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A Journal on Surgery
Indexed/Abstracted in: EMBASE, Scopus, Emerging Sources Citation Index
Chirurgia 2007 October;20(5):249-52
Occult mediastinal hemorrhage producing pseudoaneurysm formation after diagnostic mediastinoscopy
Apostolakis E., Panagopoulos N., Koletsis E., Dougenis D.
Department of Cardiothoracic Surgery Patras University School of Medicine, Patras, Greece
Mediastinoscopy is a safe method for staging and diagnosis of lung cancer and mediastinal diseases. Postoperative hemorrhage produced by injury of aortic arch or its branches, of the pulmonary artery and/or superior vena cava, is a very rare but life-threatening complication. Herein, we report the first case in the literature of a post-mediastinoscopy pseudoaneurysm due to traumatic injury of the aortic arch. A 67-year-old male patient admitted to our department to be subjected to a routine mediastinoscopy and sampling of enlarged lymph nodes, located in the right paratracheal area. Biopsy revealed thymolipoma. The immediate postoperative chest X-ray performed routinely was similar to the preoperative. The patient was discharged on the 2nd postoperative day in good clinical condition. Two weeks later the patient was readmitted with consistent cough, pallor and tachycardia. The chest X-ray showed further enlargement of the antero-superior mediastinum and a right pleural effusion. Thoracic CT scanning showed a 10 cm in diameter well organized pseudoaneurysm, around the ascending aorta and aortic arch. The patient was urgently transferred to the operating theater. Median sternotomy was performed; a partial bypass was initialized by femoro-atrial arterio-venous cannulation at normothermia. The organized thrombus of the pseudoaneurysm was evacuated and the site of leakage of the aortic wall was located and sutured. The patient was extubated after 6 hours and discharged five days later uneventfully. Post-mediastinotomy pseudoaneurysm is a very rare complication due to traumatic injury of the arterial vessel of the mediastinum. It develops gradually (within days) and insidiously after the operation. The symptoms are produced by compression and deviation of mediastinal organs and the diagnosis is based on the thoracic CT scan. In comparison with a postoperative bleeding, which usually does not require cardiopulmonary bypass, the safe management of a pseudoaneurysm requires an emergency operation with cardiopaulmonary bypass support.