Catheter directed thrombolysis is a minimally invasive procedure that results in a significant reduction in venous obstruction after deep vein thrombosis. The technique implies the performance of phlebographies to monitor the thrombolysis progression. The objective of this paper is to describe the use of vascular ultrasound to follow the thrombus lysis and to adjust the catheter position according to the progression of the thrombolysis. This is the first case reported describing the application of ultrasound to monitor the thrombolysis. A 36-year woman was admitted ilio-femoral vein. The ipsilateral great saphenous vein was the percutaneous access to perform the anterograde thrombolysis. The procedure, including the control of thrombus lysis, as well as catheter progression was performed under ultrasound guidance. The thrombolysis took 52 hours. The patient has two years of follow-up without any complaint. The use of vascular ultrasound to monitor the thrombolysis has several theoretical advantages in patients with adequate biotopes. It minimizes the number of venograms and can be performed at the bedside. It is effective and inexpensive.
BACKGROUND:Placement of chest drain following thoracoscopic procedures has been the gold standard. Nevertheless, a drainless approach may be safe and feasible in selected patients and procedures. In this study we aim to report our clinical experience after drainless video-assisted thoracoscopic surgery.METHODS:We retrospectively analyzed data of all subjects submitted to drainless video-assisted thoracoscopic surgery at our centre between January 1, 2010 and December 31, 2019. The preoperative clinical and surgical data and the immediate postoperative data were retrospectively evaluated through the consultation of the clinical processes and the computer registry system. We used descriptive statistics: mean or median, according to data distribution, and absolute or relative frequencies.RESULTS:We included 161 patients, mean age of 31 years (min:15; max:78). We analyzed data from patients submitted to: thoracic sympathectomy(67.1%), wedge resection, for lung biopsy, metastasis or small nodules resection (21.7%), mediastinal cysts removal (6.2%), pleural lesions resection (3.7%) and emphysematous bullae resection (1.2%). The average length of stay was 1 day. Residual pneumothorax was noted in 15 patients (9.3%). Postoperative pleural drain placement due to pneumothorax occur in 4 patients (2.5%). There was no intra-hospitalar mortality.CONCLUSIONS:Video-assisted thoracoscopic surgery without postoperative chest drain seems to be valid and safe according to our results.
INTRODUCTION:Ruptured abdominal aortic aneurysm's treatment relies on the emergent surgery, considering preoperative prognosis. There are several scores that estimate perioperative mortality of ruptured abdominal aortic aneurysm, however, the accuracy of such algorithms in some populations remains unknown.OBJECTIVE:Compare the prognostic validity of the Weingarten score with the Glasgow Aneurysm Score and the Vancouver Scoring System. Validation of three prognostic ruptured abdominal aortic aneurysms tools for the Portuguese population.MATERIAL AND METHODS:A retrospective analysis of consecutive patients with ruptured abdominal aortic aneurysm surgically treated, in a peripheral and in a referral hospital between 2012 and 2016 was performed. The 30-day mortality discriminative power was analysed using each score.RESULTS:120 patients were included. The mean Glasgow Aneurysm Score was 98.53 ± 19.57, the Vancouver Scoring System was 3.64 ± 1.43. The Weingarten score classified 51 (43.2%) patients as stable and 67 (56.8%) as unstable. The three scores demonstrated some predictive value concerning mortality, although Glasgow Aneurysm Score demonstrated the highest area under the ROC curve (0.74) and the best discriminatory capacity for cut-off points with higher specificity. Neither of the scores demonstrated clinically useful predictive value.CONCLUSIONS:The Weingarten score did not present as a superior prediction model of preoperative mortality in ruptured abdominal aortic aneurysm. None of the scores, even when optimized for a higher specificity, could select which patients will not benefit from surgical intervention. The Glasgow Aneurysm Score was validated for the Portuguese population.
INTRODUCTION:Inflammation is a common underlying feature of atherosclerosis. Several inflammatory biomarkers have been reported to have prognostic value, in several areas, including in vascular surgery. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) may permit to identify patients at greater risk for cerebrovascular events, tailor patient management, improve preoperative status and possibly develop target anti-atherosclerotic therapy. However, studies reporting usefulness of these hematological biomarkers in the context of carotid artery disease are still scarce. The aim of this study was to review the literature concerning the prognostic ability of NLR and PLR in the subpopulation of vascular patients with carotid artery disease.METHODS:A Medline search was performed in order to identify publications focused on the physiopathology of NLR and PLR and their impact in the management of patients with carotid artery disease.RESULTS:The study identified 18 articles with a total of 5339 patients. NLR is associated with carotid intima-media thickness, carotid plaques, carotid stenosis, symptomatic stenosis and intra-stent restenosis after carotid artery stenting and cognitive dysfunction after carotid endarterectomy. PLR is associated with carotid stenosis, symptomatic stenosis and predicts post-operative outcomes after carotid artery revascularization, including post-operative stroke, acute coronary syndrome and all-cause mortality.CONCLUSIONS:The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have the ability to predict sub-clinic atherosclerosis, atherosclerosis progression in carotid artery disease and propensity for carotid stenosis to become symptomatic along with morbidity following CEA and carotid stenting. Consequently, these parameters may be considered to tailored therapy and improve patient management.
Pancoast tumours are defined as tumours arising from the upper lobe and invading the thoracic inlet,representing less than 5% of all lung cancers. Clinical features depend on the involved structures. For many years invasion of the spine was considered unresectable and fatal. Due to the progress in spine surgery, en bloc resection including the spine is nowadays possible. We report the first case of a successful en bloc vertebral resection of a Pancoast tumour in a 66 year-old male, with a squamous cell carcinoma, treated at our department in a multidisciplinary setting, after induction chemoradiotherapy. An en bloc resection including the left upper lobe, the first three ribs and the vertebral body of D2, was performed through a Paulson incision after posterior cervico-dorsal arthrodesis. A complete R0 resection was confirmed on the pathology specimen. Currently, one year after surgery, although no local recurrence has occurred, the patient is being treated with immunotherapy due to disease progression in the right acetabulum which was irradiated (20Gy) and then submitted to iliac resection and prothesis reconstruction.
Foreign body (FB) aspiration in adults is usually associated with predisposing risk factors. Clinical manifestations are immediate but less frequently it could lead to insidious lung damage, as demonstrated by the presented case. We present a case of unsuspected FB aspiration, mimicking an infection vs lung tumour. After left lower lobectomy, pathology revealed a foreign body (animal bone) at the origin of the lingular bronchus.
INTRODUCTION:Congenital chest wall deformities are common in children, causing self and parental concern mainly due to cosmesis. These defects rarely cause severe symptoms in patients.CASE REPORT:11-year-old girl with a complex chest wall deformity and severe scoliosis causing progressive neurological loss of function. When mobilized to prone position for orthopedic surgery, she suffered sudden hypotension immediately followed by a cardiac arrest, that reverted after moving the child back to supine position. The cardiac arrest was interpreted as a result of a decrease in venous blood return secondary to heart and great vessels compression. She was then proposed and submitted to a modified Ravitch procedure with retrosternal metal bar placement in order to allow ventral positioning. This was successfully achieved, and the patient underwent scoliosis correction 3 months later. After more than a year of follow up, she reduced the need for non-invasive ventilation and tolerates prone positioning.CONCLUSION:This case report alerts medical community that beyond cosmesis concerns, severe chest wall deformities can cause life-threatening events if not correctly managed.
Objectives We aim to report our experience on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for postcardiotomy shock (PCS). Methods Single center, retrospective study of all patients on VA-ECMO for PCS, from November 2006 to July 2019. Pediatric and adult patients were analysed separately. Primary outcomes were survival to discharge and one-year survival. Results Twenty-nine patients were included. Pediatric group (group PED) (62%, n=18): mean age 1,3±2,1 years and 39% male. Adults (group AD) (38%, n=11): mean age 55,6±15,9 years and 64% male. Indications in group PED were complex congenital heart surgery (94%) and heart transplant (6%), with 27% being reoperations; in group AD valvular surgery (45%), aortic surgery (21%), coronary artery bypass grafting (18%) and pulmonary endarterectomy (9%); 45% were reoperations. ECMO support was initiated intraoperatively due to failure to wean from cardiopulmonary bypass in 28% of group PED and 73% of group AD. Central cannulation was performed in all pediatric patients and 82% adults. Bleeding was the most common complication in both groups (group PED 39%, group AD 45%). Mean ECMO support time was respectively 6,2±4,9 and 6,2± 3,6 days for group PED and group AD. Weaning rate was 44% in group PED (with 2 patients bridged to LVAD) and 45% in group AD. Survival to discharge as well as one-year survival were both 28% in group PED and 18% in group AD. Conclusion Despite low survival and high complication rates, VA ECMO support provides a survival benefit in refractory cases, with a dismal prognosis, that would otherwise die.
OBJECTIVES:Our objective was to examine the results of ECMO post cardiotomy in Centro Hospitalar Universitário S. João (CHUSJ).METHODS:Between 2011 and 2019, 13 patients were cannulated for refractory cardiogenic shock post-cardiotomy; 8 (61,5%) male and 5 (38,5%) female. Patients under 18 years old were excluded. Data was collected from hospital archives concerning preoperative comorbidities, open-heart surgery procedure, dates of ECMO cannulation and decannulation, postoperative complications, hospital mortality and cause of death. Follow-up was obtained by review of the last outpatient observation. The outcomes investigated were hospital mortality and survival at 12, 36 and 60 months.RESULTS:After a median ECMO-VA therapy of 6 days (1-16 days), 7 (53,8%) patients were successfully decannulated; from these 2 succumbed from stroke and septic shock, one is still in intermediate care convalescing steadily and 4 were discharged. Overall 8 (61,5%) patients died. 5 (38,5%) survived, 4 were discharged home and 1 is still in intermediate care. Survival (after discharge) at 12, 36 and 60 months was respectively 25%, 16,7% and 8,3%. Regarding postoperative complications, reoperation for bleeding was necessary in 5 (38.5%), stroke was diagnosed in 2 (15,4%), dialysis in 6 (46,2%), leg ischemia affected 5 (38,5%) and mediastinitis occurred in 1 (7,7%).CONCLUSIONS:VA ECMO saves a life in each three patients suffering from refractory cardiogenic shock after cardiac surgery. Despite risks associated with advanced cardiopulmonary support, survivors maintain good health condition.
Myxomas are the most common cardiac tumors; however right ventricular myxomas are very rare. We present the case of an asymptomatic 74 year old female with a right ventricular myxoma originating from the interventricular septum diagnosed during a routine echocardiographic examination. Initially the patient refused surgery due to being asymptomatic, but agreed to be operated two months later. Surgical removal was uneventful, as was the postoperative course. Histopathological analysis confirmed the suspected diagnosis of cardiac myxoma.
Introduction/Study Goals: Thoracic sympathectomy is considered to be the most effective treatment for hyperhidrosis, a procedure traditionally performed under general anesthesia. Nowadays it's a minimally invasive procedure, which makes it possible to perform under sedation with local anesthesia. The goal in this study was to assess the efficacy and safety of this anesthetic technique in video-assisted thoracic sympathectomy.MATERIAL AND METHODS:The study took place in Centro Hospitalar Universitário Lisboa Norte, between June 2017 and September 2019. The anesthetic technique consisted in a propofol infusion titrated to achieve a moderate to deep sedation, in addition to local anesthesia with lidocaine 2% and ropivacaine 0,75% on surgical incisions. All patients were assessed subsequently for pain and anesthetic or surgical complications, with a 30-day follow-up.RESULTS:From a final sample of 63 patients, most were female (70%), with age ranging between 15 and 57 years old. There were no intra-operative complications. On the immediate postoperative period there were only two cases of poorly controlled pain.CONCLUSION:Results showed efficiency and safety with sedation associated with local anaesthesia as an anaesthetic technique for video-assisted thoracic sympathectomy. This anaesthetic approach avoids possible complications associated with general anaesthesia and one lung ventilation, with good analgesic efficacy. However, there is still the need for a bigger sample to confirm the obtained results and to strengthen sedation as an anesthetic approach in thoracic sympathectomy.
32 years-old female patient presented with lumbar pain. Computed tomography revealed varicosity of the communicating vein between the left renal vein and the left ascending lumbar vein. This entity may pose technical difficulties during aortoiliac surgeries and renal surgeries as iatrogenic injury of this vessel may cause life- -threatening retroperitoneal hemorrhage.
59-year-old women with permanent atrial fibrillation and previous haemorrhagic stroke was admitted for percutaneous left atrial appendage occlusion. Shortly after, AmplatzerTM device migration into the left ventricular outflow tract was confirmed. Unsuccessful transcatheter mobilization led to an emergent surgery for device retrieval and LAA closure. No events at 6-month follow-up.
