Neoadjuvant nivolumab plus chemotherapy increases pathologic complete response rates in resectable non-small cell lung cancer, but the operative safety of this approach in bulky, invasive N2 disease with suspected great-vessel involvement remains uncertain. A 64-year-old woman had left upper lobe adenocarcinoma with bulky single-station N2a disease and suspected aortic arch invasion. After three cycles of nivolumab plus carboplatin-paclitaxel, imaging showed only limited nodal shrinkage. At lobectomy, the subaortic lymph node was broadly adherent to the arch and surrounding structures, causing hemorrhage that required cardiopulmonary bypass and arch resection. Pathology showed pathologic complete response, but lymphocyte-predominant inflammation and fibrosis extended to the aortic adventitia. Radiographic response and pathologic complete response after chemoimmunotherapy do not necessarily indicate safe technical resectability in bulky, invasive N2 lung cancer. Multidisciplinary surgical planning should preserve caution when great-vessel invasion is suspected.
Desmoid-type fibromatosis is a rare, benign fibroblastic neoplasm characterized by infiltrative growth and a tendency for local recurrence despite the absence of metastatic potential. It has been associated with prior trauma or surgery, and postoperative lesions arising in the chest wall can present a major diagnostic challenge. In patients after lung cancer resection, a new pleural-based or chest wall mass at a previous port site is often interpreted as pleural dissemination, chest wall recurrence, or port-site implantation, even when the primary tumor is pathologically low risk. A 70-year-old woman underwent minimally invasive resection for lung adenocarcinoma, and the final pathological stage was pT1miN0M0 (pStage IA1). She remained asymptomatic, and routine postoperative surveillance was performed. At 10 months after surgery, computed tomography revealed a newly developed, well-demarcated soft-tissue mass arising from the chest wall at the thoracoscopic port site, adjacent to the pleura; the mass rapidly enlarged to 3.0 cm by 14 months. Positron emission tomography/computed tomography with fluorine-18 fluorodeoxyglucose showed mild tracer uptake within the lesion (maximum standardized uptake value, 2.5). Although the primary lung adenocarcinoma was pathologically low risk, pleural dissemination or port-site recurrence could not be confidently excluded based on imaging alone. Considering the need for definitive diagnosis and local control, the patient underwent en bloc resection of the lesion with chest wall excision including the seventh rib. Grossly, the tumor was firm and fibrous. Histopathological examination demonstrated a proliferation of bland spindle-shaped cells embedded in abundant collagenous stroma with infiltrative margins, consistent with desmoid-type fibromatosis. The postoperative course was uneventful. As the surgery was performed recently, long-term follow-up data are not yet available. Desmoid-type fibromatosis can occur at a thoracoscopic port site more than one year after lung cancer surgery and may mimic pleural dissemination or port-site recurrence, even after resection of minimally invasive adenocarcinoma. When malignancy cannot be excluded preoperatively, surgical excision with an adequate margin can establish the diagnosis and achieve local disease control.
The graft insertion technique is an effective choice for redo aortic root reconstruction in cases with extensive annular destruction. Nevertheless, its impact on postoperative left ventricular outflow tract (LVOT) geometry and flow dynamics has not been investigated in detail. A 69-year-old woman who underwent aortic valve replacement for infective endocarditis developed prosthetic valve dehiscence with paravalvular leakage and a large aortic root pseudoaneurysm after 4 months. Because the native annulus was completely destroyed, redo aortic root replacement using the Bentall procedure with the graft insertion technique was performed. Intraoperative examination revealed no macroscopic evidence of active infection but raised concerns regarding potential LVOT narrowing after the insertion of the inverted graft. Postoperative contrast-enhanced computed tomography demonstrated significant LVOT narrowing, with a minimal diameter of 14 mm, despite the implantation of a 19-mm bioprosthetic valve. Moreover, four-dimensional flow (4D-flow) magnetic resonance imaging (MRI) revealed accelerated systolic flow at the narrowed LVOT, indicating functional LVOT stenosis. This case emphasizes an important pitfall of the graft insertion technique—postoperative LVOT narrowing caused by the intraventricular portion of the inverted graft. Postoperative morphological and hemodynamic evaluation using advanced imaging modalities, including 4D-flow MRI, may be required to ensure the safety of this technique in complex aortic root reconstruction.
Aortoesophageal fistula (AEF) after thoracic aortic repair is a rare and devastating complication with an extremely high mortality (33–100
BackgroundPulmonary wedge resection is a lung-sparing procedure, with mechanical staplers enhancing surgical safety. Staple line reinforcement reduces air leakage; however, its effect on preventing mechanical vascular injury remains unclear. Staple-related vascular injuries rarely cause life-threatening complications. Here, we report a rare case of hemorrhagic shock caused by intercostal artery perforation from a protruding staple leg following thoracoscopic wedge resection with a reinforced stapler, which was likely triggered by lung collapse and re-expansion.Case presentationA 76-year-old man underwent thoracoscopic wedge resection of right segment 6 for suspected metachronous lung adenocarcinoma using a reinforced stapler with a gold cartridge. The surgery was uneventful. On postoperative day (POD) 1, accidental chest drain removal caused lung collapse. After drain reinsertion and lung re-expansion on POD 2, the patient developed hemorrhagic shock on POD 3. Emergency thoracotomy revealed massive intrathoracic hemorrhage from the eighth intercostal artery due to a staple leg protruding through the reinforcement and perforating the artery during lung inflation. Hemostasis was achieved using electrocautery and artery ligation, followed by removal of the protruding staple and additional staple line reinforcement. The postoperative course was uneventful, and the patient was discharged on POD 10.ConclusionsMechanical vascular injury due to staple protrusion can occur despite reinforced staplers. Lung collapse and re-expansion may alter the spatial relationship between the staple line and adjacent chest wall vessels, thereby increasing arterial injury risk. Careful staple line inspection, appropriate cartridge selection based on tissue thickness, and chest drain management are essential for preventing this rare complication.
The Konno procedure is an effective option for performing aortic valve replacement in pediatric patients utilizing an aortoventriculoplasty patch with a right ventricular outflow patch. However, re-do procedures are technically demanding and carry a non-negligible risk of surgical complications when the prosthetic materials are infected. We report a case of a patient who successfully underwent a re-do Konno procedure and an aortic root replacement for prosthetic valve endocarditis involving an aortoventriculoplasty patch. A 21-year-old male patient had undergone multiple aortic valvular surgeries since childhood. The patient’s subsequent clinical course was complicated by prosthetic valve endocarditis caused by Propionibacterium acnes that occurred at the age of 19 years, which was treated with antibiotics. Due to the occurrence of a subdural hematoma associated with recurrent endocarditis and exacerbated residual paravalvular leak, the patient was referred to our hospital to receive the appropriate multidisciplinary care throughout the perioperative period. After managing the intracranial hemorrhage, aortic root replacement along with reconstruction of the Konno patch and right ventricular outflow tract was performed using a fresh autologous pericardium. Postoperative echocardiography revealed hemodynamic stability without residual paravalvular leakage. Computed tomography revealed the absence of pseudoaneurysms. The patient was discharged uneventfully after six weeks of antibiotic treatment. The re-do Konno procedure and aortic root replacement can be effective surgical options to resolve sustained infection with indwelling prosthetic materials.
Tracheobronchial branching anomalies are uncommon, but increase the risk of intraoperative vascular or bronchial injury if not recognized preoperatively. An independent origin of the right B2 bronchus from the bronchus intermedius is particularly rare and may be accompanied by complex pulmonary venous and arterial variations. Careful preoperative anatomical assessment is crucial when planning anatomical segmentectomy in such cases. A 73-year-old woman was referred to our hospital after a 12-mm partially solid nodule with a cavity at the border between segments S1 and S3 in the right upper lobe was incidentally detected on chest computed tomography (CT). Transbronchial biopsy confirmed squamous cell carcinoma. Bronchoscopy and coronal chest CT showed a displaced right B2 bronchus arising from the bronchus intermedius, with a common B1 + 3 bronchus arising from the right main bronchus. Contrast-enhanced three-dimensional CT bronchography and angiography revealed a complex venous pattern, with V1b draining into the superior pulmonary vein and two additional veins from segment S1 draining into the central vein, as well as a so-called top pulmonary vein formed by a portion of V2 draining into V6. The A3a branch arose from the interlobar pulmonary artery, and no recurrent A2 branch was present. The patient underwent three-port video-assisted thoracoscopic surgery of right S1 + S3 segmentectomy with hilar lymph node dissection. Because the lesion was small and clinically early stage, anatomical segmentectomy was considered feasible provided that an adequate surgical margin could be secured. Despite incomplete fissures between the upper and middle and between the upper and lower lobes, the operation was completed safely by following the preoperative three-dimensional vascular and bronchial roadmap, with careful hilar dissection and indocyanine green-guided identification of the intersegmental plane. The postoperative course was uneventful. The final pathological diagnosis was pT1bN0M0 stage IA2 squamous cell carcinoma, with a pathological surgical margin of 2.7 cm. This case shows that detailed preoperative three-dimensional assessment of the bronchovascular anatomy, including displaced bronchi and atypical pulmonary veins, can facilitate safe anatomical segmentectomy in the presence of rare tracheobronchial anomalies. Such planning is important to avoid vascular injury and to secure adequate surgical margins in segmentectomy for early-stage lung cancer.
Background Extralobar pulmonary sequestration is a rare disease and is frequently associated with congenital malformations. Herein, we report an adult case of an unusual extralobar sequestration accompanied by a bronchogenic cyst and the concurrent absence of the left pericardium. Case presentation A 57-year-old female patient presented with an abnormal shadow on a chest radiograph. Contrast-enhanced computed tomography revealed a partially enhanced cystic mass in the left anterior mediastinum. Another cystic lesion was detected on the left side of the trachea in the upper mediastinum. The anterior mediastinal mass was suspected to be a cystic thymoma, and thus, a left thoracoscopic surgery was performed for its resection. The mass originated from a left pulmonary hilar region and was covered by an independent visceral pleura. The feeding artery originated from the left pulmonary artery with no connection to the bronchus. Histopathological results revealed that the mass consisted of alveolar cells, bronchial epithelium, cartilage, and a cystic structure with highly viscous contents, and it was finally diagnosed as extralobar sequestration. Conclusions Extralobar sequestration should be considered a differential diagnosis for atypical anterior mediastinal masses near the hilar region, especially in patients with other congenital malformations.
Renal artery aneurysm (RAA) is a rare but potentially life-threatening vascular pathology. Surgical management depends on the aneurysm’s location and morphology. In cases with extensive aortic calcification or anatomical complexity, standard clamping techniques may be infeasible, requiring alternative hemostatic strategies. We present a unique case of RAA in a patient with Takayasu’s arteritis and diffuse aortic calcification, in whom intra-aortic balloon occlusion and patch aortoplasty were used as a salvage technique during surgical repair. An 80-year-old woman with a history of Takayasu’s arteritis was referred for surgical treatment of an enlarging right RAA (55 × 74 mm), incidentally detected on imaging during hospitalization for pneumonia. Preoperative computed tomography (CT) demonstrated diffuse calcification of the entire aorta and an aneurysm located at the origin of the right renal artery. The distal segment of the right renal artery was occluded, and the right kidney could not be identified. Due to anticipated bleeding risk and poor clamping accessibility, cardiopulmonary bypass was established via the right femoral vessels. Multiple intra-aortic balloon occlusion catheters were inserted, though several ruptured intraoperatively. Hemostasis was ultimately achieved by inflating a balloon inserted directly through the operative field and performing a patch closure of the dilated right renal artery ostium. The patient required massive transfusion and temporary renal replacement therapy postoperatively. She was discharged to rehabilitation on postoperative day 49. Postoperative CT confirmed patch integrity, but a localized aortic dissection at the balloon site was observed. This case illustrated the technical challenges of surgical approaches for RAA in patients with severe aortic calcification due to Takayasu’s arteritis. Intra-aortic balloon occlusion is a useful alternative to conventional clamping but carries a risk of rupture, particularly in calcified aorta. Patch aortoplasty may be considered for elderly patients where graft replacement is not feasible. Preoperative imaging is essential to plan individualized strategies for bleeding control and vascular access in high-risk patients.
Life expectancy in patients with hemophilia A has increased owing to advances in factor VIII replacement, and the prevalence of age-related comorbidities such as coronary artery disease (CAD) is rising. However, coronary revascularization in severe hemophilia A remains challenging because both antithrombotic therapy and surgery can precipitate serious bleeding. We report a case of minimally invasive coronary artery bypass grafting (MICS-CABG) in a patient with severe hemophilia A, focusing on perioperative factor VIII management. A 50-year-old man (height 167 cm, weight 81 kg) with severe hemophilia A (baseline factor VIII activity < 1
The human leukocyte antigen (HLA) is a major histocompatibility complex antigen found in almost all human cell membranes. Half of the HLA alleles are inherited from each parent. However, little is known about the relationship between HLA and abdominal aortic aneurysms. Herein, we present a rare surgical case of a saccular common iliac artery aneurysm associated with HLA-A26 and HLA-B27 in a young adult patient, along with a literature review. A 26-year-old Japanese man presented with high fever and right lower abdominal pain. Contrast-enhanced computed tomography revealed appendicitis, a 20-mm saccular aneurysm at the origin of the left common iliac artery, and an 8-mm gastric varix. After undergoing laparoscopic appendectomy, the patient was referred to our institution for management of this rare aneurysm. His mother had a history of uveitis and ankylosing spondylitis treated with steroids, suggesting that he may have inherited HLA-B27. Endovascular aortic repair was performed using an AFX2 stent graft under general anesthesia. The patient’s postoperative course was uncomplicated, and he was discharged on postoperative day three. Postoperative HLA typing revealed HLA-A11, HLA-A26, HLA-B27, and HLA-B35 positivity. When aortic aneurysms are incidentally found in young patients, HLA typing should be considered in addition to specific antibodies for collagen diseases. Patients with a medical or family history of collagen disease–related vasculitis and specific HLA types should undergo careful cardiovascular follow-up.
Chordoma is a malignant bone and soft tissue tumor derived from remnants of the embryonic notochord. It accounts for 1–4
Pancreaticoduodenal artery aneurysms (PDAAs) are associated with celiac axis stenosis and occlusion. PDAAs carry a risk of sudden rupture and therefore require prompt treatment. Sjögren’s syndrome (SS), a systemic autoimmune disease, has recently been reported in association with various arterial aneurysms. To our knowledge, no previous report has described concurrent PDAAs and cerebral aneurysms (CAs) associated with SS. Here, we present a rare case of PDAAs and CAs associated with SS. A 69-year-old Japanese woman with a history of chronic hepatitis was referred to our hospital. She had a 20-year history of dry mouth, a one-month history of taste disturbance, and joint pain. Laboratory tests revealed she was SS. Abdominal ultrasonography performed for chronic hepatitis incidentally revealed aneurysms around the pancreas. Contrast-enhanced computed tomography (CECT) demonstrated multiple PDAAs, including two anterior superior PDAAs, three anterior inferior PDAAs, one inferior PDAA, and two dorsal pancreatic artery aneurysms. The origin of the celiac axis was occluded. CECT also revealed three CAs: an anterior communicating artery (AcomA) aneurysm with a bleb, a right middle cerebral artery aneurysm, and a right M1 bifurcation aneurysm. We planned a three-stage treatment strategy. First, an aorto-hepatic bypass using a reversed great saphenous vein graft was performed. The graft was proximally anastomosed to the abdominal aorta 15 mm above the inferior mesenteric artery, routed through the mesocolon near the ligament of Treitz, and passed between the stomach and pancreas. It was then distally anastomosed to the common hepatic artery. The gastroduodenal artery (GDA) was ligated to prevent competitive flow between the GDA and the graft. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. Twenty days later, coil embolization of the PDAAs was performed as the second treatment. Fifty days thereafter, stent-assisted coil embolization of the AcomA aneurysm was performed as the third treatment. Twelve months after the aorto-hepatic bypass, the graft remained patent, and the sizes of the remaining CAs were unchanged. Our case highlights the potential for systemic aneurysm formation in patients with SS and demonstrates that staged multidisciplinary treatment can be safely and effectively performed.
Background Primary undifferentiated pleomorphic sarcoma (UPS) of the sternum is rare, and surgical resection remains the mainstay of treatment. Extensive sternal resection necessitates reconstruction to preserve respiratory function, protect mediastinal structures, and maintain upper limb support. Various reconstruction techniques have been described, but optimal methods for high-risk patients remain unclear. We report a case of total sternal resection reconstructed using a sandwich technique with polymethyl methacrylate (PMMA) and polytetrafluoroethylene (PTFE) sheets. Case presentation A 79-year-old man with multiple comorbidities presented with a painful anterior chest wall mass. Imaging revealed a 3-cm localized sternal lesion, and biopsy confirmed UPS. Total sternal resection was performed, preserving the left pectoralis major muscle for flap coverage. A PMMA sheet sandwiched between PTFE sheets was anchored to the ribs, providing rigid yet lightweight chest wall support. A pedicled pectoralis major musculocutaneous flap covered the defect. Postoperative recovery was uneventful, with preserved pulmonary and upper limb function. Histopathology confirmed negative margins. At 8 months, a solitary left supraclavicular lymph node metastasis was treated with radiotherapy. The patient remains progression-free at 18 months. Conclusion Total sternal resection followed by sandwich technique reconstruction can provide stable chest wall support while preserving respiratory and upper limb function, even in elderly patients with comorbidities. This case highlights atypical metastatic patterns of sternal sarcomas, emphasizing the need for careful follow-up. The sandwich technique is a safe and reproducible option for extensive sternal reconstruction in high-risk patients.
Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital heart defect associated with high mortality during infancy if not surgically corrected. Its occurrence combined with hypoplastic left heart syndrome is highly uncommon, presenting considerable diagnostic and technical challenges. Identifying such an anomaly before surgery can be challenging, particularly in patients with complex cardiac anatomy. Intraoperative recognition requires immediate adjustments of the surgical approach, especially regarding myocardial protection and coronary artery reconstruction. A female infant was delivered at 39 weeks of gestation with a birth weight of 3038 g. She was prenatally diagnosed with a variant of hypoplastic left heart syndrome, which was characterized by mitral and aortic stenosis, double-outlet right ventricle, and moderate tricuspid regurgitation. At birth, she underwent bilateral pulmonary artery banding to manage heart failure symptoms. Preoperative imaging did not provide sufficient visualization of the coronary arteries. At 15 days of age, she underwent the Norwood procedure with right ventricle-to-pulmonary artery shunt and tricuspid valve repair. During surgery, it was observed that the left coronary artery originated from the right pulmonary artery. To maintain coronary perfusion, a cannula was inserted into the main pulmonary artery, connecting it to a cardiopulmonary bypass circuit. Subsequently, the left coronary artery was reimplanted into the neoaorta to preserve alignment and minimize tension. The postoperative course included extracorporeal membrane oxygenation for 3 days because of right ventricular dysfunction, with sternal closure on postoperative day 13. At 7 months, she underwent a bidirectional cavopulmonary shunt. At 2 years of age, she continues to be monitored on heart failure medication and exhibits a stable clinical status. In patients with complex congenital heart disease, a thorough assessment of the coronary artery anatomy is essential for surgical planning. In cases of unfeasible preoperative diagnosis, prompt intraoperative management must ensure myocardial protection and long-term coronary artery function. This case demonstrates that careful intraoperative decision-making can lead to successful outcomes, even in cases of unexpected anatomical findings.
Myasthenia gravis (MG) without thymoma is often treated with extended thymectomy to improve symptom control and reduce immunotherapy requirements. Schwannoma of the recurrent laryngeal nerve (RLN) is rare, and surgical resection is usually curative. However, operative manipulation carries a risk of temporary or permanent vocal fold paralysis. When these conditions coexist, choosing staged versus single-stage surgery is non-trivial. A synchronous operation can consolidate perioperative care and recovery but demands careful planning to prevent respiratory complications, particularly if RLN palsy or myasthenic crisis occur. A 65-year-old woman with generalized, thymoma-negative MG (acetylcholine-receptor antibody positive) had no hoarseness or dysphagia. Flexible laryngoscopy confirmed mobile vocal folds bilaterally. Chest radiography showed mediastinal widening without diaphragmatic paralysis. Contrast-enhanced CT and MRI revealed a right anterior mediastinal cystic lesion and a solid mass in the left tracheoesophageal groove abutting the RLN. ^18F-fluorodeoxyglucose positron emission tomography demonstrated uptake in the solid lesion (SUV_max 4.89). Transesophageal endoscopic ultrasound–guided fine-needle aspiration yielded spindle cells compatible with schwannoma, and the mass was considered RLN-derived. A single-stage median sternotomy was undertaken. Extended thymectomy was performed with bilateral phrenic exposure and en bloc removal of thymic/perithymic fat, followed by nerve-sparing enucleation of the left RLN tumor through a longitudinal epineurial window and meticulous intracapsular dissection, preserving macroscopic neural continuity. The postoperative intensive care unit course was uneventful: no dyspnea or dysphagia, normal voice, and laryngoscopy confirmed intact vocal fold mobility. A chest radiograph on postoperative day 5 was unremarkable, and the patient was discharged on day 7. Histopathology showed alternating Antoni A/B areas with virtually no mitoses; tumor cells were strongly S-100–positive, confirming schwannoma. In carefully selected patients with stable MG and no preoperative vocal fold dysfunction, single-stage median sternotomy enables safe concomitant extended thymectomy and RLN schwannoma enucleation. Success hinges on nerve-sparing technique and proactive perioperative planning for airway protection and potential MG crisis.
Partial anomalous pulmonary venous connection (PAPVC) is a congenital anomaly in which a part of the pulmonary veins drain into the right heart system. Many cases of PAPVC remain asymptomatic and often do not present clinical problems. However, when performing a lung resection, it becomes important in terms of surgical techniques and complications. A 70-year-old woman was referred to our hospital for evaluation of an abnomal shadow on chest radiography performed during medical check-up. A contrast-enhanced chest computed tomography (CT) revealed a part-solid nodule in the right upper lobe (RUL). Additionally, PAPVC was observed, in which almost all pulmonary veins, except for a small part of the basal segmental pulmonary vein (PV), drained into the azygos vein. The patient was diagnosed with suspected primary lung cancer (cT1miN0M0, stageⅠA1) with PAPVC. We performed righit upper wedge resection while preserving the PAPVC. We reported rare PAPVC presenting an inverted Scimitar sign. To the best of our knowledge, this is the first case report of its kind. The tumor was located very close to the main trunk of the anomalous PV. Resection of the main trunk would have resulted in the loss of all pulmonary veins except for the basal segmental PV. Furthermore, the surgical margin would have been unchanged when comparing right upper lobectomy with wedge resection. Therefore, wedge resection of the RUL was selected. The resection margins were negative.
Contrast-Induced Encephalopathy (CIE) is a rare complication, most commonly reported after carotid or coronary interventions, possibly due to reporting bias. We present a case of CIE following two-debranching thoracic endovascular aortic repair (TEVAR). A 79-year-old man with hypertension, hyperlipidemia, stage 4 chronic kidney disease (CKD), and prior cerebral infarction underwent emergency 2-debranching TEVAR for a ruptured thoracic aortic aneurysm (TAA). A total of 200 mL of contrast medium was used pre- and intraoperatively. On postoperative day (POD) 1, the patient remained unconscious despite sedation cessation. Non-contrast brain Computed tomography (CT) showed left hemispheric cerebral edema and high-density areas suggestive of contrast extravasation, raising suspicion for CIE. Conservative management with hydration and supportive care led to gradual recovery, with imaging on POD9 showing near-complete resolution. Although rare, CIE should be considered in cases of delayed consciousness recovery after TEVAR, particularly in high-risk patients. Early diagnosis and conservative treatment are essential for good outcomes.
Lung transplantation (LTx) is an established treatment for end-stage lung disease. However, bronchial complications after LTx remain a major challenge. Bronchial stenosis is the most common bronchial complication, for which the main treatment strategies are endoscopic and surgical interventions. This report describes a case of sudden-onset bronchial stenosis following bilateral LTx that was successfully managed by surgery. A 46-year-old man underwent bilateral LTx from a brain-dead donor for pulmonary Langerhans cell histiocytosis and pulmonary hypertension. He was discharged 1 month later without any complications. Although there were no significant abnormal findings on chest computed tomography (CT) scans obtained 3 months after LTx, he complained of sudden-onset dyspnea at 5 months following LTx. Chest radiography showed decreased lucency in the right lower lung field, and CT demonstrated severe stenosis of the right bronchus intermedius, with the stenotic segment measuring approximately 0.8 cm in length. Limited aeration remained in the middle and lower lobes. His respiratory condition deteriorated rapidly, and he was intubated and admitted to the intensive care unit. Repeat CT performed on the following day revealed complete obstruction of the bronchus intermedius and total atelectasis of the right middle and lower lobes. After urgent transfer to our hospital, bronchoscopy revealed complete obstruction of the bronchus intermedius, indicating a need for urgent surgical intervention. Right thoracotomy was performed via the fifth intercostal space. After division of the main pulmonary artery through the interlobar fissure, sleeve resection with end-to-end reconstruction was performed for the stenotic segment of the bronchus intermedius. The postoperative course was uneventful, and the patient was discharged on postoperative day 15. No restenosis has been observed on repeat CT or bronchoscopy, and he has remained well during 2.5 years since surgery. Bronchial stenosis can occur after LTx even distal to the anastomotic site, particularly in the right bronchus intermedius, and may progress rapidly to complete obstruction. Surgical intervention may be an effective strategy when endoscopic management is not feasible.
