Left Subclavian Artery and Jugular Vein Replacement With Chest Wall Resection and Reconstruction for Pre-Treated Ewing Sarcoma

This is the case of a 53-year-old woman, nonsmoker, diagnosed with Ewing sarcoma of the left thoracic outlet. The lesion involved the subclavian vessels, first left 2 ribs, and brachial plexus, possible involvement of the apex of the left lung. No distant metastasis were evident on the scans.

The patient underwent induction chemotherapy (5 cycles of VAC regimen) according to the multidisciplinary evaluation. The lesion was reduced from 66x80x65 mm to 39x18mm.

Of note, before the surgery, the patient presented with a hyposphygmic left upper limb, with significant neurological impairment and hypotrophy of the musculature of left arm, forearm and hand. She underwent left manubriotomy, first and second left ribs resection en bloc with phrenic nerve, brachial plexus, left jugular vein and subclavian artery.

A left jugular-innominate vein by-pass was performed with reinforced PTFE 8.0mm prosthesis, and the subclavian artery by-pass with Goretex 8.0mm prosthesis. The chest wall defect was repaired with a 15x15cm Vycril prosthesis.

The pathologist reported an R0 resection of the Ewing sarcoma. The patient developed a left chylothorax requiring a surgical second look which was insufficient and the patient underwent to pleuro-peritoneal Denver shunt implant.

At the end of the video a picture of the vascular interposition grafts and a picture of the specimen are showed.

References

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