Nisal K. Perera

Outcomes after pulmonary metastasectomy for colorectal cancer

Surgical resection offers the greatest likelihood of cure for appropriately selected patients with pulmonary colorectal carcinoma metastases. We hereby report our experience over the last 19 years at the Austin Hospital, Thoracic Surgery Unit.

Total Aortic Repair for Acute Type A Aortic Dissection Complicated by Malperfusion or Symptomatic Branch Vessel Malalignment

Malperfusion or persistent perfusion of the false lumen with acute type A aortic dissections is a major cause of morbidity and mortality. We describe our experience with total aortic repair in patients with acute type A dissection with recurrent or ongoing branch ischemia, true lumen collapse, or rapid dilatation of a false lumen after initial surgical repair.

Technical aspects of total aortic repair in the surgical management of acute type A aortic dissection

Traditional surgical techniques for the management of acute type A aortic dissection (ATAAD) focus on open distal anastomosis with or without hemiarch replacement under a period of deep hypothermic circulatory arrest. This is associated with high rates of false lumen (FL) patency, which exposes the patient to the risk of ongoing end-organ malperfusion and to the formation of complex arch and thoracoabdominal dissection aneurysms. Furthermore, persistent malperfusion is a major source of morbidity and mortality and is not easily reversed following traditional central repair. Arch replacement using the “branch first” technique allows for complete root, ascending and arch replacement (1-3). A long landing zone is created for proximal endografting with a covered stent. Extended thoracoabdominal stenting is performed in patients with: Ongoing or recurrent branch vessel ischaemia or malperfusion; Radiological true lumen (TL) collapse; Rapid dilatation of the FL; Markers of compromised TL perfusion. The following video (Video 1) illustrates a case of TAAD with clinical and radiological malperfusion and shows the benefits of “branch first” arch replacement followed by stent grafting in this situation. Video 1 Technical aspects of total aortic repair in the surgical management of acute type A aortic dissection.

Coronary artery bypass graft pseudo-aneurysm following sternal wire removal

Sternal wire removal after median sternotomy is frequently performed for anterior chest wall discomfort or for local wound complications. Although necessary for achieving a stable sternal closure, the use of sternal wires and their removal have been associated with a number of intraand post-operative complications. These include ventricular laceration on insertion, aortic injury from fractured wires and fatal pericardial bleeding. To our knowledge, there have been no cases reported in the literature of a coronary artery bypass graft pseudo-aneurysm resulting from the removal of a sternal wire. We hereby report our recent experience. An 89-year-old female presented with a 4-month history of wound breakdown over the upper sternum. She had undergone coronary artery bypass grafting with a reverse saphenous vein graft (SVG) to the left anterior descending coronary artery (LAD), in situ left internal mammary artery to the obtuse marginal artery and SVG to the posterior descending coronary artery 22 years prior. On examination, there was a prominent upper sternal wire associated with superficial skin breakdown and granuloma formation (Fig. 1). She experienced significant chest trauma from a motor vehicle accident 3 years prior with contrast enhanced computed tomography of her thoracic aorta at that time showing no significant intra-thoracic abnormalities. The patient was electively taken to the operating room for excision of the granuloma and removal of the upper sternal wire. At the time of operation, the granuloma tract was found to be extending through the anterior table of the sternum. The tract was excised and the wire removed uneventfully. The patient re-presented to the emergency department 2 months later with a pulsatile mass and haemoserous discharge from the sternal wound. Computed tomography coronary angiography was performed. A large pseudo-aneurysm was seen, originating from the proximal SVG to the LAD and eroding through the manubrium into the superficial soft tissues (Fig. 2a,b). The SVG to the LAD was patent distally and filled a large proximally occluded LAD system. It also filled the right coronary artery via left to right collaterals. The SVG to posterior descending coronary artery was occluded and the left internal mammary artery to obtuse marginal artery was patent. Given the patient’s advanced age and frailty, she was not a candidate for re-operative cardiac surgery. The SVG to the LAD was a critical graft as it supplied coronary flow to the LAD and right coronary artery systems. Because of this and following a herald Fig. 1. Upper sternal granuloma.