Case Presentation: Aortic Injury During VATS Lobectomy

Introduction

Major vascular injuries of pulmonary artery branches and pulmonary veins during anatomic thoracoscopic pulmonary resection for lung cancer have been widely described and reported in the literature, as well as shown in a large number of videos. In this short but impressive clip, the authors present an unpredictable and very rare vascular injury occurring during VATS left upper lobectomy.

Case Presentation

A 69-year-old patient underwent a VATS left upper lobectomy for a 3.5 cm lesion of the apical-posterior segment of the upper lobe. In the pre-operative work-up, a bronchoscopy and a CT-guided needle biopsy were performed. As the two procedures failed to obtain a pre-operative histological diagnosis, the patient was scheduled for an intraoperative needle biopsy of the lesion to confirm the malignancy of the nodule before the performance of a left upper lobe resection (a wedge resection was considered not feasible as the tumor was centrally located).

The patient was placed in the right lateral decubitus position. A 4 cm utility incision was performed in the 4th intercostal space and the camera port was placed in the 7th intercostal space in the anterior axillary line. Through the utility incision, the authors used an automatic biopsy gun (Bard Monopty, 18 gauge, 20 cm length) to obtain tissue specimens of the target lesion.

After performing the biopsy, a large amount of blood appeared in the chest cavity. The lung was retracted anteriorly, revealing a large aortic hematoma, and bleeding from the descending thoracic aorta. Bleeding control was achieved by compressing the site of the injury. The authors converted to an open procedure, performing a lateral muscle sparing thoracotomy. The systemic blood pressure and heart rate remained stable. The authors opened the adventitia of the descending thoracic aorta to remove the hematoma and better expose the site of the bleeding. A 2 to 3 mm hole in the lateral wall of the aorta was visualized and sutured with non-absorbable 4-0 monofilament suture.

The frozen section was positive for adenocarcinoma. The authors then proceeded to perform a left upper lobectomy with mediastinal and hilar lymphadenectomy. The patient recovered well and was discharged on the sixth post-operative day without any further intervention.

Conclusion

This potentially fatal complication highlights some limitations of VATS procedures. The two dimensional image and limited maneuverability can lead to an incorrect evaluation of the distances between the structures inside the chest cavity. In this case, before firing the automatic biopsy gun, the authors should have retracted the upper lobe anteriorly toward the utility incision, widening the distance between the nodule and the lung hilum and the descending aorta. However, in the case of a lesion centrally located in the lung not amenable to wedge resection, the authors believe that a needle biopsy represents a feasible and safe procedure to obtain a tissue specimen.