AJR 2003; 181:95-97
© American Roentgen Ray Society
Angiographic Ablation of an Ectopic Mediastinal Hyperplastic Parathyroid Gland Using a Left Internal Mammary Artery Coronary Bypass
S. Ernst1,2,
K. Cupisti3,
J. Kemper1,
C. Dotzenrath4,
P. E. Goretzki3,5 and
G. Fürst1
1 Department of Diagnostic Radiology, University of Duesseldorf, Moorenstr. 5,
D-40225 Duesseldorf, Germany.
2 Present address: Department of Diagnostic and Interventional Radiology,
Marien-Krankenhaus gGmbH, Dr.-Robert-Koch-Str. 18, 51465 Bergisch Gladbach,
Germany.
3 Department of General and Trauma Surgery, University of Duesseldorf, D-40225
Duesseldorf, Germany.
4 Department of General and Endocrine Surgery, St. Antonius Kliniken, Carnaper
Str. 55, D-42283 Wuppertal, Germany.
5 Department of Surgery, Städt. Kliniken Neuss Lukaskrankenhaus GmbH,
Preussenstr. 84, D-41464 Neuss, Germany.
Received September 9, 2002;
accepted after revision December 6, 2002.
Address correspondence to S. Ernst
(stefan.ernst{at}mkh-bgl.de).
Introduction
In patients with renal failure, autonomous hyperparathyroidism is common.
Subtotal parathyroidectomy or total parathyroidectomy with autotransplantation
is the treatment of choice
[1].
We report transvascular ablation of a fifth supernumerary mediastinal
parathyroid gland performed to avoid a repeated rethoracotomy.
Case Report
A 58-year-old man who had been undergoing chronic hemodialysis for 5 years
because of cirrhotic kidney disease presented with increasing bone pain. In
addition, he was treated for arterial hypertension. There had been no
pathologic fractures, anorexia, polyuria, or polydipsia.
The parathyroid hormone level was 1794 pg/mL (normal range, 51–54
pg/mL), although surgical resection of all four parathyroid glands with a
forearm autograft had been performed 6 months earlier (parathyroid hormone
level: before surgery, 2000 pg/mL, and after surgery, 1463 pg/mL; serum
calcium level: before surgery, 2.58 mmol/L, and after surgery, 2.54 mmol/L
[normal range, 2.0–2.6 mmol/L]). Histologic examination revealed four
hyperplastic glands. Eleven years earlier the patient had undergone cardiac
bypass surgery with three aortovenous bypasses. In addition, the left internal
mammary artery had been used as a bypass. Two days after surgery,
rethoracotomy had to be performed because of mediastinal bleeding. Five years
earlier a fistula for intermittent hemodialysis had been established at his
left wrist.
Now a fifth ectopic hyperplastic parathyroid gland was suspected in the
upper mediastinum on 99mTc sestamibi scintigraphy and confirmed at
MR imaging (Fig. 1A).
Diagnostic transbrachial angiography revealed a blood supply of the ectopic
parathyroid gland via the left internal mammary artery, which was used as a
coronary bypass to the left anterior descending artery
(Fig. 1B).
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Fig. 1A. —58-year-old man who had been undergoing hemodialysis for 5
years presented with increasing bone pain. Parathyroid hormone level was 1794
pg/mL (normal range, 51–54 pg/mL) although surgical resection of all
four parathyroid glands had been performed 6 months earlier. MR image shows
ectopic parathyroid gland (arrow) in mediastinum that was suspected
on 99mTc sestamibi scintigraphy (not shown).
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Fig. 1B. —58-year-old man who had been undergoing hemodialysis for 5
years presented with increasing bone pain. Parathyroid hormone level was 1794
pg/mL (normal range, 51–54 pg/mL) although surgical resection of all
four parathyroid glands had been performed 6 months earlier. Posteroanterior
projection from transbrachial angiography shows blood supply of ectopic
parathyroid gland (arrow) via small branch of left internal mammary
artery, which was used as coronary bypass.
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The risk of a repeated rethoracotomy was judged to be high after the
history of significant mediastinal bleeding with rethoracotomy, because in
these patients the pericardium is not closed and adherent to the sternum. The
risk of damage of the bypass grafts during rethoracotomy is high.
Therefore, the patient was sent to the radiology department for
transvascular therapy. A 4-French sheath was placed in the left brachial
artery, and the tip of a 4-French catheter (Osborn, MeritMedical, Angleton,
UT) was introduced into the left mammary artery after administration of 5000 U
of heparin. The brachial vascular approach was chosen because it offered
easier access to the internal mammary artery and minimized the risk of
cerebral embolism. The branch feeding the gland was catheterized with a 140-cm
3-French coaxial microcatheter (Tracker Catheter, Boston Scientific, Cork,
Ireland), and 5 mL of an emulsion of 96% alcohol and Lipiodol (iodized oil,
Byk Gulden, Konstanz, Germany) was administered
(Fig. 1C). Finally, the feeding
branch was occluded with two endovascular coils ([2 x 3 x 22 mm]
VortX, Boston Scientific). Final control angiography revealed persistent
opacification of the gland and complete occlusion of the vessel. The left
mammary artery coronary bypass was patent
(Fig. 1D). CT after the
procedure showed accumulation of the emulsion of alcohol and Lipiodol in the
gland and the surrounding mediastinal tissue
(Fig. 1E).
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Fig. 1C. —58-year-old man who had been undergoing hemodialysis for 5
years presented with increasing bone pain. Parathyroid hormone level was 1794
pg/mL (normal range, 51–54 pg/mL) although surgical resection of all
four parathyroid glands had been performed 6 months earlier. Angiogram shows
emulsion of 96% alcohol and Lipiodol (iodized oil, Byk Gulden, Konstanz,
Germany) applied via coaxial microcatheter.
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Fig. 1D. —58-year-old man who had been undergoing hemodialysis for 5
years presented with increasing bone pain. Parathyroid hormone level was 1794
pg/mL (normal range, 51–54 pg/mL) although surgical resection of all
four parathyroid glands had been performed 6 months earlier. Final control
angiogram after occlusion of branch with two vascular coils reveals complete
occlusion of feeding vessel and patent left internal mammary artery.
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Fig. 1E. —58-year-old man who had been undergoing hemodialysis for 5
years presented with increasing bone pain. Parathyroid hormone level was 1794
pg/mL (normal range, 51–54 pg/mL) although surgical resection of all
four parathyroid glands had been performed 6 months earlier. CT image shows
accumulation of emulsion of alcohol and Lipiodol in gland (arrow) and
surrounding mediastinal tissue.
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The parathyroid hormone level decreased from 1794 pg/mL to 52 pg/mL and
remained normal during 14 months of follow-up. The serum calcium level
decreased to 1.68 mmol/L, and during follow-up to 1.52 mmol/L. The patient was
released 2 days after intervention. The bone pain resolved almost completely
within 3 weeks. The remaining blood level of the parathyroid hormone was due
to the autograft in the right forearm. The fistula for hemodialysis at the
left arm and the coronary bypass were not affected by the intervention.
Discussion
In renal autonomous hyperparathyroidism, subtotal parathyroidectomy or
total parathyroidectomy with autotransplantation is the procedure of choice
[1]. However, in up to 30% of
cases, supernumerary parathyroid glands are present
[2]. Most of them are adjacent
to the thymus and are resected by routine transcervical thymectomy during
cervical exploration. But other locations deeper in the chest with blood
supplies from different vessels are also possible. In these cases, surgical
treatment with sternotomy, thoracotomy, or via video-assisted thoracoscopic
approach is associated with elevated risk
[3]. The literature contains
numerous case reports concerning aberrant parathyroid adenomas in primary
hyperparathyroidism treated by angiographic ablation. In 1975, Doppman et al.
[4] reported the successful
transvascular embolization of parathyroid adenomas. He used autologous clot,
Gelfoam (gelatin sponge, Upjohn, Kalamazoo, MI), and silicone rubber for
obstruction of the feeding arteries.
Use of ionic contrast material, alcohol, or a mixture of alcohol and
Lipiodol have been reported in the literature
[5].
Cook et al. [6] reported a
successful repeated transcatheter ablation of a recurrent mediastinal
parathyroid adenoma with ionic contrast medium 6 years after alcohol
ablation.
Alcohol has been reported to be an effective agent for parathyroid gland
ablation. In our patient, we combined the toxic effect of alcohol with the
vasoocclusive effect of Lipiodol, thereby also improving the visibility of the
suspension.
Definitive occlusion of the lesion-supplying branch was achieved by
additionally applying microcoils. We accepted that in case of relapse,
treatment via this branch would be precluded and access via other vessels
would be necessary.
Other imaging modalities and treatments have been used for minimal invasive
ablation of parathyroid adenomas. Sonographically guided alcohol ablation was
performed by Charboneau et al.
[7] to avoid the repeated
operation of their patient. Recently, Bennedbaek et al.
[8] successfully used a
sonographically guided laser for ablation of a parathyroid adenoma.
During the past decade considerable advances have been made in
miniaturizing catheters and improving the steerability of guidewires. Such
materials allow transvascular access to lesions in high-risk areas and the
application of toxic agents.
We recommend this minimally invasive procedure, especially in patients with
high perioperative risk.
References
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Introduction
Case Report
