A rare case of calcifying fibrous pseudotumor of the pleura with an accompanying vascular anomaly in the pulmonary ligament

A 27-year old man without any significant comorbidities was admitted to the Department of Thoracic Surgery for the diagnosis and treatment of an operable tumor found accidentally during a routine examination. Tomography revealed a paraspinal tumorous lesion on the left side of the thoracic wall (Figs. 1, 2). The tumor was described as heterogeneous with calcifications in almost 1/4 of its volume. The examination did not show any additional vessels or atypical branches of the main artery.
The presentation of the tumor in magnetic resonance indicated a benign, extrapleural lesion with calcifications, modeling the adjacent lung parenchyma, tangent to the descending aorta and intercostal artery, with no infiltration of the neighboring structures (Fig. 3).
The patient was qualified for tumor resection with the use of video-assisted thoracoscopy. A polycyclic tumorous lesion adjoined to the surface of the lower lobe of the left lung was revealed intraoperatively. Taking into consideration the size and location of the lesion, a decision was made to mobilize the lung by releasing the pulmonary ligament. When a superficial incision of the ligament was performed, an artery was damaged – most likely a branch of the aorta. Conversion to classic anterolateral thoracotomy was performed due to massive hemorrhage. The bloody fluid accumulated in the pleural cavity was evacuated, and pressure was applied to the site of the bleeding. The damaged artery was sewn with vascular sutures on its distal section and the aortic wall. The tumor was excised within normal lung parenchymal margins. Due to significant blood loss, 3 units of packed red blood cells were administered; additional 3 units were administered postoperatively. Other blood derivatives, cryoprecipitate and fresh-frozen plasma (FFP), had to be used as well. A significant decrease in cardiopulmonary parameters necessitated the administration of catecholamines (even in the postoperative period). The restoration of normal arterial pressure and heart rate increased the drainage dynamics of serous and bloody pleural fluid to over 350 ml/h. Despite the lack of any radiological indications of hematoma, a decision was made to conduct rethoracotomy. The source of bleeding was located in the distal section of the previously sutured artery. Blood leakage was also found on the suture line on the aorta. The sites of bleeding were sewn with vascular sutures and covered with hemostatic dressings. The treatment was...


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