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Address for reprints: Pierre-Benoit Pagès, MD, PhD, Department of Thoracic and Cardiovascular Surgery, CHU Dijon, Hôpital du Bocage, 14 rue Gaffarel, BP 77908, 21079 Dijon, France.
Department of Thoracic and Cardiovascular Surgery, Dijon University Hospital, Bocage Central, Dijon, FranceINSERM UMR 1231, University of Burgundy, Dijon, France
The surgical technique and key steps of autologous pericardial conduit for pulmonary artery resection to avoid pneumonectomy in lung neoplasms are presented.
Autologous pericardial conduit perfusion after unclamping the pulmonary artery.
It has been reported to be safe and feasible, with good oncologic results, and appears to be the middle point between sleeve lobectomy and pneumonectomy when considering disease-free survival and overall survival.
The advantages of pericardium are an adequate thickness, resistance, free of cost, availability on both sides of the chest, superior biocompatibility compared with heterologous tissues, and adequate amount of tissue.
An operative technique with an autologous custom-made pericardial conduit to prevent pneumonectomy has not been described recently in detail according to the literature.
Figure 1Computed tomography scan with proximal lung malignancy before pulmonary artery resection.
Five patients underwent pulmonary artery resection during lobectomy for lung neoplasms with an autologous custom-made pericardial conduit in our center from January 2018 to May 2022 (Figure 2): 4 patients for their first surgery and 1 after redo thoracotomy to convert circumferential resection to custom-made pericardial conduit for early stenosis. All patients signed an informed written consent for the publication following the Cardio-vascular and Thoracic Surgery French Society’s (SFCTCV) recommendations (IRB00012919, September 13, 2022).
Figure 2Length and shape verification of autologous pericardial conduit perfusion after unclamping. A, Before lung re-expansion. B, After lung re-expansion and pericardium replacement.
Surgeries were performed with the patient under general anesthesia using a double-lumen endobronchial intubation. In all cases, a posterolateral thoracotomy in the fifth space was achieved.
The conduit technique was taken from the pericardium along the phrenic nerve in a rectangular shape (Video 1). The conduit was shaped around a 20-mL syringe, and sutured with a 5.0 nonresorbable running suture, with the epicardial layer facing inside. Then, the pericardial conduit was dipped in a 0.9% saline solution. The pericardial defect can be replaced by polytetrafluoroethylene mesh if necessary.
Before clamping, patients received a bolus of 50 UI/kg of heparin in 60% (n = 3) cases and heparinized solution flush only in 40% (n = 2) cases. We never used any neutralization at the end of the procedure.
The proximal side of the pulmonary artery was controlled by a Satinsky clamp without any distal control, and the pulmonary veins were clamped with a vascular tourniquet.
The conduit was sutured with 2 hemicircumferential direct running sutures with 5.0 nonabsorbable sutures to obtain a well-positioned pericardial graft. After the conduit interposition, and before tying the suture to re-establish the whole artery continuity, we first removed the vein’s tourniquet to drain air from the conduit and then opened the Satinsky clamp to ensure hemostasis. At the end of the procedure, we spread surgical sealant on the anastomosis (COSEAL; Baxter).
Margins were verified by using frozen section. Systematic mediastinal lymph node dissection was associated as well as the releasing of the pulmonary ligament. Median clamping time was 75 ± 29 minutes, median blood loss was 550 ± 239 mL, and median follow-up was 25.7 ± 15 months.
The conduit patency was assessed with computed tomography (CT) during the oncologic follow-up. We never experienced thrombosis, but one kink without abnormal blood flow or symptoms and one stenosis appeared, with a reduction of more than 50% of the artery caliber between the trunk and the last branches due to mediastinal postoperative radiation therapy. One patient died within 30 days after surgery, from reasons unknown. One patient had an early mediastinal progression without stenosis or thrombosis and died 40 days after surgery.
Discussion
Different techniques of sleeve lobectomy have been described to avoid pneumonectomy, which comes with a high postoperative mortality.
In case of main pulmonary artery involvement by neoplasm or nodes, techniques have been described primarily with a direct suture of the pulmonary artery.
Conduit interposition is an unusual technique rarely reported. Here, we reported our experience of 5 revascularizations of the lower lobe using a custom-made pericardial conduit without any early thrombosis. No patient experienced thrombosis or hemoptysis after revascularization and no major complications leading to emergency pneumonectomy, as previously reported.
Concerning the patency evaluation with CT or lung perfusion, the protocol still remains unclear. In our study, CT scan was performed during hospitalization in cases with a suspicion of thrombosis or for other complications. Hopefully, most of the patients who had no severe stenosis or kink are tolerating the procedure well.
Pulmonary artery resection with autologous pericardial conduit seems to be feasible and oncologically effective in selected cases for the past 2 decades.
The authors thank Carrie Gillis for reviewing the manuscript.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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