Case Report
Iatrogenic Posterior Mediastinal Hematoma Treated by Video-assisted Thoracoscopic Surgery (VATS)
Pablo A. Ordóñez Lozano
, Beatriz Díaz Sanz, Javier García Tirado
Corresponding author
Department of Thoracic Surgery, Miguel Servet University Hospital, Zaragoza, Spain
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(C and D) Right lung tumor before and after receiving argon-helium cryoablation targeted therapy (30/10/2020; 4/11/2020). (E and F) Esophageal stenosis, and then esophageal covered metal mesh stent (MTN-SE-S-20/100-A-8/650) implantation under DSA (5/1/2021; 6/1/2021). (G and H) Tracheal space occupying, esophageal space occupying after esophageal covered metal mesh stent implantation (7/6/2023). (I and J) Rigid bronchoscopy combined with flexible bronchoscopy to remove the new organisms in the esophagus and then move the esophageal covered metal mesh stent up 1<span class="elsevierStyleHsp" style=""></span>cm(7/6/2023). (K and L) Rigid bronchoscopy combined with flexible bronchoscopy to remove tracheal new organisms and then Y-shaped covered metal mesh stent (size: 16<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>mm trachea/12<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>mm left principal bronchus/15<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>mm right principal bronchus) was implanted (7/6/2023; 9/6/2023). (M) Chest CT was used to evaluate the placement of double stents (10/6/2023). 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Ordóñez Lozano, Beatriz Díaz Sanz, Javier García Tirado" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Pablo A." "apellidos" => "Ordóñez Lozano" "email" => array:1 [ 0 => "paordonnezl@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Beatriz" "apellidos" => "Díaz Sanz" ] 2 => array:2 [ "nombre" => "Javier" "apellidos" => "García Tirado" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Thoracic Surgery, Miguel Servet University Hospital, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1038 "Ancho" => 2007 "Tamanyo" => 291679 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Mediastinal widening visible on chest X-ray; (B) mediastinal hematoma (MH) visible in the sagittal section of the CT; (C) MH visible in the coronal section of the CT; (D) MH visible in the axial section of the CT at the level of T6; (E) video-thoracoscopic view of the MH; (F) video-thoracoscopic view after drainage of the MH. White arrow: azygos vein. Blue arrow: esophagus.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 52-year-old patient was admitted on a scheduled basis for left radical mastectomy due to infiltrating ductal carcinoma and for placement of a subcutaneous venous reservoir (SVR) on the same day, accessing through the right jugular vein after failed puncture of the ipsilateral subclavian vein.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On the first postoperative day, the patient reported pain in the right hemithorax, a chest X-ray (CXR) was performed, where mediastinal widening and right pneumothorax were observed, which was managed with pleural drainage, without incident. Subsequently, she presented tachycardia and a 1<span class="elsevierStyleHsp" style=""></span>g/dL decrease in hemoglobin was observed. They requested a computed axial tomography (CT) with intravenous contrast that showed an extensive retroesophageal mediastinal hematoma (MH) from the cervical level to the esophageal hiatus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), without pericardial or pleural effusion. She presents with clinical worsening, presenting mucocutaneous pallor and decreased state of consciousness. Given the clinical situation and the CT findings, it was decided to perform urgent surgical intervention using right video-assisted thoracoscopic surgery (VATS) for revision and decompression of the hematoma, under general anesthesia and selective bronchial intubation. A nasogastric tube is placed to outline and identify the esophagus during surgery. In the video-thoracoscopic examination, a significant hematoma was observed in the posterior mediastinum from the apex to the base of the hemithorax. The posterior mediastinum is opened with an ultrasonic scalpel, retroesophageal dissection, and abundant clots are evacuated. No point or area of active bleeding is observed. The patient is extubated to the Intensive Care Unit (ICU) where she remains for 48<span class="elsevierStyleHsp" style=""></span>h.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">During her hospital stay, she does not require vasoactive drugs or transfusion of blood products. She had an adequate postoperative evolution, and she was discharged from the hospital 4 days after surgery.</p><p id="par0020" class="elsevierStylePara elsevierViewall">During outpatient follow-up, she did not report pain, dyspnea, or dysphagia. Radiological control is performed with CXR one month after the surgical intervention and chest CT without contrast at 9 months where complete resolution of MH is observed, without sequelae.</p><p id="par0025" class="elsevierStylePara elsevierViewall">MH can be classified as spontaneous or acquired, and the latter as iatrogenic<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> as in our case after the placement of an SVR, or post-traumatic (non-iatrogenic). The diagnosis is confirmed by performing a CT scan, especially with intravenous contrast. Sometimes, it is visible on the CXR, as in this case, and on the transthoracic or transesophageal echocardiogram.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment depends on the underlying cause, severity, location, and local effect of the hematoma itself. It can be conservative in small hematomas, or with endovascular techniques (through embolization or stent placement) depending on the source of bleeding, or less frequently through surgical intervention to control active bleeding or for its evacuation in large hematomas that can cause significant morbidity due to local compression.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Despite the advantages demonstrated by VATS in general, this approach has been rarely described as an option for the treatment on MH,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3–5</span></a> but in the absence of acute, massive bleeding it can be an option in centers accounting for extensive experience in minimally invasive thoracic surgery.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1038 "Ancho" => 2007 "Tamanyo" => 291679 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Mediastinal widening visible on chest X-ray; (B) mediastinal hematoma (MH) visible in the sagittal section of the CT; (C) MH visible in the coronal section of the CT; (D) MH visible in the axial section of the CT at the level of T6; (E) video-thoracoscopic view of the MH; (F) video-thoracoscopic view after drainage of the MH. White arrow: azygos vein. Blue arrow: esophagus.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fatal mediastinal hematoma following right internal jugular vein cannulation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "N. Luthra" 1 => "N. Goyal" 2 => "K. Garg" 3 => "K.Y. Sawhney" 4 => "H. Kaur" 5 => "A. 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