Thoracic Endovascular Aortic Repair for a Ruptured Mycotic Aortic Pseudoaneurysm Secondary to Esophageal Carcinoma

A 47-year-old female presented to the emergency department with new episodes of hematemesis. She had a background of unresectable T4b + N1 + M0 esophageal squamous cell carcinoma. Contrast CT thoracic aorta diagnosed a ruptured mycotic aortic pseudoaneurysm of the descending aorta, forming a life threating aorto-esophageal fistula secondary to neoplasm. Due to the high risk of fatal haemorrhage, she underwent successful emergency thoracic endovascular aortic repair (TEVAR). Mycotic aortic pseudoaneurysms are a rare and often fatal complication of esophageal carcinomas. They represent a small subsection of aorto-esophageal fistulas. Early diagnosis with cross sectional imaging and vascular control of the sentinel bleed is essential for survival. TEVAR may be used as a bridge to palliative treatment in the case of unresectable esophageal carcinoma.

Sectioning of C2 nerve roots during C1–2 fusion: report of aberrant vertebral artery during C2 nerve root sectioning. Illustrative case

BACKGROUND Sectioning the C2 nerve root is increasingly utilized during posterior C1–2 fusion, as the nerve overlies the entry point for C1 lateral mass screws and the C1–2 joint. Nerve sectioning improves visualization for screw placement and enables joint decortication for arthrodesis. While rare, vascular injury is a devastating complication of atlantoaxial fusion. Anomalous vascular anatomy at C1–2 greatly increases risk of iatrogenic injury. OBSERVATIONS A 78-year-old female with rheumatoid arthritis and prior C2–7 fusion presented with myelopathy from a compressive pannus at C1–2. She underwent C1 laminectomy and C1–2 posterior instrumented fusion. Intraoperatively, arterial bleeding occurred as the right C2 nerve root was sectioned. Vertebral artery injury was suspected, and tamponade was performed while vascular control was established. The artery passed aberrantly beneath the nerve root in the C1–2 foramen. It was repaired microsurgically, and patency was confirmed using indocyanine green. The remainder of the fusion was aborted. The patient wore a cervical collar and was treated with aspirin for 6 weeks before undergoing instrumented fusion. The patient suffered no deficits. LESSONS Although rare, anomalous vertebral artery anatomy increases risk of injury at time of C2 nerve root sectioning. Preoperative assessment of the vasculature is vital.

Placenta Accreta Spectrum Outcomes Using Tourniquet and Forceps for Vascular Control

Objective: To evaluate the use of tourniquet and forceps to reduce bleeding during surgical treatment of severe placenta accreta spectrum (placenta increta and placenta percreta).Methods: A tourniquet was used in the lower part of the uterus during surgical treatment of severe placenta accreta spectrum. Severe placenta accreta spectrum was classified into two types according to the relative position of the placenta and tourniquet during surgery: upper-tourniquet type, in which the entire placenta was above the tourniquet, and lower-tourniquet type, in which part or all of the placenta was below the tourniquet. The surgical effects of the two types were retrospectively compared. We then added forceps to the lower-tourniquet group to achieve further bleeding reduction. Finally, the surgical effects of the two types were prospectively compared.Results: During the retrospective phase, patients in the lower-tourniquet group experienced more severe symptoms than did patients in the upper-tourniquet group, based on mean intraoperative blood loss (upper-tourniquet group 787.5 ml, lower-tourniquet group 1434.4 ml) intensive care unit admission rate (upper-tourniquet group 1.0%, lower-tourniquet group 33.3%), and length of hospital stay (upper-tourniquet group 10.2d, lower-tourniquet group 12.1d). During the prospective phase, after introduction of the revised surgical method involving forceps (in the lower-tourniquet group), the lower-tourniquet group exhibited improvements in the above indicators (intraoperative average blood loss 722.9 ml, intensive care unit admission rate 4.3%, hospital stays 9.0d). No increase in the rate of complications was observed.Conclusion: The relative positions of the placenta and tourniquet may influence the perioperative risk of severe placenta accreta spectrum. The method using a tourniquet (and forceps if necessary) can improve the surgical effect in cases of severe placenta accreta spectrum.

P065 Heart Rate and Heart Rate Variability in paediatric sleep disordered breathing: Is LF a proxy for vascular motor tone

In children, sleep disordered breathing (SDB) is associated with changes in cardiac and vascular remodeling and hence may alter cardiac rhythm. Heart rate variability (HRV) measured during different sleep stages and at discreet times across the night, where vascular tone is known to change, provides an opportunity to better understand the effect of SDB on the cardiac function. 50 children diagnosed with SDB and 51 healthy children underwent overnight polysomnography to determine sleep staging. HRV (mean NN, SDNN, RMSSD, LF, HF, and LF:HF) was determined for the following segments pre-sleep; 3 slow wave sleep and 3 segments during rapid eye movement sleep (SWS1, SWS2, REM3, REM2, REM1). Children with SDB demonstrated higher heart rate (decreased mean NN) in all sleep segments. All HRV variables were similar between groups pre-sleep and REM3 and SWS3. LF and LF:HF were significantly lower in SWS1&2 and REM1 while as were SDNN and rMSSD were lower in the SDB group in REM1&2. LF remained low in the SDB group but rose to pre sleep levels in the control group. Children with SDB have increased heart rate across the night even when HRV is similar between the groups. This suggests intrinsic changes to the cardiac components that determine heart rate. The HRV difference between groups was greatest post acrophase (body temperature dropping) and post nadir (body temperature rising) of the circadian cycle. We propose that impaired peripheral vascular control and sustained cardiac remodelling may underlie the heart rate and HRV changes observed in children with SDB.

Superior mediastinal tumour excision through upper partial sternotomy and chamberlain incision

Superior mediastinal mass excision can be performed by various approaches such as partial sternotomy, mini trapdoor incision, anterior cervical transsternal approach and lateral thoracotomies. However, adequate exposure especially of superior surface seems to be difficult. Total four patients of superior mediastinal mass were admitted in the department of cardiothoracic and vascular surgery, Safdarjung hospital, New Delhi between June 2019 to May 2021. All of them were operated by upper partial sternotomy with right or left chamberlain extension of incision. It is safe and effective in terms of exposure with early recovery as well as cosmesis. Hence, we advocate the use of upper partial sternotomy with left or right chamberlain incision which provides good exposure in addition to ease of patient position, vascular control and emergency institution of cardiopulmonary bypass.

Medullary vein architecture modulates the white matter BOLD cerebrovascular reactivity signal response to CO2: observations from high-resolution T2* weighted imaging at 7T

ABSTRACTBrain stress testing using blood oxygenation level-dependent (BOLD) MRI to evaluate changes in cerebrovascular reactivity (CVR) is of growing interest for evaluating white matter integrity. However, even under healthy conditions, the white matter BOLD-CVR response differs notably from that observed in the gray matter. In addition to actual arterial vascular control, the venous draining topology may influence the WM-CVR response leading to signal delays and dispersions. These types of alterations in hemodynamic parameters are sometimes linked with pathology, but may also arise from differences in normal venous architecture. In this work, high-resolution T2*weighted anatomical images combined with BOLD imaging during a hypercapnic breathing protocol were acquired using a 7 tesla MRI system. Hemodynamic parameters including base CVR, hemodynamic lag, lag-corrected CVR, response onset and signal dispersion, and finally ΔCVR (corrected CVR minus base CVR) were calculated in 8 subjects. Parameter maps were spatially normalized and correlated against an MNI-registered white matter medullary vein atlas. Moderate correlations (Pearson’s rho) were observed between medullary vessel frequency (MVF) and ΔCVR (0.52; 0.58 for total WM), MVF and hemodynamic lag (0.42; 0.54 for total WM), MVF and signal dispersion (0.44; 0.53 for total WM), and finally MVF and signal onset (0.43; 0.52 for total WM). Results indicate that, when assessed in the context of the WM venous architecture, changes in the response shape may only be partially reflective of the actual vascular reactivity response occurring further upstream by control vessels. This finding may have implications when attributing diseases mechanisms and/or progression to presumed impaired WM BOLD-CVR.