Video-assisted Thoracoscopic Procedure Research Articles

Bullous lung disease in pregnancy: a case report.

Bullous lung disease presenting as a pneumothorax in pregnancy has not been reported in the literature to date. We present the case of a woman in her third pregnancy presenting to routine antenatal clinic with a secondary spontaneous pneumothorax in the third trimester. We describe the multidisciplinary approach to her management with obstetrics, obstetric anaesthesiology, cardiothoracic surgery and midwifery. This included decision making around conservative management in the initial disease course, preparation for delivery and a plan for definitive surgery postnatally. Caesarean section was performed at 36 weeks' gestation owing to worsening chest pain. The underlying pathological process was deemed to be bullous lung disease which was confirmed on histology obtained from a video-assisted thoracoscopic surgery procedure done postnatally. We demonstrate the importance of the multidisciplinary team approach in the care of complex and rare medical conditions in pregnancy.

Video-assisted thoracoscopic (VATS) era in surgical treatment of spontaneous pneumothorax

Background: VATS is now regarded by many surgeons to be the gold standard in the surgical management of a variety of thoracic conditions, such as spontaneous pneumothorax (SP), pleural diseases, and indeterminate lung nodules. Aim and objectives: to describe different VATS techniques in patients with spontaneous pneumothorax.Summary: Several clinical management issues remain unanswered. Firstly, the duration of prolonged air leak that warrants VATS remain controversial. Current recommendations range from five days by BTS to three days advocated by our institute with more than a decade of experience with VATS for SP. Furthermore, whether VATS should be offered to all patients with low general anesthetic risk presenting with first episode of SP is unclear. Furthermore, the evolution of surgical techniques to allow ipsilateral thoracoscopic approach to treat contralateral bullous lesion may redefine the indications for CT scan in SP. Technically, the debate will continue among the surgeons on the type of VATS procedure that will minimize pneumothorax recurrence. Most surgeons will agree that some form of bullectomy (endoscopic staple or suturing) is mandatory. However, the nature of pleurodesis (mechanical, chemical, or both) that follow is often at the discretion of the individual clinician.

Motor block and hypotension following a high thoracic erector spinae plane block.

Dear Editor, Erector spinae plane blocks (ESPBs) are becoming more prevalent in clinical practice for postoperative pain control following truncal procedures. ESPBs are often quoted as being easy to perform and having few complications. We describe a patient with a thoracic epidural spread after administering an ultrasound-guided unilateral high thoracic ESPB for a video-assisted thoracoscopic procedure (VATS). A 62-year-old woman with chronic smoking, hypertension, and asthma was scheduled for an elective right VATS upper lobectomy for a malignant lesion. Her body weight was 78 kg, and she had no functional limitations. After obtaining informed consent, standard Canadian Anesthesia Society monitors were applied. She received preprocedural 1 mg of intravenous midazolam. The block was performed in the block room by an anesthesia resident under an experienced attending anesthesiologist’s supervision. In a sitting position, right ESB was performed using a linear ultrasound transducer oriented in the parasagittal plane. An out-of-plane approach was used due to the shorter needling distance, thus mitigating discomfort. After contacting the T4 TP, 20 ml of 0.5% ropivacaine was injected, and a local anesthetic was seen spreading deep to the erector spinae muscle. She was transferred to the operating room following an uneventful 10 min of monitoring in the block room. Upon directing the patient to move from the stretcher to the operating table, she noted having decreased bilateral lower limb sensation and motor weakness. Physical exam revealed decreased strength in hip flexion and a bilateral truncal sensory from T4 to L4 dermatomes. Her blood pressure had dropped to 73/36. She did not have any shortness of breath, chest pain, or light headedness. An awake radial arterial line was placed, and a phenylephrine infusion was initiated at 20 mcg/min. With her blood pressure stabilized, the decision was made to proceed with surgery. With surgical stimulation, she was able to wean off the phenylephrine infusion. She had no motor weakness or sensory loss following an uncomplicated 3 h long VATS lobectomy. In the post-anesthetic care unit (PACU), Pain scores were between 4 and 6, and blood pressure was 99/66. In a review, the incidence of complications of ESPBs is 0.2%, including bilateral lower limb weakness, motor block, transient apathy, aphasia, dizziness, loss of consciousness due to systemic toxicity and pneumothorax.[1] Selvi et al.[2] reported an unexpected motor weakness following bilateral T11 ESPB, and De Cassai et al.[3] reported near-complete lower extremity immobility following bilateral L3 ESPB for lumbar laminectomy. Our patient experienced bilateral motor and sensory block along with significant hypotension 15 min after a high unilateral thoracic ESPB. Given the symmetrical nature of the blockade and its resolution, we postulated that the local anesthetic injected had spread to the epidural space via the costotransverse foramen.[3] This may be related to the orientation and the angulation of the needle. Such a precipitous and unexpected drop in blood pressure could result in hemodynamic instability and cardiac compromise in some patients. Although seemingly rare, caution must be taken. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Video-assisted thoracoscopic surgery for primary hyperparathyroidism with ectopic parathyroid adenoma in thymus

Introduction. Primary hyperparathyroidism is rare pathology in children (2?5:100,000). In more than 85% of patients, a single adenoma is present, and its extirpation is usually the only treatment a patient requires. In approximately 15?80% of cases, ectopic mediastinal parathyroid tissue can be found inside the thymus. Case outline. Our patient was a 13-year-old boy, who presented with multiple bone fractures in the previous period of time, and fatigue. Parathyroid hormone levels preoperatively were extremely high (1320 pg/ml ? more than 19 times higher than normal). Serum calcium was also elevated (total 3.55 mmol/l; ionized 1.41 mmol/l). He was examined and diagnosed as primary hyperparathyroidism by a pediatric endocrinologist. Imaging procedures for the preoperative localization of parathyroid adenomas were done (99mTc sestamibi scintigraphy and magnetic resonance imaging suggested ectopic mediastinal parathyroid adenoma). The patient underwent video-assisted thoracoscopic surgery procedure. After exploration of the mediastinum and chest, no ectopic parathyroid tissue was found, so total thoracoscopic thymectomy was performed. Final pathological section confirmed parathyroid adenoma inside the thymus. Conclusion. We believe that if no parathyroid tissue is found during surgical exploration of mediastinum, in a child with preoperatively detected parathyroid adenoma in anterior mediastinum, recommendation is to think about possible intrathymic localization and consider removing the thymus. Greater sample size is necessary for higher reliability of this statement.

AN UNCONVENTIONAL CONNECTION: IATROGENIC NEPHROPLEURAL FISTULA AFTER PERCUTANOUS NEPHROLITHOTOMY

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A nephropleural fistula is an abnormal connection between renal parenchyma and pleural lining, it’s a known complication of percutaneous nephrolithotomy (PCNL) which can happen in both immediate and delayed setting (1). We describe a case of 88-year-old female who developed this fistula 2 days after the procedure. CASE PRESENTATION: 87-year-old female with a past medical history of recurrent UTIs and right nephrolithiasis presented with right sided flank pain. CT abdomen pelvis showed 8 mm right ureteral calculus and mild right hydronephrosis. Urine and blood cultures grew E. coli. She was diagnosed with urosepsis and treated with IV ceftriaxone. She required a right ureteric stent and patient was discharged home. A few weeks later, the patient was admitted to the hospital for a cystoscopy and replacement of her right sided JJ stent. She underwent right sided percutaneous nephrolithotomy. On Post-op day 2, the patient started to develop hypoxemia while ambulating, and required 3L nasal canula to maintain oxygen saturation >95%. Chest X ray revealed new bilateral pleural fluid collections. Patients hemoglobin dropped from 11.9 to 6.6. CT scan of the chest showed moderate to large right basilar hemothorax with a communication between right kidney to the right pleural cavity. Thoracic surgery was consulted for evaluation/management of right hemothorax. The patient required a video-assisted thoracoscopic surgery procedure with hemothorax evacuation and intercostal tube placement and drainage. The patient's condition improved, and the chest tube was removed with closure of the nephropleural fistula. Deemed medically fit to be discharged with follow up for the removal of her JJ stent through cystoscopy. DISCUSSION: Iatrogenic nephro-pleural fistula is a very rare but potentially life-threatening complication following PCNL. There are only a handful of case reports in the current literature. Most often occurring in the immediate phase during intraoperative fluoroscopy (1). The direct connection created intra-operatively between the thoracic cavity and renal collecting system allows the build up of fluid and urine into the chest. This can potentially lead to the development of pleural effusions and invariably compromising respiratory function & status. Most fistulas can be managed conservatively with the use of thoracentesis without the need for further surgical intervention. However rarely more aggressive treatment is required including temporary chest tube placement with or without pleurodesis for recurrent/refractory fistulas(2). CONCLUSIONS: This case highlights the importance of a considering a delayed nephropleural fistula following an uneventful PCNL in patients complaining of respiratory symptoms following stent removal. A delayed nephropleural fistula should be considered in any patient that develops shortness of breath, increasing oxygen requirement or evidence of pleural effusions. Reference #1: Kaler, K. S., Cwikla, D., & Clayman, R. V. (2016). Delayed Nephropleural Fistula After Percutaneous Nephrolithotomy. Journal of endourology case reports, 2(1), 99–102. https://doi.org/10.1089/cren.2016.0050 Reference #2: Baugh, A. D., Youssef, E., Hasan, S. S., Siddiqui, N. S., Elsamoloty, H., Shahrour, K., & Javaid, T. (2016). Nephropleural Fistula Effectively Managed with Serial Thoracentesis: A Case Report. Journal of endourology case reports, 2(1), 212–214. https://doi.org/10.1089/cren.2016.0102 DISCLOSURES: No relevant relationships by Sanchit Chawla, source=Web Response No relevant relationships by hussain karimi, source=Web Response

SUN-491 A Diagnosis of Thyroid Cancer Reveals a Triple Threat

Introduction: The risk of secondary malignancies is increased in patients with papillary thyroid cancer (PTC). It is not completely clear if this risk is due to radioactive iodine treatment or due to other causes. We present a case of a patient diagnosed with papillary thyroid cancer (PTC) found to have lung cancer and small lymphocytic lymphoma which appear to be unrelated to radioactive iodine treatment.Case Presentation: A 72 yo woman with a history of Graves’ disease, atrial fibrillation, and hyperparathyroidism initially presented to care for weight loss. She was found to have hyperthyroidism and was treated with methimazole. Thyroid ultrasound revealed multiple nodules including a 17mm right lower pole nodule with irregular borders for which she underwent FNA. Pathology demonstrated atypical-cells of undetermined significance (AUS), but thyroseq revealed a BRAF V600E mutation. She underwent total thyroidectomy with pathology showing multifocal thyroid cancer, 12mm and 0.8mm with 3/11 involved lymph nodes and right parathyroid adenoma. Given a questionable lower left lung nodule on preop CXR, she underwent CT chest which revealed a 2cm lung nodule. She had video assisted thoracoscopic (VATS) left lower lobe wedge resection with completion left lower lobectomy for a 3 cm lung adenocarcinoma with negative margins and 33 negative lymph nodes. She was subsequently treated with RAI after recovery from VATS procedure. Pretreatment thyroglobulin was 0.8 ng/ml with negative thyroglobulin antibodies. One month after her RAI treatment, ultrasound of the neck revealed suspicious bilateral level IV lymph nodes which increased in size during short term follow up. Serum thyroglobulin was 0.3ng/ml with negative antibodies and TSH 0.29 mIU/L. Biopsy of right level IV lymph node was positive for PTC with thyroglobulin washout >5000 while left level IV lymph node was negative for PTC and Tg washout was 0.1. She subsequently underwent right-sided modified radical neck dissection, with lymph nodes revealing PTC also involved by small lymphocytic lymphoma. She had repeat RAI ablation for thyroid cancer and is being actively monitored for her small lymphocytic lymphoma and lung adenocarcinoma.Conclusion: We present a patient with no known history of malignancy who presented with 3 de novo primary malignancies. This case may demonstrate an increased risk of malignancy in patients with thyroid cancer not necessarily related to radioactive iodine treatment.

Risk factors and 90-day mortality after video-assisted thoracoscopic lobectomy for lung cancer: the discussion is still open

American College of Chest Physician (ACCP) promotes the use of video-assisted thoracoscopic procedure over thoracotomy for patients with stage I NSCLC for anatomical pulmonary resection in experienced centers (1). Video-assisted thoracoscopic surgery (VATS) lobectomy has been demonstrated to be a safe, minimally invasive approach for the surgical treatment of lung cancer. Minimally invasive surgery seems to reduce postoperative morbidity and early mortality. For this reason it is currently the recommended surgical approach for early stage lung cancer surgical patients. But which are the real risk factors for vats lobectomy? And is thirty-day mortality an adequate quality indicator?

Use of the novel lung-stabilizing device during a video-assisted thoracoscopic surgical procedure

Use of the novel lung-stabilizing device during a video-assisted thoracoscopic surgical procedure

96-20: Hybrid ablation for long-standing persistent AF. A 2 stage non-concomitant approach using the Cobra Fusion Device and catheter ablation - single-centre experience

Introduction: Treatment of long-standing persistent Atrial Fibrillation (LsPsAF) remains challenging, with the optimal ablative approach unclear. We describe our experience in non-concomitant hybrid AF ablation using the Cobra Fusion device followed by catheter ablation. Methods: LsPsAF patients with unfavourable characteristics for catheter ablation alone (continuous AF duration >1 year, enlarged left atrium (LA), previous failed catheter ablation) are chosen for the procedure. The first stage is a right, video-assisted thoracoscopic (VATS) approach. The Cobra Fusion RF system (Atricure Inc, West Chester, OH) is used to deliver epicardial RF ablation forming a “box lesion” to isolate the LA Posterior Wall (LAPW). All patients then return for a staged catheter procedure approximately 60 days later, with, if required, additional lesions to complete LAPW isolation. The procedure is completed with a cavo-tricuspid isthmus ablation line. Summary of Results: 41 patients had the VATS procedure. Epicardial ablation was performed in 38 (2 had dense pericardial adhesions). 1 patient had a CVA which developed 24 hours post operatively and 5 patients developed a transient phrenic nerve palsy post op. 24 patients have undergone the 2nd catheter ablation stage. The LAPW was isolated at baseline in 7 patients. Posterior wall isoloation was achieved at 2nd stage in all but 1. 9 patients have greater than 1 year follow up. 7 of them (78%) are in SR with only 1 on antiarrhythmics (AA) (13%). 21 patients have greater than 3 months follow up. Of those, 17 remain in SR with only 3 of them on AA. Conclusions: 81% of LsPsAF patients in our series are in sinus rhythm on preliminary follow-up following non-concomitant hybrid ablation. 77% are in SR at over 1 year post the 2nd stage procedure with the longest follow-up patients now over 2 years. Further research is required to determine long-term outcomes from this technique, but these results are encouraging for patients with LsPsAF.

Repeat Procedures After Hybrid Thoracoscopic Ablation in the Setting of Longstanding Persistent Atrial Fibrillation: Electrophysiological Findings and 2-Year Clinical Outcome.

In order to increase success rates of invasive treatment of persistent atrial fibrillation, the hybrid approach was developed, combining video-assisted thoracoscopic epicardial procedure with conventional endocardial catheter ablation. Currently, there are no reports of electrophysiological findings and clinical outcomes of repeat procedures after the hybrid approach. Out of 64 patients who were treated by hybrid ablation for persistent atrial fibrillation (AF), 14 underwent the repeat catheter ablation and were selected for this study. All 14 patients initially presented with longstanding persistent atrial fibrillation and markedly dilated atria. The hybrid procedure was performed in a single act and the mean time to redo procedure was 346 ± 227 days. In 57% of patients indication for redo procedure was regular atrial tachycardia, and the rest presented with recurrent atrial fibrillation. In 36% of patients, recovered conduction was found along the previous ablation lesions. Only 9% of pulmonary veins were reconnected (0.36 veins per patient) and 7% of box lesions were not complete. The overall success rate at 2 years follow-up after the repeat procedure, including second repeat procedure and patients taking antiarrhythmic drugs, was 64% (57% without drugs and further ablation). One case of moderate pulmonary vein stenosis was detected as a consequence of hybrid procedure. Hybrid atrial fibrillation ablation results in durable lesions and high rates of chronic pulmonary vein isolation even after long-term follow-up. Most of the repeat procedures after the hybrid approach are related to left atrial flutters that could be successfully treated by catheter ablation.

Intraoperative Bronchopleural Fistula During Thoracoscopic Lobectomy: The Role of End-Tidal CO2 Monitoring.

Video-assisted thoracoscopic surgery has become a common procedure in pediatric surgery. We present a case of accidental intraoperative bronchopleural fistula during a video-assisted thoracoscopic surgery procedure, which was first identified by the anesthesia team. We discuss differential diagnoses including the role of end-tidal carbon dioxide monitoring as an aid to prompt diagnosis.

EComment. Minimally invasive techniques for malignant pericardial effusions

We have read with great interest the article by Mirhosseini et al. concerning risk factors affecting the survival rate in patients with symptomatic pericardial effusion undergoing surgical intervention [1]. They conclude that patients with underlying malignant diseases, particularly lung cancer or an invasion of the thorax, detected by computed tomography, have poor survival and are at a greater risk of postoperative death. Therefore, minimally-invasive therapies should be considered as a more acceptable alternative for these high-risk patients. The aim of our brief comment is to highlight the advantages of pericardiocentesis followed by intrapericardial cisplatin administration in patients with cardiac tamponade due to lung cancer. At our centre, we consider pericardiocentesis and subsequent cisplatin administration as the method of choice for preventing recurrence of malignant pericardial effusion. Our results were documented in a 5-year study [2]. In our study, death was attributed to generalized carcinomatosis causing respiratory failure in all patients. No patient died of recurrent cardiac tamponade. The main advantage of this treatment is that cisplatin infusion neither causes pain nor influences the haematological profile, because of the minimal systemic absorption from the pericardium. Intrapericardial fibrosis due to cisplatin infusion proved not to cause constrictive pericarditis even in long-term survivors. Pericardiocentesis followed by intrapericardial administration of cisplatin is safe and effective in preventing the re-accumulation of malignant pericardial effusion in the majority of oncologic patients and should be the gold standard. In case of recurrence or diagnostic dilemmas, the creation of a pleuropericardial window through a mini-thoracotomy or a video-assisted thoracoscopic surgery procedure is the last alternative and is absolutely indicated. Conflict of interest: none declared.

NUT midline carcinoma with cutaneous metastases

NUT midline carcinoma with cutaneous metastases

Ward-based, nurse-led, outpatient chest tube management: analysis of impact, cost-effectiveness and patient safety

Prolonged drainage and air leaks are recognized complications of elective and acute thoracic surgery and carry significant burden on inpatient stay and outpatient resources. Since 2007, we have run a ward-based, nurse-led clinic for patients discharged with a chest drain in situ. The aim of this study is to assess its cost-effectiveness and safety. We present a retrospective review of the activity of the clinic for a period of 12 months (November 2009-10). An analysis of the gathered data is performed, focusing specifically on the duration of chest tube indwelling, the indications, complications and cost efficiency. The nurse-led clinic was housed in the thoracic ward with no additional fixed costs. Seventy-four patients were reviewed (53 males, 21 females, mean age of 59) and subsequently discharged from the clinic in this time period, accounting for 149 care episodes. Thirty-three (45%) of the patients underwent a video-assisted thoracoscopic surgery procedure, 35 (47%) of them a thoracotomy and 7 (9%) had a bedside chest tube insertion. Following hospital discharge, the chest tubes were removed after a median of 14 days (range 1-82 days). Fifty-eight percent of the patients were reviewed because of a prolonged air leak, 26% for persistent fluid drainage and 16% due to prolonged drainage following evacuation of empyemas. For the care episodes analysed, we estimate that the clinic has generated an income of €24,899 for the department. Hourly staffing costs for the service are significantly lower compared with those of the traditional outpatient clinic: €15 vs. €114. Our results show that a dedicated chest tube monitoring clinic is a safe and efficient alternative to formal outpatient clinic review. It can lead to shorter hospital stays and is cost effective.

Thoracoscopic patch insulation to correct phrenic nerve stimulation secondary to cardiac resynchronization therapy

Cardiac resynchronization therapy is an established therapy for heart failure, improving quality of life and prognosis. Despite advances in technique, available leads and delivery systems, trans-venous left ventricular (LV) lead positioning remains dependent on the patient's underlying venous anatomy. The left phrenic nerve courses over the surface of the pericardium laterally and may be stimulated by the LV pacing lead, causing uncomfortable diaphragmatic twitch. This paper describes a video-assisted thoracoscopic (VATS) procedure to correct phrenic nerve stimulation secondary to cardiac resynchronization therapy. Most current ways of avoiding phrenic stimulation involve either electronic reprogramming to distance the phrenic nerve from the stimulation circuit or repositioning the lead. We describe a case where the phrenic nerve was surgically insulated from the stimulating current by insinuating a patch of bovine pericardium between the epicardium and native pericardium of the heart thus completely resolving previously intolerable and incessant diaphragmatic twitch. The procedure was performed under general anaesthesia with single-lung ventilation and minimal use of neuromuscular blocking agents. Surgical patch insulation of the phrenic nerve was performed using minimally invasive VATS surgery, as a short-stay procedure, with no complications. No diaphragmatic twitch occurred post-surgery and the patient continued to gain symptomatic benefit from cardiac synchronization therapy (New York Heart Association Class III to II), enabling return to work. In cases where the trans-venous position of a LV lead is limited by troublesome phrenic nerve stimulation, thoracoscopic surgical patch insulation of the phrenic nerve could be considered to allow beneficial cardiac resynchronization therapy.

Combined Unilateral-Thoracoscopic and Mediastinoscopic Thymectomy

To achieve maximal benefit, after thymic tissue and mediastinal fat were removed by thoracoscopic thymectomy, a transverse cervical incision allowed access to remove fat in the neck. A mediastinoscopy was then performed for removal of the fat in the retrosternal area superior to the innominate vein. In 15 cases, ectopic thymic tissue was found. There were three cases in which the residual superior horns of thymus were found in the neck and three in the retrosternal area. The combined use of a mediastinoscope and a thoracoscope can remove almost all the thymus, including ectopic tissues. Long-term results are still being awaited.

Pulmonary Sequestration: Angioarchitecture Evaluated by Three-Dimensional Computed Tomography Angiography

Pulmonary sequestration represents an anomaly of nonfunctioning tracheobronchial branching with retention of the embryonic systemic arterial supply. We report a case of intralobar pulmonary sequestration, in which the abnormal supplying artery and especially the abnormal draining vein were demonstrated by three-dimensional computed tomography angiography and were confirmed and treated using a video-assisted thoracoscopic procedure.

Unusual presentation of spontaneous pneumomediastinum: a case report

The diagnosis of spontaneous pneumomediastinum in an acute hospital setting can present as a challenge. We present a case of 32 year Caucasian male with gradual swelling of his face and neck with increasing hoarseness of voice. He was treated for anaphylaxis with little improvement. He underwent a video-assisted thoracoscopic surgery procedure (VATS) with a definite diagnosis of sub pleural bleb.

Video‐Assisted Thoracoscopic Implantation of the Left Ventricular Pacing Lead for Cardiac Resynchronization Therapy

To study the feasibility and efficacy of video-assisted thoracoscopic (VAT) placement of the left ventricular pacing lead for cardiac resynchronization therapy (CRT) where the conventional transvenous coronary sinus approach has failed. Seventeen patients underwent the VAT procedure. Indications for CRT were ischemic cardiomyopathy in six patients and nonischemic cardiomyopathy in 11. The procedure was performed under general anesthesia with single-lung ventilation. Three 2-cm incisions were used on the left chest wall to place the screw-in lead near the obtuse marginal arteries high on the lateral wall of the left ventricle (LV). The VATS approach was successful in 13/17 (76%) patients. Median procedure time was 75 minutes (range 55-135). A learning curve was observed that appeared to plateau at 75 minutes procedure time after four cases. Median length of hospital stay was 2 days (range 2-8) with one patient requiring intensive care. Satisfactory thresholds and impedances of 2.3 +/- 0.9 V/0.5 ms and 560 ohms, respectively, were achieved at mean follow-up of 226 days. All patients reported symptomatic benefit with reduction in New York Heart Association score from III preoperatively to II postoperatively. VAT placement of the epicardial pacing lead is feasible, safe, and efficacious. It should be considered in cases where the transvenous route has failed or as an alternative in prolonged or hazardous transvenous procedures.

Recurrent hydropneumothorax as a presenting feature of malignant mesothelioma

A 73-year-old former smoker with previous occupational exposure to asbestos presented with a pneumothorax that was initially managed by simple aspiration. Despite this, it re-accumulated and a bronchopleural fistula was suspected. A video-assisted thoracoscopic procedure was performed and revealed an abnormally thickened pleura that turned out to be a mesothelioma. All persistent pneumothoraces should be investigated.