Portuguese Journal of Cardiac Thoracic and Vascular Surgery

Advancing Vascular Surgery: The Role Of Artificial Intelligence And Machine Learning In Managing Carotid Stenosis

Ana Daniela Pias — 2024-10-12

Introduction: Cardiovascular diseases affect 17.7 million people annually, worldwide. Carotid degenerative disease, commonly described as atherosclerotic plaque accumulation, significantly contributes to this, posing a risk for cerebrovascular events and ischemic strokes. With carotid stenosis (CS) being a primary concern, accurate diagnosis, clinical staging, and timely surgical interventions, such as carotid endarterectomy (CEA), are crucial. This review explores the impact of Artificial Intelligence (AI) and Machine Learning (ML) in improving diagnosis, risk stratification, and management of CS.

Methods: A comprehensive literature review was conducted using PubMed and SCOPUS, focusing on AI and ML applications in diagnosing and managing extracranial CS. English language publications from the past two decades were reviewed, including cross-referenced scientific articles.

Results: Recent advancements in AI-enhanced imaging techniques, particularly in deep learning, have significantly improved diagnostic accuracy in identifying carotid plaque vulnerability and symptomatic plaques. Integration of clinical risk factors with AI systems has further enhanced precision. Additionally, ML models have shown promising results in identifying culprit arteries in patients with previous cerebrovascular events. These advancements hold immense potential for improving CS diagnosis and classification, leading to better patient management.

Conclusion: Integrating AI and ML into vascular surgery, particularly in managing CS, marks a transformative advancement. These technologies have significantly improved diagnostic accuracy and risk assessment, paving the way for more personalized and safer patient care. Despite clinical validation and data privacy challenges, AI and ML have immense potential for enhancing clinical decision-making in vascular surgery, marking a pivotal phase in the field's evolution.

Tailored Perioperative Medicine For Frail Patients Undergoing Vascular Surgery: A Narrative Review

Bernardo Miguel — 2024-10-12

Frailty is a concept that is emerging as an important tool in the preoperative assessment of patients. The incidence of frailty in vascular surgery patients is high and is expected to increase concomitantly with the aging of the population. The identification of these patients and their optimization in the perioperative period can lead to an improvement in their outcomes with a reduction in morbidity and mortality. In this narrative review we address the concept of frailty applied to vascular surgery patients as well as assessment tools for its evaluation. This review focus not only on the most utilized evaluation tools but also on the most recent and specific frailty evaluation instruments that are suitable for vascular surgery patients. Furthermore, we review patient optimization strategies to improve perioperative outcomes.

High And Intermediate-High Risk Pulmonary Embolism Management: A 5-Year Intensive Care Unit Casuistic Review

Inês Mendonça — 2024-10-12

Background and Objectives: The optimal management of high-risk and intermediate-high-risk Pulmonary Embolism (PE) is a matter of ongoing debate. This paper aims to assess the short and long-term clinical outcomes associated with different treatment approaches for high-risk and intermediate-high-risk PE within an Intensive Care Unit (ICU) and identify potential areas for improvement.

Methods: We conducted a retrospective analysis of patients admitted to an ICU with high and intermediate-high-risk PE between January 2018 and December 2023. The therapeutic approach and clinical outcomes were evaluated: ICU and 28-days survival, ICU and hospital length of stay, major hemorrhagic complications and direct and indirect signs of pulmonary hypertension (PHT). Demographic, comorbid state and severity at admission data were also collected (sex, age, Charlson Comorbidity and APACHE II scores).

Results: 64 patients were included: 32 high-risk PE (including 18 in cardiac arrest) [Groups 1-5] and 32 intermediate-high-risk PE [Group 6a-c]. Treatment approaches varied: Group 1 - High-risk PE treated with systemic thrombolysis (ST) (n=18); Group 2 - High-risk PE treated with Veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) plus ST (n=6); Group 3 - High-risk PE treated with VA-ECMO alone (n=5); Group 4 - High-risk PE treated with catheter-direct-therapy (n=1); Group 5 - Heparin only (n=2). Group 1 demonstrated an ICU and 28-day survival of 83.0%, while Groups 2 and 3 exhibited survival rates of 66.67% and 60.0%, respectively. There were 10 major bleeding complications in Group 1 and 2. For intermediate-high-risk PE, heparin alone was used in 90%; ICU and 28-day survival rate was 97%. Three patients exhibited signs of PHT during follow-up.

Conclusion: This paper provides insights for the decision-making process involved in managing high and intermedi-

ate-high-risk PE drawing from a 5-year retrospective cohort study conducted at an ECMO center and literature review. Fur-

ther research is needed to identify the specific subgroup within the intermediate-high-risk PE that would benefit from more

advanced treatment modalities for both short and long-term outcomes.

Segmentectomies: 5-Year Experience Of A Center

Catarina Nunes Figueiredo — 2024-10-12

Introduction: Segmental anatomical resections have been a subject of debate in recent years. There is increasing evidence that these procedures may offer some advantages in the treatment of early-stage lung cancer, with overall survival (OS) and disease-free survival (DFS) similar to those seen in lobar anatomical resections.

Materials and Methods: We conducted a retrospective analysis of patients who underwent segmentectomy at Santa Marta Hospital (HSM) between January 2018 and September 2022. Patients undergoing trauma-related segmentectomy or as a secondary procedure were excluded.

Results: 37 segmentectomies were performed, of which 34 were included in this analysis. 29 (85.3%) were performed for malignancies, 5 (14.7%) for benign conditions. Of the malignancies, 24 (82.8%) were primary lung cancer (PLC): 18 (75%) adenocarcinomas (ADC), 2 (8.3%) squamous cell carcinomas (SCC), 4 (16.7%) typical carcinoids (TC); 5 (17.2%) were colorectal-origin metastases. Among the benign cases: 3 (60%) were aspergillomas. Mean age of PLC patients was 71 years (min=56;max=88), with 9 (37.5%) females and 15 (62.5%) males. In 11 (45.8%), FEV1 or DLCO was <60%. 18 (75%) were smokers. Lesions were mostly solid nodules (N=12;50%). Others included subsolid lesions (N=11;45%) and 1 (4.2%) cystic formation.

At surgery, only 3 (12.5%) patients had a pre-operative histological diagnosis (ADC=2; SCC=1). 21 (87.5%) were stage IA, 2 (8.33%) patients were stage IB and 1 (8.33%) patient was stage IIA. Procedures were performed via VATS (N=17;70.8%), via thoracotomy (N=5;20.8%) and via RATS (N=2;8.3%). 23 (95.8%) were R0 resections.

Postoperatively: 19 (79.2%) were stage IA; 3 (12.5%) IB; ,1 (4.2%) IIB, and 1 (4.2%) IIIA. 3 (12.5%) had upstaging. 2 (8.3%) patients underwent adjuvant chemotherapy, 1 (4.2%) had completion lobectomy. 2 (8.3%) experienced recurrence. DFS was 100% at 3, 6, and 12 months, and at 3 and 5 years, was 88.9% and 66.7% respectively. OS was 100% at 3, 6, and 12 months and 95% at 3 and 5 years. Median follow up time was 29 months (IQR: 18 – 44).

Conclusion: This study reinforces the idea that segmental resections should be considered a viable option for patients with early-stage lung cancer. Although this analysis has some limitations, such as a limited number of preoperative histological diagnoses and postoperative upstaging, our results demonstrate promising OS and DFS, in accordance with recent literature.

Pancoast Tumors: 11-Year Single-Centre Experience

Catarina Pereira Moita — 2024-10-12

Introduction: Pancoast tumors encompass any tumor located on the lung apex, extending into structures in the thoracic inlet and, often, leading to the characteristic clinical syndrome. The main goal of this study is to analyze the response to multimodal treatment and outcome of patients with Pancoast tumors.

Materials and Methods: We performed a retrospective cohort single center study of patients with superior sulcus nonsmall cell lung carcinomas who underwent surgery between January of 2011 and February of 2022.

Results: A total of ten patients were considered, 80,0% were male with a mean age of 53,6 (±6,6) years. At diagnosis, two tumors were stage II and eight were stage III. Histopathology revealed eight were adenocarcinomas and two were sarcomatoid carcinomas. All patients underwent neoadjuvant treatment before surgery. Nine patients received lung lobectomy, with en bloc resection comprising, predominantly, the chest wall (80,0%) and brachial plexus (30,0%). In one patient, surgery was aborted. Surgical histopathology showed free surgical margins were achieved in eight patients (80,0%). Two patients achieved full tumoral remission (ypT0N0, 22,2%), two tumors were stage I (22,2%), two were stage II (22,2%), two were stage III (22,2%) and one tumor was stage IV (11,1%). Mean disease-free survival was 83,9 (CI95% 42,1-125,8) months. 3-month disease-free survival rate was 88,9% and 1-year and 5-year disease-free survival rates were 63,5%. After the first-year follow-up, there was no evidence of disease progression. Mean overall survival was 115,7 (CI95% 89,3-142,1) months. At 3-month, 1-year and 5-years, overall survival was 88,9%.

Conclusion: Although considering the small sample of patients, the survival of Pancoast tumors in our institution exhibits a positive outcome, when compared to current literature, Significant improvements have been reported recently, in understanding the nature of Pancoast tumors, emphasizing the importance of a multidisciplinary approach but still, further research is required.

Impact Of Open And Endovascular Caseload In Lower Limb Amputation In Portugal – An Analysis From 2000 To 2015

Filipa Jácome — 2024-10-12

Objectives: Effective revascularization is the cornerstone of limb salvage in chronic limb threatening ischemia. In recent years, less invasive endovascular revascularization techniques have supplanted surgical bypass as the primary mode of revascularization. The real impact of this transition is being increasingly questioned. This study aims to evaluate the endovascular evolution, and how it impacted the amputation rates nationwide since de beginning of the century.

Methods: Patients admitted to Portuguese public hospitals with peripheral arterial disease between 2000 and 2015 were selected. Of these, patients that underwent to limb revascularization and/ or limb amputation were evaluated. The information was obtained through the National Health Service administrative database. Three time periods (2000-2004, 2005-2009, 2010-2015) were considered to evaluate the evolution in amputation rates and type of revascularization.

Results: The global number of revascularization episodes consistently increased along the 15 analyzed years. There were 25252 admissions for revascularization (55.1% open and 44.9% endovascular). The mean incidence of endovascular procedures significantly increased 5.8 times (p<0.01), and open surgery increased 1.3 times (p<0.01) when comparing the three time periods. 34633 limb amputations (65.3% major vs 34.7% minor) were realized along 15 years. The mean incidence of lower limb amputations increased by 1.5 times thanks to minor amputation, whose mean incidence increased two-fold while with the incidence of major amputations remained stable. Additionally, mean hospital mortality associated with revascularization episodes decreased from 10.6% to 8.2% (p<0.01), on 15-year follow-up.

Conclusions: There was a significative increase in revascularization episodes over the 15 years, suggesting better access to health services and/or better diagnostic accuracy. Endovascular procedures were the most practiced. This was along with an increase in the minor limb amputation, a stabilization in major amputations incidence. This nationwide study adds to the increasing body of knowledge in the ever-pertinent discussion of revascularization types and their benefits.

A Timeline From Index Procedure To Complex Reinterventions For Thoracoabdominal Aortic Dissection

Kevin Duh — 2024-10-12

The optimal management of acute type A aortic dissection (ATAAD) remains a controversial subject. While some surgeons opt for a hemiarch approach to minimize bypass and cross-clamping time, others prefer partial or total arch replacement to prevent the need for additional operations. The advent of hybrid approaches offers a variety of options to the aortic surgeon in treating ATAAD. Herein, we present a complex case of ATAAD requiring multistage reconstruction of the aortic arch and its branch vessels utilizing hybrid techniques. A 67-year-old man presented with chest pain and hypertension, leading to diagnosis of ATAAD. He initially underwent hemiarch replacement, which required multiple further interventions secondary to progressive thoracic aorta aneurysmal dilation, innominate artery dissection, and subclavian steal syndrome. A hybrid approach of open and endovascular techniques was utilized to treat the patient’s pathology. ATAAD represents a challenging clinical entity in its acute, subacute, and long-term management. Currently, no consensus exists on ideal initial management of this disease. Nonetheless, new techniques such as fenestration of thoracic endografts can be utilized for the subsequent operations. Individualized care tailored to each case is the most effective management of this intricate disease.

Digital Arteriovenous Malformation. An Uncommon Finding: A Case Report

Fernando Téllez-Pallares — 2024-10-12

Vascular malformations (VMs) are dysplastic abnormalities of vascular channels, differing from vascular tumors by their slow growth. Arteriovenous malformations (AVMs) arise between weeks 4-10 of intrauterine life, with a prevalence of 1 in 100,000 among Caucasians. Common in the head, neck, and hands, AVMs may be asymptomatic or cause symptoms like pain, deformity, and disability. Treatments range from conservative management to amputation in severe cases. A 28-year-old male with finger trauma was found to have a vascular tumor, later diagnosed as an arteriovenous malformation, surgically removed and confirmed by histopathology. Angiography is the gold standard for diagnosing AVMs, though imaging and physical exams are often sufficient. Conservative management is preferred for minor symptoms, with surgery reserved for severe cases. Surgical intervention carries risks, especially for diffuse lesions. Treatment for hand AVMs is challenging, requiring specialized expertise due to the hand’s complex anatomy.

Sequential Double-Lung Transplantation In Kartagener Syndrome: A Case Report

Catarina Nunes Figueiredo — 2024-10-12

Kartagener syndrome (KS) is a rare congenital disorder, characterized by sinusitis, bronchiectasis and situs inversus. Lung transplantation is an effective treatment for end-stage lung failure, but dextrocardia and differences between hilar structures and pulmonary lobes require adjustments to conventional surgical technique.

We present a case of a double-lung transplant without extracorporeal oxygenation in a 48-year-old male patient with KS. Through a Clamshell incision, right-left rotation was identified. To provide an end-to-end arterial and bronchial anastomosis, longer donor PA’s and right main bronchus were preserved. Wedge resection of right inferior lobe was unnecessary and there was no left residual cardiac chamber.

Patient was discharged 32 days after surgery without complications.

Despite being anatomically challenging, lung transplant was done successfully without the need for plastic maneuvers or extracorporeal circulation. This reinforces the idea that it should be an option in end-stage lung disease.

An Unusually Large Ascending Aortic Aneurysm

Ana Margarida Silva — 2024-10-12

Surviving By A Thread Of Life For 20 Years

Vidur Bansal — 2024-10-12

Professor Doutor António Braga The Founder of the Service, School and Attitude

José F. Teixeira — 2024-10-12

President’s Message

Miguel Sousa Uva — 2024-10-12

The Future of Aortic Surgery

Florian S. Schoenhoff — 2024-10-12

Editorial Board & Table of Contents

Marina Dias Neto — 2024-10-13