Contemporary surgical outcome and symptomatic relief following vascular ring surgery in children: effect of prenatal diagnosis

OBJECTIVES

Our goal was to describe postoperative complications and outcomes in a large contemporary cohort of children with an isolated double aortic arch (DAA) or a right aortic arch (RAA) with left arterial ligament and to assess the impact of foetal diagnosis on outcomes.

METHODS

We performed a retrospective analysis of all patients who underwent surgery for DAA or RAA with left arterial ligament between 2005 and 2019.

RESULTS

A total of 132 children were operated on for a DAA (n = 77) or a RAA (n = 55). Prenatal diagnosis was made in 100/132 (75.8%). Median age at surgery for DAA was 5.0 (1.7-13.3) months and for RAA was 13.9 (6.4-20.1) months. There was no difference in the age at surgery between the prenatal and postnatal cases (8.6 [4.0-15.6] vs 5.4 months [1.8-17.7]; P = 0.37). No surgical deaths occurred. Vocal cord palsy was the most common complication, occurring in 12/132 (9%): of these, 11 resolved spontaneously and 1 required a temporary tracheostomy. Logistic regression demonstrated that older age at operation was the only predictor for a postoperative complication (P = 0.02). Overall, 21/67 (31%) of prenatally detected, symptomatic cases reported residual symptoms/signs 1 year after surgery compared to 18/28 (64%) of postnatally detected cases. Postnatal diagnosis was associated with persistent postoperative symptoms/signs [P = 0.006, odds ratio = 3.9 (95% confidence interval 1.5-9.4)].

CONCLUSIONS

Surgery to relieve a vascular ring resolves trache-oesophageal compressive symptoms in most cases, but parents/patients should be aware that symptoms/signs may persist in the first postoperative year despite effective release of the vascular ring. Earlier surgery and prenatal diagnosis may improve outcomes.

Patients experience of living with cancer associated thrombosis in France (Le PELICAN)

INTRODUCTION

Previous research in the United Kingdom and Spain has identified several areas of unmet clinical and support need for cancer patients diagnosed with cancer associated thrombosis (CAT). These included lack of information, which was directly associated with distress. Appropriate information has been shown to improve tolerance and compliance with self-injecting low molecular weight heparin (LMWH). It is not known whether such experiences are restricted to those particular countries healthcare systems and/or cultures.

METHODS

Purposive sampling of patients with CAT were recruited from an academic hospital in Colombes, France. Semi structured interviews were audio recorded and transcribed. Transcripts were coded using Invivo software. Analysis was undertaken using framework analysis.

RESULTS

Twenty four patients participated. Three major themes with associated subthemes were identified: Patients received minimal information regarding risks of CAT or how to treat it once diagnosed. However, this was not associated with distress. Patients adopted a passive role whereby the doctor was always right. They were intolerant injections and found it inconvenient to await community nurses.

CONCLUSION

The doctor patient relationship in France differs from other countries, with patients adopting a passive role with respect to information requirements. This dynamic appears to be a "two edged sword" whereby distress around CAT was minimal yet a lack of knowledge impacted on acceptability of LMWH. This has implications for the choice of anticoagulant particularly now that the DOACS have been evaluated for this indication.

Patient Experience of Living With Cancer-Associated Thrombosis in Canada (PELICANADA)

INTRODUCTION

Previous research from the United Kingdom and Spain has identified several areas of unmet clinical and support need for cancer patients diagnosed with venous thromboembolism. It is not known whether such experiences are restricted to those countries health care systems and culture. We therefore evaluated patients' experience of cancer-associated thrombosis (CAT) within a Canadian setting.

METHODS

Purposive sampling of patients with CAT attending a regional thrombosis clinic in Vancouver was undertaken. Semistructured interviews were audio recorded, transcribed, and coded using NVivo software. A deductive approach was taken by applying the framework matrix from the original study to these data on a case-by-case basis.

RESULTS

Twenty patients (10 male, 10 female) aged 39 to 74 (mean, 63) representing a breadth of different cancers participated. Commonalities between the UK and Canadian patients included the traumatic nature of experiencing CAT, the need for information, and adaptive behaviors through ritualization. Two new themes were identified: (1) Patients with incidental pulmonary emboli (iPE) were usually telephoned about their thrombus with little support and suboptimal communication; and (2) cost implications of accessing low-molecular-weight heparin varied according to insurance cover. Patients were sometimes converted to warfarin for financial reasons.

CONCLUSION

The distress associated with CAT is a common experience across different populations but may be ameliorated by early access to specialist services, information, and support. The current process for managing iPE could be improved with better communication and a dedicated clinical pathway. Funding issues may influence choice of anticoagulant.