Downhill oesophageal varices (DEV) may occur as a rare complication of superior vena cava (SVC) obstruction. DEV are usually associated with SVC obstruction caused by systemic vasculitis or mediastinal tumours. In this report, we describe a very rare case of DEV resulting from SVC graft occlusion after resection of a thymoma. A 66-year old man with an invasive thymoma was treated by radical resection and bypass grafting from the right brachiocephalic vein to the right atrium. Occlusion of the SVC graft was diagnosed postoperatively; however, the patient could be managed conservatively. Although there had been no significant findings in the oesophagus in previous endoscopic examinations, grade F2 varices were found in the proximal oesophagus in the 19th postoperative month, and DEV caused by SVC graft occlusion was diagnosed. Until now, 2 years since the diagnosis, no apparent symptoms or deterioration of the DEV have been observed. The possible development of DEV should be borne in mind during the follow-up of patients with postoperative SVC graft occlusion.

OBJECTIVES

Limited blood supply to the thoracic chest wall is a known risk factor for sternal wound complications after CABG. Therefore, bilateral internal thoracic arteries are still rarely utilized despite their proven superior graft patency. The aim of our study was to analyse whether modification of the surgical technique is able to limit the risk of sternal wound complications in patients receiving bilateral internal thoracic artery grafting.

METHODS

All 418 non-emergent CABG patients receiving bilateral internal thoracic artery CABG procedures (BITA) from January 2001 to January 2012 were analysed for sternal wound complications. Surgical technique together with known risk factors and relevant comorbidity were analysed for their effect on the occurrence of sternal wound complications by means of multivariate logistic regression analysis.

RESULTS

Sternal wound complications occurred in 25 patients (5.9%), with a sternal dehiscence rate of 2.4% (10 patients). In multivariate analysis, diabetes (odds ratio [OR]: 4.8, 95% CI: 1.9-11.7, P = 0.001), but not obesity (OR: 1.6, 95% CI: 0.7-4.2, P = 0.28) or chronic obstructive pulmonary disease (OR: 2.2, 95% CI: 0.87-5.6, P = 0.1) was a relevant comorbid condition for sternal complications. Skeletonization of ITA grafts (OR: 0.17, 95% CI: 0.06-0.5, P = 0.001) and the augmented use of sternal wires (OR: 0.24, 95% CI: 0.06-0.95, P = 0.04) were highly effective in preventing sternal complications. The use of platelet-enriched-fibrin glue (PRF) sealant, however, was associated with more superficial sternal infections (OR: 3.7, 95% CI: 1.3-10.5, P = 0.02).CONCLUSIONAdjusted for common risk factors, skeletonization of BITA grafts together with augmented sternal wires is effective in preventing sternal complications. The use of PRF sealant, however, increased the risk for superficial wound complications.

OBJECTIVES

Pulmonary hypertension is a major cause of morbidity and mortality in patients following acute pulmonary embolism. Although thrombolytic therapy decreases pulmonary arterial pressure, compared with anticoagulation alone, it has the propensity for haemorrhagic complications, distal embolization and incomplete recanalization, with the potential risk of late pulmonary hypertension. Surgical embolectomy-once performed solely on critically-ill patients-has now gained favour in a wider range of patients. In this paper we present the outcomes of patients who underwent surgical embolectomy complemented with retrograde technique and follow-up systolic pulmonary arterial pressure (SPAP).

METHODS

From January 2004 to December 2010, 30 consecutive patients with a mean age of 58 ± 15 years underwent pulmonary embolectomy at our centre. The patients were followed for a mean period of 30.5 ± 12 months. Their New York Heart Association (NYHA) classifications were assessed and their SPAPs were measured by echocardiography.

RESULTS

The overall mortality rate was 13.2% (4/30). Of the remaining patients, 19 patients (73.1%) were in NYHA classes I and II, 7 patients (26.9%) in class III and no patient in class IV. The patients' preoperative and postoperative mean SPAPs were 44.9 ± 5.7 and 34.9 ± 7.1 mmHg, respectively, which showed a significant reduction (P < 0.001). The mean SPAP in the follow-up was 29.4 ± 11.5 mmHg, which again showed significant reduction compared with early postoperation values (P < 0.001). No significant correlations were found between the level of SPAP reduction in patients' follow-up with age (P = 0.727) and total days of ICU admission (P = 0.700), but weak correlations with sex (P = 0.016) and total intubation time were noticed (P = 0.035).

CONCLUSIONS

This is the first series reporting the long-term outcome of patients undergoing surgical embolectomy complemented by retrograde embolectomy technique, demonstrating the safety and favourable long-term outcome of this technique. It is also a new element in the growing body of evidence regarding the relevance of surgical embolectomy in patients with acute pulmonary embolism. We concluded that, following surgery, not only does the pulmonary arterial pressure drop immediately, but also the trend toward normalization continues long after operation.