Favorable Aortic Remodeling Following Serial False Lumen Procedures in a Case of Chronic Type IIIb Dissection

We report a case of acute type I aortic dissection in which an emergency graft replacement of the ascending aorta and innominate artery was performed. We performed false lumen thrombosis through hybrid thoracic endovascular aortic repair to seal the primary entry tear, followed by false lumen obliteration at the level of the descending thoracic aorta, abdominal aorta, and right common iliac artery. Over a period of 4.5 years, we used Amplatzer vascular plugs and coils based on our computed tomography angiography follow-up protocol.

Delayed Pulmonary Artery Rupture after Using BioGlue in Cardiac Surgery

A 56-year-old woman, who underwent cardiac surgery 3 months previously, presented to the emergency room with pulmonary artery rupture due to the cytotoxic effects of BioGlue (CryoLife Inc., Kennesaw, GA, USA). She was successfully treated with surgical management. Although surgical glue can be effectively used for hemostasis, it can induce delayed vascular complications. Therefore, surgical glue should be used cautiously.

Late Migration of Amplatzer Septal Occluder Device to the Descending Thoracic Aorta

Percutaneous closure of atrial septal defect (ASD) has become an increasingly common procedure. Serious complications of the procedure, such as cardiac migration, are rare, and usually occur <72 hours after device placement. In this report, we present the case of a patient who underwent successful surgical treatment for the migration of an ASD occluder device to the thoracic aorta 12 months after ASD closure.

Aorta Remodeling after Endovascular Treatment of a Chronic DeBakey IIIb Aneurysm and Simultaneous Palliation of a Renal Cell Carcinoma

We report the case of a patient with a chronic DeBakey type IIIb aneurysm who underwent thoracic endovascular aortic repair to seal the primary entry tear and stent-graft insertion to cover the re-entry tear at the renal artery. The procedure was performed in order to achieve complete thrombosis in the entire thoracoabdominal false lumen, leading to favorable aortic remodeling. Simultaneously, ethanol ablation and renal artery embolization were performed to treat a renal tumor suspicious of renal cell carcinoma. Radical nephrectomy then confirmed clear cell carcinoma. To the best of our knowledge, no other cases of this type have been reported in the Korean literature.

Balloon-Supported Passage of a Stent-Graft into the Aortic Arch

A 62-year-old man was admitted, and thoracic endovascular aortic repair (TEVAR) procedure was performed to treat an accidentally detected aortic aneurysm, which was 63 mm in diameter. While performing TEVAR, the passage of the stent-graft introducer system was impossible due to the prolapse of the introducer system into a wide-necked aneurysm; this aneurysm was located at the greater curvature of the proximal descending thoracic aorta. In order to advance the introducer system, a compliant balloon was inflated. Thus, we created an artificial wall in the aneurysm with this inflated balloon. Finally, we were able to advance the introducer system into the target zone.

Comparison of Radial Artery and Saphenous Vein Composite Y Grafts during Off-pump Coronary Artery Bypass

BACKGROUND: The safety and efficacy of arterial composite grafts for total arterial revascularization have been demonstrated. The saphenous vein (SV) is a widely used graft because of its accessibility, sufficient length, and ease of manipulation. Our aim was to compare mid-term outcomes of saphenous vein Y-grafts with radial artery Y-grafts joined by anastomosis to the left internal thoracic artery. MATERIALS AND METHODS: Records of off-pump coronary artery bypass grafting with composite Y-grafts based on the left internal thoracic artery technique in 552 patients were analyzed retrospectively. After propensity score matching, 79 radial arterial (RA) composite grafts (RA group) and 79 saphenous vein composite grafts (SV group) were compared. The duration of mean follow-up was 24.6+/-14.6 months (range, 1 to 55 months). RESULTS: There were no differences in surgical mortality, all-cause mortality, or morbidity among the groups. Rates of 4-year survival were 91.7% and 96.3% in the RA and SV groups, respectively (p=0.519). The coronary reintervention-free survival rate and freedom from major adverse cardiovascular or cerebrovascular events were similar in the two groups (p=0.685, p=0.564). CONCLUSION: Construction of composite Y-grafts using the radial artery or saphenous vein showed similar mid-term results. Long-term follow-up and randomized trials will be needed to confirm our present conclusions.

Total Arch Replacement with Stented Elephant Trunk in DeBakey Type I Acute Aortic Dissection

A 67-year-old female patient was treated with conventional total arch replacement and insertion of a stented elephant trunk (SET) graft into the descending thoracic aorta for acute DeBakey type I aortic dissection at one time. She had been treated with right coronary artery stent insertion for acute myocardial infarct 4 days earlier, and at that time, she was diagnosed with acute DeBakey type I aortic dissection from the ascending aorta to the suprarenal artery based on trans-esophageal echocardiography and aorta computed tomography. Through a median sternotomy, we inserted the SET graft through the opened aorta to the descending aorta. We also performed anastomosis between the proximal stented graft and the distal aortic arch, and then performed total arch replacement. For acute DeBakey type I aortic dissection, we report total arch replacement with insertion of a SET graft as a combination of conventional surgery and the interventional technique.

Pulmonary Embolism Caused by Popliteal Venous Aneurysm

Venous aneurysms are uncommon in the lower limb and are more frequently found in the neck and thoracic and visceral veins. However, they have been reported to cause thrombosis, pulmonary thromboembolism, and other related complications. Popliteal venous aneurysms are often undetected because they are usually asymptomatic, but they may cause pulmonary thromboembolic events. We experienced a case of a 44-year-old man who was referred for recurrent pulmonary thromboembolism. He showed no other symptoms or signs except shortness of breath. A popliteal venous aneurysm was diagnosed incidentally because the examinations were performed to detect a deep vein thrombosis in relationship to the patient's history of pulmonary thromboembolism. We report a case of surgical treatment for a popliteal venous aneurysm that was complicated by pulmonary thromboembolism.

Asymptomatic renal pseudoaneurysm after percutaneous renal biopsy Volume 32, Issue 2, June 2013, pp. 87-89

No abstract available.

Asymptomatic renal pseudoaneurysm after percutaneous renal biopsy

A 37-year-old man was referred to Division of Nephrology for a new renal cystic lesion that was found on ultrasonography. Four years prior to presentation, a percutaneous renal biopsy had been performed. Computed tomography scan showed a 4.4-cm-sized renal artery pseudoaneurysm in the left kidney. Selective renal angiography revealed a pseudoaneurysm in the left lower pole of the kidney. The renal pseudoaneurysmwas successfully embolized with coil. Follow-up Doppler ultrasonography showed no internal blood flow into the aneurysmal sac. His renal function remained stable after coil embolization.

Paraneoplastic Encephalitis Associated with Thymoma: A Case Report

A 42-year-old woman with short-term memory loss visited Gangnam Severance Hospital, and her chest X-ray and computed tomography revealed a right anterior mediastinal mass. On hospital day two, she suddenly presented personality changes and a drowsy mental status, so she required ventilator care in the intensive care unit. She underwent thymectomy, and was pathologically diagnosed with thymoma, type B1. Her mental status eventually recovered by postoperative day 90. Paraneoplastic encephalopathy associated with thymoma is very rare, and symptoms can be improved by thymectomy. We report a case of paraneoplastic encephalopathy associated with a thymoma.

Paraneoplastic Encephalitis Associated with Thymoma: A Case Report

A 42-year-old woman with short-term memory loss visited Gangnam Severance Hospital, and her chest X-ray and computed tomography revealed a right anterior mediastinal mass. On hospital day two, she suddenly presented personality changes and a drowsy mental status, so she required ventilator care in the intensive care unit. She underwent thymectomy, and was pathologically diagnosed with thymoma, type B1. Her mental status eventually recovered by postoperative day 90. Paraneoplastic encephalopathy associated with thymoma is very rare, and symptoms can be improved by thymectomy. We report a case of paraneoplastic encephalopathy associated with a thymoma.

Comparison of the Radial Artery and Saphenous Vein as Composite Grafts in Off-Pump Coronary Artery Bypass Grafting in Elderly Patients: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES: Arterial grafts have a better long-term patency rate than saphenous vein (SV) when used in off-pump coronary artery bypass surgery (OPCAB). However, arterial grafts in elderly patients are often diseased. We sought to compare the early outcomes achieved by using the two different types of composite grafts. SUBJECTS AND METHODS: We conducted a randomized trial to compare radial artery (RA) and SV composite grafts based on the in situ left internal mammary artery in 60 elderly (>70 years old) patients, who were scheduled to undergo OPCAB. Clinical outcomes and 1-year postoperative CT angiography results were compared. The quality of the conduit was evaluated by employing vascular ultrasonography, optical coherence tomography (OCT), and histologic examination. RESULTS: No differences in immediate postoperative morbidity and mortality were observed between the two groups. Early postoperative CT angiography revealed a SV patency rate of 100%, which was not different from that of RA composite grafts (99.1%). CT angiography after a year showed an overall patency rate of 96.3%. The overall patency rate of the SV group at 1 year was 94.7%, which was similar to that of the RA group (97.4%). Also, there was no difference in overall survival rate between the two groups. Vascular ultrasonographic images showed strong correlations between OCT and histopathology. CONCLUSION: Our analysis of early outcomes revealed that the SV could be used as an alternative composite graft to the RA in elderly patients. Vascular ultrasonography is an accurate, real-time, and reproducible method for assessing the quality of the RA conduit.

Delayed Diagnosis of Cardiac Tamponade That Was Caused by Intramural Hematoma of the Ascending Aorta: A case report / 대한흉부외과학회지

Intramural hematoma of the aorta (IMH) is the precursor or a variant of a classic aortic dissection where hemorrhage occurs within the aorta wall in the absence of an initial intimal tear. IMH has a high rate of mortality and morbidity. The optimal therapy for IMH is uncertain, yet the involvement of the ascending aorta is usually considered as an indication for surgery due to the associated risk of rupture or cardiac tamponade. We report here on a case of a 71-year-old man who presented with syncope. Because of misdiagnosis, he underwent computed tomography (CT) after 5 hrs from arriving to the ER. Computed tomography of the aorta revealed intramural hematoma of the ascending aorta with cardiac tamponade. He also had vascular complications such as acute renal failure and visceral ischemia. We performed emergency graft replacement of the total arch and ascending aorta. He was discharged without complication on postoperative day 14.

Earlier Application of Percutaneous Cardiopulmonary Support Rescues Patients from Severe Cardiopulmonary Failure Using the APACHE III Scoring System

Percutaneous cardiopulmonary support (PCPS) is a widely accepted treatment for severe cardiopulmonary failure. This system, which uses a percutaneous approach and autopriming devices, can be rapidly applied in emergency situations. We sought to identify the risk factors that could help predict in-hospital mortality, and to assess its outcomes in survivors. During a 2-yr period, 50 patients underwent PCPS for the treatment of severe cardiopulmonary failure, and of those, 22 (44%) were classified as survivors and 28 (56%) as non-survivors. We compared the 2 groups for risk factors of in-hospital mortality and to establish proper PCPS timing. Twenty patients underwent PCPS for acute myocardial infarction, 20 for severe cardiopulmonary failure after cardiac surgery, 7 for acute respiratory distress syndrome, and 3 for acute myocarditis. Multivariate analysis showed that an acute physiology, age, and chronic health evaluation (APACHE) III score > or =50 prior to PCPS was the only significant predictor of in-hospital mortality (P=0.001). Overall 18-month survival was 42.2%. Cox analysis showed patients with APACHE III scores > or =50 had a poor prognosis (P=0.001). Earlier application of PCPS, and other preemptive strategies designed to optimize high-risk patients, may improve patient outcomes. Identifying patients with high APACHE scores at the beginning of PCPS may predict in-hospital mortality. Survivors, particularly those with higher APACHE scores, may require more frequent follow-up to improve overall survival.

Nonocclusive Mesenteric Ischemia That Developed during Redo-doubleValve Replacement Surgery, and This Was Caused by Acute Aortic Dissection / 대한흉부외과학회지

Nonocclusive mesenteric ischemia (NOMI) is a rare complication that occurs in about 0.05% of patients after open- heart surgery, and NOMI refers to the mesenteric ischemia that's caused by splanchnic vasospasm without occlusion of the great intestinal vessels. In the presently reported case, NOMI developed to maintain the blood flow to the heart and brain after several minutes of a hypotensive status and the latter was caused by acute aortic dissection that complicated an aortic cannulation procedure. Unfortunately, the patient died even though the problems were diagnosed early and proper treatment was administered. Early diagnosis of NOMI by angiography and the selective infusion of vasodilators are thought to be the only way to improve survival for patients with clinically suspected NOMI.

Hand-assisted Laparoscopic Abdominal Aortic Aneurysm Repair Through a 6 cm Incision / 대한흉부외과학회지

We performed hand-assisted laparoscopic surgery for a 67-year-old male with a 5.6 cm sized abdominal aortic aneurysm. To the best of our knowledge, this is the first report in Korea. After an initial hand dissection of the abdominal aorta under laparoscopy, we performed proximal anastomosis and distal abdominal aorta suture ligation through a 6 cm abdominal incision. Distal anastomosis was done at the bilateral common femoral arteries. He resumed his oral intake 6 hours after the surgery and discharged at the 4th postoperative day.

Open Pulmonary Thromboembolectomy in Patients with Major Pulmonary Thromboembolism

PURPOSE: We retrospectively analyzed open pulmonary thromboembolectomy in patients with acute and chronic pulmonary thromboembolism. MATERIALS AND METHODS: Between August 1990 and May 2005, 12 consecutive patients with acute and chronic pulmonary thromboembolism underwent open pulmonary thromboembolectomy at Yonsei Cardiovascular Center. Their mean age was 47.5 years, and 7 of the patients were female. Among 12 patients, 5 had acute onset, and 7 had chronic disease, and 9 patients were associated with deep venous thrombosis. Extent of pulmonary embolism was massive in 3 patients with hemodynamic instability, and submassive in 8 patients. Preoperative echocardiogram revealed elevated right ventricular pressure in all patients, and 7 patients were in NYHA functional class III or IV. Pulmonary thromboembolectomy was performed in all patients under total circulatory arrest. RESULTS: There were 2 hospital deaths (16.7%). Among the patients who survived, mean right ventricular pressure was decreased significantly from 64.3mmHg to 34.0mmHg with improvement of NYHA functional class. CONCLUSION: Open pulmonary thromboembolectomy is thought to be an immediate and definitive treatment for massive pulmonary embolism with optimal results. Even though operative mortality is still high, early diagnosis and immediate surgical intervention in highly selective patients may improve the clinical outcome.

The Effect of Epigallocatechin-3-Gallate on Intimal Hyperplasia after Vascular Grafting / 대한흉부외과학회지

BACKGROUND: Intimal hyperplasia is characterized by a proliferation of vascular smooth muscle cells in the intimal layer. Epigallocatechin-3-gallate (EGCG) is known to suppress smooth muscle cell proliferation. We propose that EGCG may have a protective effect against the development of intimal hyperplasia through the suppression of smooth muscle cell proliferation. MATERIAL AND METHOD: Human umbilical vein endothelial cells (HUVEC) and rat aortic smooth muscle cells (RASMC) were cultured with different concentrations of EGCG, and proliferation and migration speed were measured. In 20 dogs, the autologous jugular veins were interposed into the carotid arteries. For the study group (n=10), the graft was stored for 30 minutes in EGCG solution and 300 mM EGCG was applied to the perivascular space after grafting. After 6 weeks, the intimal and medial thickness was measured. RESULT: The proliferation of RASMC and HUVEC was suppressed with EGCG. The migration of RASMC was suppressed with EGCG, but that of HUVEC was not affected. In the in vivo study, the intimal thickness was thinner in EGCG group than in the control group (p<0.05), but the medial thickness did not show any difference. The intimal/medial thickness ratio was lower in the EGCG group (p<0.05). CONCLUSION: EGCG suppresses intimal hyperplasia after vascular grafting, and this may be mediated by prevention of migration and proliferation of vascular smooth muscle cells. The use of EGCG may offer new therapeutic modality to prevent intimal hyperplasia.

Restoration of Blood Pressure after Administering Methylene Blue for Vasoplegic Syndrome, which Developed after Open Heart Surgery for Septic Infective Endocarditis: A case report / 대한흉부외과학회지

Vasoplegic syndrome occurs in 8~10% of patients following cardiac surgery, and this happens in part because of inducing the inflammatory response. Nitric oxide and guanylate cyclase play an important role in this response, and this is associated with increased morbidity and mortality. For our case, we administered methylene blue (MB), an inhibitor of guanylate cyclase, early after performing cardiopulmonary bypass in a patient with vasoplegic syndrome. The patient recovered immediately after MB administration and maintained an optimal blood pressure without the aid help of any vasopressors.