery, Ufuk University School of Medicine; and Department of Thoracic Surgery, Sincan Naﬁz Korez State Hospital, Ankara, Turkey

Surgical stabilization of the rib fractures has been suc-cessfully performed for the management of pain in multiple rib fractures, ﬁxation of chronically painful nonunion, reduction of overriding ribs, and ﬂail chest cases. Herein we report a patient who was treated with titanium rib clips after a motor vehicle accident leading to pulmonary parenchymal laceration and multiple painful rib fractures. Three of the rib clips were broken 4 months after the operation. The patient underwent the second operation for restabilization of the broken ribs. We re-view the relevant literature, with particular emphasis on the management of this complication.

(Ann Thorac Surg 2014;98:2206–9) Ó 2014 by The Society of Thoracic Surgeons

Accepted for publication Feb 4, 2014.

Address correspondence to Dr Kaplan, Department of Thoracic Surgery, Ufuk University School of Medicine, Dr Ridvan Ege Teaching and Research Hospital, Mevlana Bulvarı (Konya Yolu) No: 86-88, 06520 Balgat, Ankara, Turkey; e-mail:tevﬁkkaplan@yahoo.com.

Ó 2014 by The Society of Thoracic Surgeons 0003-4975/$36.00

Published by Elsevier http://dx.doi.org/10.1016/j.athoracsur.2014.02.054

2206 CASE REPORT KAPLAN ET AL Ann Thorac Surg

FRACTURE OF TITANIUM RIB CLIPS 2014;98:2206–9

FEATURE

ARTICLE

S

Downloaded for Anonymous User (n/a) at Ufuk Universitesi from ClinicalKey.com by Elsevier on August 01, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.

(2)

R

ib fractures are the most common major thoracic injuries. Up to 40% of all thoracic trauma patients present with rib fractures and at least a third of these patients will require hospital admission[1]. Conservative management for the majority of patients with severe chest injuries has produced a reduction in mortality, complication, and hospitalization length. More recently, a resurgence of operative stabilization of rib fractures with titanium bars, plates, and screws has taken place with the implication of improved outcomes [2]. The Strasbourg thoracic osteosynthesis system (STRATOS; MedXpert GmbH, Eschbach, Germany) is based on titanium clips and bars and a vertical expandable prosthetic titanium rib system [3]. Here we present a patient whose titanium rib clips (STRATOS system) were broken, with no detectable reason after 4 months of placement, and the patient was operated again for restabilization of the painful ribs.

A 47-year-old man who was involved in a motor vehicle accident was transferred to our department. He com-plained of shortness of breath and severe left chest wall pain. Clinical examination revealed 88% of oxygen satu-ration in free air and the pain of the patient was aggra-vated with superﬁcial palpation over the lateral aspect of the left fourth to eighth ribs. Visual analog scale (VAS) for pain score was 8. Chest radiograph revealed obviously displaced fractures of the left fourth to eighth ribs (Fig 1A); computed tomography of the thorax revealed intrathoracic hematoma. The patient underwent lateral

thoracotomy to drain the hematoma. A laceration was also detected in the superior and lateral segments of the left lower lobe. The hematoma was drained and parenchymal laceration was repaired. Rib fracture stabilization was also performed on the ﬁfth to eighth ribs by using titanium rib clips (STRATOS system; Figs 1B, 1C). We used one 6 segment and three 9 segment titanium rib clips (Fig 1D). The VAS pain score was 2 one week after the operation. Four months after the operation the patient referred to our department because of chest pain. The VAS pain score was 8. Lateral chest radiograph revealed 3 broken rib clips (Fig 2A). There was no history of trauma or any other reason that may have caused a break in rib clips. The patient underwent the second operation for restabilization of the ribs. We put two 9 segment titanium rib clips over and over for each broken rib to make it more powerful (Figs 2B, 2C). The patient was discharged on the second postoperative day. The VAS pain score was 1, a month after the operation. The patient is well 1 year after the second operation (Fig 2D).

Comment

The operative repair of severe chest wall injury restores chest wall integrity, improves pulmonary function, and is associated with lower rates of long-term morbidity and pain[2]. Tanaka and colleagues[4]presented a randomized controlled trial comparing surgical stabilization to

Fig 1. (A) Chest radiograph reveals obvious displaced fractures of left fourth to eighth ribs (arrow). (B) Intraoperative view of the broken ribs. (C) Rib fracture stabilization was per-formed from fourth to eighth ribs by using rib clips. (D) Lateral chest radiograph shows the stabilized ribs by rib clips.

2207

Ann Thorac Surg CASE REPORT KAPLAN ET AL

2014;98:2206–9 FRACTURE OF TITANIUM RIB CLIPS

FEATUR

E

AR

TICLES

(3)

conservative management using internal pneumatic stabilization. They were able to show a reduction in nosocomial pneumonia, duration of ventilatory support, length of intensive care unit stay, medical costs, and also a quicker return to work in their surgical group. In addition Granetzny and colleagues [5] reported that the duration of hospital stay for the surgical group that was as half as compared with the nonsurgical group[5].

Despite numerous reports suggesting beneficial out-comes for patients with operative rib stabilization, in-dications for surgery are still variable[4, 5]. The potential indications for operative rib fracture fixation are the following: flail chest; reduction of acute pain and disability; open chest defects; symptomatic rib fracture nonunion; and thoracotomy for other indications[2–6].

Titanium prosthetic devices (STRATOS clips and bars or Synthes; West Chester, PA, plates and screws) provide a light-weight but strong rigid support for ribﬁxation and chest wall reconstruction. The advantage of these systems relate ﬁrst to the properties of the titanium material, which has a high strength to weight ratio that can inte-grate with bone, which further strengthens the recon-struction with time, and which is resistant to infection. Secondly, these titanium devices closely mimic anatomic contour of the ribs and the dynamic movements of rib clips systems have been shown to be synchronous with the normal ribs. On the other hand, plate and screw systems are especially used in broad rib fractures[3].

In the literature there are too few data about the com-plications of titanium rib clips. Bille and colleagues [7]

experienced fractures of titanium prostheses in lung herniation repair. The patient had a large anterior chest wall defect involving the costal margin, with poor muscle coverage. In our case we use three-dimensional 6 and 9 segment titanium rib clips for rib fracture stabi-lization. The fractures were on the lateral side of the fourth to eighth ribs with good muscle coverage on them and these ribs were not broad.

In our department we mainly use a rib clip system for the ﬁxation of rib fractures. In case of broad rib fractures we use a plate and screw system for stabilization. In fact, we could notﬁnd a reason for the fracture of rib clips in this case. There was no history of trauma and the patient was not working at hard labor. In the second operation we thought to use a plate and screw system, but in this instance a big incision was necessary for screwing the plates in proper position. We then decided to put 2 rib clips over and over to make it more powerful from a small incision.

In conclusion, we have an unusual experience of broken titanium rib clips, and there are too few data about the complications of titanium rib clips in the literature. Sur-geons who are concerned with chest wall reconstruction or rib fracture stabilization should keep in mind about the fracture of titanium prosthetic devices without any reason.

References

1. Holcomb JB, McMullin NR, Kozar RA, Laygas MH, Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg 2003;196:549–55.

Fig 2. (A) Lateral chest radiograph revealed 3 broken rib clips (arrow). (B) Intraoperative view of broken rib clips. (C) Intraoperative views of rib fracture restabilization by putt-ing 2 rib clips over and over for each rib fracture. (D) Lateral chest radiograph 1 year after the second operation shows the stabi-lized ribs by 2 rib clips over and over.

2208 CASE REPORT KAPLAN ET AL Ann Thorac Surg

FRACTURE OF TITANIUM RIB CLIPS 2014;98:2206–9

FEATURE

ARTICLE

S

(4)

2. Mayberry JC, Kroeker AD, Ham LB, Mullins RJ, Trunkey DD. Long-term morbidity, pain, and disability after repair of se-vere chest wall injuries. Am Surg 2009;75:389–94.

3. Conar AS, Wihlm JM, Wells FC, Qureshi N. Intermediate outcome and dynamic computerised tomography after chest wall reconstruction with the STRATOS titanium rib bridge system: video demonstration of preserved bucket-handle rib motion. Interact Cardiovasc Thorac Surg 2011;12:80–1.

4. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severeﬂail chest patients. J Trauma 2002;52:727–32.

5. Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment ofﬂail chest. Evalua-tion of the pulmonary status. Interact Cardiovasc Thorac Surg 2005;4:538-7.

6. Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg 2009;33:14–22.

7. Bille A, Okiror L, Karenovics W, Routledge T. Experience with titanium devices for rib ﬁxation and coverage of chest wall defects. Interact Cardiovasc Thorac Surg 2012;15:588–95.

Successful Management of

Esophageal Necrosis After

Endovascular Repair of Chronic

Type B Aortic Dissection

Alexander Tobisch, MD, Harald Ittrich, MD, Jakob R. Izbicki, MD, PhD, and

Alexandra M. Koenig, MD

Departments of General, Visceral and Thoracic Surgery and Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

We report the case of a 65-year-old patient with esopha-geal necrosis that developed after thoracic endovascular aortic repair (TEVAR) of a previously stented, ruptured chronic type B aortic dissection. The cause of this complication may have been related to an infected mediastinal hematoma causing esophageal compression. Emergent esophagectomy was performed with success.

(Ann Thorac Surg 2014;98:2209–11) Ó 2014 by The Society of Thoracic Surgeons

E

sophageal necrosis is a rare but lethal complication after thoracic endovascular aortic repair (TEVAR). It can occur as a result of extrinsic compression from a mediastinal hematoma or can be due to overstenting of the esophageal arteries[1–3]. Only 3 cases of esophageal necrosis after TEVAR have been reported in the litera-ture, all of which have been fatal[1–3]. We describe a case in which esophageal necrosis occurred as a complication after a TEVAR extension for a previously stented,

ruptured chronic type B dissection that was successfully managed by esophagectomy.

A 65-year-old woman had undergone TEVAR at our insti-tution in 2012 to treat a residual distal aortic dissection after successful arch replacement for an acute type A dissection. One year later, she presented to an outside institution with fever and paraplegia. An aortic graft infection was sus-pected. Magnetic resonance imaging was performed, and a diagnosis of anterior spinal artery syndrome was made by visualization of spinal cord ischemia at the C6 level. She improved with antibiotics and cerebrospinalﬂuid drainage until the abrupt onset of dysphagia. A computed tomog-raphy (CT) scan of the chest showed chronic type B aortic dissection with aneurysm of the false lumen and an asso-ciated large mediastinal hematoma compressing the esophagus and trachea (Fig 1). She was intubated and immediately transferred to our hospital for treatment of the acute aortic rupture. Successful TEVAR extension was performed across the reentry of the false lumen. A CT scan performed the next day showed no evidence of residual retrograde false lumenﬂow but did demonstrate progression of the esophagotracheal compression (Fig 2). A tracheotomy was performed. However, the patient worsened, and 2 weeks after the TEVAR extension, she became septic with Enterococcus faecium. On day 15, a chest CT scan showed air bubbles within the false lumen of the dissected aorta (Fig 3). Esophagoscopy revealed circumferential esophageal necrosis and perforation at the 24-cm to 29-cm level.

The patient was emergently taken to the operating room for exploratory thoracotomy through a right fifth intercostal incision. Dense inflammatory adhesions were dissected. The hematoma was removed, and the infected false lumen of the aneurysm was partially excised. The previously placed graft was left in place. After the he-matoma was removed, a 7-cm-long defect of the esoph-agus was observed. A decision was made to perform esophagectomy in the standard fashion. After dissection of the remaining esophagus, the resulting cavity and the esophageal bed were debrided and irrigated. To cover the graft, we decided to perform gastric pull-up during the same surgery. Through laparotomy, the stomach was mobilized and fashioned into a tube in the usual manner. Gastric pull-up reconstruction was completed by end-to-side cervical esophagogastrostomy. Chest tubes were placed. Pathology examination confirmed trans-mural ischemic esophageal necrosis.

The operation was complicated by cardiac arrest requiring 15 minutes of resuscitation and deﬁbrillation with subsequent stabilization. The postoperative course was uneventful, although paraplegia persisted. The patient was discharged to a weaning center on postoperative day 28. Currently, at 5 months after the esophagectomy, she is at a residential care facility and is eating a regular diet.

Comment

Esophageal necrosis is a rare complication after TEVAR. The 3 previously reported cases have all been fatal[1–3]. Accepted for publication Jan 6, 2014.

Address correspondence to Dr Tobisch, Department of General, Visceral and Thoracic Surgery, University Medical Centre of Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany; e-mail:alexander.tobisch@ me.com.

Ó 2014 by The Society of Thoracic Surgeons 0003-4975/$36.00

Published by Elsevier http://dx.doi.org/10.1016/j.athoracsur.2014.01.061

2209

Ann Thorac Surg CASE REPORT TOBISCH ET AL

2014;98:2209–11 ESOPHAGEAL NECROSIS AFTER TEVAR

FEATUR

E

AR

TICLES