Surgical Exclusion Research Articles

Post-Traumatic False Aneurysm of the Superficial Temporal Artery A Case Report and Review of the Literature

Post-traumatic false aneurysms of the superficial temporal artery are a rare entity. We report a case of temporal swelling with little pain in a 26-year-old man who had suffered a head injury one month earlier. It was an aneurysm of the frontal branch of the right superficial temporal artery confirmed by echo-Doppler and CT scan after injection of contrast medium. The treatment consisted of surgical exclusion and removal. Post-operative follow-up was simple.

Initial Experience with Robotic Surgical Exclusion of the Left Atrial Appendage

Atrial fibrillation (AF) is a major modifiable risk factor associated with an increased risk of ischemic stroke. It is an independent predictor of mortality and is associated with poorer outcomes among stroke patients. AF affects approximately 2.7 million people with a stroke rate of 3.5% per year. Amongst individuals with non-valvular AF that experience embolic stokes, 90% arise from the left atrial appendage (LAA), and consequently left atrial appendage closure can be considered for patients unable to tolerate anticoagulation medications.

Elderly Man With Sudden Onset Back Pain

A 65-year-old man with hypertension and ongoing tobacco use presented to the emergency department with complaints of sudden-onset severe back pain and anuria for the past day. He was diaphoretic and tachycardic, and a blood pressure of 80/50 mm Hg was noted. His abdominal examination revealed a large pulsatile lump (Figure 1A, Video). Routine laboratory parameters revealed deranged renal function and severe anemia. An emergency computed tomography (CT) angiogram of the abdominal aorta was performed. Ruptured abdominal aortic aneurysm with aortocaval fistula. The CT aortogram (Figure 1B) showed a large abdominal aortic aneurysm that ruptured into the retroperitoneum and additionally into the inferior vena cava (Figure 2A). Early and simultaneous opacification of the inferior vena cava during the arterial phase of the aortogram confirmed aortocaval communication (Figure 2B). Volume-rendered CT of the aorta showed the presence of an aortocaval fistula (Figure 3). The patient underwent urgent surgical exclusion of the ruptured abdominal aortic aneurysm and aortocaval communication closure. Unfortunately, he succumbed to multiorgan dysfunction.Figure 3Volume-rendered computed tomography showing abdominal aortic aneurysm along with early, synchronous opacification of the IVC through an aortocaval connection (arrow) and compressed infrahepatic IVC due to an adjacent retroperitoneal hematoma.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Aortocaval fistula is a rare complication of abdominal aortic aneurysm, usually secondary to erosion caused by an aneurysm.1Matsubara J. Nagasue M. Nakatani B. et al.Aorto-caval fistula resulting from rupture of an abdominal aortic aneurysm—report and review of Japanese reported cases.Eur J Vasc Surg. 1991; 5: 601-604Abstract Full Text PDF PubMed Scopus (21) Google Scholar Its clinical features include back or abdominal pain, pulsatile abdominal lump, auscultable bruit, and at times, right heart failure in chronic cases.2Cinara I.S. Davidovic L.B. Kostic D.M. et al.Aorto-caval fistulas: a review of eighteen years experience.Acta Chir Belg. 2005; 105: 616-620Crossref PubMed Scopus (32) Google Scholar Even with prompt diagnosis and appropriate management, the outcome of these patients is often dismal.3Ghilardi G. Scorza R. Bortolani E. et al.Rupture of abdominal aortic aneurysms into the major abdominal veins.J Cardiovasc Surg (Torino). 1993; 34: 39-47PubMed Google Scholar,4Paravastu S.C. Jayarajasingam R. Cottam R. et al.Endovascular repair of abdominal aortic aneurysm.Cochrane Database Syst Rev. 2014; 23 (CD004178)Google Scholar https://www.annemergmed.com/cms/asset/929341a1-8805-4876-af53-2397a9629838/mmc1.mp4Loading ... Download .mp4 (8.17 MB) Help with .mp4 files VideoAbdominal examination showing a pulsatile abdominal lump.

Case Report: Extrinsic Compression of the Left Main Coronary Artery by a Giant Sinus of Valsalva Aneurysm

Sinus of Valsalva aneurysm (SoVA) is an uncommon clinical entity, which is present in roughly 0. 09% of the general population. The cause can either be acquired or congenital. Clinically the SoVA of unruptured status are rarely captured or even diagnosed due to atypical clinical presentations. Here, we present a rare case of exertional angina pectoris and recurrent syncope due to an extrinsically compressed left coronary artery by a giant SoVA in a 50-year-old female patient. This SoVA was successfully repaired by the surgical exclusion and the patient was still doing well after 2 years of follow-up.

Spinal Dural Arteriovenous Fistulas (FAVDR) with Peri- Medullary Venous Drainage: Clinical, Radiological and Therapeutic Aspects (Case Report and Literature Review)

Spinal dural arteriovenous fistulas are rare and often unrecognized, they occur predominantly in men, with an initial clinical picture most often misleading made of chronic myelopathy in the absence of treatment, the evolution is slowly towards a definitive paraplegia. We report the case of a patient referred for a table of spinal cord compression revealing a spinal dural fistula with perimedullary venous drainage treated urgently, due to the worsening of the clinical picture. The standard treatment consists of surgical or endovascular exclusion of the fistula (in our case the fistula was surgically excluded). From this case and based on the literature, we will specify the a, clinical, radiological characteristics as well as the prognosis of these malformations, and we will discuss the possibilities of therapeutic management.

Incessant Atrial Tachycardia: Problem Solving With Minimally Invasive Surgery

A 35-year-old female with sarcoidosis sought medical attention due to palpitations. The ECG showed an atrial tachycardia (AT), apparently originating in the left atrium. A 24-hour Holter monitoring revealed AT to be present during the entire day. Cardiac magnetic resonance exhibited no cardiac involvement by sarcoidosis but registered a mildly depressed left ventricular ejection fraction (LVEF). Atrial electroanatomical mapping showed the earliest activation zone on the distal portion of the left atrial appendage (LAA). Considering the high risk for perforation with catheter ablation in this region, she was sent to thoracoscopic surgical LAA exclusion with a clip device; it was possible to witness the termination of the arrhythmia during the procedure. She was safely discharged two days after surgery and has completed a one-year follow-up without recurrence of AT or symptoms, and with normalization of LVEF.

Surgical and Endovascular Management of Extracranial Carotid Aneurysms, Outcomes from the American College of Surgeons, National Surgical Quality Improvement Program

Extracranial carotid artery aneurysms (ECAAs) are rare. Etiologies include dissection, atherosclerosis, trauma, mycotic infection, and iatrogenic. Patients are often asymptomatic at the time of diagnosis, but some present with a palpable mass or after an embolic cerebrovascular accident. Management of ECAAs includes thromboprophylaxis and surgical excision or exclusion of the aneurysmal segment. Intervention criterion for ECAAs has not been clearly delineated for either asymptomatic or symptomatic disease.

P–310 Women with endometriosis achieve live birth after a similar number of embryo transfers independent of the endometriosis subtype

Abstract Study question How many embryo transfers are needed to achieve the first live birth in women with endometriosis depending on disease localisation? Summary answer The number of transfers needed to achieve live birth in women with endometriosis is independent from the disease’s subtype. What is known already Infertility is one of the leading symptoms in women with endometriosis. Endometriosis is also known to negatively impact in-vitro fertilization (IVF) outcome. A reduction of oocyte yield, especially of mature oocytes in women with endometrioma (OMA) and deep infiltrating endometriosis (DIE) has been shown. Inflammatory processes possibly affect folliculogenesis and oocyte development, maybe impeding embryo development and implantation. In contrast, even with fewer retrieved oocytes per cycle live birth rate was not affected. However, it is currently unknown if specific endometriosis subtypes could differentially affect IVF success. This would be relevant for a more targeted counseling regarding the treatment success. Study design, size, duration This is a single-center cohort study including women (N = 229) with embryo transfer cycles leading to live birth at the Bern University Hospital between 2010 and 2017. We only included women until they achieved the first live birth at our center. Participants/materials, setting, methods: We included 86 women with endometriosis and 143 women with male factor infertility serving as comparison group. We collected patient characteristics, details from the endometriosis surgery and reproductive treatment and outcomes from medical reports. We hierarchically classified the dominant endometriosis localizations as follows: deep infiltrating endometriosis (DIE, N = 21) > ovarian endometriosis (OMA, N = 35) > superficial peritoneal endometriosis (SUP, N = 30). We compared the number of embryo transfers needed to achieve a live birth. Main results and the role of chance Women with endometriosis were older (34.5 ± 3.9 years) than women from the control group (33.4 ± 3.9), p = 0.03. Body-mass-index, previous parity or Anti-Mullerian hormone level did not differ between the groups SUP, OMA, DIE or the comparison group. The number of necessary embryo transfer cycles to achieve a live birth did not differ between women with SUP (3.4 ± 2.6 embryo transfers), OMA (2.9 ± 2.0), DIE (3.0 ± 2.4) and the comparison group (2.9 ± 2.2), p = 0.59. IVF is beneficial in women with endometriosis, especially when OMA and/or DIE affect mobility of tubes and ovaries and spontaneous pregnancy is unlikely or impossible. This could account for the equal number of transfer cycles needed to achieve a live birth in women with OMA compared to the comparison group, even though the women with endometriosis were of older age. This is reassuring when counseling women with endometriosis. Limitations, reasons for caution We did not calculate cumulative pregnancy rate per cycle, because in Switzerland IVF treatment is at the patient’s own cost and therefore biased. We wanted to include all women with endometriosis, so fresh and thawing cycles were included. Women from the comparison group had no surgical exclusion of endometriosis. Wider implications of the findings: Our study suggests that the endometriosis subtype does not determine the embryo transfer success rate after IVF and therefore is less relevant for counseling. Individualized anti-inflammatory treatment before embryo transfer might positively affect the cycles’ outcome. Studies with a larger sample are required to be more conclusive on this issue. Trial registration number BASEC 2015–00235

The Characteristics, Long-Term Outcomes, Risk Factors, and Antithrombotic Therapy in Chinese Patients With Atrial Fibrillation and Bioprosthetic Valves.

Introduction: There were few data about the clinical profiles and long-term outcomes in Chinese patients with atrial fibrillation (AF) and bioprosthetic valves.Methods: The retrospective study enrolled 903 patients with bioprosthetic valve replacement at our hospital and discharged with a diagnosis of AF from January 2010 to December 2018.Results: The median age was 65.6 (61.9–69.1) years, and 548 (60.7%) patients were women. During a follow-up period of 3.84 (2.64–5.51) years, 68 (1.8 per 100 person-years) patients died, 81 (2.1 per 100 person-years) patients developed thromboembolism, and 23 (0.6 per 100 person-years) patients experienced major bleeding. The CHA2DS2-VASc score, as a categorical variable (low, moderate, or high risk), predicted the risk of thromboembolism with the C-statistic of 0.6 (95% CI: 0.511–0.689, p = 0.046). The incidence of the CHA2DS2-VASc score increment was 11.6 per 100 person-years, and the annual reclassification rate of stroke risk (from a low or moderate group to a higher group) was 12.7%. The current proportion of oral anticoagulants was 52.3, 59, and 63.2%, respectively, in the low, moderate, and high stroke risk groups. Age (OR: 1.04, 95% CI: 1.01–1.06, p = 0.01), left atrial size (OR: 1.05, 95% CI: 1.03–1.08, p < 0.001), and rheumatic heart disease (OR: 1.49, 95% CI: 1.05–2.10, p = 0.025) were positively associated with the use of oral anticoagulants. The history of chronic kidney disease (OR: 0.20, 95% CI: 0.05–0.76, p = 0.018), prior surgical ablation (OR: 0.33, 95% CI: 0.24–0.47, p < 0.001), and antiplatelet agent use (OR: 0.08, 95% CI: 0.05–0.13, p < 0.001) were inversely related to the use of oral anticoagulants. Higher admission estimated glomerular filtration rate (HR: 0.515, 95% CI: 0.311–0.853, p = 0.01), left ventricular ejection fraction (HR: 0.961, 95% CI: 0.931–0.992, p = 0.014), concomitant surgical ablation (HR: 0.348, 95% CI: 0.171–0.711, p = 0.004), and rheumatic heart disease history (HR: 0.515, 95% CI: 0.311–0.853, p = 0.01) were associated with a lower risk of death. Surgical ablation (HR: 0.263, 95% CI: 0.133–0.519, p < 0.001) and oral anticoagulants (HR: 0.587, 95% CI: 0.375–0.918, p = 0.019) were related to a lower risk of thromboembolism.Conclusion: Chinese patients with AF and bioprosthetic valve(s) were relatively young and had a high prevalence of rheumatic heart disease with few comorbidities. The percentage of mitral bioprosthetic valve replacement was high. The proportion of concomitant surgical ablation or surgical left atrial appendage occlusion or exclusion was relatively low. The thromboembolic events were the major long-term adverse events. The anticoagulation therapy was underused in patients at moderate or high stroke risk. The CHA2DS2-VASc score was verified to be used for predicting stroke risk in this population. The stroke risk dynamically changed; it needed to be reestimated once the risk factor changed.

Percutaneous Left Atrial Appendage Occlusion: An Emerging Option in Patients with Atrial Fibrillation at High Risk of Bleeding.

Atrial fibrillation (AF) is a common cardiac arrhythmia with an estimated prevalence of 1% in the general population. It is associated with an increased risk of ischemic stroke, silent cerebral ischemia, and cognitive impairment. Due to the blood flow stasis and morphology, thrombus formation occurs mainly in the left atrial appendage (LAA), particularly in the setting of nonvalvular AF (NVAF). Previous studies have shown that >90% of emboli related to NVAF originate from the LAA, thus prevention of systemic cardioembolism is indicated. According to the current guidelines, anticoagulant therapy with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs), represents the standard of care in AF patients, in order to prevent ischemic stroke and peripheral embolization. Although these drugs are widely used and DOACs have shown, compared to VKAs, non-inferiority for stroke prevention with significantly fewer bleeding complications, some issues remain a matter of debate, including contraindications, side effects, and adherence. An increasing number of patients, indeed, because of high bleeding risk or after experiencing life-threatening bleedings, must take anticoagulants with extreme caution if not contraindicated. While surgical closure or exclusion of LAA has been historically used in patients with AF with contradictory results, in the recent years, a novel procedure has emerged to prevent the cardioembolic stroke in these patients: The percutaneous left atrial appendage occlusion (LAAO). Different devices have been developed in recent years, though not all of them are approved in Europe and some are still under clinical investigation. Currently available devices have shown a significant decrease in bleeding risk while maintaining efficacy in preventing thromboembolism. The procedure can be performed percutaneously through the femoral vein access, under general anesthesia. A transseptal puncture is required to access left atrium and is guided by transesophageal echocardiography (TEE). Evidence from the current literature indicates that percutaneous LAAO represents a safe alternative for those patients with contraindications for long-term oral anticoagulation. This review summarizes scientific evidences regarding LAAO for stroke prevention including clinical indications and an adequate patient selection.

Surgical exclusion of an idiopathic saccular aneurysm in the left main trunk of the coronary artery

PurposeA coronary artery aneurysm (CAA) can result in critical cardiac events such as thromboembolic complications or rupture. A saccular CAA located in the left main trunk (LMT) is the most critical form of this pathology and its surgical repair is challenging. We conducted this single-center study to review the surgical outcomes of patients with a saccular CAA in the LMT.MethodsBetween May, 2012 and June, 2020, five patients with a saccular CAA in the LMT underwent surgery at our center. The median age at operation was 66.5 (59.7–69) years and the median diameter of the CAA was 13.0 mm (IQR 11–14 mm).ResultsThe CAA was fully excluded by patch closure of the LMT orifice and direct closure of the distal LMT, supplemented by coronary artery bypass grafting with the exclusive use of arterial conduits. There was no in-hospital mortality, although one patient suffered graft spasm-related myocardial infarction with complete recovery. Post-operative angiography showed a fully excluded LMT in all patients. There was no mortality or adverse cardiac events during follow-up.ConclusionsOur surgical policy for CAA in the LMT is feasible and safe; however, coronary blood flow is dependent on reliable bypasses.

Improved outcomes in CABG patients with atrial fibrillation associated with surgical left atrial appendage exclusion.

We sought to determine the impact of left atrial appendage clip exclusion (LAACE) on coronary artery bypass grafting (CABG) outcomes among patients with pre-existing atrial fibrillation (AF). From October 1, 2015 to October 1, 2017, 4210 Medicare beneficiaries with pre-existing AF underwent isolated CABG (i.e., without ablation) with (n = 931) or without (n = 3279) LAACE. Inverse probability of treatment weighting was used to evaluate the effect of concomitant LAACE on short- and long-term outcomes after CABG. Long term risks of thromboembolism and mortality were assessed using competing-risk regression and Cox proportional hazard models. Operative mortality, length of stay, and 30-day readmission did not differ between groups. Thromboembolism risk was 26% lower for the CABG + LAACE group compared with isolated CABG over a 2-year time-to-event analysis (sub hazard ratio [sHR] 0.74, 95% confidence interval [CI] 0.54-1.00, p = .049). There were no differences in ischemic stroke rates. All-cause mortality risk was 45% lower for CABG + LAACE during the late follow-up period (91-730 days; HR 0.55, 95% CI 0.32-0.95, p = .031). The late period annual absolute all-cause mortality rate was 3.7% for CABG + LAACE and 6.9% for isolated CABG. There were lower readmission rates (31% vs. 43%, p < .001) and total inpatient days (4.0 days vs. 7.2 days, p < .01.) for the CABG + LAACE during follow-up. Total hospital in and out-patient treatment costs were similar between groups through one year. Concomitant LAA exclusion via an epicardial closure device is associated with reduced CABG mortality, thromboembolic events, and readmissions in patients with pre-existing atrial fibrillation.

Cranio-vertebral junction arteriovenous fistula presenting with subarachnoid haemorrhage: A case report

Perimedullary arteriovenous fistulas are uncommon vascular malformations particularly if they involve the craniovertebral junction. The complexity of the angioarchitecture of these lesions poses a further diagnostic challenge. Moreover, the therapeutic management is controversial and can include observation alone, endovascular occlusion, or surgical exclusion, depending on both patient and the angiographic characteristics of the lesion.

Treating a thrombotic giant dissecting renal artery aneurysm through ex-vivo vascular reconstructive surgery followed by kidney reimplantation

Renal artery aneurysms, although rare, may give rise to complications both per se (due to the risk of thrombosis and subsequent wall rupture) and by impairment of the renal function (due to extrinsic compression and high blood pressure). We describe a paucisymptomatic young patient with acute thrombosis of a massive dissecting renal artery aneurysm, for which the successful treatment was performed through ex-vivo vascular surgery followed by autotransplantation of the reconstructed kidney. The aneurysm was described through abdominal echography, computed tomography angiography, and transfemoral transcatheter arterial angiography. It originated from an atypical branch emerging at 90 degrees from the left renal artery. After a short branching off, it degenerated into a dissected aneurysmal sac as large as half a kidney (outer diameter of 60 mm), compressing the lower pole of the left kidney and delaying the lower half nephrogram. Ex-vivo surgical exclusion of the aneurysm was successfully performed. The kidney was reimplanted in the left iliac fossa (termino-lateral anastomosis between the renal artery and external left iliac artery, termino-terminal ureteric anastomosis) with excellent postoperative outcomes. For most asymptomatic aneurysms, expectant treatment is a reasonable approach. However, interventional or surgical repair is indicated in certain circumstances depending on the size of the aneurysm and its natural history, rupture risk, and interventional/surgical risks. The renovascular hypertension, dissecting and thrombotic events, its giant size, the young fertile age, and the presence of the flank pain were all indicative of the need for aneurysm exclusion in our case.

Modification of Serum Natriuretic Peptide Profile and Echocardiographic Parameters After Surgical Left Atrial Appendage Exclusion/Resection During Mitral Valve Surgery

Being a well-recognised source of cardiac embolism, the left atrial (LA) appendage (LAA) is frequently excluded during mitral valve (MV) surgery. However, the LAA is also a source of cardiac hormones and a new drug (sacubitril), which beneficially interferes with hormonal imbalance during heart failure, leads to re-evaluation of the LAA for the maintenance of adequate hormone production in the heart. We compared the effects of LAA surgical resection/exclusion in patients with MV replacement (MVR) on natriuretic peptides (NPs) and related enzymes versus similar patients, in whom the LAA was preserved. A comparison of clinical response was also carried out. Haemodynamically stable patients scheduled for MV surgery with or without elimination of the LAA were studied before and 3 months after surgery. Serum NPs, furin, corin, and neprilysin were determined. A transthoracic echocardiogram was also performed before and after surgery. Patients in the LAA intervention group exhibited lower levels of atrial natriuretic peptide (ANP) 3 months after surgery than patients with intact LAAs. There were no differences in NP and related enzyme levels pre- or postsurgery. The echocardiograms indicated a similar decrease in the diameters and volumes of the LA, and normal pulmonary arterial pressure values, in both groups. The indexed LA volume showed a positive correlation with postoperative brain natriuretic peptide. Surgical resection or exclusion of the LAA in patients with MVR promotes a decrease in ANP production at 3 months postsurgery. Echocardiography is useful when evaluating surgical replacement of the MV with elimination of the LAA.

Percutaneous endoscopic transforaminal and interlaminar lumbar discectomy for cranially migrated disc hernia

Objective. To evaluate clinical outcomes, safety, and technical peculiarities of percutaneous endoscopic transforaminal and interlaminar removal of the lumber spine cranially migrated disc hernias. Material and Methods. In 2015–2018, percutaneous endoscopic transforaminal and interlaminar removal of cranially migrated hernias of the lumbar spine was performed in 53 patients (23 men and 30 women): 2 (3.8 %) at L2–L3 level, 13 (24.5 %) at L3–L4, 18 (34.0 %) at L4–L5, and 20 (37.7 %) at L5–S1. The age of patients ranged from 25 to 76 years and averaged 43.4 ± 11.6 years. Transforaminal approach was performed at the L4–L5 level and higher (62.3 % of cases), and interlaminar approach – at the L5–S1 level (37.7 %). Based on MRI, hernias with cranial migration were divided into zones: zone I – hernias with migration to the lower edge of the superjacent vertebra pedicle – 21 (39.6 %) patients; and zone II – hernias with migration above this border – 32 (60.4 %). Results were evaluated using ODI, VAS, and the McNab scale. Statistical analysis of VAS indicators (leg and back pain) and ODI scores before and after surgery was performed using the R and Microsoft Excel 2007 software. Results. Data collection was carried out using patient questionnaires at in-person examination, telephone interviews and electronic communications. Follow-up data of different terms were monitored in all patients. In one case (when mastering this technology), at the second stage, microdiscectomy was performed at the L4–L5 level for a residual hernia fragment in migration zone II, and in another case, a conversion into microdiscectomy was performed at L3–L4 level with a hernia in zone II due to lack of venous bleeding control in a patient receiving anticoagulants. In other patients, the mean VAS scores of preoperative radicular and axial pain decreased from 7.5 ± 1.4 and 3.8 ± 1.2 to 1.4 ± 1.2 and 3.5 ± 1.3, respectively, on the next day, to 1.7 ± 1.4 and 3.2 ± 1.1 in 1 month, to 1.5 ± 1.3 and 2.8 ± 1.4 in 6 months, to 1.6 ± 1.2 and 2.0 ± 1.3 in 12 months, and to 1.6 ± 1.2 and 2.0 ± 1.3 in 24 months after surgery. In the long-term follow-up period, no radicular leg pain was observed in any patient. According to the McNab scale, up to 6 months treatment results were assessed as excellent by 19 (35.8 %) patients, and as good – by 32 (60.3 %). In the case of lumbar pain in the long term period, blockade of facet joints and radiofrequency ablation of the medial nerve branch were performed. Relapse of hernias and instability of the operated spinal segment were not revealed. The average ODI score improved from 66.4 ± 7.2 to 20.5 ± 3.2 in 1 month, to 13.6 ± 2.1 in 6 months, to 12.4 ± 2.3 in 12 months, and to 12.4 ± 2.3 in 24 months after surgery. Conclusion. Percutaneous endoscopic transforaminal and interlaminar discectomy for cranially migrated lumbar disc hernia, while adhering the surgical technique target and exclusion criteria, is a safe and effective method, avoids excessive resection of the bone-ligamentous structures of the spine, can prevent iatrogenic instability of the spinal motion segment, and promotes early postoperative activation and recovery of the patient. Cranially migrated disc henias have a low probability of recurrence.

Systematic review of the evaluation and management of coronary pseudoaneurysm after stent implantation.

Pseudoaneurysm (PSA) formation is a rare but well-known complication of coronary stenting. It develops after a procedural perforation disrupts the integrity of the vessel wall but is contained by a single wall layer, usually pericardium, extravascular thrombosis and later fibrosis. Medical literature of PSA consists primarily of case reports. A systematic review of pseudoaneurysm after coronary stenting was performed to summarize its presentation, diagnostic imaging modalities, natural history, and management approaches. Clinical presentations range from asymptomatic to hemodynamic collapse, size from small to "giant," and treatment approaches from surgical or percutaneous exclusion to "watchful waiting" and imaging surveillance. Based on current information, a management algorithm is provided recommending urgent to emergent exclusion for symptomatic PSA, elective exclusion for large and giant PSA, and "watchful waiting" and periodic imaging surveillance for small to moderate sized PSA.

Left atrial appendage exclusion is effective in reducing postoperative stroke after mitral valve replacement.

This study aimed to evaluate the role of surgical left atrial appendage (LAA) exclusion in the prevention of stroke after mitral valve replacement (MVR). We retrospectively reviewed clinical data of 860 patients who received MVR in our center from January 2008 to January 2013. The patients were randomly assigned to two surgical groups, namely LAA exclusion group (n = 521) and LAA nonexclusion group (n = 339) according to whether concurrent surgical exclusion of the LAA was to be undertaken or not before surgery in a blind fashion. MVR was performed by two experienced surgeons. The LAA was explored during the operation and mural thrombus removed in all cases. The LAA was left intact in nonocclusion group whereas the neck of the LAA was closed with a two-layer continued suture in exclusion group. The incidence of early postoperative ischemic stroke between the two groups was compared. The patients' age was 53 ± 12 years, with 48.1% male and 67.9% with rheumatic disease. Mural thrombosis was seen in 18.8% of the patients and atrial fibrillation (AF) coexisted in 62.4%. All operations were successfully performed and no difference was noted in in-hospital mortality, re-exploration for bleeding, and other major complications between the two groups. The incidence of ischemic stroke in LAA exclusion group was significantly lower than in nonexclusion group (0.6% vs. 2.7%, p = .011). The subgroup multivariate analysis showed that LAA exclusion significantly reduced the risk of postoperative stroke in patients with AF (odds ratio [OR] = 0.070, 95% confidence interval [CI]: 0.006-0.705, p = .025) but not in non-AF patients (OR = 1.902, 95% CI: 0.171-21.191, p = .601). Concurrent LAA exclusion during MVR is a safe and effective way to reduce postoperative ischemic stroke, particularly in patients with AF.

Fistulas between the Esophagus and Adjacent Vital Organs in Esophageal Cancer.

Esophageal fistulas may occur in an advanced stage or as a potentially life-threatening complication of treatment. They can be divided into esophageal-respiratory and esophageal-aorta fistulas. The diagnosis is confirmed with fluoroscopy using dilute barium oral contrast, followed by thin-section computed tomography, which defines the precise location and extent of the fistula. Flexible esophagoscopy and bronchoscopy are required for confirmation and anatomic assessment of the suspected fistula and provide additional information for treatment planning. Contamination is traditionally controlled by surgical exclusion, along with a jejunal feeding tube. Currently, fully covered self-expanding metal stents are the primary treatment option.

Seguridad de la exclusión quirúrgica del apéndice auricular izquierdo en pacientes con fibrilación auricular sometidos a cirugía valvular mitral

Introduction: atrial fibrillation is the most common sustained cardiac arrythmia in clinical practice. It is associated tosignificant morbimortality. The prevention of embolic episodes is a pillar of atrial fibrillation treatment and is basedmainly on anticoagulation. However, there is a significant proportion of patients with contraindications for anticoagula tion, to whom alternative treatments must be offered. Surgical exclusion of the left atrial appendage offers benefits inthis regard, and is associated to a lower rate of neurological events.Objective: primary endpoint: to evaluate the safety of the surgical exclusion of the left atrial appendage in patients withatrial fibrillation undergoing mitral valve surgery; secondary endpoint: to analyze the incidence of stroke in this population, and to analyze the survival rate in patients with and without left atrial appendage exclusion.Method: a single center, analytic, observational, retrospective study, comparing exclusion and no exclusion of the leftatrial appendage in patients with atrial fibrillation undergoing mitral valve surgery between January 2012 and December 2018. The variables were obtained from the institutional database. The follow up was telephonic and survival rateswere obtained from a national official database.Results: 69 patients were included (45 underwent surgical left atrial appendage exclusion). Statistically significant features between the groups were age (69.1±8.2 years without left atrial appendage exclusion; 63.6±10.3 years with leftatrial appendage exclusion, p=0.026), and the rate of surgical ablation of atrial fibrillation (29.2% without exclusion;68.9% with exclusion, p=0.002). The follow up was carried out in 33, finding no statistically significant differences between the groups. The survival rate of all patients was analyzed, finding no long term differences.Conclusion: according to the data analyzed, left atrial appendage exclusion is a safe procedure, and adds no furthercomplications to mitral valve surgery in patients with atrial fibrillation. It was not possible to prove that left atrial appendage exclusion significantly reduces the long term prevalence of ischemic stroke or modifies the survival rate.