RCAAP Repository

Morestin syndrome (MS) is a rare clinical manifestation consequent to an acute compression trauma to the thorax. In such an event, the sudden elevated pressure that happens to the airway and the rapid and retrograde blood flow results in capillary rupture in the head and neck vessel territory. This case reports a car accident victim that was dragged by a truck down a road with closed thoracic trauma resulting in MS. The patient presented with ecchymotic mask, neck and facial cyanosis and petechiae, ocular hemorrhage, otorrhagia, left clavicle fracture and spleen laceration that resolved with conservative measures. In this article, the authors present a specific acute syndrome due to trauma, with potential severe complications that should be recognized early and subject to a multidisciplinary and systemic approach in the emergency setting.

Inflammatory myofibroblastic tumours (IMTs) are rare lesions. We report a case of a 55 year-old male, admitted with a pneumonia. Further investigation revealed a left lower lobe mass and enlarged mediastinal lymph nodes. Cytology of the bronchoalveolar lavage suggested a squamous cell carcinoma. He received four cycles of chemotherapy followed by a left lower lobectomy. Pathological analysis was compatible with IMT. Three months after surgery, a new IMT nodule located in the lingula was excised. Four months later,endobronchial involvement and the presence of liver nodules were detected.Ten months after the first surgery a CT revealed a sacrum lesion. Histology was compatible with undifferentiated sarcoma and a sarcomatous transformation was assumed.

Background: Fire breather´s lung is a rare condition that occurs after hydrocarbon aspiration. Case reports published experienced a good clinical outcome with conservative treatment. To our knowledge, there are no reported cases treated with pulmonary resection. Case presentation: We report the case of a 35-year-old female trapeze artist, who suffered an accidental ingestion/ aspiration of liquid paraffin. Persistent fever and elevated inflammatory markers without clinical improvement with antibiotics and bronchoscopy was seen. Computed tomography scan showing middle lobe necrosis and abscess motivated a middle lobectomy for infection control. Postoperative recovery was uneventful. Conclusion: There are some cases described in the literature, normally with a favourable evolution with conservative treatment. Therefore, it is important to acknowledge that, in patients where serious complications have arisen, despite medical therapy, surgery may have an important role, and resection of the necrotic lung may prevent its potential life-threatening consequences.

Axillary artery injuries due to penetrating trauma are relatively uncommon. Management of these injuries is challenging due to the complex local anatomy, rigid chest walls, and associated injuries. Open exposure with direct open vascular repair has been the mainstay of operative management. We report a clinical case of a 51-year-old man victim of penetrating trauma to the axillary artery caused by a chain-saw and repaired by open surgery with a great saphenous vein interposition graft.

Renal artery aneurysms are rare. The indication for treatment at 20mm diameter comes from studies conducted before the advent of cross-sectional imaging. We present a case of a 61years-old woman with a 23mm saccular right renal artery aneurysm under surveillance for 6 years without growing.

During placement of a central venous catheter into the right subclavian vein it was found to be impossible to extract the guidewire. An Angio-Computed Tomography was performed, showing an aberrant guidewire path, as the image shows. An urgent mini-sternotomy was performed to extract both catheter and guidewire under direct visualization.

Male, 71 years old, active smoker. Referred to our outpatient clinic due to right upper lobe nodule with 4 year follow-up, which increased in size and metabolic uptake during the last year. CT scan also revealed multiple pleural plaques with a diffuse pattern. The patient underwent a right upper VATS lobectomy and mediastinal lymphadenectomy after intraoperative pathology consultation was positive for malignancy. Intraoperative with evidence of multiple hyline pleural plaques and aberrant neoformative lesions, mimicking teeth, on the diaphragm and parietal costal pleura, probably related to asbestos exposure.

An 87 year-old male presented with a 71mm proximal anastomotic aneurysm causing left renal artery displacement (Figures 1 and 2), 19 years after infra-renal aorto-aortic grafting for an infra-renal abdominal aortic aneurysm. Dilatation of visceral aorta was also observed. Management would be challenging but patient denied further intervention.

Computed tomography showing portal and mesenteric venous gas and intestinal pneumatosis, rare radiological signs that, together, favor the diagnosis of mesenteric ischemia (70% of cases). When present, mortality is around 40-90%. Surgical exploration is mandatory with assessment of the extent of intestinal ischemia and appropriate treatment.

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Background: Complex pathology of the Thoracic Aorta constitutes a challenge, needing a complex and multidisciplinary approach. The hybrid stent graft prosthesis E-vita OPEN PLUS™ avoids a two-stage surgical approach in the surgical treatment of complex thoracic aortic disease. The E-vita Open Plus™ is estimated to generate cost savings compared with current two-stage repair from about 2 years after the procedure. Methods: Between February 2017 and July 2019, a total of 6 patients, underwent one stage surgery for treatment of multisegmental thoracic aortic disease with hybrid stent graft prosthesis E-vita OPEN PLUS™ We collected the data from our records and compared them to the International E-vita Open Registry (IEOR), regarding ischemic and operative times as well as adverse events monitored during follow-up. Results/Discussion: The average patient age was 56 years (range: 36-76 years). The average Cardiopulmonary Bypass, Aortic Cross Clamping and Circulatory Arrest times where 204, 86 and 63 minutes respectively. The recovery after procedure had fewer complications and the length stay was less than described in literature. There was no in-hospital mortality. In all patients there was a reduction of aneurysm sac size and positive aortic remodeling and all where asymptomatic in regard to cardiovascular symptoms. Conclusions: The use of E-vita OPEN PLUS™ seems a safe and efficient option for patients with complex aortic arch pathology. In our experience, surgery allowed treatment of extensive thoracic aortic diseases with satisfactory short- and mid-term results.

Peripheral Arterial Disease (PAD) is a prevalent condition that predisposes the patients to major cardiovascular events. The majority of patients are asymptomatic, however PAD has a great impact in the patients’ lifestyle due to its chronic nature. The Peripheral Arterial Questionnaire (PAQ) is a validated tool to quantify the patients’ subjective experience of the disease. The aim of this work is to validate the Portuguese version of PAQ. A retrospective study of 59 patients with aortoiliac disease Trans-Atlantic Inter Society Consensus (TASC) type D from two centers in Portugal was conducted. Only 36 patients were able to answer the PAQ and two Portuguese validated questionnaires – a disease-specific (Walk Impairment Questionnaire – WIQ) and a generic one (EuroQol 5 dimensions – 5 level EQ5D-5L). Convergent validity of the PAQ was evaluated by correlating the extracted PAQ subscales and Summary score with the WIQ subscales and summary score, as with EQ5D-5L Summary score and EQ5D-5L index by calculating the covariance. The Portuguese version of the peripheral artery questionnaire presented a Cronbach’s α for the Summary scale of 0.913. Mean inter-item correlation for the Physical Function domain was 0.471, 0.551 for the Perceived Disability, and 0.464 for Treatment Satisfaction. In summary, the Portuguese version of PAQ demonstrated a good level of discrimination between patients with or without symptomatic PAD and its severity and was sensitive to the presence of risk-factors relevant for PAD.

Introduction: Venous Thromboembolism (VTE) is an important cause of morbidity and mortality. The risk of recurrence could be very high without thromboprophylaxis. New oral anticoagulants (NOACs or DOACs) represent a new step in anticoagulation. Material and Methods: We searched for papers with trials, systematic reviews and meta-analysis involving NOACs in the treatment and secondary prevention of VTE. We also searched for guidelines of two medical societies (American College of Chest Physicians and International Society of Thrombosis and Haemostasis - ISTH). Results: Six RCT (randomized controlled trial) comparing NOACs with Warfarin shew a non-inferiority in relation with recurrent VTE and major bleeding. Two RCT (SELECT-D and Hokusay cancer) and one meta-analysis shew low recurrence rate of VTE in cancer patients and higher rate of bleeding, mainly in gastrointestinal and genitourinary cancers. There are two RCTs involving NOACs in treatment of patients with Antiphospholipid Syndrome (APS). Discussion: NOACs shew non-inferiority over AVK. Guidelines of CHEST 2016 recommend NOACs for VTE treatment in no cancer patients, and Low Molecular Weight Heparin (LMWH) for cancer patients. ISTH suggest NOACs as the first option in VTE cancer patients with low risk of bleeding. A recent RCT shews no benefit and increased risk of vascular events in APS patients treated with NOACs. NOACs are the gold standard for VTE treatment and secondary prevention in no cancer patients. They could be the first option in cancer patients with low risk of bleeding.

Aortoesophageal fistulas are uncommon, dreadful vascular events, most frequently found in the setting of thoracic aorta aneurysms. Patients usually present with thoracic pain, dysphagia and sentinel hematemesis - the Chiari triad - followed by life threatening hematemesis. Emergent open surgery with debridement of necrotic tissue and in situ aortic graft repair is currently the best strategy. However, in patients which cannot withstand surgery, endovascular repair is currently gaining acceptance as a palliative treatment or as a bridge to surgery. We present a case of a 55-year-old female with a past of heavy alcohol abuse and a previously unknown massive aortic aneurysm, who presented to the emergency department complaining of acute dysphagia and epigastric pain. An abdominal ultrasound revealed left pleural effusion and suspected clots in the pleural space. A thoracic CTA was promptly done, where a spontaneous ruptured aortic aneurysm with aortoesophageal fistula was discovered. The team, fearing open surgery due to poor cardiac function, opted for a thoracic endovascular aortic repair. The aortoesophageal fistula dissected the esophageal wall in all of its thickness without rupture into the lumen. This was complicated with esophageal ischemia, aneurysmal sac infection and mediastinitis. Because the patient was in shock, in order to help control the infection, an esophageal prosthesis was placed, followed by proximal esophagostomy, distal esophageal closure and gastrostomy. Six months after initial presentation, the patient died at the emergency room, shortly after reentering with massive hematemesis and hypovolemic shock of undetermined origin.

The authors present the case of a previously healthy, 22-year-old male nonsmoker who sought emergency room treatment complaining of retrosternal pain. He reported a history of odynophagia two days before, followed by productive cough, fever and dyspnea. On chest radiography, a line could be observed surrounding the heart and the continuous diaphragm sign. The chest computed tomography scan confirmed the presence of pneumomediastinum and soft tissue emphysema. The case was discussed in a multidisciplinary team, and the possibility of surgical intervention was rejected. Conservative treatment was decided with complete resolution of the pneumomediastinum.

Pericardial effusions have multiple causes and when significant percutaneous drainage is standard. Usually removal is a simple and quick procedure with reduced risks. Still, the authors present a case were the drain surrounded the heart and great vessels, causing severe pain, bradycardia and hypotension when pulled, forcing a surgical removal of the same.

A 77-year-old female Caucasian patient with known Takayasu’s arteritis diagnosed at 20 years of age was admitted to the emergency department due to diffuse sudden- -onset abdominal pain. On physical examination, femoral pulses were feeble. Laboratory results were unremarkable. Abdominal CT angiography showed a long abdominal predominantly infra-renal aortic stenosis (Figures 1 and 2).

50-years-old male with three vessels coronary lesions. Intraoperatively thickened constrictive pericardium with multi-loculated hematic effusion. Ante-phrenic pericardiectomy was performed and the heart released posteriorly, allowing mobilization. Off-pump LITA to LAD and SVG to PD anastomosis were performed. Post-operative uneventful. Histology confirmed chronic, idiopathic inflammation. A rare and challenging surgical procedure.

Fourty-eight years old woman with history of non- -Hodgkin's lymphoma, treated with chemoradiotherapy. Mammary MRI shows multiple varicose veins along the breast parenchyma. CT angiography showed superior SVC obliteration at the azygos vein with marked subcutaneous collateral circulation. This is a superior vena cava syndrome due to non-Hodgkin's lymphoma.

Healthy man with a history of accidental aspiration of a screw into the bronchial tree. Evolution with unappreciated cough and sputum, with late diagnosis of pneumonia. He underwent therapeutic rigid bronchoscopy, evolving with extensive necrotizing pneumonia, hypertensive pneumothorax and pneumomediastinum requiring venous venous ECMO. Death on D6 of ECMO.