Case Report:Spontaneous breathing and anesthetic management of patients with tracheomediastinal fistula during carotid stent removal

doi:10.21203/rs.3.rs-2488074/v1

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Case Report

Case Report:Spontaneous breathing and anesthetic management of patients with tracheomediastinal fistula during carotid stent removal

https://doi.org/10.21203/rs.3.rs-2488074/v1

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Purpose: To report the anesthetic management in a patient with a tracheomediastinal fistula who underwent a successful internal carotid stent removal and cervical esophageal fistula debridement.

Clinical Features: A 58-yr-old man with a tracheomediastinal fistula was subjected to carotid stent removal and cervical esophageal debridement under general anesthesia. Blood tests showed mild anemia and hypoproteinemia, four coagulation items and normal electrocardiogram. Tracheoscopy revealed a tracheomediastinal fistula. The patient had a history of cerebral infarction after left middle cerebral artery stenting. To meet surgical requirements and allow the effective management of his airway, we used propofol and sufentanil for intravenous anesthesia, cervical plexus block and spontaneous breathing under intubation.

Conclusions: For this particular case, propofol and sufentanil intravenous anesthesia, coupled. With cervical plexus block and spontaneous breathing, met the surgical requirements and allowed the effective management of patient airway.

anesthetic management

carotid stent removal

cervical plexus block

spontaneous breathing

tracheomediastinal fistula

Carotid injuries account for only 3% of arterial injuries treated in civilian trauma centers¹ and carotid artery stent implantation is an effective way to treat this injury². However, the carotid artery is prone to stenosis after stent implantation. Surgery is the best way to deal with severe stenosis, but its surgical and anesthetic risks are high ³.

Tracheomediastinal fistula formation is a rare condition with potentially serious complications⁴. In order to avoid such complications, positive pressure ventilation of the tracheomediastinal fistula should be avoided during anesthesia. This greatly increases the difficulty of airway management.

Here we report the case of a patient that developed stent blockage after carotid artery stents were inserted to treat carotid artery injury. The baseline condition of the patient was poor, and the tracheoscopy suggested a tracheomediastinal fistula, which increased the anesthetic risk.

A 58-yr-old man (weight, 35 kg; height, 160 cm) was injured in his cervical esophagus and common carotid artery. The patient had vascular stents (placed > 1 year ago) and esophageal stents (placed > 4 months ago) in another hospital. He developed postoperative swallowing dysfunction and his cervical esophageal fistula did not improve. After gastrostomy, he was subjected to a gastroscopy to remove his esophageal stent, however this surgery was not successful due to granulation and firm attachment of the stent. Findings from a computed tomography (CT) of his neck showed that the lumen at the beginning of the left common carotid artery was narrowed in the shape of a rat tail, and that the rest of his common carotid artery was occluded(Fig. 1). After a multidisciplinary team consultation, the team decided to perform a carotid stent removal and cervical esophageal debridement under general anesthesia. His blood tests showed mild anemia and hypoproteinemia, four coagulation items and a normal electrocardiogram. Bronchial bronchoscopy revealed an abnormal bronchial pathway on the medial side of the right middle bronchus. When normal saline was injected into this abnormal pathway, more bubbles emerged, and airway mediastinal fistula was considered (Fig. 1). The patient had a history of cerebral infarction after a left middle cerebral artery stenting.

We monitored his SpO2, electrocardiogram and arterial blood pressure (ABP) and prepared a bronchial occluder in case of complications. Prior to induction of anaesthesia, we sprayed lidocaine into his trachea through a cricothyroid membrane puncture to reduce irritation. After 100% oxygen 100% was inhaled for 5 min in the supine position, anaesthesia was induced with 100 mg iv. propofol, 5 µg iv. sulfentanil and 1 mg iv. midazolam and manual ventilation was started using a facemask. Spontaneous breathing was resumed and bilateral chest wall movement was restored after endotracheal intubation(internal diameter, 7.5 mm). Prior to the surgery we performed a cervical plexus block with 0.13% ropivacaine injection for intraoperative analgesia. We decided to allow the patient to continue to breathe spontaneously. Anaesthesia was maintained with 5 mg kg/h propofol and sevoflurane (1 MAC).

Tofu residue in the carotid artery was observed intraoperatively, accompanied by yellow purulent secretions, and the metal stent partially detached from the internal carotid artery and entering the esophagus. The plaque and the stent were successfully removed, while the carotid artery was ligated. Subsequently, debridement of his cervical esophageal fistula was performed. Approximately 2 hours after surgery had started, the patient experienced increased blood pressure due to insufficient analgesia. Therefore, 5 µg of sufentanil was injected for analgesia. The patient had a brief apnea and resumed spontaneous breathing after 15 minutes of assisted ventilation. After the operation, the patient recovered consciousness, and the endotracheal tube was removed. Patient was observed for 1 hour, and he was returned to the ward upon normalization of his vital signs.

The choice of the method to be used to control the airway was the first challenge of this clinical case. The surgical procedure had low requirements on muscle relaxation, and intravenous anesthesia can meet the operation requirements in a relatively safe manner. However, because the operation field was cephalic, it was difficult to manage the airway using intravenous anesthesia. In addition, the surgeons informed the anaesthetists that there was a risk of major carotid bleeding when the stent was removed. Therefore we decided to use general anaesthesia and a tracheal tube rather than a laryngeal mask airway for this patient.

The method of ventilation used during the procedure was the second challenge of this clinical case. Preoperative tracheoscopy revealed a tracheomediastinal fistula. Spontaneous breathing has been recommended during anaesthesia in such circumstances to avoid serious complications, such as cardiac tamponade and pneumothorax caused by positive pressure ventilation⁵. Therefore, spontaneous breathing was allowed during surgery and a bronchial occluder was prepared to prevent failure of spontaneous breathing after anaesthesia induction or due to major bleeding during surgery. Disadvantages of this technique can include ineffective ventilation and a potential surgical hindrance.

An alternative approach to anesthetizing patients with a mediastinal fistula is to perform one-lung ventilation (OLV). However, OLV can affect normal ventilation/perfusion (V/Q) matching⁶. It can cause complications such as hypoxia, hypercapnia and atelectasis, which increase the risk of anaesthesia. Recent studies have indicated a potential role of OLV in the development of postoperative lung injury⁷. After carefully weighing benefits and risks for the patient, we considered spontaneous breathing as the preferred airway management method.

The anaesthetic agents used were the third interesting aspect of this case. We applied topical anaesthetic to the trachea in order to prevent adverse reflexes during endotracheal intubation. Sufentanil was chosen as the main analgesic, however, temporary respiratory depression occurred when the patient took 8 ug of sufentanil, which was within the normal range compared with other studies⁸. We assumed that his repiratory problems were due to increased sensitivity to opioids. Moreover, we performed a cervical plexus block with 0.13% ropivacaine before the operation, however, after 2 hours the patient experienced inadequate analgesia due to the short half-life of ropivacaine. Thus, the patient developed developed respiratory depression after sufentanil was used to improve analgesia. We conclude that analgesics with a longer half-life should be used to cervical plexus block in order to reduce intraoperative opioid use.

In summary, we report the anaesthetic management in a patient with a mediastinal airway fistula who underwent successful internal carotid stent removal and cervical esophageal fistula debridement. During the procedure, propofol, intravenous sufentanil, cervical plexus block and spontaneous breathing, were employed to effectively manage the patient’s airway.

1. Ethics approval and consent to participate:

Ethical approval for this study was provided by Clinical Research Ethics Committee of Affiliated Hospital of Guangdong Medical University, Guangdong, China (Chairman Prof Liangqing Zhang) on 09 November 2022.All experiments and methods were performed in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects and/or their legal guardian(s).

2. Consent for publication:

Informed consent to publish the data was obtained.

3. Availability of data and materials:

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

4. Competing interests:

The authors declare that they have no competing interests.

5. Funding:

None

6. Authors' Contributions:

Jiahui Li had the idea for the article, Zhenyu wang and Xiaolei Liu performed the literature search, Xiaoyan Liu, Jing Tang and Zhiyi Li identified and/or managed the case, Jiahui Li wrote the article, and Zhiyi Li is the guarantor.

7. Acknowledgements:

None

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Gonzalez A, Drummond M, McCord S, et al. Carotid endarterectomy for treatment of in-stent restenosis. Journal of Vascular Surgery 2011;54(4):1167-69. doi: 10.1016/j.jvs.2011.04.009
Choudhary C, Gildea TR, Salman R, et al. Management of tracheomediastinal fistula using self-expanding metallic stents. Ann Thorac Surg 2008;85(5):1800-2. doi: 10.1016/j.athoracsur.2007.11.045 [published Online First: 2008/04/30]
Minambres E, Buron J, Ballesteros MA, et al. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg 2009;35(6):1056-62. doi: 10.1016/j.ejcts.2009.01.053 [published Online First: 2009/04/17]
Grichnik KP, Clark JA. Pathophysiology and management of one-lung ventilation. Thorac Surg Clin 2005;15(1):85-103. doi: 10.1016/j.thorsurg.2004.09.004 [published Online First: 2005/02/15]
Dulu A, Pastores SM, Park B, et al. Prevalence and mortality of acute lung injury and ARDS after lung resection. Chest 2006;130(1):73-8. doi: 10.1378/chest.130.1.73 [published Online First: 2006/07/15]

No competing interests reported.

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Case Report:Spontaneous breathing and anesthetic management of patients with tracheomediastinal fistula during carotid stent removal

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