Annals of Vascular Surgery - Brief Reports and Innovations (Jun 2022)
Thoracoscopic repair of iatrogenic injury to thoracic aorta during minimally-invasive esophagectomy: A case report and literature review
Abstract
Introduction: Aortic injury is a devastating complication in any surgery, and although rare it can occur during intrathoracic dissection of the oesophagus. This case report describes the successful thoracoscopic management of an iatrogenic thoracic aorta injury in minimally-invasive esophagectomy. Report: Inadvertent through-and-through piercing of the lower thoracic aorta with the tip of an energy device just above the diaphragm was sustained during the intrathoracic oesophageal dissection phase of the three-field McKeown approach in a 75-year-old patient with locally advanced Siewert Type 2 gastroesophageal adenocarcinoma post neoadjuvant chemotherapy. The lower thoracic aorta was dissected and mobilized proximally and distally via a thorascopic approach, and clamped on both ends with the introduction of Debakey clamps inserted through 2 separate 2 cm incisions. Primary repair of both anterior and posterior defects was then performed with monofilament non-absorbable sutures. Total clamp time was 30 min (in 15-minute intervals). Post-repair, perfusion status to the distal viscera and lower limbs were verified and intact. The rest of the operation then proceeded uneventfully. Postoperative renal function and hepatic function were monitored daily for 5 days and remained at baseline. A Computed Tomography scan of the thoracic aorta on postoperative day 14 showed a patent thoracic aorta with no intraluminal narrowing or pseudoaneurysm. Outpatient follow-up at 3- and 6-month intervals showed no aortic complications. Discussion: This is to our knowledge the first reported case of totally thoracoscopic repair of a penetrating injury to the thoracic aorta. While open aortic repair remains the gold standard, the conventional wisdom of conversion to open repair may be challenged – contingent upon the hemodynamic stability of the patient – with additional benefit of increased exposure within a deep thoracic cavity, decreased postoperative pain and pulmonary complications without significantly prolonging operative time.
