Multistep endobronchial-endovascular approach in recurrent acute respiratory failure caused by thoracic aneurysm.

Clinical Summary A 78-year-old man with a history of TAA was admitted to the emergency department because of recurrence of respiratory failure. He was unconscious, with cyanosis and severe hypertension (220/ 120 mm Hg). On thoracic examination, wheezes were heard at the lower third of the left lung. Arterial blood gas analysis revealed an arterial oxygen partial pressure of 40 mm Hg, a carbon dioxide partial pressure of 120 mm Hg, and a pH value of 6.93. The patient was intubated and mechanically ventilated. Preoperative chest radiography and computed tomography showed a large aortic aneurysm with compression of the tracheobronchial tree (Figure 1). Fiberoptic bronchoscopy confirmed extrinsic compression of the trachea just proximal to the carina and a significant narrowing of the left main bronchial branch 3 to 4 mm below the carina. After stabilization, the patient was weaned by using sedatives and extubated. Because of coexisting disease (coronary artery disease, renal insufficiency, and chronic obstructive pulmonary disease), which made the patient not an ideal operative candidate, a multistep endobronchial-endovascular intervention was planned. In the first step the patient continued to spontaneously breathe. Sedation was achieved with intravenous remifentanil (0.1 g · kg 1 · min ) and propofol (3 mg · kg 1 · h ). A 14-mm covered endobronchial Nitinol stent (Ultraflex stent; Boston Scientific CO, Natick, Mass) was placed in the left main bronchus with the aid of a rigid bronchoscope. A second 13-mm Y-shaped silicon stent (Tracheobronxane; Novatech, Plan de Grasse, France) was placed in the carina and right main bronchus (Figure 2, A and B). In the second step the patient was placed in the supine decubitus position on a radiolucent table and draped sterilely for emergency left thoracotomy in case serious complications ensued. Cardiopulmonary bypass standby was available. General anesthesia was induced with intravenous remifentanil (0.5 g · kg 1 · min ), propofol (2 mg · kg 1 · h ), and cisatracurium (200 g · kg ) and maintained with remifentanil (0.25 g · kg 1 · min ), propofol (3 mg · kg 1 · h ), and cisatracurium (1.7 g · kg 1 · min ). Two 3636 C114T Medtronic Talent stent grafts (Medtronic, Santa Rosa, Calif) were implanted (Figure 2, A) by using the standard technique. The endotracheal tube was removed 2 hours later, and the patient was dismissed from the intensive care unit on postoperative day 1 and discharged on postoperative day 2 after an uncomplicated course. In the third step, on postoperative day 15, the carinal stent was removed, and a new stent (Polyflex stent; W. Rusch AG, Kernen, Germany) was positioned in the trachea (Figure 2, C). In the fourth step, on postoperative day 147, the tracheal stent was removed. A left main bronchus metal stent was left in place. At 1 year of follow-up, the patient is alive and functions independently. He remained asymptomatic, and no further episode of respiratory distress occurred (Figure 2, D).