Arteriovenous Fistula: A Rare Complication After Nuss Procedure for Pectus Excavatum

Post-operative arrest following pectus excavatum repair: A case report with a systematic review of the published case reports

Key Clinical Message

Common complications after PE surgery include ventricular tachycardia, cardiac arrest, pneumothorax, and bar displacement. These can lead to severe outcomes, emphasizing the need for caution and meticulous post-operative monitoring. Patients and their families should be well-informed about potential risks during the consent process.

Abstract

The objective of this study was to raise awareness among medical staff and surgeons about potential complications, particularly rare and life-threatening ones, associated with pectus excavatum (PE) surgery. PE is the most common chest wall deformity, characterized by sternal depression. Patients primarily seek treatment for cosmetic concerns, but some also report exercise intolerance and shortness of breath. Although surgical repair is the standard treatment, the incidence and nature of severe complications remain unclear and underreported. This study presents a case of a lethal cardiac event following PE surgery and conducts a systematic review of published case reports. This study describes a case of a lethal complication of ventricular fibrillation and cardiac arrest following the Ravitch procedure for correction of PE in a 10-year-old boy. A systematic review of relevant cases of PE surgery complications was conducted. Of the 506 initial records retrieved, 93 case reports from 83 articles were identified over the 23 years. Among them, 72 patients were male, and 20 cases were female. The average age of patients was 19.2 ± 7.7 years (range: 5-53). Complications had occurred up to 37 years from the time of surgery, with most of the cases (22.5%) occurring during the operation. The most frequent complications included cardiothoracic issues and displacement of the implanted steel bar. In nine patients, complications led to fatal outcomes. Due to the possible risks of PE surgery, particularly in cosmetically motivated cases, surgeons must exercise extreme caution and remain vigilant for rare and potentially life-threatening complications.

Does the Nuss procedure for treating pectus excavatum compromise the long term internal mammary artery flow? A systematic review

INTRODUCTION

The Nuss procedure is the most common procedure used to treat patients with pectus excavatum. The effect of the Nuss bars on the long-term internal mammary artery flow (IMA) is not well studied. This could have an impact on patients requiring a coronary artery bypass grafting surgery after the Nuss procedure. We performed a systematic review to study the impact of the Nuss bars on the IMA long term flow.

METHODS

A Medline search from January 1990 to August 2020 was performed using [Nuss OR thoracoscopic pectus OR minimally invasive pectus] AND [Internal mammary OR Internal thoracic OR IMA OR ITA]. English language papers only were included. This trial was registered with PROSPERO under registration number CRD42021234010.

RESULTS

A total of 48 papers were identified using the reported search, of which three represented the best evidence to answer the clinical question. One study looked at the IMA flow via computed tomography (CT)-angiography on the 10th postoperative day after the Nuss procedure and found 15 out of 34 patients (44%) to have abnormal IMA blood flow but with no clinical consequences. Two studies looked at the IMA flow after removal of the Nuss-bar. The first study utilized CT-angiography on the 5th postoperative day after Nuss-bar removal and found four out of the six patients studied (67%) to have abnormal flow. The last study was composed of 19 patients and looked at IMA flow during the presence of the Nuss-bars and after its removal utilizing Doppler-angiography. It found 11 out of 19 patients (58%) to have abnormal blood flow with the bars in place. After removal of the bars, only two patients (10%) were found to have unilateral IMA obstructed flow.

CONCLUSION

In patients undergoing the Nuss procedure for management of pectus excavatum, the internal mammary artery flow is compromised in 44%-58% of patients with the bar in situ. When these patients are assessed 10 days following removal of the bar, some reversal of compromised IMA flow is evident. However, in up to 67% of patients, abnormal IMA flow remains. Further studies are required to determine whether this abnormal flow is permanent, which will require examining patients at longer follow-up intervals. Patients undergoing coronary artery bypass grafting who have a history of a Nuss procedure should receive preoperative IMA imaging.

Complications associated with the minimally invasive repair of pectus excavatum

The minimally invasive pectus excavatum repair (Nuss repair) is performed by pediatric general surgeons and pediatric and adult thoracic surgeons around the world. Complications related to pediatric surgical procedures are always a major concern for surgeons and their patients, and as with all surgery, especially pectus surgery, complications can be life-threatening. The purpose of this article is to discuss early and late complications of pectus excavatum surgery and potential preventive strategies to minimize them.