DOI 10.1378/chest.88.3.476 1985;88;476-479Chest

 J B Martinot, O Pedemonte, P L Baele, J Dautrebande, P Jaumin and M Goenen and surgical management.aorto-caval fistula. Fiberoptic oximetric findings Dissecting aneurysm of the ascending aorta with

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_FIGURE 1. Lateral and AP chest roentgenograms.

476 Dissecting Aneurysm of Ascending Aorta (Martiriot et ai)

lung. No instance of massive hemorrhage accompany-

ing bronchoscopy was noted.

Linton6 reported the results oftreating longstanding

foreign bodies in 16 patients. In six of these patients,

the foreign body could be removed through the bron-

choscope. One of the six required lobectomy because

of abscess. One of the 16 patients required bron-

chocotomy for removal of the foreign body, and six

required pulmonary resection. No instance of massive

hemorrhage at the time ofbronchoscopy was recorded.

Foreign body bronchiectasis may require lung resec-

tion following prolonged sojourn of foreign bodies in

the tracheobronchial tree. Cooley et oP reported on 14

such patients at the Mayo Clinic.

As noted by Bogedain,8 foreign bodies in the pulmo-

nary parenchyma may migrate to an intrabronchial

position and be removed transbronchoscopically many

years later.

In a review of the over 2,500 documented

cases,’3’46�” the author was unable to find another

instance of massive hemorrhage accompanying re-

moval of an intrabronchial foreign body, whether

performed acutely or after prolonged sojourn.

CONCLUSION

The tracheobronchial endoscopist should have this

possible complication in mind and manage to meet it

by: 1) tamponading the bronchial system on the side

that is bleeding; 2) carrying out endotracheal intuba-

tion; 3) suctioning the contralateral side for blood that

has spilled over from the hemorrhage; and 4) and

performing immediate thoracotomy on the affected

side.

REFERENCES

1 Jackson C, Jackson CL. Diseases of the air and food passages of

foreign-body origin. Philadelphia: W. B. Saunders, 1936.

2 ClerfL. Foreign bodies in the air and food passages: observations

on end-results in a series of nine hundred fifty cases. SurgGynecol Obstet 1940; 328-39

3 Abdulmajid OA, Ebeid AM, Motawen MM, Kleibo IS. Aspi-

rated foreign bodies in the tracheobronchial tree: report of 250

cases. Thorax 1965; 31:635-40

4 Kosloske AM. Bronchoscopic extraction of aspirated foreign

bodies in children. Am J Dis Child 1982; 136:924-275 Schloss, MD, Pham-Dang H, Rosales JK. Foreign bodies in the

tracheobronchial tree-a retrospective study of 217 cases.

J Otolaryn 1983; 12:212-16

6 LintonJSA. Long-standing intrabronchial foreign bodies. Thorax1957; 12:164-70

7 Cooley JC, Ginsberg RL, Olsen AM, Kirklin JW. Foreign body

bronchiectasis. J Thorac Surg 1956; 51 :615-178 Bogedain W. Migration of schrapnel from lung to bronchus.

JAMA 1984; 251:1862-1963

9 Aytac A, Yurdakul Y, Ikizier C, Olga R, Saylam A. Inhalation of

foreign bodies in children. Report of 500 cases. J Thorac

Cardiovasc Surg 1977; 74: 145-5010 Cohen SR, Lewis GBJr, Herbert WI, Geller KA. Foreign bodies

in the airway. Five-year retrospective study with special refer-

ence to management. Ann Otol 1960; 89:437-4211 Slim MS. Yacoubian HD. Complications offoreign bodies in the

tracheobronchial tree. Arch Surg 1966; 92:388-93

Dissecting Aneurysm of theAscending Aorta with Aorto-cavaiFistuia*Fiberoptic Oximetric Findings andSurgical ManagementI. B. Martinot, M.D.;t 0. Pedemonte, M.D.;t P L. Baele, M.D. ;1

I Dautrebande, M.D.;� P Jaumin, M.D.;�J and M. Goenen, M.D.t

*From the Cliniques Universitaires Saint-Luc, Brussels, Belgium.

tlntensive Care Unit.�Department of Anesthesiology.§Department of Radiology.#{182}Department of Thoracic and Cardiovascular Surgery.Reprint requests: Dr Goenen, Service Soins Intensifs, CliniquesUniversitaires St. Luc, 10, Av Hippocrate, 1200 BrusseLs, Belgium

 © 1985 American College of Chest Physicians by guest on July 12, 2011chestjournal.chestpubs.orgDownloaded from

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FIGURE 2. Simultaneous recording of pressures and oximetry during fiberoptic catheter insertion. Uppertracing: systemic blood pressure; middle tracing: pressures at the tip of the catheter (CV superior vena

cava; BA: right atrium; RV: right ventricle; PA: pulmonary artery; PW: pulmonary arter wedge pressure);

bottom tracing: oxygen saturations at the tip of the catheter (SVO,). Arrow 1: initial stepwise increase of

oxygen saturation; arrow 2: pressure gradient reflects narrowing of the cavo-atrial junction.

CHEST I 88 I 3 I SEPTEMBER, 1985 477

A patient presented the rare complication of a dissecting

aneurysm ofthe ascending aorta ruptured into the superior

vena cava producing a left-right fistula. Continuous ox-

imetric measurements by a fiberoptic pulmonary artery

floated catheter was used to localize the site of the shunt.

Emergency surgical repair was successfully performed.

I ntracardiac rupture of a dissecting aortic aneurysm is a

rare event. Although previous cases of rupture into theright atrium (BA) have been reported, we are unaware of anyother report of communication into the superior vena cava(SVC).’ We recently had the opportunity to study and localize

the site of fistula by continuous fiberoptic measurementof SVO,. This was confirmed by aortic angiogram andsurgery.

CASE REPORT

This 66-year-old white man had a regurgitant aortic valve replaced

in July, 1984 with a Carpentier bioprothesis. The valve was tricuspid

and of a myxoid degenerative type. The postoperative course wasuneventful and the patient was discharged on oral acenocoumarol

therapy.

In September, increased venous circulation on the upper chest

was noticed; blood pressure was 180/110 mm Hg.In mid-November, the patient experienced, at rest, sharp pain on

the right side of his neck radiating to his chest and lasting several

hours. Since then, the patient has complained ofgeneral malaise and

loss of appetite.

On the 25th of November, he developed sudden dyspnea anddiscomfort in the right upper quadrant of the abdomen, and on the

28th he was admitted to a local hospital with biventricular cardiac

failure. He developed ventricular tachycardia and fibrillation re-

versed by cardioversion. The patient was transferred to our hospital

for presumed prosthesis dysfunction.

Pulse rate was 110/mm; blood pressure, 160/80 mm Hg. Neck veins

were distended, as were the veins on the upper chest. The liver was

� �C.!

Ficuas 1. Aortic angiogram. Right posterior oblique position. 1,5seconds after aortic injection. Open arrow: path between the sac and

the SVC. Large black arrow: pulmonary artery. Medium blackarrows: aneurysm’s false lumen. Small arrows: right coronary artery

and opacified right cavities.

tender and enlarged 4 cm below the costal margin. A grade 4/6

diastolic murmur was maximal on the right sternal border.

Laboratory studies disclosed a fibrinogen of 480 mg/100 ml, a

white blood cell count ofl6,100/cu mm with 87 percent neutrophils.

Serum glutamic oxaloacetic transaminase was 80 units; glutamic

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FIGURE 3. Diagram of defects found at operation.

478 Dissecting Aneurysm of Ascending Aorta (Marfinot et a!)

pyruvic transaminase was 82 units; plasma creatinine was

2.55 mg/100 ml; prothrombin time was 24 seconds and syphilisserology was positive (VDRL(-); TPHA:L1160; IF:11800.)

The electrocardiogram showed left axis deviation and left

ventricular hypertrophy. Cardiomegaly was marked on the chest

x.ray film. Pulsed Doppler echocardiography results ruled outaortic, mitral or tricuspid regurgitation.

We then looked for an aorto-cardiac fistula. Blood samples

obtained after pulmonary artery (PA) catheter placement showed

high oxygen saturation in RA (93 percent) and PA (83 percent). The

aortic angiogram showed an enlarged aortic root, with an intimal tearwhich started from its left anterior side. Contrast medium revealed

the dissection, filled a right antero-lateral sac, and ended up in theRA. Later x-ray films showed contrast medium in a thin path

extending from the sac to the SVC (Fig 1).The patient�s condition deteriorated and it was decided to carry

out an emergency repair. After induction of anesthesia, a fiberoptic

pulmonary artery floated catheter (Opticath, Oximetric, Mt View,

CA) was inserted, providing continuous measurement of hemo-

globin oxygen saturation. The catheter was externally calibrated andinserted via the right internaijugular vein. It could not progress from

the SVC into the BA with the balloon inflated. A sudden increase in

saturation from 54 percent to 94 percent occurred 18 cm from the

puncture site, while on fluoroscopy the end of the catheter waslocated just above the RA. A gradient of5 mm Hg was noted from

SVC to BA. The auncular V wave was markedly enlarged (Fig 2).

Surgery was performed under cardiopulmonary bypass. The

prosthesis appeared in perfect shape. The aneurysm was corrected

by a Dacron graft interposition. The fistula was dissected and shown

close to the vena cava. All cultures remained sterile.Postoperative oximetric and hemodynamic measurement results

were normal. The patient did well and was discharged on December

19, 1984 (Table 1).

-. DIsCUSSION

Dissecting aneurysms of the ascending aorta may have

unusual clinical presentations resulting from the compres-sion of surrounding structures, occlusion of other vessels,perforation, hemorrhage (eg, into the tracheobronchial tree),extension into the atrial septum, or from aorta-right heart

fistula.

Table 1-Hemodynamic and Oximetric Values

Measurements Asleepbefore repair

Asleepafter repair

Systemic blood

(mmHg) pressure 81/35 125/72Mean central

(mmHg) venous

pressure 17 4

Mean pulmonary

(mmHg) arterialpressure 23 15

Oxygen saturation

(%)inSVC 42to58* 71Oxygen saturation

(%)inRA 93.9 69Mixed venous (%)

oxygen saturation 91. 1 66Oxygen saturation

(%) in radial artery 97.2 97

Right cardiac (Llmin)

output (Fick) 17.3 5

*Range of fiberoptic measurements during placement.

Rupture into the SVC has been documented from a sinus

of Valsalva aneurysm but not from a proximal aortic dissec-

tion.2Postoperative false aneurysms of the ascending aorta are

unusual complications of cardiac surgery and develop from

cannulation, clamping or needle puncture sites.3 Our patienthad a classic dissecting aneurysm of the ascending aorta

starting at some distance from previous surgical sutures and

rupturing into the SVC. To our knowledge, this is the first

case to be documented (Fig 3).

Massive left-right shunt led to “ventncularization” of theBA pressure curve. The cavo-atrial pressure gradient could

only be explained by external compression ofthe SVC, whichwas confirmed at operation.

No arterial wave was recorded in the proximal SVC. Two

explanations are proposed for this fact: the stream ofthe left-right shunt was directed towards the HA and the compressionofcavo-atrialjunction resulted in damping ofthe venous wave

form.For many years, technical problems prevented the use of

fiberoptic oximetry for diagnostic purposes during cardiaccatheterization.4 We used a new kind of equipment, withsuccess, to localize the outlet of the aortocavai fistula.Originally designed for continuous monitoring of bloodoxygen saturation at one given site over long periods of time,this system updates and displays every second the averaged

value for the preceding five seconds.5’6This feature, as well as

incomplete blood mixing, may explain why the printoutshowed a stepwise increase in saturation where an abrupt risewas expected. Obviously, shorter averaging times are needed

for diagnostic use of this technique. Later controls showedthat the external calibration ofthe system had overestimated

all values by 8 percent. As a result, the small differences

between high saturation levels in the HA, right ventricle and

PA were not detected.

REFERENCES

1 Nicod P, Firth BC, Peshock RM, Gaffney FA, Hillis LD. Ruptureof dissecting aortic aneurysm into the right atrium: clinical andelectrocardiographic recognition. Am Heart J 1984; 107:1276-78

2 Kaye GC, Edmondson SJ, CaplinJL, Tunstall-Pedoe DS. Ruptureofan aneurysm ofthe sinus ofValsalva into the superior vena cava.

 © 1985 American College of Chest Physicians by guest on July 12, 2011chestjournal.chestpubs.orgDownloaded from

ischaemic Heart Disease, Exercise and Related TopicsThe Toronto Rehabilitation Centre will host the third international symposium November 2-4

at the Royal York Hotel, Toronto, Ontario. For information, contact Ms. Johanna Kennedy or Ms.

Anna Ceci at the center, 345 Rumsey Road, Toronto M4G 1117 (416:425-6630).

CHEST I 88 I 3 I SEPTEMBER, 1985 479

Thorax 1984; 39:475-76

3 Photiou SA, Kaul ‘[‘K, Mercer JL. False aneurysm ofthe ascend-

ing aorta with artico-right atrial fistula. Thorax 1981; 36:796-97

4 Frommer PL, Ross JJr, Mason DT, Gault JH, Braunwald E.

Clinical applications ofan improved, rapidly responding fiberoptic

catheter. Am J Cardiol 1965; 15:672-79

5 Baele PL, McMthan JC, Marsh HM, Sill JC, Southorn PA.

Continuous monitoring of mixed venous oxygen saturation in

critically ill patients. Anesth Analg 1982; 61:513-17

6 Gore JM, Sloan K. Use ofcontinuous monitoring ofmixed venous

saturation in the coronary care unit. Chest 1984; 86:757-61

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DOI 10.1378/chest.88.3.476 1985;88; 476-479Chest

J B Martinot, O Pedemonte, P L Baele, J Dautrebande, P Jaumin and M GoenenFiberoptic oximetric findings and surgical management.

Dissecting aneurysm of the ascending aorta with aorto-caval fistula.

 July 12, 2011This information is current as of

 

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