Difficult Ventilation in a Patient with a Giant Aortic Aneurysm: A Challenge for the Anesthesiologist

Patients with Marfan syndrome present anatomic variations that may increase the risk of a difficult airway. Moreover, they can present large aortic aneurysms, which may cause extrinsic airway compression. Therefore, difficult ventilation during general anesthesia poses a challenge in that the anesthesiologist has to promptly make a crucial differential diagnosis. Multidisciplinary preoperative assessment and planning of the airway and ventilation management are of utmost importance in such uncommon and highly complex clinical cases. Fiberoptic bronchoscopy is probably a really useful tool in order to assess the severity and extent of the airway compression, both preoperatively and intraoperatively. We present a clinical case where difficult ventilation occurred immediately after the induction of general anesthesia.

Nefroprotección en frío para reparo de ectasia aórtica y aneurismas ilíacos bilaterales ante la presencia de riñón ectópico pélvico / Cold nephroprotection for repair of aortic ectasia and bilateral iliac aneurysms in the presence of pelvic ectopic kidney

Resumen Los riñones ectópicos pélvicos solitarios asociados a degeneración aneurismática de las arterias ilíacas y la aorta abdominal son eventos muy raros. Los enfoques quirúrgicos para la corrección de aneurismas con compromiso renal son un desafío por la falta de consenso actual, en especial cuando cursan con riñones ectópicos pélvicos solitarios funcionales asociados. Por tal motivo, una de las estrategias que ha demostrado buenos resultados a corto y mediano plazo es la nefroprotección en frío, la cual puede ser usada con seguridad en estos pacientes. En el caso que se presenta, se evidenció una ectasia aórtica con aneurismas ilíacos bilaterales asociados con un riñón ectópico pélvico solitario en un paciente masculino de 75 años, con hipertensión arterial y dislipidemia. Se realizó una reconstrucción aortoilíaca bilateral y una reconstrucción de la arteria hipogástrica, además de reimplante de la arteria renal ectópica bajo irrigación renal en frío, sin complicaciones y preservación de la función renal.

Abstract Solitary pelvic ectopic kidneys associated with aneurysmal degeneration of the iliac arteries and abdominal aorta are very rare events. Surgical approaches for the correction of aneurysms with renal involvement are challenging due to the lack of current consensus, especially when they are associated with functional solitary pelvic ectopic kidneys. For this reason, one of the strategies that has shown good results in the short and medium term is cold nephroprotection, which can be used safely in these patients. In the present case, aortic ectasia with bilateral iliac aneurysms associated with a solitary pelvic ectopic kidneys was evidenced in a 75-year-old male patient with arterial hypertension and dyslipidemia. Bilateral aortoiliac reconstruction was performed with hypogastric artery reconstruction and reimplantation of the ectopic renal artery under cold renal irrigation, without complications and preservation of renal function.

Quadricuspid Aortic Valve with Ruptured Sinus of Valsalva Aneurysm: a Case Report

Abstract Quadricuspid aortic valve (QAV) and sinus of Valsalva aneurysm (SVA) are rare congenital anomalies. We report an elderly patient with QAV associated with a ruptured SVA to the right atrium. Transthoracic echocardiographic and computed tomographic images are presented. We emphasize the important role of computed tomography angiography in establishing and confirming the diagnosis and facilitating treatment planning. The patient was successfully operated by a minimally invasive approach.

Impact of Reconstructing Intercostal Artery on Spinal Cord Circulation During Open Surgery for Thoracoabdominal Aortic Aneurysm

ABSTRACT Introduction: We evaluated the outcomes of the selective intercostal artery reconstruction for preventing spinal cord injury during thoracoabdominal aortic aneurysm repair. Methods: We retrospectively assessed 84 consecutive patients who underwent thoracoabdominal aortic aneurysm repairs between 2004 and 2016. The mean age of the patients was 57.3 years. We performed preoperative multidetector computed tomography in 74 patients (88.0%) to identify the Adamkiewicz artery. Spinal cord injury preventive measures included motor evoked potential monitoring, hypothermia induction, Adamkiewicz artery or other intercostal artery reconstruction, and cerebrospinal fluid drainage. Results: The hospital death rate was 5.9%, and paraplegia occurred in four patients (4.7%). The Adamkiewicz artery or other intercostal arteries were reconstructed selectively in 46 patients (54.7%). Of these patients, 41 underwent postoperative multidetector computed tomography, which revealed occlusion of the reconstructed grafts in 23 patients (56.0%). There was no paraplegia in the patients who underwent reconstruction of the Adamkiewicz artery, which was patent on postoperative multidetector computed tomography. Univariate analysis showed no significant effect of various risk factors on the development of spinal cord injury. Conclusion: Outcome of open surgery for thoracoabdominal aortic aneurysm in our institution regarding spinal cord injury was satisfactory. The benefits of Adamkiewicz artery reconstruction remain inconclusive, and further larger studies are required to identify its validation for spinal cord protection in thoracoabdominal aortic aneurysm repair.

A Case of Effective Zone 0 TEVAR Using Squid-Capture Assisted in situ Stent-Graft Fenestration, for Endoleak from the Fenestration of Najuta / 日本心臓血管外科学会雑誌

We report the case of a 76-year-old man who developed type IA endoleak through the fenestration after 1-debranch TEVAR using a Najuta endograft. The patient was admitted with expansion of the aneurysm after TEVAR, for additional therapy. Type IA endoleak through a fenestration has remained a significant clinical concern and its treatment is challenging. We performed Zone 0 TEVAR using the “Squid-Capture” technique assisted in situ stent-graft fenestration. Cerebral vessels were perfused by a percutaneous cardiopulmonary support system during in situ stent-graft fenestration, and the cerebral branch was clamped at the proximal site. It is difficult to operate the catheter inside the endoskeleton structure of a Najuta endograft, but several innovations were effective. Test dilation of the balloon catheter was performed to ensure that the wire did not interfere with the endoskeleton. Avoiding interference with the endoskeleton is important. The Squid-Capture technique allows safe and secure puncture of the graft. The operation was completed successfully. After this procedure, the endoleak disappeared. It is considered to be a useful method for treatment of endoleak through the fenestration.

Two Cases of Descending Aortic Diverticulum Associated with the Right-Sided Aortic Arch / 日本心臓血管外科学会雑誌

Case 1 is a 70-year-old male. He has a history of cholelithiasis and left inguinal hernia. A preoperative examination of the inguinal hernia showed the enlargement of the mediastinal shadow, and he was referred to our department. A close examination revealed a right-sided aortic arch, a right descending aorta, and a descending aortic diverticulum. No subjective symptoms, intracardiac malformations, or other cardiovascular diseases were observed. The surgery was scheduled for descending aorta replacement including a diverticulum with right posterior lateral 4th intercostal thoracotomy and lower body partial extracorporeal circulation. However, due to aortic intima injury at the proximal end, hypothermic cerebral circulatory arrest and proximal anastomosis were performed by the open proximal method. There was no problem with the postoperative course, and he was discharged 19 days after surgery. Case 2 is a 51-year-old female. Born in China, she has lived in Japan for 15 years. No notable history. An abnormal shadow was shown on chest Xp performed in a medical examination, and aortic malformation was suspected on chest CT. She was referred to our department. The diagnosis was right-sided aortic arch, right descending aorta, aberrant left subclavian artery, and Kommerell diverticulum. There were no subjective symptoms and no intracardiac malformations. The operation was a two-stage operation. As the initial surgery, median sternotomy was performed, total arch replacement with intrathoracic reconstruction of the left subclavian artery, and open stent graft insertion, and the Kommerell diverticulum was covered with an open stent graft. We did not treat the diverticulum because it was located on the dorsal side. At 15 days after surgery, we performed embolization of the origin of the left subclavian artery from the Kommerell diverticulum. There was no problem with the postoperative course, and she was discharged 19 days after the initial surgery.

Treating Neurogenic Heterotopic Ossification around a Femur Following Paraplegia after an Open Surgery for Thoracoabdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 59-year-old man who was diagnosed with hypertension and a large thoracoabdominal aortic aneurysm was referred to our hospital for surgical treatment. He underwent open surgery and thoracic endovascular aneurysm repair in three stages. He developed paraplegia after the third surgery. Despite acute postoperative treatment and rehabilitation, his lower extremity motor function and bladder and bowel dysfunction did not improve. He was transferred to a recovery hospital 67 days after the third surgery. However, he was readmitted to our hospital about four months later for management of a refractory decubitus ulcer and recurrent urinary tract infections. Computed tomography revealed hematoma and calcification around the femur. Based on the clinical course and imaging findings, we diagnosed neurogenic heterotopic ossification associated with postoperative paraplegia in this patient. He had flap reconstruction for the ulcer. Finally, he was discharged 79 days after readmission. To date, no study has reported neurogenic heterotopic ossification associated with postoperative aortic aneurysm paraplegia. The mechanism underlying this condition is similar to the widely accepted process associated with traumatic spinal cord injury, and conservative treatment comprising pressure ulcer treatment and antibiotics was continued. Although acute rehabilitation is important after highly invasive aortic aneurysm surgery, rehabilitation is limited by the risk of neurogenic heterotopic ossification in patients with postoperative paraplegia, and recovery and maintenance of activities of daily living are challenging. To our knowledge, early diagnosis and prompt treatment for these complications are important considering neurogenic heterotopic ossification.

Intrapleural Urokinase and Antibiotic Therapy for Empyema after In Situ Reconstruction of the Aorta and Lobectomy for Aortopulmonary Fistula due to Thoracic Aortic Aneurysm Rupture / 日本心臓血管外科学会雑誌

A 62-year-old man presented with hemoptysis and hoarseness. He was diagnosed with an aortopulmonary fistula due to a thoracic aortic aneurysm rupture and was referred to our department. Emergency in-situ reconstruction of the aorta and pulmonary lobectomy were performed. Nine days postoperative, he developed empyema. Intrapleural urokinase and antibiotic therapy were selected as management instead of a video-assisted thoracoscopic debridement and decortication due to his worsening condition. The treatment was successful, and he was discharged from the hospital without any further complications. This study highlights the benefit of intrapleural administration of urokinase and antibiotics in patients with acute empyema, when surgical treatment is inappropriate.

Xanthogranulomatous Inflammation of the Aortic Aneurysm Wall after Endovascular Aortic Repair for Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 77-year-old woman underwent endovascular abdominal aortic repair (EVAR) for an abdominal aortic aneurysm (AAA)．Five years after surgery, she visited the hospital with the chief complaint of a fever. Enhanced computed tomography (CT) showed enlargement of the AAA around the stent-graft and a mass, which was suspected to be an abscess, outside the aneurysm. A blood test revealed a high level of inflammatory response. The patient was diagnosed with infectious AAA. She received antibiotics; however, the inflammatory response did not completely improve. A second CT scan revealed that the suspected abscess had a spreading tendency. The patient was referred to our hospital for a highly suspected stent-graft infection. We performed Y-graft replacement using a rifampicin-immersed graft, and as much as possible of the wall around the aortic aneurysm was removed. The inflammatory response improved rapidly after the operation, and the patient was discharged 15 days later. According to the results of a pathological examination, a diagnosis of xanthogranulomatous inflammation and fibrosis was made. Here, we report a rare case of xanthogranulomatous inflammation of the aortic aneurysm wall after EVAR.

Shared decision-making and specific informed consent in patients with aortic aneurysms

ABSTRACT Objective To analyze the refusal rate of elective aortic aneurysm surgery in asymptomatic patients after the presentation of a detailed informed consent form followed by a meeting where patient and their families can analyze each item. Methods We conducted a retrospective analysis of 49 patients who had aneurysms and were offered surgical treatment between June 2017 and February 2019. The patients were divided into two groups: the Rejected Surgery Group, which was composed of patients who refused the proposed surgical treatment, and the Accepted Surgery Group, comprising patients who accepted the proposed surgeries and subsequently underwent them. Results Of the 49 patients, 13 (26.5%) refused surgery after reading the informed consent and attending the comprehensive meeting. We observed that patients who refused surgery had statistically smaller aneurysms than those who accepted surgery (9% versus 26%). These smaller aneurysms were above the indication size, according to the literature. Conclusion One-quarter of patients who were indicated for elective surgical repair of aortic aneurysms rejected surgery after shared decision-making, which involved presenting patients with an informed consent form followed by a clarification meeting for them and their families to analyze each item. The only factor that significantly influenced a rejection of the procedure was the size of the aneurysm; patients who rejected surgery had smaller aneurysms than those who accepted surgery.

Innominate Artery Cannulation for Proximal Aortic Surgery

ABSTRACT Introduction: The aim of this study was to evaluate the efficacy and safety of innominate artery cannulation strategy with side-graft technique in proximal aortic pathologies. Methods: A total of 70 patients underwent innominate artery cannulation with a side graft for surgery on the proximal aorta from 2012 to 2020. There were 46 men and 24 women with an average age of 56±13 years. The indications for surgery were type A aortic dissection in 17 patients (24.3%), aortic aneurysm in 52 patients (74.3%), and ascending aorta pseudoaneurysm in one patient (1.4%). The innominate artery was free of disease in all patients. Hypothermic circulatory arrest with antegrade cerebral perfusion was utilized in 60 patients (85.7%). Three patients had previous sternotomy (4.2%). The most common surgical procedure was ascending aorta with hemiarch replacement in 34 patients (48.5%). Results: The mean cardiac ischemia and cardiopulmonary bypass times were 116+46 minutes and 164+56 minutes, respectively. Mean antegrade cerebral perfusion time was 27+14 minutes. The patients were cooled between 22°C and 30°C during surgery. Thirty-day mortality rate was 7.1% (five patients). One patient (1.4%) had stroke, one patient (1.4%) had temporary neurologic deficit, and eight patients (11.4%) had confusion and agitation that resolved completely in all cases. There was no local complication or arterial injury. Conclusion: Cannulation of the innominate artery with side graft is safe and effective for both cardiopulmonary bypass and antegrade cerebral perfusion. This technique provides satisfactory neurologic outcomes for proximal aortic surgery.

Surgical Correction of Ascending Aortic Aneurysm Without Coronary Dilatation After Kawasaki Disease in a 3-Year-Old Child

Abstract Kawasaki disease (KD) is an inflammatory condition that may affect genetically predisposed individuals in pediatric ages after infectious/environmental triggering. An infrequent finding associated with KD is ascending aortic aneurysm during or after the acute phase of the disease. In this Multimedia presentation, we describe a three-year-old girl submitted to surgical treatment.

Rare Presentation of Sinus of Valsalva Aneurysm Treated by Aortic Valve Reimplantation Technique

Abstract Sinus of Valsalva aneurysm is a rare cardiac abnormality which can be acquired or of congenital origin. A spontaneous rupture into the right atrium is possible and, if not adequately treated, may result in a progressive heart failure due to the left-to-right intracardiac shunt. If ruptured sinus of Valsalva aneurysm is diagnosed, surgical repair is indicated, and different surgical techniques have been reported. If concomitant aortic regurgitation is present, aortic valve replacement is usually performed. Herein, we describe an uncommon clinical presentation of a ruptured sinus of Valsalva aneurysm which has been corrected by aortic valve reimplantation.

Follow-up Results of Endovascular Aneurysm Repair Following Abdominal Visceral Debranching

ABSTRACT Introduction: The aim of this study is to present a series of six cases with thoracoabdominal aneurysm treated with hybrid technique in our center. Methods: Between May 2015 and December 2018, the data of six patients with thoracoabdominal aneurysms and various comorbidities who underwent visceral debranching followed by endovascular aortic aneurysm repair were reviewed retrospectively. Results: Patients' mean age was 65.3±19.6 years. All of them were male. Comorbidities were old age, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, previous surgical interventions, and/or esophageal hemangioma. Except for one patient who underwent coronary artery bypass grafting (inflow was taken from ascending aorta), debranching was performed from the right iliac artery. Debranching of four visceral arteries (superior mesenteric artery, celiac trunk, and bilateral renal right arteries) was performed in three patients, of three visceral arteries (superior mesenteric artery, celiac trunk, right renal artery) was performed in one, and of two visceral arteries (superior mesenteric artery, celiac trunk) was performed in two patients. Great saphenous vein and 6-mm polytetrafluoroethylene grafts were used in one and five patients, respectively, for debranching. Endovascular aneurysm repair was performed following debranching procedures as soon as the patients were stabilized. In total, three patients died at the early, mid, and long-term follow-up due to multiorgan failure, pneumonia, and unknown reasons. Conclusion: Hybrid repair of thoracoabdominal aneurysms may be an alternative to fenestrated or branched endovascular stent grafts in patients with increased risk factors for open surgical thoracoabdominal aneurysm repair; however, the procedure requires experience and care.

Tratamiento endovascular con técnica de chimenea para patologías del arco aórtico / Endovascular management with chimney technique for pathologies ofthe aortic arch

Introducción. La patología del arco aórtico se ha tratado principalmente con cirugía por vía abierta, pero con una alta morbimortalidad. Las técnicas endovasculares híbridas y las reconstrucciones en "chimenea" son una técnica válida y segura para disminuir el riesgo y la mortalidad. Métodos. Se presentan dos pacientes con patología del arco aórtico y contraindicación de manejo quirúrgico abierto, atendidos en el Servicio de Cirugía Vascular, Hospital Universitario Clínica de San Rafael, Bogotá, D.C., Colombia. Resultados. Se realizaron dos procedimientos endovasculares del arco aórtico para tratar un aneurisma torácico roto y una úlcera aórtica sintomática, con cubrimiento de los troncos supra aórticos con una endoprótesis y canalización de los vasos supra aórticos con prótesis cubiertas y uso de la "técnica de chimenea", de manera exitosa. Discusión. La patología del arco aórtico es de alta complejidad y se asocia con una morbimortalidad elevada por lo que, en los últimos 20 años se han desarrollado diferentes técnicas utilizando procedimientos percutáneos. Conclusión. La "técnica de chimenea" se puede realizar de una manera mínimamente invasiva en pacientes con patología del arco aórtico, no candidatos para cirugía abierta, con resultados exitosos.

Introduction. Aortic arch pathology has been treated mainly by open surgery, but with high morbidity and mortality. Hybrid endovascular techniques and "chimney" reconstructions are a valid and safe techniques to reduce risk and mortality. Method. Two patients with pathology of the aortic arch and contraindication for open surgical management, treated at the Vascular Surgery Service, Hospital Universitario Clínica de San Rafael, Bogotá, Colombia, are presented. Results. Two endovascular aortic procedures were performed successfully to treat a ruptured thoracic aneurysm and a symptomatic aortic ulcer, with coverage of the supra-aortic trunks with an endoprosthesis and cannulation of the supra-aortic vessels with covered prostheses and use of the "chimney technique". Discussion. The pathology of the aortic arch is highly complex and is associated with high morbidity and mortality, being the reason that during the last 20 years, different techniques have been developed using percutaneous procedures. Conclusions. The "chimney technique" can be performed with successful results in a minimally invasive manner in patients with pathology of the aortic arch, who are not candidates for open surgery

Epidemiological Analysis of 12 Years of Open Thoracoabdominal Aortic Aneurysm Repair in the Brazilian Public Health System

ABSTRACT Introduction: Although endovascular correction is a promising perspective, the gold-standard treatment for thoracoabdominal aortic aneurisms and type-B dissections with visceral involvement remains open surgery, particularly due to its well-established long-term durability. This study aims to describe and evaluate public data from patients treated for thoracoabdominal aortic aneurism in the Brazilian public health system in a 12-year interval. Methods: Data from procedures performed between 2008 and 2019 were extracted from the national public database (Departamento de Informática do Sistema Único de Saúde, or DATASUS) using web scraping techniques. Procedures were evaluated regarding the yearly frequency of elective or urgency surgeries, in-hospital mortality, and governmental costs. All tests were done with a level of significance P<0.05. Results: A total of 812 procedures were analyzed. Of all surgeries, 67.98% were elective cases. There were 328 in-hospital deaths (mortality of 40.39%). In-hospital mortality was lower in elective procedures (26.92%) than in urgency procedures (46.74%) (P=0.008). Total governmental expenditure was $3.127.051,56 — an average of $3.774,22 for elective surgery and $3.791,93 for emergency surgery (P=0.999). Conclusion: The proportion of urgency procedures is higher than that recommended by international literature. Mortality was higher for urgent admissions, although governmental costs were equal for elective and urgent procedures; specialized referral centers should be considered by health policy makers.

A Modified Ascending Aortic Cannulation Technique in Minimally Invasive Totally Thoracoscopic Cardiac Surgery

ABSTRACT Cannulation through the femoral artery is the preferred method of establishing peripheral cardiopulmonary bypass in minimally invasive totally thoracoscopic cardiac surgery. However, faced with the contraindication of femoral artery cannulation, modified ascending aortic cannulation is an alternative approach to minimally invasive totally thoracoscopic cardiac surgery.

Successful Surgical Treatment of Coronary Aneurysm, Ascending Aortic Aneurysm, and Bicuspid Aorta for a Kawasaki Disease Patient

Abstract Kawasaki disease was first reported in 1967, and it was classified as an autoimmune vasculitis of the small and medium arteries. It is a self-limiting condition that occurs mostly in childhood, but it may involve complications — such as coronary artery aneurysms, myocardial ischemia, and arrhythmias — with significant morbidity and mortality that occur later in life. In this article, we present the association of an ascending aortic aneurysm with bicuspid aortic disease in addition to coronary aneurysm in a 55-year-old patient diagnosed with Kawasaki disease.

Mid-Term Results of Left Carotid-Subclavian Bypass in Patients Undergoing Zone 2 TEVAR

ABSTRACT Introduction: The aim of this study was to present the mid-term results of patients who had undergone a carotid-subclavian bypass surgery after a thoracic endovascular aortic repair (TEVAR) stent-graft implantation with proximal landing at zone 2 of the aorta. Methods: A total of 66 patients had undergone TEVAR and carotid-subclavian bypass between January 2015 and May 2020 at our clinic. Five of these patients were lost to follow-up, so 61 patients were included in this retrospective study. At follow-up visits, patency of the carotid-subclavian bypass grafts was evaluated with physical examination and radiological imaging. Results: The mean follow-up time was 15.11±12.29 months (ranging from 1 to 56 months). There were 3 (4.91%) in-hospital deaths of patients admitted with bilateral lower limb and visceral malperfusion. There were also 2 (3.27%) deaths unrelated to the procedure. Carotid-subclavian graft occlusion occurred in 3 (4.91%) patients. The occlusion was detected with radiological imaging within a period of 12 to 24 months. The graft patency rate was 100% in the first 12 months. The mean graft patency time (survival) was 52.56±2.10 months. Conclusion: Periprocedural carotid-subclavian bypass surgery with synthetic grafts is a recommended procedure with high patency and acceptably low mortality and morbidity rates in TEVAR.

Aortic valve repair: An exciting journey / Reparación valvular aórtica: una experiencia emocionante

Abstract Aortic valve repair has become an attractive alternative to aortic valve replacement in most of the patients with aortic insufficiency. To improve reproducibility and durability "geometric anatomy" of the valve has been developed to guide the repair. Expert centers were able to publish remarkable short- and long-term results for aortic valve sparing procedures. Therefore, data comparing composite valve grafting and aortic valve sparing procedures revealed similar early mortality. Also, late mortality, thromboembolism, stroke and bleeding risks were significantly lower in patients undergoing aortic valve repair and late durability was equivalent1. However, the complexity of the procedures makes aortic valve repair difficult to be adopted into daily surgical practice. Accordingly, starting your own aortic valve repair program requires conviction, training, facilities, quality control and a well structured heart valve team to let your program succeed.

Resumen La reparación valvular aórtica se ha convertido en una alternativa atractiva al reemplazo, en la mayoría de pacientes con insuficiencia aórtica. Para mejorar la reproducibilidad y la durabilidad, se ha desarrollado una "anatomía geométrica" de la válvula para guiar la reparación. Los centros expertos han publicado resultados notables a corto y largo plazo en preservación valvular aórtica. Además, los estudios que compararon el cambio valvular por tubo valvulado con los procedimientos de preservación valvular, mostraron una mortalidad temprana similar, con riesgos de mortalidad tardía, como tromboembolia pulmonar, accidente cerebrovascular y hemorragia, significativamente menores en los pacientes sometidos a reparación valvular aórtica, con una durabilidad tardía equivalente1. Sin embargo, la complejidad de los procedimientos dificulta la adopción de la reparación valvular aórtica en la práctica diaria. En consecuencia, comenzar un programa de reparación valvular aórtica requiere convicción, capacitación, instalaciones, control de calidad y un equipo bien estructurado para que sea exitoso.