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Introduction: Atrial fibrillation (AF) contributes to increased morbidity and mortality. Pharmacological and percutaneous catheter therapies are unsatisfactory, with potential serious adverse effects. Cox-Maze III/IV surgery, with higher rates of success, has not been widely adopted because of the associated complexity of the procedure. Methods: We performed a retrospective analysis of the first patients submitted to surgical ablation of AF with occlusion of the left atrial appendage with a totally videothoracoscopic (VATS) approach in our institution. We describe the surgical technique and our results, including duration of surgery, hospital stay, complications and maintenance of sinus rhythm after surgery, at 6, 12 and 18 months of follow-up. Results: We studied 15 patients (ages ranging from 39 to 75 years old; 54,5% female gender). Mean time since the diagnosis of AF was 5,75 years. All had been submitted to prior catheter ablation (mean of 2 attempts). Mean diameter and volume of the left atrium was 42 mm (M-mode) and 70 ml (43 ml/m2), respectively. Mean duration of surgery was 2 hours and 22 minutes. In one patient we had to convert the surgery to median sternotomy. Mean hospital stay was 4,8 days. Mean time of follow-up was 12 months. During follow-up, 91%, 90% and 80% of the patients were in sinus rhythm at 6, 12 and 18 months, respectively. Conclusion: This surgical approach represents a real benefit for those patients with multiple attempts of catheter ablation without success. However, a larger sample of patients with a longer period of follow-up is necessary for further conclusions.

Introduction: The risk stratification of lung resection is fundamentally based on the results of pulmonary function tests. In patients considered to be at risk, major surgery is generally denied, opting for potentially less curative therapies. Objective: To evaluate the postoperative outcomes of major lung surgery in a group of patients deemed high risk. Methods: We performed a retrospective review of clinical records of all patients submitted to lobectomy, bilobectomy or pneumonectomy in a 3-year period in a reference Thoracic Surgery Unit. The patients were then divided in two groups: group A composed of patients with normal preoperative pulmonary function and group B which included patients with impaired lung function, defined as FEV1 and/or DLCO ≤60%. Results: A total of 234 patients were included, 181 (77.4%) in group A and 53 (22.6%) in group B. In group B, patients had more smoking habits, were more often associated with chronic obstructive pulmonary disease and were also more frequently submitted to thoracotomy. When surgery was motivated by primary lung cancer this group had a more advanced clinical stage of the disease. In the postoperative period, these patients had longer hospital stay, longer chest drainage time and greater need for oxygen therapy at home, however, no statistically significant difference was noted in morbidity or mortality. Conclusions: Major thoracic surgery can be safely performed in selected patients considered to be high risk for resection by pulmonary function tests. A potentially curative surgery should not be denied based on respiratory function tests alone.

Objectives: Compare the incidence of Postoperative atrial fibrillation (PAF) after anatomical lung resection for Non- Small-Cell Lung Cancer (NSCLC) following open surgery versus VATS. Methods: Single center retrospective study of all consecutive patients diagnosed with NSCLC submitted to anatomical lung resection from 2015 to 2019 (N=564). Exclusion criteria: prior atrial fibrillation, previous lung surgery, concomitant procedures, pneumectomy, non-pulmonary resections, urgency surgery. Study population of 439 patients. Primary end-point: incidence of PAF. Univariable analysis was used to compare the baseline characteristics of the 2 groups. Inverse probability of treatment weighting (IPTW) multivariable logistic regression was used including 23 clinical variables to analyze the effect of the approach. The balance was assessed by standardized mean differences. Results: Thoracotomy was performed in 280 patients (63.8%) and 159 (36.2%) were submitted to VATS. Patients submitted to VATS were more likely to be females, had a lower prevalence of non-adenocarcinoma cancer, stage TNM IIIIV, Diabetes Mellitus, respiratory disease, and chronic heart failure. They were submitted less often to neoadjuvant therapy, bilobectomy and they presented higher levels of diffusing capacity for carbon monoxide. After IPTW adjustment, all clinical covariates were well balanced. PAF occurred in 8.6% of the patients undergoing thoracotomy and 3,8% of the patients after VATS. After IPTW adjustment, VATS was not associated with a lower incidence of PAF (OR 0.40; CI95%:0.140-1.171; p=0.095). Conclusion: In this study, minimally invasive non–rib spreading VATS did not decrease the incidence of PAF when compared with standard thoracotomy regarding anatomical lung resection for NSCLC.

Introduction: Chronic venous disease (CVD) of the lower limbs is a very prevalent medical condition with important socioeconomic repercussions. Small saphenous vein (SSV) incompetence, although less frequent than great saphenous vein (GSV) incompetence, presents a more challenging treatment, with higher rates of complication and recurrence. Objectives: To determine the incidence and associated risk factors of varicose veins recurrence in patients submitted, for the first time and exclusively, to SSV surgery with 5 years of follow-up. Methods: Retrospective analysis of all exclusively first-time SSV surgeries, at Angiology and Vascular Surgery Service of Hospital Beatriz Ângelo, between January 1st, 2013, and December 31st, 2014. In March 2019, the authors performed clinical and venous doppler ultrasound reassessment of all included patients. Results: A total of 23 limbs were evaluated, 56.5% were female and the mean age was 51.8 years. All patients were symptomatic and underwent ligation of the saphenopopliteal junction (SPJ), 26.1% and 43.5% had total and partial SSV stripping, respectively. After venous doppler ultrasound at 5-year follow-up, we found that 21.7% did not present a correct SPJ ligation due to failure to identify its location, with a statistically significant association between SPJ ligation and varicose vein recurrence. In follow-up, we also diagnosed GSV incompetence in 21.7% for the first time, which is in agreement with the fact that this is a chronic disease. Finally, we found that all patients with symptomatic recurrence at 5-year follow-up had CVD, however, some asymptomatic patients also had ultrasound changes. Conclusion: Routine preoperative localization of the SPJ by doppler ultrasound guidance could have an impact in minimizing varicose vein recurrence. Imaging recurrence does not always translate into clinical recurrence. Because this is a chronic disease, patients should keep general care to prevent disease progression, even after surgery.

Introduction: Gluteal pseudoaneurysms are extremely rare and respond to pelvic trauma, penetrating wounds, inflammation or infection in the gluteal region. Clinical cases: Two men, 73 and 82 years respectively, who presented gluteal pseudoanerysm after drainage of perianal abscess the first one and after trauma the second one. In both cases the diagnosis was made by imaging tests (doppler ultrasound that was completed with computed tomographic angiography). The first one was successfully treated by ultrasound-guided injection of thrombin at the pseudoaneurysm sac. However, secondary treatment with thrombin injection and coil embolization was performed due to pseudoaneurysm reperfusion. The second one was successfully treated by embolization with hydrocoils through contralateral percutaneous femoral access as well as thrombin injection by direct ultrasound-guided puncture. Discussion: The incidence, presentation and surgical strategy are discussed. Current literature is also reviewed. Conclusion: Ultrasound scan is the first diagnostic test, computed tomographic angiography can give more topographic information. We found selective percutaneous embolization to be the treatment of choice. Open surgical treatment should be reserved for selected cases.

Supravalvular aortic stenosis is a rare congenital anomaly (less than 0.05% of all congenital heart defects). This aortic root anomaly consists in a narrow aortic lumen immediately above the aortic valve and represents the least common form of left ventricular outflow tract obstruction. Clinical presentation is usually in the first decades of life. In most cases, the aortic valve leaflets are morphologically normal. However, aortic insufficiency due the high systolic pressure proximal to the sinotubular junction is the most commonly abnormality described. There are very few cases described in the literature with concomitant valvular and supra-valvular aortic stenosis.

Introduction: Iliac artery aneurysms (IAA) are a rare entity with a prevalence lower than 2% in the general population involving typically the common iliac artery in 70-90%. Case-report: This is the clinical case of an 88 years-old male patient with an isolated giant IAA, 84mm maximum diameter, diagnosed following a four-month period of lower abdominal discomfort and pelvic hyperemic mass. The IAA was successfully excluded with an endovascular approach with an aorto-uni-iliac endograft Endurant II (Medtronic Cardiovascular, Santa Rosa, CA, USA) followed by a femorofemoral right to left bypass. Discussion: Asymptomatic IAA are difficult to identify due to their anatomical location deep within the pelvis but once symptomatic they are associated with a high rate of morbidity and mortality. Their management has evolved toward an endovascular first approach over the past decades, nevertheless, the type of operative repair depends on patient anatomy, clinical stability and the presence of other concomitant aneurysms.

Chest wall tumours are challenging subjects. In the present article we describe a case of a 51 year old female who developed an angiosarcoma eight years after radiotherapy treatment due to left breast cancer at age 41. She had resection of the anterior segments of the 3rd to 5thribs followed by chest wall reconstruction, using MatrixRib fixation system®, Marlex® mesh and latissimus dorsi muscle flap. After two years the angiosarcoma relapsed. Considering the predicted extent of the chest wall resection, a reconstruction using titanium plates was not an option, so we opted to shape neo-ribs of Methyl Methacrylate using rubber drains as a mold. It affords very good anatomical contour of the chest wall and more physiological function than other options, although only long-term follow-up and future studies will determine the performance of this method.

The tumours of the pleura are a vast and diverse field. One of the lesser known and less common tumour is the solitary fibrous tumour of the pleura, representing about 5% of these types of tumours. The authors present the case of a woman admitted in the emergency department with symptoms of dizziness and vomits. Imaging studies show a giant thoracic mass on the left hemithorax, with a biopsy indicating a solitary fibrous tumour. The patient was referred for surgery, which was performed via thoracotomy. In the postoperative period she developed an acute pulmonary oedema secondary to lung reexpansion and fluid overload, with a good response to fluid restriction and intravenous diuretics.

The management of abdominal aortic aneurysms, especially ruptured abdominal aortic aneurysms, continues to challenge vascular surgeons. A ruptured abdominal aortic aneurysm is associated with a high mortality rate. If cardiopulmonary resuscitation is required before surgical repair, mortality rates are said to be even higher. However, cardiac arrest in patients with ruptured abdominal aortic aneurysm does not accurately predict a nonsalvageable state or preclude functional survival. In these cases, agressive management may be the only hope for survival, and cardiac arrest should not as such contraindicate repair. The objective of this study is to present a successful case of repair of ruptured abdominal aortic aneurysm after cardiac arrest.

Saccular mycotic aorto-iliac aneurysms are rare but, when ruptured, they are an important life-threatening condition. We present the case of a 52 years-old male transferred from another hospital and admitted to the emergency room with a ruptured iliac artery aneurysm. He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Image study with computed tomographic angiography revealed a ruptured left common iliac artery saccular aneurysm. The patient was instantaneously and successfully submitted to endoaneurismorraphy of the hypogastric artery, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femorofemoral bypass. Blood culture revealed a Streptococcus anginosus and the patient received appropriate targeted antibiotics. Post-operative period was uneventful and the patient discharged ten days after admission. He has now eleven months of follow up with no intercurrences. Even though surgical approach carries a relative risk of perioperative morbidity, it is a feasible and durable solution for extreme situations like the one here described.

Hypertension is, in a minority of cases, secondary to an identifiable cause. In this context, the aetiology of the blood pressure elevation is essential since it may be treatable. We present a case of a young woman with hypertension secondary to fibromuscular dysplasia (FMD) of the renal artery in which the endovascular treatment was crucial for its management.

This large atrial mass was removed from a 33-yearold patient admitted to the emergency department for severe venous congestion. Its hard texture, grayish discolouration and wall infiltration prompted radical excision and partial atrial reconstruction. Histopathology was compatible with a thrombus, discarding malignancy.

A 40 years-old woman with a previous history of a right pneumothorax in 2013 had a left pneumothorax with persistent air leak in 2020. The computerized tomography scan of the chest described diffuse emphysematous changes with multiple “small bullae” in the upper lobes. She was submitted to mechanical and chemical pleurodesis with a wedge apical resection by uniportal video-assisted thoracic surgery. Pathological findings confirm the diagnosis of pulmonary lymphangioleiomyomatosis.

Laryngotracheobronchial papillomatosis is a rare dis- ease, with few reported cases. Histologically has been report- ed has a benign proliferation of the epithelium, limited to the larynx but it may occasionally become aggressive and result in persistent and recurrent involvement of the tracheobronchial tree, extending in more severe cases to the lungs.

An 83-year-old woman with a history of ileocecal appendix cancer underwent a staging thoracic-abdominal-pelvic computed tomography. Two extremely rare anatomic variants were identified: the right vertebral artery presented an anomalous origin from the aortic arch distal to the left subclavian artery and a retro-esophageal course; right common carotid artery agenesis.