Editorial comment
The surgeon and the art of planning for the unforeseen
O cirurgião e a arte de planear o imprevisto
Joana Saraiva
Cirurgia Cardiotorácica, CHUC, Coimbra, Portugal
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array:22 [ "pii" => "S0870255123001956" "issn" => "08702551" "doi" => "10.1016/j.repc.2023.04.005" "estado" => "S300" "fechaPublicacion" => "2023-08-01" "aid" => "2190" "copyrightAnyo" => "2023" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "dis" "cita" => "Rev Port Cardiol. 2023;42:745-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:17 [ "pii" => "S0870255123002627" "issn" => "08702551" "doi" => "10.1016/j.repc.2023.01.024" "estado" => "S300" "fechaPublicacion" => "2023-08-01" "aid" => "2200" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2023;42:747-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in Cardiology</span>" "titulo" => "Uncommon electrocardiographic presentation of acute left circumflex coronary artery occlusion" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "747" "paginaFinal" => "748" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Apresentação eletrocardiográfica incomum de oclusão aguda da artéria coronária circunflexa esquerda" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3116 "Ancho" => 3341 "Tamanyo" => 963505 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Electrocardiographic changes before and after stent angioplasty of the culprit lesion: (A) admission electrocardiogram depicting ST-segment depression at the J point in I, II, aVF, III and V3-V6 and ST-segment elevation at the J point in aVR and V1 (aVR>V1); (B) conventional coronary artery angiographic images depicting (top to bottom) acute proximal occlusion of the left circumflex artery (arrow), a good result after culprit lesion stenting, an unobstructed left anterior descending artery and high-grade lesions in the right coronary artery (arrowheads); (C) electrocardiogram after stent angioplasty of the culprit lesion depicting complete resolution of ST-segment changes and signs of inferior (QRS complex fragmentation in aVF and III) and lateral (R-wave amplitude and R/S amplitude ratio in V1 >3 mm and >0.5, respectively, and loss of R-wave height in V6) infarction.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Andreas Y. Andreou, Elena Leonidou, Theodoros Christou, Evi Christodoulou" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Andreas Y." "apellidos" => "Andreou" ] 1 => array:2 [ "nombre" => "Elena" "apellidos" => "Leonidou" ] 2 => array:2 [ "nombre" => "Theodoros" "apellidos" => "Christou" ] 3 => array:2 [ "nombre" => "Evi" "apellidos" => "Christodoulou" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255123002627?idApp=UINPBA00004E" "url" => "/08702551/0000004200000008/v1_202308010538/S0870255123002627/v1_202308010538/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "S0870255123001944" "issn" => "08702551" "doi" => "10.1016/j.repc.2019.09.022" "estado" => "S300" "fechaPublicacion" => "2023-08-01" "aid" => "2191" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2023;42:741-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Repair of a gigantic ascending aortic pseudoaneurysm – A challenging approach" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "741" "paginaFinal" => "744" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Reparação de pseudoaneurisma gigante da aorta ascendente – Uma abordagem desafiante" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2016 "Ancho" => 2340 "Tamanyo" => 421121 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A–C) Preoperative cardiac computed tomography (CCT). (A) Three-dimensional reconstruction showing the ascending aorta false aneurysm. (B) Two dimensional (2D) sagittal plane; <span class="elsevierStyleItalic">yellow arrows</span>: pseudoaneurysm eroding through the sternum; <span class="elsevierStyleItalic">red arrow</span>: periprosthetic posterior cavity. (C) 2D axial plane, <span class="elsevierStyleItalic">yellow arrows</span>: extrinsic main pulmonary artery compression due to pseudoaneurysm. (D) Intra-operative transoesophageal echocardiography (CT); <span class="elsevierStyleItalic">yellow arrow</span>: sizing of pseudoaneurysm (102 mm).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sara Ranchordás, Sara Guerreiro, Márcio Madeira, Manuel Canada, José Pedro Neves" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Sara" "apellidos" => "Ranchordás" ] 1 => array:2 [ "nombre" => "Sara" "apellidos" => "Guerreiro" ] 2 => array:2 [ "nombre" => "Márcio" "apellidos" => "Madeira" ] 3 => array:2 [ "nombre" => "Manuel" "apellidos" => "Canada" ] 4 => array:2 [ "nombre" => "José Pedro" "apellidos" => "Neves" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255123001944?idApp=UINPBA00004E" "url" => "/08702551/0000004200000008/v1_202308010538/S0870255123001944/v1_202308010538/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "The surgeon and the art of planning for the unforeseen" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "745" "paginaFinal" => "746" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Joana Saraiva" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Joana" "apellidos" => "Saraiva" "email" => array:1 [ 0 => "joana.c.saraiva@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cirurgia Cardiotorácica, CHUC, Coimbra, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "O cirurgião e a arte de planear o imprevisto" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The treatment of ascending aorta pseudoaneurysms requires creative and technically challenging solutions.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The literature describes several case reports and small series with different forms of treatment, from surgery to endovascular occlude devices or endograft.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Surgical mortality ranges 6.9 to 15.4%,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> but remains the standard technique.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">When I was asked to write this editorial, I thought that the most important thing would be to emphasize, not the problem itself, but the ability to plan and the solution idealized and executed by the authors, because it is there that the crux of the question lies.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Taking this into consideration, Ranchordás et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> presented a carefully planned surgical solution to post-surgical pseudoaneurysm of the ascending aorta, considering all the aspects and using multiple techniques to achieve success.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this type of disease, when the patient is stable, it is important to ensure the best conditions for hemostasis, namely, to discontinue anticoagulants or other drugs that may enhance bleeding, and promptly correct coagulation deficits.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Another aspect to be highlighted is the ability to simplify the case and make choices. Not always treating everything is the best solution and weighing up the cost-benefit ratio of each surgical act shows unique maturity and insight.</p><p id="par0035" class="elsevierStylePara elsevierViewall">For example, the authors chose to close the pseudoaneurysm neck with direct sutures instead of replacing the entire aorta, in line with other reports.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Also, the patient had a periprosthetic leak, the surgical resolution of which would entail high risk. The authors, having considered the possibility of percutaneous closure, chose not to close it during surgery, thus shortening the bypass time, the need for cardioplegia and avoiding an accumulation of surgical risk.</p><p id="par0045" class="elsevierStylePara elsevierViewall">As for the technique used, one of the major problems in pseudoaneurysms is the high risk of rupture during reentry into the thorax.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2,5</span></a> Thus, it is urgent to protect the brain from ischemic injury and reduce the risk of exsanguination as much as possible.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> There are several possible approaches.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,5</span></a> In this case, the authors resorted to deep hypothermia, cannulation of the right subclavian artery, associated with femoro-femoral bypass and use of an Endoclamp. They also used left ventricle venting through a left mini thoracotomy, to decompress the heart and avoid myocardial injury by ventricular fibrillation and distension,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,5</span></a> even though this implied another incision.</p><p id="par0050" class="elsevierStylePara elsevierViewall">As described, the use of endoclamps is often associated with failures due to displacement, rupture of the balloon or rupture of the aorta.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In this case, the authors reported balloon rupture, but it partially did the job providing a period of brain protection.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In this way, I look at this article, not as a description of an innovative technique, but as a lesson in planning, of choices based on risk-benefit and in assuming that we do not always have to treat everything at the same time or surgically.</p><p id="par0060" class="elsevierStylePara elsevierViewall">We should engage the multiple options currently available (surgical and percutaneous) to ensure the patient receives the best and most “comorbidity-free” treatment possible.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systematic review of interventions to repair ascending aortic pseudoaneurisms" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "H.C. 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Sundt 3rd" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2006.02.081" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2006" "volumen" => "82" "paginaInicial" => "81" "paginaFinal" => "98" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16798195" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Repair of a gigantic ascending aortic pseudoaneurysm – challenging approach" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Ranchordás" 1 => "S. Guerreiro" 2 => "M. Madeira" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2019.09.022" "Revista" => array:4 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2023" "volumen" => "42" "itemHostRev" => array:3 [ "pii" => "S0022534716309612" "estado" => "S300" "issn" => "00225347" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical exclusion of postsurgical pseudoaneurysm of the ascending aorta" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Barik" 1 => "A.N. Patnaik" 2 => "R.V. Kumar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Ann Pediatr Cardiol" "fecha" => "2014" "volumen" => "7" "paginaInicial" => "135" "paginaFinal" => "137" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reoperation for giant false aneurysm of the thoracic aorta: how to reenter the chest?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Bachet" 1 => "M. Pirotte" 2 => "F. Laborde" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2006.12.044" "Revista" => array:7 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2007" "volumen" => "83" "paginaInicial" => "1610" "paginaFinal" => "1614" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17462366" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0022534707025700" "estado" => "S300" "issn" => "00225347" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000004200000008/v1_202308010538/S0870255123001956/v1_202308010538/en/main.assets" "Apartado" => array:4 [ "identificador" => "93357" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000004200000008/v1_202308010538/S0870255123001956/v1_202308010538/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255123001956?idApp=UINPBA00004E" ]
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