Iatrogenic tracheal rupture: bovine pericardial patch repair without flap reinforcement

Abstract

We describe a case of an extensive post-intubation membranous tracheal rupture in a 67-year old patient after emergency intubation. This was managed surgically by bovine pericardial patch repair. Other cases of autologous and bovine patch repair of tracheal lacerations exist in the literature, and we believe this is the first report of successful bovine patch repair without accessory autologous tissue reinforcement. This technique may be used in surgically managed cases of membranous tracheal rupture where primary repair is unsuitable, thereby reducing procedural complexity.

CASE PRESENTATION

A 67-year old female was found unresponsive at home, and her airway and ventilation were compromised. On arrival in the emergency department of a regional hospital, orotracheal intubation was performed by a junior doctor on duty. Right-main endobronchial intubation was noted on post-intubation chest X-ray, with the cuff displaced towards the right and grossly overinflated. Upon deflation of the cuff, there was a significant air leak in addition to haemoptysis and tracheal injury was suspected.

Bronchoscopy subsequently demonstrated a large posterior tracheal rupture in the pars membranosa. The lesion measured ∼6 cm and it extended to within ∼1.5 cm of the carina. Computed tomography of the chest also revealed small volume pneumomediastinum. The patient was transferred to our institution for definitive management. At repeat bronchoscopy, the defect was seen to open widely with each respirator delivered breath, and this was considered to pose significant risk of tube herniation and subsequent acute loss of airway and ventilation. The patient thus promptly proceeded to surgical repair.

SURGICAL TECHNIQUE

The patient's critical preoperative state was of undifferentiated aetiology, and haemodynamic instability mandated vasopressor infusion support intra-operatively. In addition, obesity and marginal premorbid functional status raised concerns regarding her ability to tolerate prolonged single-lung ventilation. Therefore, in the interests of expeditious repair, the decision was taken to forego preparation of a muscle flap, and provisions were made for instituting emergency femoro-femoral cardiopulmonary bypass should cardiorespiratory complications occur intra-operatively.

The patient was placed in the left lateral position with hips rotated at 45°, and the right femoral vessels were then isolated and taped. Following bronchoscopy, the endotracheal tube was advanced into left main bronchus. A right non-muscle-sparing posterolateral thoracotomy was performed through the fourth intercostal space. The azygos vein was tied to facilitate dissection into the mediastinum. The edges of pars membranosa were macerated on direct inspection and were debrided.

The resultant defect was reconstructed with a bovine pericardial patch (Edwards Lifesciences model 4700). This was anchored with interrupted 4-0 Prolene-0 sutures at both ends and secured with a continuous 4-0 Prolene-0 suture. The patch was intentionally oversized in order to minimize the risk of postoperative tracheal stenosis (Fig. 1). Tisseel Fibrin Sealant was applied to the suture line to seal needle holes, and the repair was pressure tested under water to 40 cm H₂O. Dual lung ventilation was then re-instituted and a single 28 French intercostal catheter was inserted into the right pleural space. Prior to transfer to the ICU, the ETT was positioned at the level of the carina and the cuff was left deflated.

Figure 1:

Bovine pericardial patch in situ.

At bronchoscopy 9 days post-operatively, the repair was secure (Fig. 2). The patient remained intubated due to concurrent medical issues, and eventually underwent surgical tracheostomy on day 17 without complication to facilitate discharge from ICU. She was transferred back to the referring hospital at 7 weeks postoperatively for rehabilitation prior to eventual discharge home.

Figure 2:

Bronchoscopic appearance of patch repair on postoperative day 9.

DISCUSSION

Post-intubation tracheal rupture (PiTR) is a rare complication of endotracheal intubation, and the incidence is estimated to be 1 per 20 000 intubations. Females are affected in 85% of cases and the intubation is emergent in 30%. Other risk factors include obesity, age >50 years, operator inexperience and cuff overinflation [1]. All of the above characteristics applied to our patient.

The indications for non-operative management in PiTR have expanded in recent years. Mediastinitis complicating PiTR is not universal as with oesophageal perforation, and patients may be managed non-operatively, provided ventilation is not jeopardized and other complications including pneumomediastinum, surgical emphysema and pneumothorax are controlled [1–4]. Ideally, such patients are extubated early post-injury but specialized ventilation techniques, such as bilateral flexible mainstem intubation via tracheostomy may facilitate prolonged ventilation should institutional capacity permit [4, 5]. Large defect size was also previously considered an indication for surgical repair but, in recently published series, lesions of up to 7.5 cm were successfully managed conservatively [4].

Surgical repair is indicated if the above requirements are not met or if the injury is diagnosed intra-operatively, and primary sutured repair of membranous tracheal wall defects is traditional [6]. However, several instances of reinforced pericardial patch, both autologous and bovine, have been reported. Foroulis et al. [7] reported autologous pericardial patch repair, reinforced with a pedicled serratus anterior flap, of a defect diagnosed intra-operatively during Ivor-Lewis oesophagectomy. Barbetakis et al. [8] describe bovine pericardial patch repair of a membranous defect, also diagnosed intra-operatively at Ivor-Lewis oesophagectomy, with reinforcement by apposition of the gastric conduit to the posterior trachea. Daniel Knott et al. [9] reported a patch repair of an iatrogenic membranous tracheal defect, also using bovine pericardium, buttressed with an epicardial fat pad, although in this case there was late luminal extrusion.

An instance of un-reinforced pericardial patch repair exists in the literature: Rousie et al. [10] reported successful un-reinforced pericardial patch for repair of a membranous tracheal rupture. In this instance, autologous pericardium was harvested and the patient was extubated within several hours after surgery.

In the case described herein, the bovine patch and fibrin sealant were adequate to make the repair sufficiently robust for prolonged single-lumen ventilation in a patient not suitable for early extubation. While the fate of bovine pericardium has not been tested in this context, no early or intermediate complications were sustained in our case. This allowed relatively expeditious surgery in a high-risk patient, and we believe that this technique may prove useful in cases that must proceed to surgery, especially in emergently intubated patients with significant comorbidity.

Conflict of interest: none declared.