Resident Case Report Competition

49-year-old female presented with history of metastatic neuroendocrine tumor of the terminal ileum and symptomatic oligoprogression in the right cervicothoracic region. Diagnosis was made 12 months prior, when she presented with new onset syncopal episodes. During initial workup, findings were notable for PET-avid lesions in the terminal ileum, small bowel mesentery, liver, interventricular cardiac septum, and right paratracheal region. A biopsy of the paratracheal lesion revealed a Grade 2 well-differentiated neuroendocrine tumor with Ki-67: 3-5%. She was started on long-acting octreotide. At 12 month follow up, the patient experienced progressive dysphagia, dysphonia, and neuropathic symptoms in her right upper extremity including weakness.
Her performance status was excellent. Physical exam notable for a palpable right supraclavicular mass and normal neurovascular exam of the right upper extremity. Recent imaging showed 6.4 cm right paratracheal mass with focal involvement of the proximal right common carotid, distal innominate, and encasement of the proximal right subclavian artery. The tumor extended along the vertebral artery and involved the neural foramina at C6/C7. The case was presented at our neuroendocrine multidisciplinary tumor board meeting with recommendation for surgical resection of the right cervicothoracic mass followed by staged small bowel resection. Preoperative assessment was satisfactory. The patient was informed of the risks, benefits, and alternatives to surgery. She wanted to proceed with surgical resection.

In the operating room, the patient was placed supine with a shoulder roll and arms tucked. General anesthesia was induced, and monitoring lines including an endotracheal tube with recurrent laryngeal nerve monitoring were placed. Standard antibiotic and deep vein thrombosis prophylaxis were given. A low-neck thyroidectomy incision was made and extended lateral to the right and down to the upper chest at the midline in case a sternal split was required. During lateral and central neck dissection, the right recurrent laryngeal nerve was noted to be encased by the tumor distally and will need to be sacrificed. It was also determined that the distal innominate, proximal subclavian, and common carotid artery needed to be resected en-block with the tumor. To limit ischemia, arterial reconstruction was performed prior to tumor resection. An 8mm graft was sutured as end-to-side to another 8mm graft. Next, we sutured end-to-end beveled the 8mm graft to a 12mm graft. This created a 12mm to 8mm tapered graft with an additional 8 mm side branch to recreate the innominate artery bifurcation. Weight based heparin given. Arterial clamping and resection were performed. The anastomosis was constructed first in the innominate artery, followed by common carotid which established cerebral blood flow. Clamp time was 15 minutes. Finally, the right subclavian artery anastomosis was performed. We finalized the en-bloc resection of the tumor by dividing deep neck muscular adherences and pleura. The Ansa hypoglossi was dissected off sternothyroid muscle and sutured to the right recurrent laryngeal nerve. Direct layngoscoscopy was performed and carboxymethylcellulose gel was injected into the right paraglottic space. The patient tolerated the procedure well. Discharged on day 4 on regular diet without complications. At 1-, 6-, and 10-month follow up the patient is asymptomatic and without evidence of disease progression.

Authors
Jarot Guerra (1), Anastasios Maniakas (2), Sophia Khan (3), Anthony Estrera (4), Ravi Rajaram (1)
Institutions
(1) University of Texas MD Anderson Cancer Center, Houston, TX, (2) UT MD Anderson Cancer Center, Houston , TX, (3) UT MD Anderson Cancer Center, Houston, TX, (4) University of Texas - Houston, Houston, TX 

Papillary thyroid carcinoma (PTC) most commonly metastasizes to cervical lymph nodes. There are only rare reports of PTC presenting first as a primary lung lesion, and even fewer as a mediastinal mass rather than within the lung parenchyma. We present a case of an incidentally found massive intrathoracic cystic lesion with a normal appearing thyroid on axial computer tomography (CT) imaging who was then found to have disseminated papillary thyroid carcinoma.

This patient is a 63-year-old sheep farmer from Guyana who presented with a known 12.3cm intrathoracic mass which had been present for 30 years. Based on its appearance on CT scan and MRI of the neck, the pre-operative differential included an ecchinococcal cyst or bronchogenic cyst. Axial imaging suggested the mass was encapsulated by the right upper lobe (RUL) with calcifications present on the cyst edges and a 2cm mural nodule noted on the inferior portion.

In the OR the chest was free of pleural adhesions. Due to the size of the mass and presumed likely ecchinococcal etiology, an anterior thoracotomy was made in the 5th interspace to facilitate safe removal. To decrease the mass size, needle aspiration was performed and 30% hypertonic saline was injected for sterilization of possible cyst contents. With the mass decompressed, circumferential dissection was performed. Of note, the mass did not involve the right lung but rather had displaced the entire RUL secondary to mass effect. After removal the cyst was opened on a back table and contained ~500cc of brown fluid.

The patient was extubated at the end of the case and he was discharged on post operative day 3 without complications. Final pathology demonstrated lymphoid cells with well differentiated papillary thyroid carcinoma, positive for TTF1 and thyroglobulin. He was then referred to Otolaryngology and underwent dedicated neck ultrasound which demonstrated a right sided 2cm thyroid nodule with high-risk features and an enlarged level 4 node concerning for metastatic disease. He underwent total thyroidectomy, right central neck dissection and right lateral neck dissection. Final pathology demonstrated bilateral multifocal PTC, 4/7 central neck nodes and 3/15 of lateral neck nodes with metastatic disease. He is planned for radioactive iodine therapy.

This case illustrates a rare example of metastatic papillary thyroid carcinoma presenting as a massive intrathoracic cyst. In retrospect, this cyst had some characteristic features of an enlarged lymph node including calcifications and the absence of daughter cysts. It is odd that the thyroid was radiographically normal and that the cystic lymph node was displaced down into the thoracic cavity when these nodes more commonly displace structures in the neck. However, it does illustrate a key diagnostic pearl of thyroid cancer which is that it is best diagnosed using a dedicated thyroid ultrasound; CT or MRI of the neck is not the optimal imaging modality for examining thyroid tissue and a negative scan should not be used to rule out thyroid disease. Interestingly, this patient had this mass for several decades and thus his thyroid disease may have progressed after the cyst was already present.

Authors
Camille Yongue (1), Michael Dorsey (2), Arianna Winchester (3), Michael Persky (3), Xiaoqing O'Leary (4), Amie Kent (3)
Institutions
(1) NYU Langone Medical Center, NY, (2) NYU Langone Health, New York, NY, (3) NYU Langone Health, New York, NY, (4) NYCHHC Bellevue, New York, NY 

We report the case of a 75-year-old woman with prior aortic valve replacement using a stentless prosthesis, referred for severe prosthetic regurgitation and deemed at prohibitive risk for redo surgery. She underwent percutaneous valve-in-valve transcatheter aortic valve replacement with a self-expandable prosthesis. Immediately after valve deployment, acute left main coronary artery occlusion resulted in cardiac arrest. During attempted coronary intervention, the transcatheter valve migrated into the ascending aorta, and a second valve implantation attempt using a balloon-expandable prosthesis failed due to balloon rupture (image). Following multidisciplinary Heart Team discussion, the patient was emergently transferred to the operating room.
Shortly after resternotomy, the patient suffered a second cardiac arrest requiring immediate central cardiopulmonary bypass. Given hemodynamic collapse and the position of the migrated transcatheter valve, brief hypothermic circulatory arrest was employed to allow safe valve retrieval and direct inspection of the ascending aorta, followed by explantation of the degenerated stentless prosthesis and implantation of a new surgical valve. Inability to wean from cardiopulmonary bypass despite maximal pharmacologic support necessitated initiation of venoarterial extracorporeal membrane oxygenation.
Intraoperative transesophageal echocardiography revealed severe acute right ventricular dysfunction not present preoperatively, raising strong suspicion of right coronary artery compromise and prompting urgent coronary artery bypass grafting, with immediate hemodynamic improvement. Ongoing refractory cardiogenic shock required escalation to additional left ventricular unloading with an Impella device.
Within one week, the patient demonstrated recovery of biventricular function and was successfully weaned from all mechanical circulatory support. Postoperative echocardiography showed excellent prosthetic valve function, and the patient was discharged home after a short period of rehabilitation.
This case highlights the lethality of catastrophic valve-in-valve TAVR failure and demonstrates that survival depends on immediate surgical rescue and coordinated, sequential use of advanced mechanical circulatory support within an experienced multidisciplinary Heart Team.

Authors
Catarina Novo (1), Mariana Campos (1), Belisa Gomes (1), João Monteiro (1), João Cardoso (1), Nelson Santos (1), Paulo Neves (1)
Institutions
(1) Unidade Local de Saúde Gaia/Espinho, Vila Nova de Gaia, Porto 

Objective
To describe a previously under-recognized mechanism of non-occlusive mesenteric ischemia (NOMI) caused by advancement of elemental enteral feeding in a post-esophagectomy patient receiving pharmacologic splanchnic vasoconstriction for high-output chyle leak.

Case Summary
A 66-year-old obese man with a history of prior open bariatric surgery (vertical banded gastroplasty) underwent Ivor Lewis esophagectomy for distal esophageal adenocarcinoma. The operation was initiated laparoscopically but converted to an open approach via prior midline incision after recognizing the extent of gastric adhesions and identifying incarceration of the right gastroepiploic artery within a known incisional hernia. A feeding jejunostomy tube was placed in Witzell fashion.

Postoperatively, the patient developed a high-output abdominal chyle leak, likely related to extensive lysis of adhesions and lymphadenectomy. Given persistent output and a failed attempt at lymphangiography with embolization, maximal medical management was continued and included total parenteral nutrition, octreotide, and midodrine. Notably, preoperative imaging demonstrated calcified celiac and superior mesenteric artery origins, suggesting limited mesenteric perfusion reserve.

After clinical stabilization and a decrease in chyle output, elemental jejunal feeds were restarted and advanced to goal. Within hours, the patient developed severe abdominal pain, lactic acidosis, and shock. Computed tomography ruled out pulmonary embolism, and transthoracic echocardiography demonstrated preserved biventricular function without intracardiac thrombus. Exploratory laparotomy revealed diffuse transmural small-bowel necrosis with patent mesenteric vessels and no evidence of arterial or venous occlusion. In the setting of abrupt clinical deterioration, negative cardiopulmonary evaluation, and these operative findings, a diagnosis of non-occlusive mesenteric ischemia was made. Given the extent of ischemia, and following a detailed discussion with the family, care was transitioned to comfort-focused measures, and the patient unfortunately expired.

Conclusions
This case demonstrates a lethal physiologic mismatch in which pharmacologic splanchnic vasoconstriction fixes intestinal oxygen delivery at a low-flow state while elemental enteral feeding sharply increases metabolic demand through active nutrient transport. In patients with chyle leak, obesity, prior abdominal surgery, vascular calcification, or impaired autoregulation, advancement of elemental feeds may precipitate NOMI despite preserved systemic hemodynamics. Trophic feeding or parenteral nutrition should be strongly considered until splanchnic vasoconstrictive therapy is discontinued.

Authors
Ido Haimi (1), Reza Mehran (2)
Institutions
(1) University of Texas MD Anderson Cancer Center, Houston, TX, (2) University of Texas, Houston, TX 

Aorto-esophageal fistula (AEF) is a rare but fatal condition. We describe the management of a patient who developed AEF following esophagectomy for esophageal adenocarcinoma, requiring a hybrid endovascular and surgical strategy.Case Report:A 43-year-old man underwent esophagectomy with the Ivor Lewis technique for distal esophageal adenocarcinoma. The postoperative course was complicated by the development of an esophago-bronchial fistula (EBF) and an AEF, resulting in hemorrhagic shock. The EBF was managed with multiple esophageal stent placements. Emergency TEVAR was performed for the AEF, achieving rapid hemodynamic stabilization. After five months, the patient presented with recurrent hemoptysis: computed tomography angiography (CTA) revealed a 7-mm aortic pseudoaneurysm just above the proximal margin of the endograft. An endovascular extension was performed using two additional TEVAR modules, with coverage of the left subclavian artery and stenting of the left common carotid artery. Recurrence of EBF required new esophageal stent placement. A PET scan revealed a hypermetabolic collection adjacent to the descending aorta, and surgical extraction of the esophageal prostheses was planned. CTA revealed further disease progression, characterized by increased aortic infiltration and the development of two additional pseudoaneurysms: a distal lesion proximal to the celiac trunk and a proximal lesion involving the aortic arch at the origin of the left carotid artery stent.After multidisciplinary discussion, a staged hybrid strategy was adopted. Initial TEVAR excluded the distal pseudoaneurysm, followed by eradication of the infectious source with esophagectomy and removal of the gastric conduit via right thoracotomy and cervical esophageal diversion. Three days later, definitive aortic repair was performed with aortic arch replacement using the frozen elephant trunk technique (FET). The aortic arch tissue in zone 2 was found to be severely friable, and the distal anastomosis was made directly onto the previously implanted TEVAR. An E-vita Open Neo 28 prosthesis was placed, and the distal anastomosis was completed. Inspection of the supra-aortic vessels revealed protrusion of the previously implanted carotid stent into the aortic arch, which was easily resected.The carotid wall was extremely friable and could not be safely mobilized; therefore, the anastomosis between the carotid artery and an 8-mm Dacron graft was protected by placement of a covered stent.Intraoperative cultures grew Escherichia coli and Mycoplasma salivarium. Follow-up CTA confirmed complete pseudoaneurysm exclusion and adequate surgical reconstruction.The patient was discharged from intensive care after 11 days and transferred to the referring hospital.Discussion and Conclusion:AEF following esophagectomy is a rare but highly lethal condition. TEVAR is essential for emergency stabilization but may be insufficient in the presence of infection, leading to progressive aortic wall destruction. In this case, TEVAR achieved acute stabilization but failed to prevent disease progression.Hybrid strategies combining endovascular and open repair provided definitive treatment. FET technique allowed complete exclusion of affected aortic segments.Management of complicated AEF requires a staged, multidisciplinary approach, appropriate timing of each step, and intraoperative flexibility.Hybrid strategies should be considered complementary rather than a failure of endovascular therapy.

Authors
Valeria Santamaria (1), Khaoula Nasser (2), Marco Vola (3), daniel Grinberg (4)
Institutions
(1) Hopital cardiologique Louis Pradel, Lyon, NA, (2) Hôpital Cardiologique Louis Pradel, Lyon, NA, (3) N/A, Saint Etienne, France, (4) Hopital cardiologique Louis Pradel, Lyon, NY