Ascending aortic aneurysms are asymptomatic and are usually discovered as an incidental finding on chest imaging. However, larger aneurysms can present with symptoms resulting from compression of surrounding structures including the trachea, bronchi, and the esophagus which can result in hoarseness, cough chest pain or back pain.
Ascending aortic aneurysms are asymptomatic and are usually discovered as an incidental finding on chest imaging. However, larger aneurysms can present with symptoms resulting from compression of surrounding structures including the trachea, bronchi, and the esophagus which can result in hoarseness, cough chest pain or back pain. The presence of an aortic arch anomaly, specifically an aberrant right common carotid artery, in a background of an aortic arch aneurysm is extremely rare with a worldwide incidence of <1%. They are usually asymptomatic but can result to catastrophic life threatening events and pose significant challenges to surgical or endovascular treatment. This is a case of a 63-year old Filipino male who presented with a sudden onset of dull back pain radiating to the left anterior chest. Workup revealed an ascending and aortic arch aneurysm with an aberrant right common carotid artery arising directly from the transverse aorta. Surgical aortic arch debranching was done to repair the aberrant vessels prior to Thoracic Endovascular Aortic Repair (TEVAR) wherein a custom-made Thoracic Valiant graft was deployed on the aneurysm. The patient was discharged on the 4th day after TEVAR without any complaints of dyspnea, back pain nor chest pain with no neurologic and visceral organ dysfunction. This case has emphasized that knowledge on the anatomy of the aortic arch is imperative in planning out thoracic surgery and endovascular interventions especially on rare anatomic anomalies such as seen in this case. Keywords aortic aneurysm, aberrant right common carotid artery, TEVAR
Resumen: Introducción. Entre las reconstrucciones de defectos titulares de cabeza y cuello, el injerto libre microvascularizado braquial medial no ha adquirido mucha popularidad debido a las variaciones anatómicas que se reflejan en la vascularización de éste. Nuestro objetivo es realizar una descripción de la anatomía y técnica quirúrgica, así como una revisión de la literatura describiendo las ventajas y desventajas de este tipo de injerto. Material y método. Presentamos el caso de una paciente con carcinoma epidermoide de mucosa yugal izquierda con afectación ganglionar ipsilateral. Se procedió a su resección con márgenes más disección cervical funcional. La reconstrucción del defecto se llevó a cabo mediante un injerto libre microvascularizado braquial medial de brazo izquierdo. Discusión. Pensamos que el injerto libre braquial medial de brazo se trata de una opción más segura a la hora de la reconstrucción de defectos cervicofaciales, aportando una serie de ventajas entre las que destacan: no sacrificio de una arteria terminal, cierre primario de la zona donante, mínimo defecto estético, y poseer una piel fina, elástica y sin vello.
8570 Background: For selected patients with MESCC, S + RT has recently been shown to improve patients’ ability to ambulate and reduce opioid and corticosteroid use when compared with RT alone, with a trend towards survival benefit. (Patchell et al Lancet 2005) The economic impact of adopting this intervention has not been assessed previously. Methods: An analytic decision model was constructed based on the results from Patchell et al. (2005) The perspective of the public health care insurer of Ontario was adopted for the analysis. Costing was performed by using Ontario data for the following items: surgery, radiotherapy, hospitalization, home care services, palliative hospice, and medications. Utilities were obtained from the Harvard University Catalogue of preference score (HUC) and the Health Outcomes Data Repository Data - Health Utility list (HODaR). The primary analysis is a cost-utility analysis comparing surgery and radiotherapy (S+RT) with radiotherapy alone (RT). A probabilistic sensitivity analysis with Monte-Carlo simulation was performed. Results: When comparing S+ RT with RT alone, the incremental cost-effectiveness ratio (ICER) is CAD$ 43,796 per QALY gained. The cost-utility of S + RT is CAD$ 509,084 per QALY and that of RT alone is CAD$ 2,381,246 per QALY. S + RT costs approximately CAD$ 33 more when compared with RT alone per ambulatory day gained. The cost of surgery is partially offset by the decreased cost of hospice palliative care since more patients remain ambulatory and stay at home. Monte-Carlo simulation showed that there is a 25% chance that S + RT may dominate RT alone. The results are sensitive but generally robust to changes in assumptions about the costs of surgery, home care and palliative hospice care. Conclusions: S+RT is likely cost-effective when compared with RT alone for the treatment of MESCC in selected patients, and should be considered by health care policy makers. No significant financial relationships to disclose.
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