This case report showed the challenges experienced when performing hybrid surgery with preoperative coil embolization for an aberrant artery originating from the thoracic aorta in PS. A previous study has reported two cases of massive intraoperative hemorrhage due to aberrant arterial injury . Thus, in patients who undergo surgery for PS, the appropriate and safe management of an aberrant artery is the most important factor considered by thoracic surgeons. With the development of endovascular techniques, several reports have shown that preoperative coil embolization is effective in decreasing the risk of serious intraoperative hemorrhage [3,4,5,6,7]. However, challenges associated with the procedure, similar to those observed in the current case, have not been discussed in previous studies.
To date, there is no established treatment guideline for PS, and data about hybrid surgery is limited. In previous cases, patients at high risk of recurrence and hemorrhage, such as those with large pulmonary lesions and inflammatory changes due to repeated infections, commonly undergo hybrid surgery [4, 5]. Although hybrid surgery with preoperative coil embolization was performed for an aberrant artery of 3.5 mm , the precise cutoff diameter of the aberrant artery for hybrid surgery remains unclear. The method of embolization and not the indication may change depending on the aberrant artery thickness. Previous studies have reported that coils were thought to be more suitable in small, tortuous, and branched vessels, whereas plugs were particularly suited for large, short, and high-flow vessels [4, 9]. In addition, hybrid surgical procedures with stent graft rather than with coil embolization was commonly performed for PS with the aneurysmal anomalous artery [10, 11]. Therefore, for patients with a larger vessel diameter or aneurysm formation, hybrid surgery with plugs and stent graft may be a good indication. Furthermore, the preoperative coil embolization may be useful for patients with PS who undergo video-assisted thoracoscopic surgery to prevent the risk of bleeding in poor visual point, such as under the diaphragm [3, 5]. From January 2009 to December 2020, 15 patients underwent surgical resection for PS at our institution. Then, three (20%) had preoperative coil embolization for an aberrant artery. The indication for the procedure was based on the surgeon’s discretion. In the current case, we performed preoperative coil embolization to decrease the risk of serious intraoperative hemorrhage, because radical resection of lung cancer was simultaneously performed.
In several cases, hybrid surgery with preoperative coil embolization is feasible and effective in preventing intraoperative active hemorrhage. However, in patients with an aberrant artery originating from the thoracic aorta, as in the current case, where and how to dissect the aberrant artery should be assessed, with consideration of the presence of an intravascular coil. That is because the length of the aberrant artery originating from the thoracic aorta was not long enough compared with the one originating from the abdominal aorta. Savic et al. showed that 73.9% of aberrant arteries were supplied from the thoracic aorta in 373 patients with PS, whereas 18.7% originated from the abdominal aorta . In the current case, the point of dissection in the aberrant artery was not discussed, and the intravascular coil in the location to be dissected was not assumed. If embolization is performed using coil for the aberrant artery supplied from the thoracic aorta, the aberrant artery must be dissected after confirming the location of the intravascular coil via palpation or radiography, and the vessel should be sufficiently exfoliated to the periphery. Otherwise, Sakai et al. proposed that endostapling with intravascular coils for an aberrant artery was a simple and safe technique . Thus, studies with a larger number of patients should be conducted to determine the safety and efficacy of hybrid surgery and its indications.