746 CASE REPORT HEID ET AL
ECC AND CARDIAC ARREST FOR PULMONARY ARTERY STENTING
References
1. Allen KB, Dowling RD, Fudge TL, et al. Comparison of
transmyocardial revascularization with medical therapy in
patients with refractory angina. N Engl J Med 1999;341:1029
36.
2. Hughes GC, Biswas SS, Yin B, et al. A comparison of mechan-
ical and laser transmyocardial revascularization for induction
of angiogenesis and arteriogenesis in chronically ischemic
myocardium. J Am Coll Cardiol 2002;39:1220 8.
3. Allen KB, Dowling RD, Angell W, et al. Transmyocardial
revascularization: five-year follow-up of a prospective, ran-
domized, multicenter trial. Ann Thorac Surg 2004;77:1228 34.
4. Allen GS. Mid-term results following thoracoscopic
transmyocardial laser revascularization. Ann Thorac Surg
2005;80:553 8.
5. Yuh D, Simon B, Fernandez A, et al. Totally endoscopic
robot-assisted transmyocardial revascularization. J Thorac
Cardiovasc Surg 2005;130:120 4.
Extracorporeal Circulation and
Cardiac Arrest in an Awake
Patient: A Safe Approach for Single
FEATURE ARTICLES
Lung Pulmonary Artery Stenting?
Florian Heid, MD, Stefan Guth, MD,
Eckhard Mayer, MD, Sascha Herber, MD,
Christoph Dber, MD, PhD, Irene Tzanova, MD, and
Christian Werner, MD, PhD
Departments of Anesthesiology, Cardiothoracic and Vascular
Surgery, and Radiology, Johannes Gutenberg-University,
Mainz, Germany
We describe the anesthetic concept and approach in a
single lung patient scheduled for pulmonary artery stent-
ing due to recurrence of a pulmonary artery sarcoma after
left pneumectomy.
(Ann Thorac Surg 2006;82:746 7)
2006 by The Society of Thoracic Surgeons
P ulmonary artery sarcomas are rather rare events. We
describe a patient with a history of left pneumec-
tomy due to pulmonary artery sarcoma. Tumor recur-
rence led to rapid deterioration and this single lung
patient was scheduled for pulmonary artery stenting. We
focused on the anesthetic management of this excep-
tional case, which included extracorporeal circulation
and cardiac arrest in an awake patient.
A left-sided pneumectomy and thromboendarterectomy
of the right pulmonary artery due to primary pulmonary
artery sarcoma was performed on a 50-year-old man in
November 2003. He was in full remission until May 2005
when his health status rapidly deteriorated with dyspnea
and cyanosis leading to emergency hospital admission.
Computerized tomography revealed tumor recurrence,
reducing the diameter of the right pulmonary artery to
Accepted for publication Nov 23, 2005.
Address correspondence to Dr Heid, Department of Anesthesiology,
Johannes Gutenberg-University, Langenbeckstr. 1, Mainz, 55131 Ger-
many; e-mail: heid@uni-mainz.de.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Ann Thorac Surg
2006;82:746 7
Fig 1. Magnetic resonance angiography before intervention. Note
severe stenosis of the right pulmonary artery (white arrow).
pencil size (Fig 1). Corresponding to these findings, his
impaired pulmonary blood flow led to facial edema and
increased central venous pressure (20 mm Hg). Anatomic
conditions excluded any surgical option; hence an endo-
vascular approach with stent graft implantation was
planned. Considerations concerning anesthetic manage-
ment evolved from the need for temporary but complete
outflow obstruction in an already dilated and insufficient
right ventricle.
After establishing standard monitoring (ie, electrocar-
diogram, noninvasive arterial blood pressure, peripheral
transcutaneous oxygen saturation), the patients right
radial artery was cannulated and a central venous line
through the right internal jugular vein was inserted.
After local anesthesia of the left groin (30 mL of mepiva-
caine, 1%), his femoral artery and vein were catheterized
and connected to a cardiopulmonary bypass circuit. Dur-
ing these measures and thereafter the patient was mod-
erately sedated by intravenous infusion of remifentanil
(0.06 to 0.1g kg-1min-1), with preserved spontaneous
breathing and undiminished responsiveness, corre-
sponding to a Ramsey score of 2. The right femoral vein
was cannulated and an introducer sheath was inserted,
and through this a guidewire was advanced. Before the
guidewire reached the right atrium extracorporeal circu-
lation (ECC) was started to avoid hemodynamic distur-
bance in case of potential dysrhythmia. With the onset of
the ECC, the ventilatory drive of the patient ceased due
to complete extracorporeal oxygenation, and he only
breathed if he wanted to talk to a team member. Right
atrial and ventricular passage of the guidewire was
uneventful, and no dysrhythmias occurred. With the tip
of the guidewire in the pulmonary artery a maximum
ECC flow (3.5 L/min) could not relieve the heart com-
pletely. This was confirmed by a persistent pulsatile flow
through the radial arterial line. Therefore, prior to bal-
loon dilatation, we induced cardiac arrest by bolus injec-
tion of adenosine (24 mg) through the central venous
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.11.065
Ann Thorac Surg
2006;82:7479
Fig 2. Angiographic image after stent implantation. Pulmonary ar-
tery is well dilated (black arrow).
line. Cardiac arrest lasted for approximately 30 seconds
and endovascular maneuvers were performed. Alto-
gether, four temporary arrests were necessary for dila-
tion and stent implantation (Fig 2). Immediately after
stent placement, the central venous oxygen saturation
increased from 68% to 78%, whereas the central venous
pressure decreased to 10 mm Hg. After removal of the
central endovascular catheters, the patient was weaned
from ECC without difficulty. The femoral cannulas were
removed and the groin was closed. During all measures
and maneuvers our patient remained responsive and
comfortable. The following clinical course of the patient
was uneventful and he was discharged 6 days after the
intervention.
Comment
Primary pulmonary artery sarcoma is a very rare tumor
with only a few hundred cases having been reported in
the literature [1]. Without surgery the median survival
time is 1.5 month. However, surgery can potentially
prolong survival time to 10 months [1]. Eighteen months
after the first surgical intervention this patient had a
tumor recurrence leading to right ventricle outflow ob-
struction with severe circulatory impairment develop. In
the absence of a surgical option, an interventional ap-
proach was conceptualized. In this patient there was
specific concern that complete right ventricular outflow
obstruction during balloon inflation and stent release
might result in complete cardiac failure. This led us to
select ECC to support systemic and pulmonary circula-
tion during the stent procedure. In addition, transient
cardiac arrest was induced to avoid any cardiac distur-
bance during stent release. Moreover, avoidance of a
mediastinal mass syndrome was achieved by deliberately
preserving the patients ability to breathe spontaneously.
We believed that general anesthesia and mechanical
ventilation might have the potential to obstruct our
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
CASE REPORT ZIMPFER ET AL 747
ENDOVASCULAR STENT-GRAFT TREATMENT
patients airway or pulmonary artery by collapsing tumor
masses. During the whole procedure the patient was only
slightly sedated, and he tolerated the procedure well and
felt comfortable. We have found only one comparable
case in the literature [2]. To reduce an increase in right
ventricular afterload these colleagues also established
percutaneous cardiopulmonary support. However they
performed the complete procedure under general
anesthesia.
We believe that this approach is unique. With the
combination of preserved spontaneous breathing, ECC
and temporary cardiac arrest, balloon inflation and stent
release was safe, yet the technical efforts and expenses
may cause controversial viewpoints. However, in a pa-
tient whose oxygenation was dependent on only two
lobes of a single lung combined with circulatory failure
we saw the medical and surgical needs of the patient
most safely met with the use of ECC under local anes-
thesia combined with light sedation.
In selected patients this approach is a safe technique
with surprisingly high patient comfort and is an effective
FEATURE ARTICLES
alternative to techniques implementing general
anesthesia.
References
1. Anderson MB, Kriett JM, Kapelanski DP, Tarazi R, Jamieson
SW. Primary pulmonary artery sarcoma: a report of six cases.
Ann Thorac Surg 1995;59:148790.
2. Asato Y, Amemiya R, Kiyoshima M, Shioyama Y, Asato M.
Pulmonary artery stenting for recurrent lung cancer after left
pneumonectomy. Ann Thorac Surg 2002;73:1962 4.
Treatment of Acute Type A
Dissection by Percutaneous
Endovascular Stent-Graft
Placement
Daniel Zimpfer, MD, Martin Czerny, MD,
Joachim Kettenbach, MD, Maria Schoder, MD,
Ernst Wolner, MD, Johannes Lammer, MD, and
Michael Grimm, MD
Departments of Cardiothoracic Surgery and Interventional
Radiology, University of Vienna Medical School, Vienna,
Austria
Acute type A dissections are a life threatening condition
requiring immediate surgical intervention to avoid aortic
rupture or pericardial tamponade. Success of surgical
intervention is markedly limited in those patients with
advanced age, neurological deficits, and multiple co-
morbidities at the time of treatment. We report the
successful endovascular stent-graft treatment in a patient
suffering from an acute type A dissection. Due to the
Accepted for publication Nov 22, 2005.
Address correspondence to Dr Zimpfer, Waehringer Guertel 18-20, Vi-
enna, A-1090 Austria; e-mail: daniel.zimpfer@meduniwien.ac.at.
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.11.066