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Arteriovenous Fistula: A Rare Complication After Nuss Procedure for Pectus Excavatum
Ann Thorac Surg 2015;100:1463–5
CASE REPORT BEAN ET AL ARTERIOVENOUS FISTULA AFTER NUSS PROCEDURE
1463
Fig 2. Chest computed tomography, mediastinal window, threedimensional reconstruction. The arrows show the position in the middle mediastinum and the cephalocaudal orientation of the wire going inside the lung parenchyma in left and right panels.
that include respiratory excursion or gravitational forces may be more relevant to this clinical presentation. Likewise, the movement favored by physical exercise could be added to the hypothesis of migration in this case. Certainly under any mechanism, the K-wire is able to reach any imaginable site in the body [6, 7]. In view of the multiple reports across the literature of complications after the use of K-wire, it is necessary to take preventive measures [8]. Some physicians recommend bending one tip of the wire to prevent its movement. For some authors, close clinical and radiographic postoperative follow-up examinations are essential after insertion of orthopedic wires, which should be withdrawn once treatment has concluded [2]. In conclusion, this case adds to the evidence that emphasizes the risks of K-wire use. It also shows the feasibility of the thoracoscopic approach when the clinical condition of the patient is stable.
References 1. Abbas A, Richmond N, McCormack DJ, et al. A 27-year-old man presenting with acute chest pain and dyspnea. Chest 2009;135:1684–7. 2. Zhang W, Song F, Yang Y, Tang J. Asymptomatic intracardiac migration of a Kirschner wire from the right rib. Interact Cardiovasc Thorac Surg 2014;18:525–6. 3. Anic D, Brida V, Jelic I, Orlic D. The cardiac migration of a Kirschner wire. A case report. Tex Heart Inst J 1997;24:359–61. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
4. Tubbax H, Hendzel P, Sergeant P. Cardiac perforation after Kirschner wire migration. Acta Chir Belg 1989;89:309–11. 5. Bezer M, Aydin N, Erol B, Lac¸in T, G€ uven O. Unusual migration of K-wire following fixation of clavicle fracture: a case report. Ulus Travma Acil Cerrahi Derg 2009;15: 298–300. 6. Foster GT, Chetty KG, Mahutte K, Kim JB, Sasse SA. Hemoptysis due to migration of a fractured Kirschner wire. Chest 2001;119:1285–6. 7. Lorenz G, Steinau G, Schumpelick V. [Intra-abdominal migration of a Kirschner wire from the femoral neck.]. Chirurg 1993;64:973–4. 8. Park S-Y, Kang J-W, Yang DH, Lim T-H. Intracardiac migration of a Kirschner wire: case report and literature review. Int J Cardiovasc Imaging 2001;27(Suppl 1):85–8.
Arteriovenous Fistula: A Rare Complication After Nuss Procedure for Pectus Excavatum Jonathan F. Bean, MD, David Wax, MD, and Marleta Reynolds, MD Division of Pediatric Surgery, Department of Surgery, and Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
We report a case of a 13-year-old female patient who underwent the Nuss procedure for surgical correction of pectus excavatum. As a result of the procedure, the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.067
FEATURE ARTICLES
Fig 3. Thoracoscopic view. The introduction of the wire tip (long arrow) into the pericardial fat over the auricle (arrowhead) is shown on the left. The lung (thin arrow) and superior vena cava are shown (star). The ring clamp pulling the wire in the cephalic direction (star) is shown on the right.
1464
CASE REPORT BEAN ET AL ARTERIOVENOUS FISTULA AFTER NUSS PROCEDURE
Ann Thorac Surg 2015;100:1463–5
patient developed an arteriovenous fistula between the left internal mammary artery and the pulmonary venous system. (Ann Thorac Surg 2015;100:1463–5) Ó 2015 by The Society of Thoracic Surgeons
P
FEATURE ARTICLES
ectus excavatum is the most common congenital anomaly of the anterior chest wall and affects approximately 1:400 live births [1]. A variety of complications have been described since the inception of the minimally invasive Nuss procedure for surgical correction of pectus excavatum. We report the first arteriovenous fistula from the left internal mammary artery to the pulmonary venous system resultant from the Nuss procedure. A 13-year-old female patient with pectus excavatum was evaluated in our pediatric surgery clinics. History revealed that she had chest pain and dyspnea associated with the chest wall anomaly. Her preoperative Haller index was 3.6, and preoperative exercise pulmonary testing revealed decreased capacity. Because of the symptomatic nature of the pectus excavatum, she underwent a thoracoscopically assisted Nuss procedure in 2009 with the placement of two bars. Her postoperative course was uncomplicated. After 3 years, the therapy was completed and the Nuss bars were removed. In the immediate postoperative period, a new grade 3 continuous murmur was detected at the third intercostal space on the left chest. Transthoracic echocardiography performed at that time revealed normal cardiac anatomy and function, but it also showed extracardiac blood flow anterior to the right ventricle. The patient was otherwise asymptomatic and hemodynamically normal. Cardiology initially cleared the patient for discharge. At subsequent outpatient cardiology follow-up, the echocardiographic findings were reinterpreted as an arteriovenous fistula, and magnetic resonance angiography of the chest was obtained that confirmed the presence of a fistula between the left internal mammary artery and the pulmonary venous drainage of the left lung. The patient underwent coil embolization of fistula from the left internal mammary artery with near complete resolution of the arteriovenous fistula. Preembolization (Fig 1) and postembolization (Fig 2) angiographic images are shown.
Fig 1. Preembolization angiography of the fistula connecting the left internal mammary artery (solid arrow) and the left pulmonary veins (arrow outlines).
intuitive, but given the relatively recent development of this therapy, other rare complications are being reported as experience and use of this treatment expands. The most commonly reported complications associated with the Nuss procedure include: atelectasis, pleural effusion, Horner syndrome, pneumothorax, bar shift or flip, and wound infections [2]. Other reported complications include allergic reaction to the bar material, bar infection, pericarditis, pericardial effusion, hematomas, diaphragmatic laceration, and breakage of the stabilizer or wires [2]. The most dramatic and
Comment The Nuss procedure has become a well-accepted treatment for pectus excavatum that achieves resolution of the chest wall malformation with excellent cosmesis. Many of the most common complications of this procedure are Accepted for publication Nov 18, 2014. Address correspondence to Dr Reynolds, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611; e-mail: [email protected].
Fig 2. Postembolization angiography of the left internal mammary artery.
Ann Thorac Surg 2015;100:1465–7
References 1. Chung CS, Myrianthopoulos NC. Factors affecting risks of congenital malformations. I. Analysis of epidemiologic factors in congenital malformations. Report from the Collaborative Perinatal Project. Birth Defects Orig Artic Ser 1975;11:1–22. 2. Kelly RE Jr, Mellins RB, Shamberger RC, et al. Multicenter study of pectus excavatum, final report: complications, static/ exercise pulmonary function, and anatomic outcomes. J Am Coll Surg 2013;217:1080–9. 3. Nath DS, Wells WJ, Reemtsen BL. Mechanical occlusion of the inferior vena cava: an unusual complication after repair of pectus excavatum using the nuss procedure. Ann Thorac Surg 2008;85:1796–8. 4. Ballouhey Q, Leobon B, Trinchero JF, Baunin C, Galinier P, Sales de Gauzy J. Mechanical occlusion of the inferior vena cava: an early complication after repair of pectus excavatum using the Nuss procedure. J Pediatr Surg 2012;47:e1–3. 5. Jeong JY, Suh JH, Yoon JS, Park CB. Delayed-onset hypovolemic shock after the Nuss procedure for pectus excavatum. J Cardiothorac Surg 2014;9:15. 6. Park HJ, Lee SY, Lee CS, Youm W, Lee KR. The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients. Ann Thorac Surg 2004;77: 289–95. 7. Umuroglu T, Bostanci K, Thomas DT, Yuksel M, Gogus FY. Perioperative anesthetic and surgical complications of the Nuss procedure. J Cardiothorac Vasc Anesth 2013;27:436–40.
Spontaneous Regression of Metastatic Extraskeletal Myxoid Chondrosarcoma Tomonari Kinoshita, MD, Ikuo Kamiyama, MD, PhD, Yuichiro Hayashi, MD, PhD, Keisuke Asakura, MD, PhD, Takashi Ohtsuka, MD, PhD, Mitsutomo Kohno, MD, PhD, Katsura Emoto, MD, PhD, Robert Nakayama, MD, PhD, Hideo Morioka, MD, PhD, and Hisao Asamura, MD, PhD Division of General Thoracic Surgery, Department of Surgery, Departments of Pathology and Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1465
Spontaneous regression of tumors is very unusual and is defined as a partial or complete disappearance of metastatic tumors without any treatment. This phenomenon has been reported in almost all types of cancer. The patient was a 25-year-old woman who presented with multiple pulmonary nodules on her bilateral lungs on the annual chest roentgenograph. Simultaneously, a swelling mass on her subcutaneous inguinal region was observed. The diagnosis of the inguinal mass was extraskeletal myxoid chondrosarcoma. The inguinal mass and pulmonary nodules spontaneously regressed without any treatment after biopsy. The patient was doing well without evidence of recurrence at 1 year after the operation without any additional therapy. Our case is the first clinical one that indicated a possibility of histologic regression of extraskeletal myxoid chondrosarcoma. (Ann Thorac Surg 2015;100:1465–7) Ó 2015 by The Society of Thoracic Surgeons
S
pontaneous regression of tumors is very unusual. Various mechanisms including immune mediation are considered to be associated with this phenomenon. However, the apparent incidence and underlying mechanisms remain unclear. It is believed that spontaneously induced immunologic responses could be an important mechanism in the spontaneous regression of the tumor [1]. We herein report a case of the spontaneous regression of metastatic lung tumors of extraskeletal myxoid chondrosarcoma (EMC). To the best of our knowledge, this is the first clinical case that indicated a possibility of histologic regression of EMC. The patient was a 25-year-old woman who presented with multiple pulmonary nodules on her bilateral lungs on the annual chest roentgenograph. Simultaneously, a swelling mass on her subcutaneous inguinal region was observed; we performed a needle biopsy of this mass. The diagnosis of the inguinal mass was EMC. The inguinal mass and pulmonary nodules spontaneously regressed without any treatment after biopsy (Fig 1A, 1B), except for one lesion located on her right lower lobe, which regrew (Fig 1C). Therefore, right lower lobectomy was performed. These nodules were round and well circumscribed with partial necrosis and consisted of multiple lobules of small and eosinophilic round cells (Fig 2A). Although tumor cells were propagating along the bronchial tract (Fig 2B), no tumor cells could be found in other lesions. The pathologic diagnosis was confirmed as pulmonary metastasis of EMC. The patient was doing well without evidence of recurrence at 1 year after the operation without any additional therapy.
Accepted for publication Dec 30, 2014. Address correspondence to Dr Kinoshita, Division of General Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan; e-mail: t.kinoshita@ a7.keio.jp.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.107
FEATURE ARTICLES
serious complications of the Nuss procedure are perforation of the heart or other mediastinal structures or mechanical obstruction of the inferior vena cava [3–7]. Our case of a traumatic arteriovenous fistula resulting from the Nuss procedure was initially detected in the postoperative period by the presence of a new cardiac murmur. Echocardiography helped to reveal the extracardiac blood flow likely associated with the arteriovenous fistula. Definitive diagnosis was obtained only with magnetic resonance angiography. As in the other cases that resulted in cardiovascular complications, a thorough cardiac examination, echocardiography, and magnetic resonance imaging of the thoracic cavity aided in the detection and evaluation of our patient. Arteriovenous fistula is a potential complication after the Nuss procedure. Our case demonstrates the necessity for thorough preoperative and postoperative cardiopulmonary physical examinations. Surgeons should consider the possible formation of a traumatic arteriovenous fistula in any patient who develops a new cardiac murmur after Nuss procedure.
CASE REPORT KINOSHITA ET AL METASTATIC EXTRASKELETAL MYXOID CHONDROSARCOMA
CASE REPORT BEAN ET AL ARTERIOVENOUS FISTULA AFTER NUSS PROCEDURE
1463
Fig 2. Chest computed tomography, mediastinal window, threedimensional reconstruction. The arrows show the position in the middle mediastinum and the cephalocaudal orientation of the wire going inside the lung parenchyma in left and right panels.
that include respiratory excursion or gravitational forces may be more relevant to this clinical presentation. Likewise, the movement favored by physical exercise could be added to the hypothesis of migration in this case. Certainly under any mechanism, the K-wire is able to reach any imaginable site in the body [6, 7]. In view of the multiple reports across the literature of complications after the use of K-wire, it is necessary to take preventive measures [8]. Some physicians recommend bending one tip of the wire to prevent its movement. For some authors, close clinical and radiographic postoperative follow-up examinations are essential after insertion of orthopedic wires, which should be withdrawn once treatment has concluded [2]. In conclusion, this case adds to the evidence that emphasizes the risks of K-wire use. It also shows the feasibility of the thoracoscopic approach when the clinical condition of the patient is stable.
References 1. Abbas A, Richmond N, McCormack DJ, et al. A 27-year-old man presenting with acute chest pain and dyspnea. Chest 2009;135:1684–7. 2. Zhang W, Song F, Yang Y, Tang J. Asymptomatic intracardiac migration of a Kirschner wire from the right rib. Interact Cardiovasc Thorac Surg 2014;18:525–6. 3. Anic D, Brida V, Jelic I, Orlic D. The cardiac migration of a Kirschner wire. A case report. Tex Heart Inst J 1997;24:359–61. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
4. Tubbax H, Hendzel P, Sergeant P. Cardiac perforation after Kirschner wire migration. Acta Chir Belg 1989;89:309–11. 5. Bezer M, Aydin N, Erol B, Lac¸in T, G€ uven O. Unusual migration of K-wire following fixation of clavicle fracture: a case report. Ulus Travma Acil Cerrahi Derg 2009;15: 298–300. 6. Foster GT, Chetty KG, Mahutte K, Kim JB, Sasse SA. Hemoptysis due to migration of a fractured Kirschner wire. Chest 2001;119:1285–6. 7. Lorenz G, Steinau G, Schumpelick V. [Intra-abdominal migration of a Kirschner wire from the femoral neck.]. Chirurg 1993;64:973–4. 8. Park S-Y, Kang J-W, Yang DH, Lim T-H. Intracardiac migration of a Kirschner wire: case report and literature review. Int J Cardiovasc Imaging 2001;27(Suppl 1):85–8.
Arteriovenous Fistula: A Rare Complication After Nuss Procedure for Pectus Excavatum Jonathan F. Bean, MD, David Wax, MD, and Marleta Reynolds, MD Division of Pediatric Surgery, Department of Surgery, and Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
We report a case of a 13-year-old female patient who underwent the Nuss procedure for surgical correction of pectus excavatum. As a result of the procedure, the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.067
FEATURE ARTICLES
Fig 3. Thoracoscopic view. The introduction of the wire tip (long arrow) into the pericardial fat over the auricle (arrowhead) is shown on the left. The lung (thin arrow) and superior vena cava are shown (star). The ring clamp pulling the wire in the cephalic direction (star) is shown on the right.
1464
CASE REPORT BEAN ET AL ARTERIOVENOUS FISTULA AFTER NUSS PROCEDURE
Ann Thorac Surg 2015;100:1463–5
patient developed an arteriovenous fistula between the left internal mammary artery and the pulmonary venous system. (Ann Thorac Surg 2015;100:1463–5) Ó 2015 by The Society of Thoracic Surgeons
P
FEATURE ARTICLES
ectus excavatum is the most common congenital anomaly of the anterior chest wall and affects approximately 1:400 live births [1]. A variety of complications have been described since the inception of the minimally invasive Nuss procedure for surgical correction of pectus excavatum. We report the first arteriovenous fistula from the left internal mammary artery to the pulmonary venous system resultant from the Nuss procedure. A 13-year-old female patient with pectus excavatum was evaluated in our pediatric surgery clinics. History revealed that she had chest pain and dyspnea associated with the chest wall anomaly. Her preoperative Haller index was 3.6, and preoperative exercise pulmonary testing revealed decreased capacity. Because of the symptomatic nature of the pectus excavatum, she underwent a thoracoscopically assisted Nuss procedure in 2009 with the placement of two bars. Her postoperative course was uncomplicated. After 3 years, the therapy was completed and the Nuss bars were removed. In the immediate postoperative period, a new grade 3 continuous murmur was detected at the third intercostal space on the left chest. Transthoracic echocardiography performed at that time revealed normal cardiac anatomy and function, but it also showed extracardiac blood flow anterior to the right ventricle. The patient was otherwise asymptomatic and hemodynamically normal. Cardiology initially cleared the patient for discharge. At subsequent outpatient cardiology follow-up, the echocardiographic findings were reinterpreted as an arteriovenous fistula, and magnetic resonance angiography of the chest was obtained that confirmed the presence of a fistula between the left internal mammary artery and the pulmonary venous drainage of the left lung. The patient underwent coil embolization of fistula from the left internal mammary artery with near complete resolution of the arteriovenous fistula. Preembolization (Fig 1) and postembolization (Fig 2) angiographic images are shown.
Fig 1. Preembolization angiography of the fistula connecting the left internal mammary artery (solid arrow) and the left pulmonary veins (arrow outlines).
intuitive, but given the relatively recent development of this therapy, other rare complications are being reported as experience and use of this treatment expands. The most commonly reported complications associated with the Nuss procedure include: atelectasis, pleural effusion, Horner syndrome, pneumothorax, bar shift or flip, and wound infections [2]. Other reported complications include allergic reaction to the bar material, bar infection, pericarditis, pericardial effusion, hematomas, diaphragmatic laceration, and breakage of the stabilizer or wires [2]. The most dramatic and
Comment The Nuss procedure has become a well-accepted treatment for pectus excavatum that achieves resolution of the chest wall malformation with excellent cosmesis. Many of the most common complications of this procedure are Accepted for publication Nov 18, 2014. Address correspondence to Dr Reynolds, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611; e-mail: [email protected].
Fig 2. Postembolization angiography of the left internal mammary artery.
Ann Thorac Surg 2015;100:1465–7
References 1. Chung CS, Myrianthopoulos NC. Factors affecting risks of congenital malformations. I. Analysis of epidemiologic factors in congenital malformations. Report from the Collaborative Perinatal Project. Birth Defects Orig Artic Ser 1975;11:1–22. 2. Kelly RE Jr, Mellins RB, Shamberger RC, et al. Multicenter study of pectus excavatum, final report: complications, static/ exercise pulmonary function, and anatomic outcomes. J Am Coll Surg 2013;217:1080–9. 3. Nath DS, Wells WJ, Reemtsen BL. Mechanical occlusion of the inferior vena cava: an unusual complication after repair of pectus excavatum using the nuss procedure. Ann Thorac Surg 2008;85:1796–8. 4. Ballouhey Q, Leobon B, Trinchero JF, Baunin C, Galinier P, Sales de Gauzy J. Mechanical occlusion of the inferior vena cava: an early complication after repair of pectus excavatum using the Nuss procedure. J Pediatr Surg 2012;47:e1–3. 5. Jeong JY, Suh JH, Yoon JS, Park CB. Delayed-onset hypovolemic shock after the Nuss procedure for pectus excavatum. J Cardiothorac Surg 2014;9:15. 6. Park HJ, Lee SY, Lee CS, Youm W, Lee KR. The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients. Ann Thorac Surg 2004;77: 289–95. 7. Umuroglu T, Bostanci K, Thomas DT, Yuksel M, Gogus FY. Perioperative anesthetic and surgical complications of the Nuss procedure. J Cardiothorac Vasc Anesth 2013;27:436–40.
Spontaneous Regression of Metastatic Extraskeletal Myxoid Chondrosarcoma Tomonari Kinoshita, MD, Ikuo Kamiyama, MD, PhD, Yuichiro Hayashi, MD, PhD, Keisuke Asakura, MD, PhD, Takashi Ohtsuka, MD, PhD, Mitsutomo Kohno, MD, PhD, Katsura Emoto, MD, PhD, Robert Nakayama, MD, PhD, Hideo Morioka, MD, PhD, and Hisao Asamura, MD, PhD Division of General Thoracic Surgery, Department of Surgery, Departments of Pathology and Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1465
Spontaneous regression of tumors is very unusual and is defined as a partial or complete disappearance of metastatic tumors without any treatment. This phenomenon has been reported in almost all types of cancer. The patient was a 25-year-old woman who presented with multiple pulmonary nodules on her bilateral lungs on the annual chest roentgenograph. Simultaneously, a swelling mass on her subcutaneous inguinal region was observed. The diagnosis of the inguinal mass was extraskeletal myxoid chondrosarcoma. The inguinal mass and pulmonary nodules spontaneously regressed without any treatment after biopsy. The patient was doing well without evidence of recurrence at 1 year after the operation without any additional therapy. Our case is the first clinical one that indicated a possibility of histologic regression of extraskeletal myxoid chondrosarcoma. (Ann Thorac Surg 2015;100:1465–7) Ó 2015 by The Society of Thoracic Surgeons
S
pontaneous regression of tumors is very unusual. Various mechanisms including immune mediation are considered to be associated with this phenomenon. However, the apparent incidence and underlying mechanisms remain unclear. It is believed that spontaneously induced immunologic responses could be an important mechanism in the spontaneous regression of the tumor [1]. We herein report a case of the spontaneous regression of metastatic lung tumors of extraskeletal myxoid chondrosarcoma (EMC). To the best of our knowledge, this is the first clinical case that indicated a possibility of histologic regression of EMC. The patient was a 25-year-old woman who presented with multiple pulmonary nodules on her bilateral lungs on the annual chest roentgenograph. Simultaneously, a swelling mass on her subcutaneous inguinal region was observed; we performed a needle biopsy of this mass. The diagnosis of the inguinal mass was EMC. The inguinal mass and pulmonary nodules spontaneously regressed without any treatment after biopsy (Fig 1A, 1B), except for one lesion located on her right lower lobe, which regrew (Fig 1C). Therefore, right lower lobectomy was performed. These nodules were round and well circumscribed with partial necrosis and consisted of multiple lobules of small and eosinophilic round cells (Fig 2A). Although tumor cells were propagating along the bronchial tract (Fig 2B), no tumor cells could be found in other lesions. The pathologic diagnosis was confirmed as pulmonary metastasis of EMC. The patient was doing well without evidence of recurrence at 1 year after the operation without any additional therapy.
Accepted for publication Dec 30, 2014. Address correspondence to Dr Kinoshita, Division of General Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan; e-mail: t.kinoshita@ a7.keio.jp.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.107
FEATURE ARTICLES
serious complications of the Nuss procedure are perforation of the heart or other mediastinal structures or mechanical obstruction of the inferior vena cava [3–7]. Our case of a traumatic arteriovenous fistula resulting from the Nuss procedure was initially detected in the postoperative period by the presence of a new cardiac murmur. Echocardiography helped to reveal the extracardiac blood flow likely associated with the arteriovenous fistula. Definitive diagnosis was obtained only with magnetic resonance angiography. As in the other cases that resulted in cardiovascular complications, a thorough cardiac examination, echocardiography, and magnetic resonance imaging of the thoracic cavity aided in the detection and evaluation of our patient. Arteriovenous fistula is a potential complication after the Nuss procedure. Our case demonstrates the necessity for thorough preoperative and postoperative cardiopulmonary physical examinations. Surgeons should consider the possible formation of a traumatic arteriovenous fistula in any patient who develops a new cardiac murmur after Nuss procedure.
CASE REPORT KINOSHITA ET AL METASTATIC EXTRASKELETAL MYXOID CHONDROSARCOMA