Preoperative embolization of thyroid arteries in a patient with a large cervicomediastinal hyperfunctioning goiter

We present the case of a 61-year-old male patient with chronic obstructive pulmonary disease and a large cervicomediastinal multinodular hyperfunctioning goiter that made thyroidectomy a daunting task, especially considering the risk of intraoperative bleeding. The preoperative computed tomographic (CT) scan showed the right thyroid lobe very deeply rooted in the mediastinum, below the horizontal plane passing through the aortic arch. The thyroid mass imprinted the arterious and venous innominate trunks. To avoid a median sternotomy and remove the enlarged thyroid through a cervical approach alone, we decided to reduce the goiter in volume preoperatively by embolizing the thyroid arteries. We embolized the superior and inferior left, and the inferior right thyroid arteries. We spared the superior right thyroid artery because its blood supply contributed little to thyroid perfusion. After embolization, the patient was treated with antithyroid agents and corticosteroid drug therapy. At the same time, severe leukocytosis developed, thyroid hormone values increased, and a CT scan obtained 7 days after embolization showed the thyroid unchanged in volume. We therefore discharged the patient and were waiting for his laboratory blood chemical findings to return to normal. Thirty days later the patient was readmitted to hospital, and a new CT scan showed that the thyroid mass had diminished to half its initial volume. We could therefore perform a total thyroidectomy through a cervical approach alone. The only problem arose in dissecting tight right inferior laryngeal nerve adhesions to the thyroid capsule, probably sequelae of postembolization thyroiditis. Even though preoperative thyroid-artery embolization cannot be considered a routine technique in cervicomediastinal goiter surgery, in a rare patient who presents with a voluminous goiter such as the one we describe here, it is a useful procedure.