RCAAP Repository

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Introduction: Thoracic Endovascular Aortic Repair (TEVAR) has enabled the treatment of aortic pathology that previously required open surgery, with higher morbidity and mortality. The need for a favorable landing zone (Lz), without compromising the patency of the supra-aortic vessels meant that Ishimaru Lz 2 was the most proximal technically feasible Lz. We developed a hybrid technique for the creation of a more proximal Lz in high risk patients - in the first stage, debranching/ rerouting of the supra-aortic vessels, with or without ascending aorta replacement, was performed; a few weeks later, a TEVAR with a LZ in the distal ascending aorta was performed. This technique allowed the avoidance of the more aggressive total arch and proximal descending aorta replacement (Elephant Trunk or Frozen Elephant Trunk - FET) in high risk patients. We reviewed all patients who underwent hybrid arch surgery in our Department to create a more proximal Lz that allowed safe TEVAR stent placement. From November 2007 to October 2019, 15 patients required hybrid surgery to achieve treatment - 9 by replacing the ascending aorta and debranching supra-aortic vessels and 6 by debranching and re-routing supra-aortic vessels to the native ascending aorta. All underwent computed tomography angiography within 30 days of surgery and had follow-up with annual appointments and imaging control. Patients’ average age was 65.5 (+/- 11.5) years, 73.3% being male. Average follow-up was 54.7 (+/- 46.2) months. The most common diagnosis was thoracic aortic aneurysm (66.7%), followed by chronic type B aortic dissection (20.0%), pen- etrating atherosclerotic ulcer (6.7%) and reintervention due to endoleak (EL, 6.7%). No in-hospital mortality was registered. ICU and hospital stay was 1.3 (0.8) days and 9.8 (10.3) days, respectively. Survival at 1- and 5- years was 84.6% and 65.8%, respectively. No EL was detected in 66.7% (n=10) of patients. Incidence of early EL was 20.0% (n=3), of which two-thirds had spontaneous resolution, and late EL was 13.3% (n=2). Endovascular reintervention was required in one patient. TEVAR in the context of hybrid surgery is associated with low morbidity and mortality, with a low incidence of EL and good early and long term survival.

Introduction: Mediastinal staging is a hot topic in thoracic oncology. According to the guidelines, and besides other criteria, in the presence of a primary lung cancer with increased mediastinal lymph node uptake on PET-CT, a negative result after lymph node sampling by Endobronchial Ultrasound (EBUS) is not enough to rule out mediastinal lymph node involve- ment, demanding a cervical mediastinoscopy to vouch for the results. Methods and Objectives: In order to study the percentage of lymph node surgical upstaging in patients with neg- ative mediastinal node staging by EBUS and evaluate the role of mediastinoscopy in these patients, we conducted a search in our department’s database using the key-word EBUS in the period concerned between January 2014 and August 2020. A total of 302 patients were found. After applying defined criteria, we obtained 42 cases. Results: Lymph node surgical upstaging occurred in 11 (26%) patients, of which 8 were upstaged to N2 and 3 to N1. Most of the cases were single station. Only in 5 (12% of the total) of the 11 patients, the upstaging was related to lymph node stations previously sampled by EBUS. Upstaging was more frequent among males and lower lobe tumours. Discussion and Conclusions: Regarding the 8 upstage cases for N2, 5 were single station. Of these 8 cases, only 5 would be approachable by cervical mediastinoscopy. Furthermore, 2 of them were single station, eligible for upfront surgery. Then, only in 3 (7%) of the 42 cases cervical mediastinoscopy would be of foremost importance.

Objectives: Identify risk factors for major perioperative complications (MPC) after anatomical lung resection for NonSmall-Cell Lung Cancer (NSCLC) and establish a scoring system. 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: previous lung surgery, concomitant non-lung cancer related procedures, urgency surgery. Study population: 520 patients. Primary end-point: MPC defined as a composite endpoint including at least one of the in-hospital complications. Univariable and Multivariable analyses were developed to identify predictors of perioperative complications and create a risk score. Discrimination was assessed using the C-statistic. Calibration was evaluated by Hosmer and Lemeshow test and internal validation was obtained by means of bootstrap replication. Results: Mean age of 65 years and 327 (62.9%) were males. Mean hospital stay of 9 days after surgery. Overall MPC rate was 23.3%. Male gender, hypertension, FEV1<75%, thoracotomy, bilobectomy/pneumectomy and additional resection were independent predictors of MPC. A risk score based on the odds ratios was developed - Major Perioperative Complications of Lung Resection (MPCLR) scoring system - and ranged between 0 and 14 points. It was divided in 5 groups: 1-2 points (positive preditive value 15%); 3-4 (PPV 25%); 5-7 (PPV 35%); 8-9 (PPV 60%); >10 points (PPV 88%). The score showed rea- sonable discrimination (C-statistic=0.70), good calibration (P=.643) and it was internally validated (C-statistic=0,70 BCa95% CI,0.65-0.79). Conclusions: This study proposes a simple and daily-life risk score system that was able to predict the incidence of perioperative complications.

Introduction: A recent survey revealed that most pediatric surgeons use intraoperative fluoroscopy and routine postoperative chest radiography for catheter tip location in central line placement. The aim of this study is to review all cases of ultrasound-guided central line placements and to evaluate the role of postoperative chest radiography. Methods: Retrospective data analysis of children submitted to percutaneous central line insertion under ultrasound control over a 2-year period in a pediatric surgery department. Data collected included: age, indication for central venous access, catheter type, usage of intraoperative fluoroscopy and postoperative chest radiography, complications, and whether chest radiography dictated any catheter-related intervention. Results: Fifty-five long-term central lines were successfully established in children aged between 1 month and 17 years. All patients had the catheter tip position confirmed either by intraoperative fluoroscopy (96%), chest radiography (85%) or both (82%). Catheter tip overlying the cardiac silhouette (right atrium) on chest radiography was reported in 4 cases; these findings led to no change in catheter positioning or other catheter-related intervention. There were no catheter-related complications. Conclusions: Percutaneous central line insertion under US-control is safe and effective even in small children. Post- operative chest radiography did not dictate any modification of catheter tip positioning after central line placement with ultrasound and fluoroscopic control or identified any other complication, thus should not be used routinely.

Introduction: Transthoracic biopsies under fluoro-computer tomography (CT) guidance play an important role on the diagnosis and management of lung nodules, permitting histological examination and differentiation between benign and malignant lesions(1). Furthermore, with recent advances in target therapy, it is increasingly necessary to obtain tumor tissue for the analysis of molecular fingerprints allowing personalized treatment(1). Although many studies report low complication rates for this procedure, they are not negligible, urging the need for a structured and reproducible guide to reduce technique-related complications(1,2).

Introduction: Near infrared spectroscopy is a non-invasive method to assess regional oxygenation and is being used in transcatheter aortic valve implantation to document periods of cerebral hypoperfusion, where cerebrovascular events are one of the most feared complications. Alkaptonuria is a rare metabolic disease characterized by accumulation of homogentisic acid in tissues and body fluids. The accumulation of pigment might interfere with the absorption of near infrared light, used in near infrared spectroscopy monitoring. We present a case of near infrared spectroscopy failing to accurately monitor cerebral oximetry in a woman, with alkaptonuria, undergoing a transcatheter aortic valve implantation.

Introduction: Solitary fibrous tumor of the pleura (SFTP) is a rare neoplasm that accounts for less than 5% of all pleural tumors. We present the case of a 73-year-old man with a history of recurrent episodes of severe hypoglycemia secondary to a large malignant SFTP. This paraneoplastic manifestation of SFTP occurs in less than 5% of cases and is referred to as Doege-Potter syndrome. Although rare, this is an important and reversible cause of hypoglycemia, which is resolved by complete surgical resection of the tumor. We describe the pathogenesis, diagnosis, and treatment of Doege-Potter syndrome. Key imaging findings and pathologic correlation are shown.

Introduction: Osteosarcoma is the most common primary bone tumor in children and young adults. Although osteosarcoma is a tumor with a great metastatic potential, mainly to the lung; pleural metastasis in patients with osteosarcoma are rarely reported. We present a case of 16 years-old male with a pleural metastasis of a tibial osteosarcoma diagnosed 4years earlier. He was submitted to a left thoracotomy and intra-operatively a pleural mass and a left upper lobe lesion was identified. Video-assisted resection of the extra-pulmonary mass and a wedge resection of the left upper lobe lesion was performed. The surgery was uneventful. The patient is clinically well, asymptomatic, maintains active surveillance.

Introduction: Phlegmasia cerulea dolens is a potentially life-threatening complication of deep venous thrombosis, causing marked swelling and sudden severe pain in the limb, associated with cyanosis, edema and compartment syndrome that together compromise arterial supply. There is no consensus on its treatment. Case Report: A 36-year-old woman, with a history of cosmetic surgery 8 days before admission (abdominal liposuction), was admitted to the emergency department with edema, cyanosis, severe pain, decreased temperature and tenderness of the left lower limb. At physical exam, no distal pulses on the left lower limb were found. Angio-CT was performed, showing occlusion of left femoral vein, external and common iliac veins. The patient started treatment with enoxaparin (80 mg, subcutaneous, bid) and percutaneous mechanical thrombectomy (PMT) of the left iliac vein sector was performed, followed by balloon angioplasty and stenting of the left iliac vein sector. It was also deployed a temporary filter in the inferior vena cava. Thrombophilic workup was negative. The patient presented thorough clinical remission after the procedure (Villalta score 0). Two years after surgery, the patient is asymptomatic, and the Doppler ultrasound is unremarkable concerning morphologic changes throughout the left iliac vein sector. Conclusion: The treatment of phlegmasia cerulea dolens is challenging due to its severity and poor prognosis. Minimally invasive procedures, such as PMT can be an alternative to open surgery. It can also avoid the use of thrombolytics in patients with relative / absolute contraindications to its use.

Femoral vein duplication is an anatomical abnormality with high prevalence in general population. Its diagnosis is through imaging exams, with greater emphasis on Doppler ultrasonography. The identification is crucial because it masks the clinical symptoms of deep vein thrombosis. Besides being an important anatomical pathway and, while in duplicity, it can be used as a possible vascular substitute, therefore making the knowledge of the anatomical path and its variants essential. Ultrasonography has attractive advantages over other methods, collecting data from patients in physiological conditions with- out the need of contrast, or exposure to ionizing radiation, providing anatomical details of the venous system and anatomical variations. When thrombus is suspected in a duplicated segment, examination of the lower limb with anatomical variation should not be used to justify the presence of duplication in the contralateral limb.

An 84-year-old woman, with background history of atrial fibrillation, cerebral vascular disease, ischemic heart failure by coronary disease with several stent implantation, presented in the emergency room with syncope. The chest radiograph evidenced the coronary trajectory by their calcification.

A 67-year-old man with fatigue and dyspnea, in NYHA class IV, was admitted to our hospital. His evaluation, physical examination, and other investigations were carried out. An atypical finding was found and he was referred for cardiac surgery.

A 23-year-old man presented with fever and cervical swelling. Contrast-enhanced CT-scan with oblique sagittal planes reconstructions with extensive collection with gaseous areas, involving multiple cervical and mediastinal spaces is shown, reflecting a cervical-mediastinal necrotizing fasciitis. Note the circumference to the laryngotracheal axis. He underwent combined surgery by ENT and thoracic surgery and was discharged without sequelae after long hospitalization. This case demonstrates the importance of working in a multidisci- plinary team to treat complex pathologies.

A 85 year-old, female patient, with an active colon neoplasm, was diagnosed with extensive ilio-femoro-popliteal deep vein thrombosis. She presented with severe oedema of the left lower limb and a cyanotic foot. Pedal pulses were palpable. Despite immediate anticoagulation, the patient expired at 72h.

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