Surgical treatment of pseudoaneurysm of the ascending aorta in a patient with sepsis

Abstract Pseudoaneurysm of the ascending aorta (PAA) is a hazardous and potentially fatal cardiovascular disease. This condition is caused by the rupture of at least one layer of the vessel and contained by the remaining vascular layers or the surrounding mediastinal structures. We presented the surgical treatment of a patient with sepsis and large PAA and brachiocephalic trunk, which was compressing the brachiocephalic trunk leading to syncope.

Innominate vs. axillary artery cannulation in aortic surgery: a systematic review and meta-analysis

Abstract Objective: To investigate whether axillary artery cannulation has supremacy over innominate artery cannulation in thoracic aortic surgery. Methods: A comprehensive search was undertaken among the four major databases (PubMed, Excerpta Medica dataBASE [EMBASE], Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing axillary to innominate artery cannulation in thoracic aortic surgery. Databases were evaluated and assessed up to March 2017. Results: Only three studies fulfilled the criteria for this meta-analysis, including 534 patients. Cardiopulmonary bypass time was significantly shorter in the innominate group (P=0.004). However, the innominate group had significantly higher risk of prolonged intubation > 48 hours (P=0.04) than the axillary group. Further analysis revealed no significant difference between the innominate and axillary groups for deep hypothermic circulatory arrest time (P=0.06). The relative risks for temporary and permanent neurological deficits as well as in-hospital mortality were not significantly different for both groups (P=0.90, P=0.49, and P=0.55, respectively). Length of hospital stay was similar for both groups. Conclusion: There is no superiority of axillary over innominate artery cannulation in thoracic aortic surgery in terms of perioperative outcomes; however, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing optimal arterial cannulation site.

Esternotomia parcial para tratamento de lesão iatrogênica do tronco braquiocefálico durante traqueostomia / Partial sternotomy for management of iatrogenic brachiocephalic trunk injury during tracheotomy

A toracotomia mediana é uma via de acesso que atravessa longitudinalmente o esterno e pode ser subdividida em vertical total, parcial superior e parcial inferior. Na prática cirúrgica, o uso da esternotomia mediana parcial é uma alternativa que proporciona menor agressão cirúrgica. O tronco braquiocefálico é um dos grandes vasos torácicos mais acometidos em traumas e sua abordagem classicamente é feita por esternotomia mediana. Neste trabalho, apresenta-se o uso da esternotomia parcial superior em "T" invertido como possibilidade de via de acesso em situação de lesão traumática iatrogênica do tronco braquiocefálico.

The median thoracotomy is an access incision made longitudinally through the sternum and variants can be subdivided into total vertical and partial upper or partial lower vertical incisions. In surgical practice, using a partial median sternotomy is an alternative option that causes less surgical aggression. The brachiocephalic artery is one of the thoracic vessels most often affected in traumas and it can be accessed via a median sternotomy. This report describes use of an upper partial sternotomy to provide access in a case of traumatic iatrogenic injury of the brachiocephalic trunk.

Innominate Artery Injury: A Catastrophic Complication of Tracheostomy in a Trauma Patient, Operative Procedure Revisited.

Tracheostomy is a routine life-saving operative procedure in the event of airway obstruction especially in faciomaxillary injuries. Bleeding is the most common complications of tracheostomy, innominate artery (IA) of normal width reaching second tracheal ring is very rare, and injury to IA can be a catastrophic complication. We reported a case of 40-year-old male presented with profuse bleeding from oral and nasal cavity following road traffic injury. During tracheostomy, there was a sudden forceful gush of blood coming out of incision site, warning a major vessel injury. Right-sided trap door thoracotomy procedure was performed, and the avulsed right IA was repaired as a life-saving procedure.

Lesión transfixiante de tronco arterial braquiocefálico por traumatismo torácico penetrante / Brachiocephalic trunk perforating injury by penetrating thoracic trauma

Las lesiones del tronco arterial braquiocefálico (TABC) son infrecuentes y se han descrito en el contexto de traumatismos penetrantes o contusos de la región torácica y cervical. Son características su elevada morbimortalidad y dificultad diagnóstica. PRESENTACIÓN DEL CASO: Paciente de género masculino, de 19 años, consultó en Servicio de Urgencia por heridas torácicas tras ser agredido por terceros con arma blanca. Ingresó sin deterioro hemodinámico encontrándose en examen físico una herida en la región esterno clavicular derecha y una herida en hemitórax izquierdo dorsal. Se realizó radiografía de tórax que mostró ensanchamiento mediastínico y hemotórax izquierdo mínimo. Por sospecha de lesión vascular se complementó estudio con angiotomografía computada de tórax que mostró doble extravasación del medio de contraste a nivel del TABC, compatible con lesión transfixiante, además de hemomediastino y hemotórax izquierdo mínimo, sin evidencias de lesión de vía aérea o esofágica. Se realizó pleurotomía para tratamiento del hemotórax. Evolucionó en buenas condiciones generales, sin deterioro hemodinámico, porlo que se decidió resolución endovascular por el equipo de Cirugía Vascular Periférica, realizándose instalación de endoprótesis recubierta en TABC, sin incidentes. No presentó complicaciones postoperatorias. Se realizó Angiotomografía de control con endoprótesis in situ. A 9 meses de seguimiento, el paciente está asintomático. DISCUSIÓN: Las lesiones del TABC son graves. El ensanchamiento mediastínico en la radiografía de tórax debe hacer sospechar lesión de grandes vasos y/o troncos supraaórticos, la que se confirma mediante estudio angiográfico en un paciente estable o en la exploración quirúrgica de urgencia, si presenta deterioro hemodinámico...

Brachiocephalic trunk lesions are rare and have been described in the context of penetrating or blunt thoracic and cervical trauma. They have a high morbidity and its diagnostic is difficult. CASE PRESENTATION: A 19 years oldman, presented in emergency room with chest injuries after being attacked with a knife. He entered without hemodynamic deterioration. In physical examination a wound in the right sternoclavicular region and a dorsal wound in the left hemithorax were found. Chest x-ray showed widened mediastinum and minimum left hemothorax. For suspected vascular injury, a chest computed angiotomography was performed, that revealed double extravasation of contrast medium at brachiocephalic trunk, consistent with a perforating injury, hemomediastinum and minimum left hemothorax. It showed no evidence of airway oresophageal injuries. Pleurotomy was performed for hemothorax treatment. He evolved in good general condition, without hemodynamic deterioration. Endovascular resolution was decided by Vascular Surgery team. A coated stent in the brachiocephalic trunk was installed without incidents. No postoperative complications were presented. The control angiotomography showed stent in situ. At 9 -month follow-up, the patient is asymptomatic. DISCUSSION: Brachiocephalic trunk injuries are serious. A injury of great vessels and/or supraaortic trunks should be suspected with a image of widened mediastinum on chest x ray, and it is confirmed by angiography in a stable patient or by emergency surgical exploration, if hemodynamic deterioration is present...

Estenose aórtica supravalvar em adulto com anomalia de vasos da base e insuficiência aórtica / Supravalvular aortic stenosis in adult with anomalies of aortic arch vessels and aortic regurgitation

A estenose aórtica supravalvar é uma rara cardiopatia congênita, bastante incomum em adultos. Apresentamos um caso de estenose aórtica supravalvar em adulto com anomalia de vasos do arco aórtico, já com presença de insuficiência aórtica importante, tratado com êxito por meio de plastia da aorta ascendente e troca valvar aórtica.

The supravalvular aortic stenosis is a rare congenital heart defect being very uncommon in adults. We present a case of supravalvular aortic stenosis in adult associated with anomalies of the aortic arch vessels and aortic regurgitation, which was submitted to aortic valve replacement and arterioplasty of the ascending aorta with a good postoperative course.

Revascularização simultânea do miocárdio e dos troncos supra-aórticos / Simultaneous myocardial and supra-aortic trunks revascularization

Relatamos o caso de uma paciente de 58 anos com síndrome coronariana aguda, com acometimento triarterial. Em decorrência de angina refratária, foi indicada cirurgia de revascularização do miocárdio (RM) de urgência. Na avaliação pré-operatória, foram detectadas lesões obstrutivas na origem do tronco braquiocefálico, artérias carótida comum esquerda e carótida interna esquerda. A paciente foi submetida, concomitantemente, a RM e revascularização dos troncos supra-aórticos (bypass extra-anatômico), além de endarterectomia da artéria carótida interna esquerda. A paciente teve uma boa evolução, com alta hospitalar no sétimo dia pós-operatório. Atualmente, dois anos após o procedimento, encontra-se em acompanhamento ambulatorial, assintomática.

We report the case of a 58-year-old patient, with a three vessel disease with unstable angina. Due to refractory angina, she was referred to urgent coronary artery bypass graft (CABG). In the preoperative evaluation were found severe obstructive lesions in the brachiocephalic trunk origin, left common carotid origin and left internal carotid artery. The patient underwent CABG, supra-aortic trunks revascularization (extra-anatomic bypass) and carotid endarterectomy in the same procedure. She presented an uneventful recovery and was discharged home on the seventh postoperative day. Currently, two years after the procedure, she continues under follow-up, symptomless.

Tratamiento endovascular de lesiones traumáticas de troncos supra aórticos / Endovascular treatment of traumatic supra aortic trunk lesions

Introduction: Traumatic lesions of supra aortic trunks (SAT) have an elevated morbidity and mortality, and its treatment is technically challenging. Endovascular techniques offer an effective solution with a lower risk, making it an attractive alternative. Objectives: Retrospective review of all the patients with SAT lesions treated with endovascular techniques. Results: Between March 2000 to August 2009, 8 patients were treated, 6 men, mean age 33.6 years. Three patients suffered blunt and 5 a penetrating trauma. The injured vessels were subclavian artery in 5, brachiocephalic trunk in two and common carotid in one. Of the 5 patients with subclavian artery injury, three had associated brachial plexus injury. Six patients were treated with an endo-graft and one with coil-embolization. One patient suffered an early partial collapse of his endograft, requiring an additional bare metal stent to maintain patency. In this series there was neither neurological morbidity nor operative mortality. Follow-up is 24.3 months, and primary assisted patency is 100 percent at 21.9 months with two patients lost to follow-up. Conclusions: Endovascular treatment of SAT lesions is effective, showing low morbidity and mortality with a good mid-term patency.

Introducción: Las lesiones traumáticas de troncos supra aórticos (TSA) tienen elevada morbimor-talidad, y su tratamiento presenta un desafío técnico. Las técnicas endovasculares se presentan como una alternativa atractiva y de menor riesgo para su solución efectiva. Objetivos: Evaluar los resultados del tratamiento endovascular de las lesiones de TSA. Material y Método: Se revisaron retrospectivamente todos los pacientes sometidos a tratamiento endovascular de lesiones de TSA. Resultados: Entre Marzo de 2000 y Agosto de 2009 se intervinieron 8 pacientes, 6 hombres, edad promedio 33,6 años. El mecanismo traumático fue contuso en 3 y penetrante en 5. Los vasos afectados fueron arteria subclavia en 5, tronco braquiocefálico en 2 y carótida común en uno. De los pacientes con lesión subclavia, tres presentaron compromiso de plexo braquial asociado. Siete pacientes fueron tratados con implante de endoprótesis y uno mediante embolización. Un paciente requirió un stent no cubierto para tratar el colapso parcial precoz de una endoprótesis. No hubo morbilidad neurológica de novo ni mortalidad operatoria. El seguimiento clínico promedio es 24,3 meses. Dos pacientes se perdieron al seguimiento. La permeabilidad primaria asistida es 100 por ciento a 21,9 meses. Conclusiones: El tratamiento endovascular de lesiones de TSA es efectivo, con baja morbimortalidad y con buena permeabilidad a mediano plazo.

Anatomical variation of the brachiocephalic trunk and common carotid artery in neck dissection / Variación anatómica del tronco braquicefálico y arteria carótida común en disecciones de cuello

Variations in the trajectory of the brachiocephalic trunk and the common carotid artery predispose to disorders which might be critical in a tracheotomy and/or surgeries. Dissection of 110 formol fixed adult cadavers, both sexes, were performed to increase the anatomic knowledge of the neck vessels and its variations. Cadavers were from the Laboratory of Descriptive and Topographic Anatomy of the Federal University of São Paulo- Paulista Medical School- UNIFESP-EPM. In 109 of these cadavers no variations were found while in one (0.9%) it was possible to observe a variation in the trajectory of the brachiocephalic trunk and in the right common carotid artery.

Las variaciones en el trayecto del tronco braquiocefálico y de la arteria carótida común predisponen a complicaciones que pueden ser fatales durante una traqueotomía y/o cirugías. Con el objetivo de ampliar el conocimiento anatómico de estos vasos del cuello y de sus variaciones, decidimos diseccionar 110 cadáveres, formalizados, adultos, de ambos los sexos, provenientes del Laboratorio de Anatomía Descriptiva y Topográfica de la Universidad Federal de São Paulo-Escuela Paulista de Medicina ¡ UNIFESP-EPM. En 109 (99,1%) de los cadáveres no encontramos variaciones En un caso (0,9%) observamos variación en el trayecto del tronco braquiocefálico y de la arteria carótida común derecha.

Cirurgia do arco aórtico com perfusão cerebral bilateral pelo isolamento do tronco braquiocefálico e da artéria carótida esquerda / Aortic arch surgery with bilateral cerebral perfusion by isolation of brachiocephalic trunk and left carotid artery

OBJETIVO: Estudar os resultados da técnica descrita por Carreira et al. com utilização de perfusão cerebral seletiva bilateral (PCSAB) pelo isolamento do tronco braquiocefálico e artéria carótida esquerda. MÉTODOS: Quinze pacientes foram operados consecutivamente entre de junho de 2005 e setembro de 2007. Os dados foram analisados por programa informatizado Epi Info e significância estatística com p<0,05. RESULTADOS: No grupo analisado, 53,3 por cento dos pacientes eram do sexo masculino e a idade média era de 59,86±15,4 anos. Com relação à doença de base, 60 por cento dos pacientes apresentavam dissecção aguda do tipo A, 6,7 por cento tipo B e 33,3 por cento aneurisma da aorta e arco. O tempo médio de CEC e de anoxia foi de 177,6±39,4 e 135,9±34,0 minutos, respectivamente. Nesse grupo, 86,7 por cento dos pacientes não foram submetidos a parada circulatória total, com tempo médio de PCSA unilateral e bilateral de 10,9±2,0 e 57,2±21,2 minutos, respectivamente. A temperatura média da hipotermia foi de 23,0±2,9ºC. A artéria subclávia esquerda foi ligada em dois (13,3 por cento) pacientes, e nove (60 por cento) foram submetidos a anastomoses proximal e distal com tubos separados. Utilizou-se endoprótese vascular na aorta descendente em quatro (26,7 por cento) pacientes. Três (20 por cento) pacientes morreram, todos do subgrupo de dissecção aguda. Nenhum dos sobreviventes apresentou seqüelas neurológicas, com média de acompanhamento tardio de 11,7±9,6 meses. Nenhum dos fatores estudados apresentou relação estatisticamente significativa com a mortalidade (p>0,05). CONCLUSÃO: A técnica de PCSAB é reprodutível e apresenta resultados semelhantes aos da literatura mundial. A excelente evolução neurológica e o fácil controle de sangramentos nas linhas de sutura podem ter contribuído com os resultados obtidos.

OBJECTIVE: To evaluate the results of a technique described by Carreira et al. using bilateral antegrade selective cerebral perfusion by isolating the brachiocephalic trunk and the left carotid artery. METHODS: Fifteen patients were operated between June 2005 and September 2007. Data analysis were performed using Epi Info and statistical significance was set at p<0.05. RESULTS: Of the 15 patients, 53.3 percent were male; mean age was 59.86±15.4 years; 60 percent presented with type A acute aortic dissection; 6.7 percent type B; and 33.3 percent aneurysm of aorta and arch. Mean CPB and aortic clamping time was 177.6±39.4 and 135.9±34.0 minutes, respectively. In this group, 86.7 percent were not submitted to total circulatory arrest, with mean unilateral and bilateral selective cerebral perfusion time of 10.9±2.0 and 57.2±21.2 minutes, respectively. Mean hypothermic temperature was 23.0±2.9ºC. Two had left subclavian artery ligature, 60 percent used separated aortic grafts, and four used aortic endoprosthesis. Three (20 percent) patients died, all of them in the acute aortic dissection group. There were no neurological complications. The mean follow up time was 11.7±9.6 months. Regarding mortality, none of the parameters were statistically significant (p>0.05). CONCLUSION: The technique of bilateral selective cerebral perfusion described by Carreira et al. can be performed by others and presents similar results to the international literature. The excellent neurological outcome and easy bleeding control on surgical sutures lines are the major advantages of this new procedure.

An infant with "dying spells".

A 45-day-old infant presented with the unusual and intriguing symptom of episodic crying and loss of consciousness. The infant was discovered to have a vascular compression of the trachea by the innominate artery, almost serendipitously. He was cured of his symptoms by anterior suspension of the innominate artery.

Metabolic Changes after Revascularization in a Patient with Innominate Artery Occlusion by Localized in vivo Proton Magnetic Resonance Spectroscopy

Localized in vivo proton magnetic resonance spectroscopy (1H-MRS) has been used to measure the metabolic status of the human brain in a non-invasive manner; thus, it is often called "a non-invasive biochemical assay". MRS is more sensitive than magnetic resonance imaging (MRI) in detecting ischemic damage by measuring the metabolic changes that occur prior to the anatomic changes. We report a patient who presented with innominate artery occlusion and symptoms of posterior circulation insufficiency and showed favorable metabolic changes by 1H-MRS after revascularization. He showed no visible lesion in brain MRI, but in 1H-MRS, decreased N-acetylaspartate (NAA) signal was noted in a resting state. After revascularization, both symptomatic improvement and recovery of NAA signal were observed. 1H-MRS may provide valuable clinical information in diagnosis and management of cerebral hypoperfusion at a much earlier stage prior to the anatomic changes.

Síndrome de compresión traqueal y apnea refleja causado por arteria innominada anómala (AIA) / Tracheal compression and reflex apnea syndrome caused by anomalus innominate artery

El origen anómalo de la arteria innominada es una de las causas de síndrome de dificultad respiratoria asociado a "crisis de apnea refleja" en niños. Comunicamos dos pacientes (de 2 y 11 meses de edad) en los cuales fue realizada exitosamente la arteriopexia de la arteria innominada. Ninguno de los dos ha repetido "crisis de apnea refleja" y se encuentran libres los síntomas. Los episodios de "apnea refleja" constituyen una indicación absoluta para el tratamiento quirúrgico

Tratamento cirúrgico das lesöes ulceradas no tronco braquiocéfalico: relato de dois casos / Surgical treatment of ulcerated lesions in the brachiocephalic trunk: report of 2 cases

a aterosclerose dos ramos do arco aórtico costuma acometer uma zona anatômica que inclui a cúpula do arco e os orificios dos seus três ramos. Menos frequentemente, podem aparecer lesöes ulceradas na parede da aorta proximal à artéria inominada e nas porçöes proximais desse vaso e da subclávia esquerda, acompanhadas de embolizaçäo periférica para cérebro e extremidades superiores. Os sintomas de hipoperfusäo cerebral somente constituem indicaçäo cirúrgica quando levam a risco da vida, enquanto a embolizaçäo para o cérebro, olhos e membros constitui indicaçäo cirúrgica absoluta. As operaçöes que abordam diretamente a lesäo arterial, quer se trate de endarterectomia ou de substituiçäo por enxertos, têm melhores resultados do que as operaçöes de "bypass" transcervical. Säo relatados os casos de dois pacientes com lesäo ulcerada de tronco braquiocefálico, o segundo com extensäo para a artéria subclávia direita. A sintomatologia era da embolizaçäo de repetiçäo; em um deles, para o cérebro e no outro, para o membro superior direito, inclusive com perda de dados. Em ambos foi realizado, através de esternotomia mediana, enxerto da aorta para o tronco braquiocefálico com exclusäo da circulaçäo pelo tronco e endarterectomia de subclávia direita no segundo. Ambos estäo assintomáticos com seguimentos de 9 a 67 meses