RCAAP Repository

A 26 year old male, submitted to resection of a ganglioneuroma of the right pulmonary apex through a right Grunenwald approach. The mass insinuated through the innominate vessels, extending posteriorly to the subclavian artery, which it encircled for over 180 degrees, and the right thyrocervical arterial trunk, which was ligated.

A 42 years-old female presented with right inguinal swelling with one year of evolution. Magnetic resonance imaging was suggestive of inguinal endometriosis adherent to femoral vessels. Due to the rarity of this pathology (prevalence 0.3-0.6%), clinical suspicion is essential. Surgical excision is the treatment of choice.

A 48 year-old female patient presented with arterial hypertension. Computed tomography angiography revealed small stenoses alternating with areas of dilatation (due to small fusiform aneurysms) in the middle to distal portions of the main renal arteries, creating a “string of beads” appearance, findings in keeping with fibromuscular dysplasia.

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Rib fractures are frequent in trauma patients, being most of them managed on a non-surgical way. However, in selected cases, it is advocated. Chest wall stabilization (CWS) only recently has been best characterized. Available data shows plenty of benefits related to CWS versus non-surgical treatment in selected cases. Even though, it is only performed in a small number of patients according to some national databases. There are lots of topics to define concerning CWS such as the subgroups that benefit most, the time of surgery, which ribs should be stabilized and which incision should be performed. Most of these subjects need to be tailored for each patient. So far, no guidelines for CWS are available, although some algorithms have been proposed based on a combination of clinical experience and risk factors. In high-volume trauma centers it has become a common procedure. The complexity of some cases demands a careful evaluation, especially in the context of multiple injuries, and it should be taken into account in the decision.

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Background: A transient postoperative drop in platelet count is an expected finding after aortic valve replacement using extracorporeal circulation. The implantation of the Perceval valve has been associated with a more intense drop of platelet count compared to other bio-prostheses. This study analyses and compares the platelets progression associated with the Perceval and Intuity valves. Methods: The data was collected retrospectively for patients submitted to isolated aortic valve replacement with the Perceval valve (80 patients) and the Intuity valve (141 patients) in our institution between March 2014 and December 2018. The groups were further divided into those who receive platelet transfusion and those who did not. Results: The minimum values of platelet count were 54% and 67% of the preoperative platelet count in the patients treated with a Perceval and an Intuity valves, respectively (p<0.001). In the patients transfused with platelets, the minimum values were 52% and 79% of the preoperative platelet count, respectively (p<0.01). Recovery of the count was faster in the patients treated with an Intuity valve. Abnormal bleeding and transfusion of packed red blood cells were not significantly different between groups (without platelet transfusion: p=0.71 and p=0.99, respectively; with platelet transfusion: p=0.58 and p=0.99, respectively). Conclusion: Compared to the Intuity valve, the Perceval valve is associated with a transient, but significant, drop in platelet count. This drop was not associated to an increased risk of bleeding. Platelet transfusion, in this setting, should be judicious and not only ruled by absolute values.

Patients undergoing angioplasty and stent insertion require double prophylactic anti-aggregation or monotherapy. This is a challenging procedure with a high risk of morbidity and coronary mortality. The aim of this protocol is to provide guidelines for a presurgical approach to patients with a coronary stent who will be undergoing non-coronary surgery. This protocol highlights potential complications that may occur, namely those related with the cardiac stent and the evaluation of cardiac risk, and notes the thrombotic and hemorrhagic risks associated with the surgical procedure and the decision algorithms for both elective surgery and urgent surgery involving the suspension and re-introduction of antiplatelet therapy. Our main goal is to outline an optimized approach to these cases in order to improve cardiac outcomes and to minimize the risk of complications.

Objectives: Primary spontaneous pneumothorax (PSP) is defined as a pneumothorax without obvious underlying lung disease. Definitive treatment should be offered to patients with recurrent or persistent PSP. The aim of this study was to compare the effectiveness of medical pleurodesis (MP) with video assisted thoracic surgery (VATS) on definitive treatment of PSP. Methods: 10 years’ retrospective study of PSP patients that underwent VATS or MP. Baseline characteristics, perioperative and follow-up data were compared. Results: A total of 133 patients were included (MP=54; VATS=79). Baseline characteristics were similar between groups, with a male predominance (MP 83.6 vs VATS 85.5%) with a mean age of 24.78 and 25.81 years old, respectively. Post interventional length of hospital stay was similar (MP 4.94 vs VATS 4.47 days, p=0.20), but chest tube duration was longer in the VATS group (MP 2.94 vs VATS 3.56 days, p=0.03). The overall complications rate was low with no statistically significant difference between groups (MP 5/54 vs VATS 7/79, p=1.00). Regarding the follow-up, MP had a significant higher PSP recurrence rate (MP 11.1% vs VATS 1.3%, p=0.042), most occurring over the first two years. Conclusion: Despite both MP and VATS are safe methods with short hospital stay and few complications associated, the results of this study show that VATS had a significantly lower rate of recurrences. Overall, VATS should be offered as the first line treatment to patients with PSP.

Objective/Background: Peripheral artery disease (PAD) is an important manifestation of systemic atherosclerosis. Obesity is a risk factor for atherosclerosis and for cardiovascular events. However, the relationship between obesity and PAD is unclear. We hypothesized that anthropometric measures of adiposity, in particularly of central obesity will be associated with PAD severity, in patients undergoing aorto-bifemoral bypass. Methods: A prospective observation study was conducted. From 2009 and 2012 a total of 46 males who underwent aorto-bifemoral bypass were enrolled prospectively. 17 with intermittent claudication (IC) and 29 with chronic limb threatening ischemia (CLTI). They were followed for 5 years. The anthropometric measures, weight, body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and the seric levels of hemoglobin, triglycerides, and albumin were recorded. The mortality and cardiovascular events in following five years were also registered. Results: The groups did not differ in the mean age (IC 60.69±7.46 versus CLTI 64.51 ±8.42 years, p=0.712), diabetes (IC 18% versus CLTI 45%, p=0.06), hypertension (IC 70% versus CLTI 52%, p=0.21), hypercholesterolemia (IC 18% versus CLTI 45%, p=0.47) and smoking habits prevalence (IC 100% versus CLTI 86%, p=0.11). The anthropometric measures: weight, WC and WHR were significant lower in CLTI compared to IC patients (IC 72.74±9.84 Kg versus CLTI 65.92±10.89 Kg, p=0.043; IC 98.65±8.19 cm versus CLTI 89.38±15.91 cm, p=0.017; IC 1.06±0.06 versus CLTI 1.01±0.06, p=0.038). The serum levels of hemoglobin, albumin and triglycerides were also lower in CLTI patients (IC 14,40±1.63g/dL versus CLTI 13.3±1.89g/dL, p=0.048; IC 4.6±0.81g/dL versus CLTI 4.3± 0.67g/dL, p=0.007; IC 212±95.60mg/Dl versus CLTI 111±41.53 mg/dL, p=0.001). No relation was found between the anthropometric measures at admission and the cardiovascular events or mortality at five years. Conclusion: CLTI patients had lower anthropometric measures of obesity, when compared to IC patients. These results could be explained by the fact that CLTI patients with severe atherosclerotic disease are in a state of chronic inflammation, with consequent cardiometabolic demands and catabolism.

Tetralogy of Fallot is very prevalent with correction techniques well standardized. Whenever infundibular incisions are needed, patch reconstruction seems mandatory. Recently, the small intestinal submucosal (CorMatrix, MAC’s Medical Group,) patch was introduced, with optimal results in pre-clinical studies. However, clinical results do not match its pre-clinical promises, particularly when used in right ventricular outflow tract and pulmonary artery reconstructions. We describe a case of Tetralogy of Fallot for which small intestinal submucosal (CorMatrix) patch was used as a trans-annular patch, with development of a massive pseudo-aneurysm.

Alkaptonuria is an autosomal recessive inborn error of metabolism of the aromatic amino acids. Deficiency of the homogentisate1,2-dioxygenase leads to an increased blood and urinary concentration of homogentisc acid resulting in a slow accumulation of its oxidation products in the connective tissues (ochronosis). The most common clinical manifestation of ochronosis is arthropathy whereas cardiac involvement is very infrequent. We report the case of a patient with ochronotic involvement of the aortic valve who underwent a valve replacement. Some aspects of pathogenesis, and treatment are discussed.