Abstract A 74-year-old man presented with a left superior sulcus tumour invading the subclavian artery. After induction chemoradiotherapy, he underwent a vertebral artery reconstruction in addition to the subclavian artery reconstruction via a transmanubrial approach and video-assisted thoracoscopic left upper lobectomy. The final pathology was ypT4N0M0 adenocarcinoma. The technical aspects and indication for a vertebral artery reconstruction are discussed in this article. Lung cancer surgery , Vertebral artery reconstruction , Superior sulcus tumour INTRODUCTION Management of a vertebral artery in resection of a superior sulcus tumour and reconstruction of a subclavian artery is controversial, whereas sacrificing a vertebral artery is not completely safe because more than 50% of the general population are known to have an incomplete circle of Willis. Herein, we describe a patient undergoing reconstruction of a vertebral artery and a subclavian artery via a transmanubrial approach followed by video-assisted thoracoscopic lobectomy for the superior sulcus tumour. CASE REPORT A 74-year-old man, cook by occupation, who had a 12 pack-year smoking history, presented with haemoptysis and an abnormal chest X-ray. Computed tomography (CT) suggested the presence of a left superior sulcus tumour invading the subclavian artery (Fig. 1A), and positron emission tomography was negative for distant or mediastinal lymph node metastasis (clinical T4N0M0). A transbronchial lung biopsy confirmed the diagnosis of adenocarcinoma. He responded to preoperative chemoradiotherapy (carboplatin and paclitaxel with 50 Gy of radiotherapy). Preoperative CT angiography suggested an incomplete circle of Willis and a dominant left vertebral artery (Fig. 1B and C); therefore, reconstruction of the dominant left vertebral artery was deemed essential to ensure postoperative cerebral perfusion. Figure 1: View largeDownload slide Preoperative computed tomography (CT) suggesting a superior sulcus tumour that may invade the left subclavian artery (A). CT angiography demonstrating the hypoplastic right vertebral artery (B, white arrow) and the absence of the posterior communicating arteries (C, grey arrows). Figure 1: View largeDownload slide Preoperative computed tomography (CT) suggesting a superior sulcus tumour that may invade the left subclavian artery (A). CT angiography demonstrating the hypoplastic right vertebral artery (B, white arrow) and the absence of the posterior communicating arteries (C, grey arrows). The subclavian vein was mobilized, clamped and divided via the transmanubrial approach. Then, the subclavian artery was dissected proximally and distally to the invading tumour. The left vertebral artery was dissected and mobilized, while other branches were ligated and divided. Following administration of 5000 units of heparin, purse-string sutures were placed, and a 6-Fr catheter sheath was inserted into the aortic arch and another 5-Fr into the vertebral artery. The 2 sheaths were connected, and peripheral perfusion was maintained (Fig. 2A). Because of extensive tumour invasion involving the arterial wall, the subclavian artery was replaced using an 8-mm polytetrafluoroethylene prosthesis. The vertebral artery was anastomosed to the prosthesis in an end-to-side fashion (Fig. 2B). Following the transmanubrial procedure, video-assisted thoracoscopic left upper lobectomy and mediastinal lymph node dissection (negative) were performed. The total operative time was 8 h and 50 min (Video 1). The pathology was ypT4N0 adenocarcinoma with negative margins without invasion to the subclavian artery. The patient developed a postoperative chyle leak and underwent ligations of the branches of the thoracic duct on postoperative day 3 via the transmanubrial approach. Anticoagulation with warfarin was continued for 6 months. He showed no evidence of disease at 12 months postoperatively. Video 1 The highlight of the surgical procedure. Video 1 The highlight of the surgical procedure. Close Figure 2: View largeDownload slide One catheter sheath in the aortic arch and another in the left vertebral artery were connected (A). The left vertebral artery was anastomosed to the prosthesis with 7-0 polypropylene suture (B). Figure 2: View largeDownload slide One catheter sheath in the aortic arch and another in the left vertebral artery were connected (A). The left vertebral artery was anastomosed to the prosthesis with 7-0 polypropylene suture (B). DISCUSSION Postoperative cerebral infarction may lead to mortality either in the short- or long term in patients with advanced non-small-cell lung cancer . Sekine et al.  described a case series showing that postoperative cerebral infarction may be associated with poor survival. They recommended an angiography and a potential reconstruction in selected patients with superior sulcus tumours invading the subclavian artery, although no 3-year survivor was noted. Usually, cerebral angiography is not routinely considered as an essential component of preoperative evaluation for resection of a superior sulcus tumour. However, sacrificing a vertebral artery is not completely safe . Previous data have shown that more than 50% of the general population are known to present with an incomplete circle of Willis, and approximately 25% of the general population show hypoplastic vertebral arteries . In our patient, preoperative CT angiography demonstrated an incomplete circle of Willis, a remarkably hypoplastic right vertebral artery and fluctuating blood flow through either of the posterior communicating arteries, which could have caused a serious ischaemia in the basilar artery system, had the reconstruction of the dominant left vertebral artery not been performed. This case study suggests that it is important to investigate the circle of Willis in a patient who potentially requires a reconstruction of a subclavian artery in resection of a superior sulcus tumour. Moreover, a transmanubrial approach in this setting provided us an excellent operative field to perform an effective anastomosis to maintain the blood flow through the basilar artery. Conflict of interest: none declared. REFERENCES 1 Sekine Y , Saitoh Y , Yoshino M , Koh E , Hata A , Inage T et al. . Evaluating vertebral artery dominancy before T4 lung cancer surgery requiring subclavian artery reconstruction . Surg Today 2018 ; 48 : 158 – 66 . Google Scholar CrossRef Search ADS PubMed 2 Yang Y , Liu H , Ma L , Zeng J , Song Y , Xie X. Sudden cerebral infarction after interventional vertebral artery embolism for vertebral artery injury during removal of C1-C2 pedicle screw fixation: a case report . Int J Clin Exp Med 2015 ; 8 : 16803 – 7 . Google Scholar PubMed 3 Krabbe-Hartkamp MJ , van der Grond J , de Leeuw FE , de Groot JC , Algra A , Hillen B et al. . Circle of Willis: morphologic variation on three-dimensional time-of-flight MR angiograms . Radiology 1998 ; 207 : 103 – 11 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
European Journal of Cardio-Thoracic Surgery – Oxford University Press
Published: Jun 1, 2018
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