The surgical approach to the management of subclavian artery injuries is usually guided by the location and clinical presentation. With the advent of endovascular surgery, many surgeons are likely to have limited experience with the trap door approach sometimes necessary for control and repair of proximal left subclavian artery (LSA) injuries due to their relative rarity. A 69-year-old male sustained a left lower neck stab wound 3 weeks before his presentation with a pulsatile left supraclavicular swelling, weak radial pulse, and upper extremity weakness. Duplex ultrasound scan revealed a pseudoaneurysm confirmed on computed tomography angiogram and shown to be fed from the LSA. The patient successfully underwent elective open surgical repair of the injury located in the first portion of the subclavian artery through a trap door approach. Although the injury might have been treated minimally invasively with endovascular repair, this technique is currently not available in Nigeria and most Sub-Saharan African countries. Surgery remains the only treatment option for these types of injuries in low-resource countries. Surgeons involved in the management of vascular injuries should, therefore, be conversant with all surgical approaches, including the trap door incision which should be part of their armamentarium.

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Neurofibroma and schwannoma are rare benign peripheral nerve sheath tumors and both combined account for the majority of intrathoracic neurogenic tumors seen in adults. They are difficult to distinguish clinically except by immunohistochemistry. A 50-year-old female nonsmoker presented with a 2-year history of right-sided chest pain, cough, and shortness of breath. Chest X-ray showed a large right chest mass confirmed on chest computed tomography scan and measured 14 cm Χ 15 cm Χ 10 cm. The patient subsequently underwent a right posterolateral thoracotomy with complete resection of the tumor, which was diagnosed on immunostains as a neurofibroma. At 1-year follow-up, the patient remains asymptomatic with no evidence of recurrent tumor.

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Objectives: Conservative management of rib fractures has been the standard of care. Recently, surgical fixation with rib plating is emerging as a superior option for flail chest (FC) and multiple rib fractures. This review details our experience with surgical fixation. Materials and Methods: The medical records of 18 patients with severe chest wall injuries referred to the cardiothoracic surgery service at a level 1 trauma center from January 2010 to December 2015 were retrospectively reviewed. 66.7% were male, mean age 58.4 ± 14.5, Glasgow Coma Score 13.3 ± 3.3, and injury severity score 20.4 ± 11.7. 77.8% (14/18) had multiple rib fractures, half with FC, 22.2% (4/18) sternal fractures, and 61.1% of patients were involved in motor vehicle accident. All patients underwent surgical stabilization except three with isolated sternal fractures treated conservatively. Results: 3.4 ± 0.5 ribs were plated in FC versus 2.4 ± 0.5 in non-FC patients. 64.2% had concomitant decortication and 7.1% lung wedge resection. All FC patients had severe lung contusion and respiratory failure requiring preoperative mechanical ventilation mean 10.7 ± 7.9 days. Postoperative ventilatory support was 7.4 ± 4.9 days in FC versus <24 h in non-FC patients. 57.1% of FC patients required tracheostomy for prolonged intubation. Mean interval to surgery, Intensive Care Unit, and hospital length of stay (LOS) was 13.3 ± 5.3, 22.4 ± 14.9, and 29.7 ± 9.2 in FC versus 5.3 ± 3.8, 10.3 ± 10.4, and 14.3 ± 9.3 days, respectively, in non-FC patients. 85.7% received blood transfusion, mean 5.7 ± 3.7 in FC versus 42.8% mean 3.7 ± 0.6 units in non-FC patients. Morbidity in FC patients were pneumonia 42.8%, empyema 14.2%, ARDS 14.2%, and acute kidney injury (AKI) 14.2% compared to non-FC patients AKI 25.0% and empyema 12.5%. There were no deaths. Conclusions: Rib plating of complicated chest wall injuries may reduce morbidity, hospital LOS, chronic disability, and should be considered in FC and multiple rib fractures.

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Total blood management during cardiopulmonary bypass requires intentional strategies to be effective. Key areas of impact involve creating a team atmosphere, reducing hemodilution, and optimizing a point of care testing. True team atmospheres realize innovative collaboration by establishing an appropriate discussion platform and maximizing complimentary gender-specific contributions. Technical strategies, from a perfusion standpoint, focus on disposable components, autologous blood management, and cardioplegia modifications. Finally, point of care testing is utilized to justify, improve, and standardize practices. Perfusion's contribution to strategic blood management contributes to improved patient outcomes.

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Objective: Off-pump coronary artery bypass (OPCAB) has been demonstrated to be a safe technique with similar outcomes to on-pump coronary artery bypass (ONCAB) in low-risk patients, while its role and benefits in high-risk patients are the subject of ongoing clinical trials. This review compares our high-risk patients aided by intra-aortic balloon pump (IABP) with low-risk patients undergoing OPCAB to identify any differences in outcomes. Materials and Methods: One hundred and twenty-four patients who underwent OPCAB surgery between January 2004 and December 2013 were retrospectively reviewed. 61.3% were males, 57.3% were African Americans, mean age was 62.7 ± 13.3, and range was 30-90 years. Patients were divided into Group 1, 26 (21.0%) patients with IABP and Group 2, 98 (79.0%) patients without IABP. Group 1 patients had higher risk profile with mean ejection fraction (EF) 26.0 ± 10.8 and EF ≤20 present in 46.1% compared to 45.2 ± 11.9 and 5.1%, respectively, in Group 2 (P < 0.001). Results: 92.35% of Group 1 and 82.7% of Group 2 patients had multivessel disease with a mean number of bypass grafts 2.9 ± 0.97 versus 2.75 ± 0.8, respectively (P < 0.364). Left internal mammary artery (LIMA) to left anterior descending (LAD) was performed in all Group 1 and 97.9% of Group 2 patients, with saphenous vein graft (SVG) to the left circumflex and right coronary arteries in 73.1% versus 62.2% and 57.7% versus 52.0% of Groups 1 and 2, respectively. Complete revascularization occurred in 88.5% and 90.8% of Groups 1 and 2, respectively (P < 0.990). 4.0% were converted to ONCAB for either hemodynamic instability or intramyocardial coronary artery. Major morbidities were re-exploration for bleeding 3.8% versus 1.0%, stroke 3.8% versus 2.0%, acute kidney injury 11.5% versus 0%, and prolonged intubation 15.4% versus 2.0% in Groups 1 and 2, respectively. Euroscore II predicted (P) versus observed (O) mortality was 4.56% versus 4.03%, for Group 1, 7.82% versus 7.69% and Group 2, 3.64% versus 3.06%, and O/P ratios 0.88, 0.98 and 0.84 respectively. Two (2.0%) females in Group 2 with single LIMA to LAD underwent repeat revascularization with SVG to the LAD within 90 days. Conclusion: IABP helps stabilize hemodynamics during OPCAB in high-risk patients with moderate to severe left ventricular dysfunction. Mean number of bypass grafts and predicted versus observed mortality were similar between the low- and high-risk groups.

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Traumatic manubriosternal dislocation is a rare sequel of blunt thoracic trauma. We report a case of 22-year-old man who presented with the history of road traffic accident and sustained manubriosternal dislocation. Initial chest X-ray did not show the lesion; however, a follow-up lateral view revealed the dislocation. In addition, the patient had fracture of the lamina of the C7 vertebra. In view of uncomplicated manubriosternal dislocation and the absence of any major associated injury, the patient was managed conservatively. In the presented case, we discuss the mechanism of injury, type of dislocation.

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Seven percent of mediastinal tumors are of thyroidal origin. The incidence of mediastinal/substernal thyroid masses ranges from 2.6% to 21% of patients undergoing thyroidectomy. The wide range in reported incidence is largely due to variation in the definition of substernal thyroid masses. They can be defined as a thyroid gland with cervical extension that descended below the thoracic inlet. The purpose of this report is to discuss an 84-year-old male with shortness of breath, pain radiating to the chest, dysphagia, and odynophagia. The patient was admitted to the hospital for retrosternal chest pain and pneumonia. A computerized axial tomography scan of the chest revealed a mediastinal mass compressing the trachea. The patient underwent neck and mediastinal exploration, with complete excision of the mediastinal thyroid. We were able to deliver the mass into the neck from the mediastinum avoiding the need for sternotomy or thoracotomy.

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Intraoperative hypotension (IOH) invariably follows the induction of general anesthesia during surgical operations. The current prevailing and predominant consensus acknowledges that IOH has immense clinical benefits such as reduced bleeding, less need for blood transfusions, and shorter surgery times and yet without significant adverse renal, hepatic, and neurological consequences. Nonetheless, our critical analysis of the surgery-acute kidney injury (AKI) literature exposed the fact that historical research had studied younger patients, with normal kidney function, involved procedures with short surgery times while concurrently excluding patients with advanced chronic kidney disease (CKD) and/or uncontrolled hypertension. We report on two patients seen in the Renal Unit of Mayo Clinic Health System, Northwestern Wisconsin, USA, to exemplify the causative relationship between IOH and postoperative AKI. Sun et al. (2015) recently demonstrated that postoperative AKI was associated with sustained intraoperative hypotensive periods of mean arterial pressure (MAP) <55 and <60 mmHg, respectively, in a graded pattern. Our experiences provide an impetus for new randomized clinical trials to determine safe levels of IOH during operations and whether interventions that promptly treat IOH, or better still that prevent IOH, and that are tailored to suit individual patient physiology, would reduce the risk of AKI. We posit that IOH is a neglected cause of postoperative AKI. We call for a preventative nephrology paradigm shift and the targeting of MAP ≥60 mmHg and/or systolic blood pressure ≥90 mmHg during surgical procedures. Particularly, in Sub-Saharan Africa with its paucity of renal replacement therapy options to manage kidney failure, every effort to limit AKI, syndrome of rapid onset end-stage renal disease, and exacerbation of kidney dysfunction in general, must be vigorously applied.

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