Publications by authors named "Pablo Lobos"

19 Publications

  • Page 1 of 1

A novel technique for large lateral enterocutaneous fistula management after intestinal transplantation.

Pediatr Transplant 2021 Jul 30:e14105. Epub 2021 Jul 30.

Department Pediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.

Background: Enterocutaneous fistula (ECF) is a serious and complex problem when affecting children, being responsible for a high morbidity burden, with an estimated mortality rate of 10 to 20%. There are many therapeutic options, including surgery and a wide variety of nonoperative strategies. Prognosis of ECF closure depends on the output and also on the patency of distal bowel. Spontaneous closure without operative intervention occurs in approximately 50% of patients with lateral ECF and distal bowel transit, but this drastically decreases in high output fistulas. High-volume fistula output and consequent skin damage are a great challenge for the health-care team.

Methods: We describe a postoperative complication that required a new nonoperative technique for the transient management of a lateral high-output ECF, involving the insertion of an occlusive device in order to redirect intestinal content to the distal bowel, reducing the fistula output.

Results And Conclusions: The main benefit of this nonoperative technique is the ability to occlude a high-output fistula, allowing the distal flow to be restored and reducing abdominal wall damage, as a bridge to definitive surgical closure.
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http://dx.doi.org/10.1111/petr.14105DOI Listing
July 2021

Impact of the COVID-19 pandemic on the pediatric population with acute appendicitis: Experience at a general, tertiary care hospital.

Arch Argent Pediatr 2021 08;119(4):224-229

Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.

Introduction: Appendicitis is the leading cause of surgical acute abdomen in pediatrics. During the COVID-19 pandemic, management strategies were reassessed and the number of visits to the emergency department dropped down, which may be associated with delayed diagnoses and complications. The objective of this study was to analyze the impact of the pandemic on children with acute appendicitis.

Methods: Analytical, retrospective, comparative study of pediatric patients with acute appendicitis in the 5 months of COVID-19 lockdown versus the same period in the previous year. Incidence, clinical data, stage, surgical approach, and complications were analyzed.

Results: The total number of appendicitis cases went down by 25% (n = 67 versus n = 50 in 2020). The mean time to consultation was 24 hours in both periods (p = 0.989). The incidence of peritonitis was 44% (n = 22) versus 37% (n = 22) (p = 0.22) in 2019. No differences were observed in terms of appendicitis stage based on surgery reports. In 2019, all surgeries were laparoscopic; while in 2020, only 42% (n = 21). The incidence of complications was 6% versus 7.5% in the previous period (p = 0.75). One patient was COVID-19 positive.

Conclusion: Although in our population the number of appendicitis cases dropped down, consultation was not delayed. The greater impact was associated with the reformulation of management strategies, in which the laparoscopic approach is avoided to reduce virus transmission.
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http://dx.doi.org/10.5546/aap.2021.eng.224DOI Listing
August 2021

Impact of the COVID-19 pandemic on surgical skills training in pediatric surgery residents.

Pediatr Surg Int 2021 Oct 16;37(10):1415-1420. Epub 2021 Jul 16.

Division of Pediatric Surgery and Urology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Potosí, 4060, Buenos Aires, Argentina.

Purpose: To analyze the initial impact of the SARS-CoV-2 pandemic on surgical skills training and performance of Pediatric Surgery Residents.

Methods: Retrospective study considering the modifications on the Pediatric Surgery Residency training from March 1st-May 31st, 2020. Exposure to OR learning opportunities was compared to the same 2018-2019 trimesters. An anonymous survey about self-perception on surgical skills development was also performed.

Results: Residents performed 209 procedures as leading surgeons during the 2020 trimester with a mean number of surgeries per resident of 20.9, representing a reduction of 46% and 56.8% compared to the 2018-2019 averages, respectively. Reduction in both the number and the percentage of total procedures (n: 209, 56.8%) compared to both 2019 (n: 354, 68.7%, p: 0.000272) and 2018 (n: 420, 76.1%, p < 0,00,001) showed statistical correlation with no changes in their complexity pattern. From the survey (response rate: 100%), hours dedicated to simulation-based training were highly increased. More time was spent studying, but only 60% achieved better preparation for surgery and 70% perceived a decrease in surgical confidence.

Conclusions: Even though the pandemic promoted new teaching strategies and the use of simulation-based training, it drastically reduced "on-the-job" learning opportunities with potential effects on residents' performance and self-confidence during surgery.
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http://dx.doi.org/10.1007/s00383-021-04961-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284692PMC
October 2021

Testis-sparing surgery for testicular tumors in children: a 20 year single center experience and systematic review of the literature.

Pediatr Surg Int 2021 May 17;37(5):607-616. Epub 2021 Jan 17.

Pediatric Surgery and Urology Division, Hospital Italiano of Buenos Aires, Andrés Lamas 812, 1406, Ciudad Autónoma de Buenos Aires, Argentina.

Purpose: Although surgical therapy for testicular tumors (TT) is often radical orchidectomy, tumor resection with preservation of healthy testicular parenchyma has been proposed. This study herein reports a 20 year single center experience applying testicular sparing surgery (TSS) as a primary operative strategy in pediatric patients. A systematic literature review summarizes the utility and outcomes of TSS in appropriately selected patients.

Methods: Pediatric patients with TT who underwent TSS between 1997 and 2018 were studied. TSS was indicated if patients presented evidence of adequately spared healthy testicular parenchyma on preoperative ultrasound and negative serum tumor markers. A systematic review of the literature was also performed.

Results: 12 cases met full inclusion criteria with 10 of 12 subjects in the prepubertal age group. Follow-up was 73 months (range 18-278 months). Only a single male patient (GSCCT) presented with early recurrence and orchidectomy was then performed. No cases of postoperative testicular atrophy were identified. Sexual maturation (Tanner stage) expected for age in each patient was documented. Review of the literature identified 34 published studies including 269 patients (94% prepubertal). Pathologic lesions here were mainly mature teratoma(s)-(62%) with a follow-up period of 4 years. Recurrent tumors were observed in only three patients (1.1%) notably two Leydig Cell Tumors and one Teratoma. Testicular atrophy reportedly occurred in only one single case (0.37%).

Discussion: TSS is a feasible alternative to radical orchidectomy in pediatric male patients with localized TT and negative tumor markers. Long term follow-up is essential to monitor testicular growth, puberty with sexual development and psychological male health.
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http://dx.doi.org/10.1007/s00383-020-04850-6DOI Listing
May 2021

Successful Treatment of Juvenile Polyposis of Infancy With Sirolimus.

Pediatrics 2019 08;144(2)

Boston Children's Hospital, Boston, Massachusetts.

Juvenile polyposis syndrome is a rare autosomal dominant condition characterized by multiple hamartomatous polyps throughout the gastrointestinal tract. Juvenile polyposis of infancy is a generalized severe form of juvenile polyposis syndrome associated with a poor prognosis. A 47-month-old female infant presented initially with gastrointestinal bleeding and protein-losing enteropathy at 4 months of age. At the age of 12 months, the condition worsened, requiring albumin infusions every 24 to 48 hours and red blood cell transfusions every 15 days. Upper gastrointestinal endoscopy, colonoscopy, and small-bowel enteroscopy revealed diffuse polyposis that was treated with multiple endoscopic polypectomies. Despite subtotal colectomy with ileorectal anastomosis, protein-losing enteropathy and bleeding persisted, requiring continued blood transfusions and albumin infusions. A chromosomal microarray revealed a single allele deletion in chromosome 10q23, involving both the and genes. Loss of function is associated with an increased activation of the protein kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway involved in cell proliferation. Treatment with sirolimus, an mTOR inhibitor, was initiated with the aim of inhibiting polyp growth. Soon after initiation of treatment with sirolimus, blood and albumin infusions were no longer needed and resulted in improved patient growth and quality of life. This case represents the first detailed report of successful drug therapy for life-threatening juvenile polyposis of infancy.
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http://dx.doi.org/10.1542/peds.2018-2922DOI Listing
August 2019

[Facial nerve schwannoma as differential diagnosis of parotid tumors in pediatrics].

Arch Argent Pediatr 2019 06;117(3):e301-e304

Servicio de Cirugía y Urología Pediátrica, Hospital Italiano de Buenos Aires.

Schwannomas are benign tumors which arise from Schwann cells and take place along peripheral nerves. Extra-temporal facial nerve schwannomas are infrequent and present as painless masses in the parotid region, slow-growing and involvement of the facial nerve. Although rare, they should be taken into account as a differential diagnosis in parotid masses in children. Surgical strategies include superficial parotidectomy and surgical tumor resection with electrical nerve stimulation and nerve preservation. The following case describes a paediatric patient treated with the previously mentioned nerve sparing surgical technique.
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http://dx.doi.org/10.5546/aap.2019.e301DOI Listing
June 2019

[Minimally invasive treatment of biliary tract injury secondary to closed abdominal trauma: Clinical case].

Arch Argent Pediatr 2018 12;116(6):e778-e781

Servicio de Cirugía y Urología Pediátrica, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.

Hepatic and biliary tract injuries due to traumatic causes are rare in pediatric patients. Of the total number of patients with closed abdominal trauma, less than 9 % have liver injury, and the frequency varies between 2 and 3 % of biliary tract lesions. Currently, the recommended treatment for closed abdominal trauma with liver injury without hemodynamic repercussion is conservative. In case of presenting intra or extrahepatic biliary tract lesion, the preferred approaches are minimally invasive, such as percutaneous or endoscopic surgery, using laparotomy in selected cases. We present the case of a patient with closed abdominal trauma and liver trauma, initially laparotomized on 2 occasions due to hemodynamic instability and hemoperitoneum; presented a subdiaphragmatic and coleperitoneal bilioma; it was performed minimally invasive percutaneous drainage under tomographic control.
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http://dx.doi.org/10.5546/aap.2018.e778DOI Listing
December 2018

[Fetal ascites as clinical presentation of inferior vena cava agenesis].

Arch Argent Pediatr 2018 08;116(4):e621-e625

Servicio de Cirugía y Urología Pediátrica, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.

Inferior Vena Cava (IVC) is composed of three segments from different embryological origin. Its lack of fusion originates a wide spectrum of anomalies of the IVC. These malformations are present in 0.07-8.7% of the population. It is generally diagnosed as an incidental finding in adult life. It represents between 5 and 9.5% of idiopathic deep vein thrombosis in patients younger than 30 years old without associated risk factors. We present a case of a term newborn with prenatal diagnosis of ascites during the 20th week of gestation. IVC Agenesis was diagnosed with the use of abdominal angiotomography. The treatment of patients with IVC Agenesis is based on the management of its complications. Due to the increased thrombotic risk of these patients, we should consider lifelong anticoagulation. We suggest initiating it during puberty.
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http://dx.doi.org/10.5546/aap.2018.e621DOI Listing
August 2018

[Post traumatic diaphragmatic rupture in children: Case report].

Arch Argent Pediatr 2018 Apr;116(2):e292-e295

Servicio de Cirugía y Urología Pediátrica, Hospital Italiano de Buenos Aires, CABA, Argentina.

Diaphragmatic rupture is a relatively uncommon entity in pediatrics that can occur as a result of a high-impact trauma. Only between 25 and 50% of the cases are detected in the initial evaluation of the patient, which increases the risk of complications. This paper presents the case of an asymptomatic 8-year-old patient who was referred to our institution after a vehicular accident. A day and a half after admission, a left pulmonary hypoventilation was detected. Computed tomography scan showed intrathoracic elevation of the splenic angle of the colon and the small bowel. Surgical exploration and treatment were performed. Deferred radiographic controls showed no signs of relapse.
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http://dx.doi.org/10.5546/aap.2018.e292DOI Listing
April 2018

Childhood Neuroblastoma: Incidence and Survival in Argentina. Report from the National Pediatric Cancer Registry, ROHA Network 2000-2012.

Pediatr Blood Cancer 2016 08 2;63(8):1362-7. Epub 2016 May 2.

Garrahan Pediatric Hospital, Buenos Aires City, Argentina.

Background: There are reports indicating a low incidence of neuroblastoma (NB) in some developing countries but no conclusive data are available from population-based studies at a national level.

Purpose: To describe the incidence and survival of 971 patients with NB in Argentina with data from the National Pediatric Cancer Registry (ROHA), and the impact of age, gender, stage, regional, and socioeconomic indicators on outcome.

Methods: All cases of NB reported to ROHA (2000-2012) were the subject of the analysis. Annual-standardized incidence rate (ASR) was calculated using the National Vital Statistics and survival was estimated. The extended human development index (EHDI) was used as the socioeconomic indicator.

Results: ASR was 8.3/1,000,000 children (0-14 years) and remained stable along this period. Regional variation in ASR ranged from 3.4 in the Northwest to 9.8 in the Central region, being most marked in the first year of life. Five-year survival rate (SR) was 47%, with no sex difference. For patients older than 18 months, it was 36%, for stage IV 23%, for those born in the Northeast region 38%, and for those with an amplified MYCN 15%. Residents in provinces with a higher EHDI had a better 5-year survival (57% vs. 41% for lower EHDI) and higher ASR (12.3 vs. 5.6 for lower EHDI). Stage and MYCN status showed an independent inferior prognosis.

Conclusions: ASR of NB in Argentina is lower than in developed countries, with considerable regional variation. SRs are also lower than in developed countries.
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http://dx.doi.org/10.1002/pbc.25987DOI Listing
August 2016

[Osteosarcoma lung metastases. Survival after chemotherapy and surgery].

Medicina (B Aires) 2015 ;75(2):87-90

Servicios de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Argentina.

Five years overall survival in osteosarcoma patients is around 70%, although in patients with metastatic disease it is only 10-30%. The objective of this study was to analyze overall survival and prognostic factors in a group of patients with metastatic osteosarcoma treated with surgical removal of the lung metastases. A retrospective review from our oncology data base revealed 38 patients treated between 1992 and 2006. The mean age at diagnosis was 18 ± 9.4 years (3-45) and mean follow-up was 57 ± 53.8 months (12-231). All patients were treated with chemotherapy and oncologic resection of the primary tumor and surgical removal of the lung metastases. We analyzed overall survival and prognostic factors: age, gender, site, time of metastasis, local recurrences, number of lung metastasis and chemotherapy response (necrosis). Overall survival of the entire series was 29% at 5 years (CI 95%: 14.5-43.5) and 26% at 10 years (CI 95%: 12-40). Significant difference in 5 year overall survival was found between good and bad responders to chemotherapy, 53% (IC 95%: 28-78) vs. 8% (IC 95%: 0-20) (p = 0.0008). No statistically significant relationship between other prognostic factors analyzed was observed. Five and ten years overall survival rates in osteosarcoma patients with lung metastasis treated with chemotherapy and surgically resection is poor. Patients with good response to chemotherapy have better prognosis.
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October 2015

[Aspiration syndrome due to laryngeal cleft in an infant].

Arch Argent Pediatr 2014 Feb;112(1):e1-5

Servicio de Otorrinolaringología Infantil, Hospital Italiano de Buenos Aires.

Aspiration is the passage of food content and endogenous secretions into the airway. Anatomical, neuromuscular or functional anomalies are among the major causes. The laryngeal cleft is a rare congenital anomaly that should be considered in the differential diagnosis of aspiration syndrome in neonates and infants. The main symptoms are stridor, recurrent respiratory infections and cyanotic crisis, cough and choking during feeding. The diagnosis is confirmed by endoscopic examination. The therapeutic behaviour will depend on the extent of the cleft, among other factors. We describe the clinical manifestations, diagnostic methods and treatment of an infant with this disease, and we emphasize the need for recognition of swallowing disorders in children in order to establish an accurate diagnosis and appropriate treatment to prevent and avoid malnutrition as well as a severe and potentially irreversible lung compromise.
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http://dx.doi.org/10.5546/aap.2014.e1DOI Listing
February 2014

[Treatment of acquired laryngeal stenosis in pediatrics: case series].

Arch Argent Pediatr 2013 Dec;111(6):e136-40

Subglottic stenosis is one of the most common causes of upper airway obstruction in children. Even though it may have a congenital origin, most of them are acquired stenosis. This condition should be suspected in any child with a history of intubation, instrumentation or trauma of the airway that is having difficulty breathing. The diagnosis is suspected by clinical, history and cervical radiograph, and is confirmed by endoscopic examination. Among others factors the treatment depends on the stenosis degree. We describe our experience with 6 patients with post-intubation subglottic stenosis treated surgically with expansion technique.
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http://dx.doi.org/10.5546/aap.2013.e136DOI Listing
December 2013

[Cervical Castleman's disease. Pediatric case report].

Arch Argent Pediatr 2013 Jul-Aug;111(4):e89-93

Servicio de Cirugía Pediátrica, Sección Cirugía General, Hospital Italiano de Buenos Aires, Argentina.

Castleman's disease (CD) is a rare entity, characterized by lymph node follicles hyperplasia. It rarely occurs in children. We present a case of a 9 year old girl with CD in the parotid region. This disease, although it's low incidence in pediatric population, may mimic a malignant neoplasm and should be a differential diagnosis in cervical masses.
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http://dx.doi.org/10.1590/S0325-00752013000400016DOI Listing
July 2014

Kaposiform hemangioendothelioma with Kasabach-Merritt phenomenon: successful treatment with embolization and vincristine in two newborns.

J Vasc Interv Radiol 2012 Mar;23(3):417-22

Vascular Anomalies Center, Hospital Italiano, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina.

Kaposiform hemangioendothelioma (KHE) is a rare vascular tumor and has a high mortality in newborns when associated with Kasabach-Merritt syndrome (KMS). In two newborns with KHE and severe KMS refractory to medical treatment, emergency embolization led to clinical improvement in the acute neonatal setting by reducing tumor volume, increasing the platelet count, and improving other clotting parameters. Systemic vincristine treatment was added for further tumor control. Both patients remained symptom-free at long-term follow-up.
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http://dx.doi.org/10.1016/j.jvir.2011.12.007DOI Listing
March 2012

Choledochal cyst in pediatric patients: a 10-year single institution experience.

Acta Gastroenterol Latinoam 2011 Dec;41(4):302-7

Department of Pediatric Surgery, Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Background: Choledochal cysts (CCs) are rare congenital dilatations of the biliar tree. The incidence is 1:150,000. A correct diagnosis and surgical treatment are important because of the long term risks of infection and neoplasia. We report our experience with CCs in children.

Patients And Methods: Patients with CC disease, who were seen at the Hospital Italiano de Buenos Aires between 1999 and 2009, were identified retrospectively from our prospectively acquired hepato-pancreatico-biliary database. Prenatal, clinical, surgical and pathological records were analysed.

Results: We included 12 children (10 girls and 2 boys), all of them affected by a cystic dilatation type I of Todani classification. Between the 4 patients with antenatal diagnosis only one presented symptoms before surgery, expressed in acolic feces. Between the 8 patients with postnatal diagnosis, the most common clinical presentation was abdominal pain, occurring in all patients. Ultrasound was used for the diagnosis of all patients. Mean age at surgery was 74 months. All patients had intraoperative cholangiograms to definitively confirm the diagnosis. Five patients underwent open surgery and 7 laparoscopic approach. From patients with a laparoscopic approach, 1 had to be converted to open surgery due to intraoperative complications and 2 underwent an initial surgery for a cholecystectomy and a CC cyst excision. The complications observed were: anastomotic biliary fistula 1, residual lithiasis in the pancreatic portion of the duct 1 and anastomotic stenosis 1. The last 2 cases required reoperation.

Conclusions: Once CCs are diagnosed, careful treatment decisions need to be taken because both intra hepatic and extra hepatic CCs, if untreated, have an increased risk of cancer. After a careful study of the cyst's characteristics, we recommend a laparoscopic approach when possible, as the best choice, after 3 months of life to increase the success of the treatment according to the size of the anatomic structure. We recommend early treatment, before 3 months of life, only in case of severe symptoms.
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December 2011

[Description of the case presented in the previous issue: Meckel's diverticulum].

Arch Argent Pediatr 2009 Aug;107(4):374-5

Servicio de Cirugía Pediátrica, Hospital Italiano de Buenos Aires, Argentina.

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http://dx.doi.org/10.1590/S0325-00752009000400018DOI Listing
August 2009

Kidney transplantation in small children with live related donors: 20 years of experience.

J Pediatr Urol 2006 Aug 10;2(4):373-9. Epub 2006 Jul 10.

Section of Pediatric Urology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Gascon 450, Buenos Aires (1181), Argentina.

Objectives: Kidney transplantation (Tx) with a live related donor is the best option available for the treatment of end-stage renal disease at any age. Modern dialysis has allowed many very young and small children to receive a renal transplant with good results in spite of the limitations of space and the size of the adult kidney. Here, we report our experience with renal Tx with live related donors in this complex group of pediatric patients.

Material And Methods: From 1978 to 2004 a kidney transplantation was performed in 211 pediatric patients. Of this group, 23 patients between 1 and 10 years of age (16 males and seven females) of less than 17 kg (8.9-16.9 kg) received their first live related donor transplantation between 1985 and 2004. Renal insufficiency was secondary to nephropathy in 11 patients, infravesical obstruction in six and renal dysplasia or renal infarcts in six.

Results: Patient and graft survival was 100% and 95.6% with an average follow up of 89.6 months (6-231). There were no vascular or urological complications. Urinary infection in five (21.7%) and acute rejection in three (13%) were the most common complications. One patient has returned to dialysis 11 years after Tx.

Conclusions: Young pediatric patients with a low body weight did not suffer a higher percentage of postoperative surgical complications, and the follow-up results are similar to those in older patients. A complex urological malformation has not prevented a living related Tx. These results encourage us to perform this procedure more frequently in younger patients when a live donor is available.
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http://dx.doi.org/10.1016/j.jpurol.2006.05.005DOI Listing
August 2006

Internal mammary artery injury after central venous catheterization.

Pediatr Crit Care Med 2007 Sep;8(5):489-91

Pediatric Intensive Care Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.

Objective: We describe an infrequent but potentially lethal complication: an iatrogenic injury of the internal mammary artery after central venous catheterization.

Design: Report of cases.

Setting: Pediatric intensive care unit.

Patients: The first patient we report on is a 3-yr-old girl who was severely neurologically damaged and was admitted to the pediatric intensive care unit for aspiration pneumonia and septic shock. Immediately after vein cannulation on the left internal jugular vein, the patient suffered hypotension and cardiac arrest, secondary to an adequately drained massive hemothorax. Restoration of spontaneous circulation was initially achieved, and the patient was transferred to the angiographic suite. Selective angiography during cardiopulmonary resuscitation for a second cardiac arrest revealed a laceration of the internal mammary artery. Resuscitation was not successful, and the patient died. The second case reported is a 7-yr-old girl admitted for bone marrow transplantation. She was electively taken to the angiographic suite for central venous insertion. An infraclavicular approach of the right subclavian vein was attempted, but radioscopy showed the guidewire inside the pleural space. Soon thereafter, the patient became hypotensive and was in shock. Radioscopy showed a large pleural effusion and a massive hemothorax was drained. Selective angiography demonstrated an injured internal mammary artery was embolized. Hemodynamics improved, and the patient was transferred to the pediatric intensive care unit, where she was extubated 12 hrs later.

Interventions: None.

Conclusions: Central venous catheter placement in the intrathoracic vein may cause potentially lethal complications in the form of an injury to the internal mammary artery. Hypotension during or immediately after the procedure should be a warning of a serious adverse event, such as massive hemothorax, that may compromise life. Adequate drainage of the pleural cavity may not completely relieve vascular compression if some of the bleeding from an injured internal mammary artery is extrapleural. Early diagnosis and treatment by selective embolization of the injured vessel in interventional radiology is the first therapeutic choice and may be life saving.
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http://dx.doi.org/10.1097/01.PCC.0000282850.25806.0ADOI Listing
September 2007
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