A Case Report, Successful Treatment for Extracardiac Conduit Thrombus in Patient after Fontan Completion / 日本心臓血管外科学会雑誌

There are no clear guidelines on thromboprophylaxis in patients following Fontan surgery. In addition, most reports on thromboprophylaxis refer to systemic thromboembolism. Therefore, there are few reports on thromboprophylaxis for extracardiac conduits. We experienced a case of thrombus in extracardiac conduit leading to liver damage after the Fontan completion. The patient was an 11-year-old girl, who underwent the Fontan procedure at 3 years of age. She was on aspirin for thromboprophylaxis. Eight years postoperatively, cardiac catheterization demonstrated severe conduit stenosis, and chronic liver damage was seen at that time. The patient successfully underwent conduit replacement. Subsequently, ascites disappeared and platelet count improved. Conduit stenosis after Fontan completion is a rare but serious complication, therefore we should always keep it in mind and aspire to early detection.

Preventive Innominate Artery Transection for a High-Risk Case of Tracheo-Innominate Artery Fistula / 日本心臓血管外科学会雑誌

An 18-year-old man with hypoxic encephalopathy was admitted because of recurrent minor bleeding a tracheal stoma, which was suspected as a tracheo-innominate artery fistula (TIF). He had undergone tracheostomy and gastrostomy 2 years prior and had mild opisthotonos and scoliosis. Although tracheal endoscopy showed no tracheal mucosal erosion, necrosis, or granulation tissue formation, contrast-enhanced computed tomography (CT) revealed a close contact between the innominate artery and the anterior wall of the trachea, and an equal height between the innominate artery and the tip of the tracheal cannula. Magnetic resonance angiography of the head showed dominant intracranial blood flow from the left internal carotid and vertebral arteries. Preventive innominate artery transection through the supra-sternal approach without sternotomy or reconstruction of the innominate artery was performed for this high-risk case of TIF. The patient's postoperative course was uneventful. Postoperative CT revealed that the innominate artery was transected and isolated from the site of tracheostomy. The preserved connection between the right common carotid and subclavian artery at the distal sutured stump helped maintain blood flow in the right internal and middle cerebral arteries. The patient was discharged on postoperative day 9 without any new neurological complications or bleeding from a tracheal stoma. TIF is a rare but fatal complication after laryngotracheal separation or tracheostomy. It is important to prevent the onset of TIF, however, there are no criteria for preventive innominate artery transection. Our preventive innominate artery transection through the supra-sternal approach is considered as one of the useful surgical treatment for high-risk cases of TIF accompanied by severe neuromuscular disorders.

Treatment Strategy for Leriche Syndrome Complicated with Ischemic Heart Disease / 日本心臓血管外科学会雑誌

Leriche syndrome is often complicated with ischemic heart disease (IHD). In such cases, as the internal mammary artery (IMA) supplies blood to the lower-limbs through a collateral network, coronary artery bypass grafting (CABG) using IMA is considered to worsen the lower-limb ischemia and use of intra-aortic balloon pumping prior to lower limb revascularization is not possible. Recent advances in endovascular technology enable us to perform endovascular treatment (EVT) even in Leriche syndrome. In 3 patients diagnosed with Leriche syndrome associated with IHD, tailor-made treatments were performed as one-stage or two-stage surgeries. Various techniques such as percutaneous coronary intervention (PCI), CABG, and open surgical revascularization or EVT of lower limbs were employed. EVT is a less invasive and more attractive alternative to open surgical revascularization, it led to new treatment options in patients with this particular circumstance. Considering the severity of pathophysiology, treatment strategy should be determined on a case-by-case basis.

Aorto-Left Atrial Fistula after Aortic Valve Replacement : a Rare Complication / 日本心臓血管外科学会雑誌

A 60-year-old man underwent aortic valve replacement for aortic valve regurgitation, tricuspid valve annuloplasty, and coronary artery bypass grafting. Postoperative echocardiography revealed shunted flow from the noncoronary sinus of Valsalva into the left atrium. The pathogenesis of this complication is considered to be uncertain ; however, it might be due to some kind of intraoperative injury. Three weeks after the initial surgery, we reoperated to repair the aorto-left atrial fistula. According to the intraoperative findings, small slits were found on the left atrial surface close to the posteromedial side of the mitral valve and the noncoronary sinus of Valsalva. The fistula was closed with transmural mattress sutures. Post-operative echocardiography showed no shunt flow. Although an aorto-left atrial fistula is a rare complication after aortic valve replacement, reoperation might be mandatory if the shunt flow is considerable. Surgeons should keep in mind the possibility of intraoperative injury to surrounding structures when performing aortic valve replacement.