Open Repair of a Complicated Late Endoleak Induced by Another Endoleak.

A 66-year-old man had an enlarging aortic aneurysm sac after an endovascular aortic replacement procedure that had been performed at another institution 4 years previously; it was without any endoleak but was complicated by the occlusion of the left limb, requiring cross-femoral bypass. Current computed tomography revealed dilatation of the proximal neck and the right common iliac artery. A type Ib endoleak was found from the distal end of the right limb of the endograft, possibly secondary to the dilatation of the artery around it; it then pressurized and caused the dilatation of the juxtarenal aorta around the proximal landing zone and induced a concomitant type Ia endoleak. The patient was operated on owing to the risk of rupture. Pelvic ischemia was a concern during decision-making. The patient underwent removal of the endograft and replacement of a bifurcated aortoiliac and femoral graft with good outcome. Midline laparotomy and a supraceliac clamping approach enable the removal of endografts with suprarenal fixation and revascularization of internal iliac arteries. Open repair offers a definitive solution for complicated endoleaks when endovascular options could be risky and ineffective.

The impact of oral anticoagulation on false lumen patency in acute type A aortic dissections.

BACKGROUND: In this study, the effect of postoperative oral anticoagulation on the false lumen patency of the distal aorta in patients with acute type A aortic dissection was investigated. METHODS: Forty-one patients (32 male, 9 female; mean age 56.8±13.6 years; range, 30 to 84 years) who were diagnosed with acute type A aortic dissection and underwent surgical treatment in our clinic, and whose entire data of both control computed tomographic assessments and all postoperative follow-up visits could be accessed were enrolled. The patients were divided into two groups according to the type of surgical intervention that was performed. Computed tomography imaging of the patients were scanned and false lumen patency rates were evaluated. Besides oral anticoagulation, preoperative, intraoperative, and postoperative risk factors that may have affected false lumen patency secondary to acute type A aortic dissection were evaluated and statistically analyzed. RESULTS: Twenty-one patients (51.2%) had concomitant hypertension. Thirty five (85.4%) of the patients had the main symptom of angina. Sixteen patients (39%) in Group 1 underwent ascending aortic replacement combined with aortic valve replacement (Bentall procedure); while 25 patients (61%) in Group 2 underwent isolated ascending aortic replacement. Mean follow-up was 43.9±26.3 (range: 5-120) months. No statistically significant difference was found between the study subgroups in any of the operation parameters except for cardiopulmonary bypass time (p=0.035) and cross-clamp time (p=0.002). Evaluation of the control contrast-enhanced tomographic imaging of the patients showed false lumen patency in the thorax in 34 patients (82.9%) and in the abdominal region in 33 patients (80.5%). When analyzing subgroups according to the type of surgical procedure, or indirectly anticoagulant use, no statistically significant difference was found in false lumen patency prevalence between the thoracic and abdominal groups (p=0.534 and p=0.922). CONCLUSION: No potential effect of postoperative anticoagulation on false lumen patency was found in cases with acute type A aortic dissection.

Circumflex coronary artery originating from the right pulmonary artery in adult.

Anomalous origin of the circumflex coronary artery from the right pulmonary artery is rare, and symptoms are related to the collateralization and amount of myocardium that it supplies. A 50-year-old woman with severe bicuspid aortic valve stenosis had the diagnosis of anomalous origin of the circumflex coronary artery from the right pulmonary artery before valve replacement. Ligation and division of the circumflex coronary artery was performed. Myocardial ischemia was not observed. The patient was discharged after an uneventful recovery.

Left Ventricular Aneurysm Repair with Endoaneurysmorrhaphy Technique: An Assessment of Two Different Ventriculotomy Closure Methods.

BACKGROUND: Left ventricular aneurysm is a serious mechanical complication of myocardial infarction and has an incidence of 10-35% after myocardial infarction. Ventricular aneurysm in patients with angina, heart failure, and ventricular arrhythmia should be surgically treated. Endoaneurysmorrhaphy is one of the repair techniques that results in better left ventricular geometry and function. After this surgical procedure the ventriculotomy is repaired either with Teflon felt strips or by direct suture of the epicardium. METHODS: In this study, we described the postoperative early outcomes of two ventriculotomy closing techniques such as Teflon felt versus direct closure after aneurysm repair. This retrospective study included a total of 73 patients (mean age > 70 years) with left ventricular aneurysm, who underwent endoaneurysmorrhaphy repair between 1997 and 2009. All selected patients were divided into two groups according to the ventriculotomy closure technique either by Teflon felt or direct by epicardial closure. The pre-, intra-, and postoperative results of these patients were analyzed accordingly. RESULTS: The postoperative early mortality rate and postoperative bleeding were not significantly different between the Teflon felt and primary closure groups (P = .246 and P = .371 respectively), but postoperative arrhythmias were significantly higher in the Teflon felt repair group (P = .049). CONCLUSION: Endoaneurysmorrhaphy is a better surgical technique in left ventricle aneurysm to restore the internal contour and preserve the surface anatomy of the ventricle. The ventriculotomy closure can be performed with two different approaches, including Teflon felt strips or by direct suture of the epicardium. Based on this study's findings, two repair techniques have similar impact on the early outcomes. However, with overall outcomes with respect to Teflon felt repair, direct closure of the ventriculotomy after endoaneurysmorrhaphy was superior.

Management of renal cell carcinoma with intracardiac extension.

Renal cell carcinoma extended to the right atrium was operated by using cardiopulmonary bypass and deep hypothermic circulatory arrest. Hypothermic circulatory arrest provides bloodless surgical field for tumor thrombus removal and adequate visceral and brain protection. The surgical technique that we used in a patient was reported in light of the literature.

Effects of thoracic and hiatal clamping in repair of ruptured abdominal aortic aneurysms.

The purpose of this study was to determine the effects of hiatal and thoracic clamping on postoperative outcome and morbidity and factors affecting mortality and morbidity. The records of 102 patients who had undergone ruptured abdominal aortic aneurysm repair between 1993 and 2005 were evaluated retrospectively. Hiatal clamping and thoracic clamping were performed in 72 patients and 30 patients, respectively. Postoperative complications and survival were evaluated comparatively between the two groups by univariate and multivariate statistical analyses. Overall mortality and hospital mortality rates were 63 (61.8%) and 24 (23.5%) patients, respectively; and there was no difference between the two groups. Postoperative respiratory complications, gastrointestinal complications, and blood requirement were higher in the thoracic clamping group. Preoperative shock and renal ischemia time (>30 min) were found to be significant predictors of hospital mortality. Postoperative renal failure was the only independent postoperative predictor of mortality. In the follow-up period, cardiac event was an independent predictor of late mortality. If hospital mortalities were excluded, 5-year and 10-year cumulative survivals were 57.82 +/- 5.85% and 38.16 +/- 6.97%, respectively. Cross-clamp level did not have a significant effect on long-term survival. Although both thoracic and hiatal clamping had no effect on mortality, postoperative respiratory complications, blood requirement, and intestinal ischemia were more pronounced in patients operated with thoracic clamping. Hiatal clamping is preferable for a safe postoperative period.

Detachment of the mitral valve anterior leaflet as a complication of aortic valve replacement.

Mitral regurgitation after aortic valve replacement is generally reported as a complication of a Manouguian's procedure for annulus enlargement. However, even if no annular enlargement procedure is performed, this complication may be encountered after isolated aortic valve replacement because of either extensive decalcification of the aortic annulus or progressive tension on the anterior leaflet of the mitral valve, caused by aortic valve sutures placed adjacent to firm or heavily calcified valve tissue. Routine transthoracic echocardiography may be inadequate for diagnosis of this condition; transesophageal echocardiography should be used both for preoperative diagnosis and for intraoperative management. We report the case of a patient who had severe mitral regurgitation that occurred after aortic valve replacement with a mechanical valve.

Management of vascular infection in the groin.

We performed this retrospective study in order to evaluate the effectiveness of different surgical methods in the treatment of inguinal vascular infections. Fourteen consecutive patients underwent surgical treatment of such infections from 1996 through 2004 in our clinic. The mean age was 52 +/- 16 years. Seven of the 14 patients underwent emergency operation due to bleeding or acute ischemia. The events that caused inguinal infection were synthetic graft implantation in 8 patients, gunshot injury in 1, arterial catheterization in 2, femoropopliteal saphenous vein bypass operation in 1, and motor vehicle accident with abdominal wall laceration in 2. The most common infecting pathogen was Staphylococcus aureus (7 patients). Sixteen operations were performed in 14 patients. These operations included lateral femoral bypass (5), obturator bypass (5), revascularization with homograft (5), and femorofemoral bypass (1). All inguinal infections were completely cured after surgery. Early complications included poor wound healing (4 patients), minor amputation (1 patient), and extension of infection to the distal anastomosis of the obturator bypass and false aneurysm formation (1 patient). Late complications were acute homograft occlusion of a femorofemoral bypass and thrombosis of a below-knee lateral femoral bypass. There was no operative or late mortality. All patients were followed up for a mean of 48.1 +/- 21.9 months. We did not encounter any aneurysmal degeneration, rupture, or reinfection in homograft patients during follow-up. We conclude that vascular infections of the groin can be cured by proper selection and application of one of the above techniques.

Perioperative determinants of mortality and morbidity in distal arch and proximal descending aortic aneurysm surgery.

BACKGROUND: The purpose of this article is to describe our experience on distal arch and proximal descending aortic aneurysm repair, and to evaluate retrospectively the determinants of mortality and morbidity. MATERIAL/METHODS: Between 1994 and 2002, 30 patients (mean age 53.4 years) underwent repair of distal arch or proximal descending aortic aneurysm approached through left thoracotomy with deep hypothermic circulatory arrest. Femoro-femoral bypass was used in all patients except for four, in whom the left subclavian artery was cannulated. Retrograde cerebral perfusion was performed in 16 patients. The mean circulatory arrest time was 30.7 min. RESULTS: Overall hospital mortality was 13.3%. Excessive blood (p=0.008) and plasma (p=0.009) transfusions, and coronary artery disease (p=0.012) were correlated with mortality. The overall rate of postoperative complications was 30%. Renal failure and respiratory failure were the most frequent complications (16.7%), while the rates of stroke and transient neurological dysfunction were 6.7% and 3.3%, respectively. Age >70 years, bypass time >140 min, distal ischemia time >55 min, and excessive blood or plasma transfusions were determinants of postoperative complications. CONCLUSIONS: Deep hypothermic circulatory arrest with left thoracotomy is a valid procedure with acceptable mortality rates in the management of aneurysms of distal arch and proximal descending aorta. Prolonged bypass and distal ischemia times and excessive blood transfusions are associated with increased postoperative morbidity.

Predictors of outcome in patients with prosthetic valve dysfunction.

BACKGROUND AND AIM OF THE STUDY: The study aim, based on the authors' experience in patients with prosthetic valve dysfunction, was to investigate risk factors for mortality and morbidity by analyzing preoperative, intraoperative and postoperative variables with respect to early and long-term survival. METHODS: A retrospective analysis was carried out of 132 patients (47 men, 85 women; mean age 46.8 +/- 12.4 years) who presented for treatment of prosthetic valve dysfunction between December 1992 and February 2003. Two patients received thrombolytic therapy and were excluded from the statistical analysis, which comprised only operatively treated patients; four patients underwent successful surgical repair of mitral mechanical prostheses; all other patients (except two who died perioperatively) underwent prosthetic valve re-replacement (n = 124). RESULTS: Overall mortality and hospital mortality rates were 15.2% and 10.6%, respectively. Postoperatively, 54 complications were seen in 42 patients (32.3%). Preoperative left ventricular end-systolic diameter (LVESD) > or = 45 mm and cardiopulmonary bypass (CPB) time > 140 min were independent risk factors for overall and in-hospital mortality. Female gender, age > 60 years and prolonged CPB time were predictors of postoperative complications. The actuarial survival rate was 87.5 +/- 0.3% at five years, and 81.7 +/- 0.4% at 10 years. A reduced left ventricular ejection fraction (LVEF) was the only independent predictor of late death and long-term survival. CONCLUSION: Preoperative LVESD > or = 45 mm and lower LVEF were found to be independent predictors of postoperative mortality and late survival, respectively. It is possible to obtain a substantial improvement in outcome and long-term survival if a valvular reoperation can be performed with shorter CPB time and before left ventricular dysfunction has developed.

Perigraft to right atrial shunt by using autologous pericardium for control of bleeding in acute type A dissections.

BACKGROUND: We report our experience with creating a perigraft to right atrial fistula by using autologous pericardium to control the inaccessible bleeding after aortic root repair in patients with acute type A aortic dissection. METHODS: Between 1994 and 2001, perigraft to right atrial fistula was used in 7 of 109 patients (mean age; 55 years) who underwent emergency operation for acute type A dissections. A chamber around the aortic graft was created by suturing a patch of pericardium to the right ventricular wall inferiorly, to the pulmonary artery medially, to the Teflon felt at the distal aortic anastomosis or innominate vein superiorly, and to the superior vena cava and right atrium laterally. A large stab wound was created on the medial aspect of the right atrium. The perigraft space was then closed expeditiously. RESULTS: None of these patients required reexploration for bleeding and they were discharged from the hospital without complications. The average blood and fresh frozen plasma requirement was 3.4 +/- 0.9 and 2.7 +/- 0.7, respectively. All underwent echocardiographic examination before discharge and no perigraft to right atrial shunt was detected. CONCLUSIONS: If intractable bleeding is encountered after the administration of protamine and thrombotic agents and a discrete bleeding site can not be found, then a perigraft to right atrial fistula using autologous pericardium can be created as a last resort. It provides primary and definite sternal closure and avoids the detrimental effects of a second pump run and continued bleeding.

Coronary artery bypass grafting in patients with poor left ventricular function.

Coronary artery bypass grafting (CABG) in patients with poor left ventricular function remains a surgical challenge and is still controversial. The purposes of this study were to evaluate the effectiveness of CABG in such patients when performed without case selection on the basis of preoperative viability tests and to determine the predictors of postperative outcome. The preoperative, perioperative, and postoperative early and mid-term follow-up data of 273 patients with < or = 30% left ventricular ejection fraction (LVEF) who underwent isolated CABG between January 1995 and November 2000 were evaluated. Preoperative echocardiography and cardiac catheterization, and postoperative control echocardiography were performed in all patients. Follow-up was achieved via monthly periodical examinations in the first 6 months, and thereafter by either regular visits or phone contact. Preoperatively, 242 (88.65%) patients were in NYHA class III or IV, and the mean LVEF was 26.51 +/- 3.64%. The overall hospital mortality total was 14 (5.13%) patients. There were 44 (16.12%) late mortalities. Postoperative morbidities were observed in 74 (27.1%) patients. Two-hundred and two (93.95%) of the surviving 215 (78.75%) patients were in NYHA class I or II at 49.55 +/- 14.84 months of follow-up. Postoperative follow-up echocardiographic examinations revealed a mean LVEF of 39.66% +/- 5.43%. The improvements in functional capacity and LVEF were significant. Advanced age, diabetes, hypertension, cross-clamp time >60 min, bypass time>120 min, and severity of functional class (class III-IV of NYHA) were found to be the determinants of mortality. However, multivariate analyses revealed only older age and class III-IV of NYHA and CCS were predictors of mortality. The low mortality and morbidity rates as well as satisfactory postoperative improvements in functional capacity and LVEF measurements support the use of CABG without the need for any viability assessment in patients with left ventricular dysfunction.

Predictive value of conventional computed tomography in determining proximal extent of abdominal aortic aneurysms and possibility of infrarenal clamping.

The present study aimed to evaluate the diagnostic reliability of computed tomography in determining the proximal extent of abdominal aortic aneurysms and the possibility of infrarenal clamping. Preoperative computed tomographic findings, together with the operative data for 95 patients, were retrospectively analyzed in light of the operative findings. Eighty-nine (93.68%) of the patients were men and 6 (6.32%) were women, with a mean age of 66.27 +/- 18.14 years. Diagnosis of infrarenal aneurysm by computed tomography was confirmed at the time of surgery in 91 (95.79%) of 95patients. The negative-predictive value of computed tomography in detecting supra-aneurysmal renal arteries was found to be 95.79%. The specificity was 98.91%. Infrarenal cross-clamping was performed in 59 (62.11%) of 95 patients, whose aortic segments between the renal artery orifices and the proximal borders of the aneurysms had a mean length of 26.4 +/- 7.11 mm by computed tomography Suprarenal clamping was required in 36 (37.89%) of the 95 patients, whose aortic segments had a mean length of 12.7 +/- 3.48 mm. We conclude that conventional computed tomography is reasonably accurate in determining the proximal extent of abdominal aortic aneurysms. Although there is a high rate of error in determining the possibility of infrarenal clamping when no specific measurements are taken, infrarenal clamping can be planned when measurement by computed tomography shows a length of > or = 26 mm between the renal arteries and the proximal extent of the aneurysm. In patients with shorter aortic segments, suprarenal aortic clamping should be considered.

Predictors of outcome after coronary bypass surgery in patients with left ventricular dysfunction.

OBJECTIVE: The aim of this study was to determine the risk factors affecting the mortality and morbidity after coronary artery bypass grafting (CABG) in patients with LV dysfunction and without any viability assessment. METHODS: The preoperative, perioperative, and postoperative early and mid-term follow-up data of 252 patients with left ventricular ejection fraction (LVEF) of < or = 30% who underwent isolated CABG from 1995 through 2000, were evaluated. No preoperative viability study was performed for patient selection. Preoperative echocardiography and cardiac catheterization, and postoperative control echocardiography were performed in all patients. Follow-up data after the discharge of these patients were obtained via monthly periodical examinations in the first 6 months, and thereafter via telephone interviews. As preoperatively, 229 (90.87%) patients were in NYHA class III or IV, and the mean LVEF was 26.58 +/- 3.66%. RESULTS: Overall mortality and late mortality rates were 16.27% and 5.16%, respectively. Postoperative complications were observed in 61 (24.21%) patients. During 49.06 +/- 15.17 months of follow-up, 185 (93.43%) of 198 (78.57%) survived patients were in NYHA class I or II and the mean LVEF was 39.64% +/- 5.68%. Advanced age, diabetes, hypertension, cross-clamp time > 60 min, bypass time > 120 min, severity of angina and functional classes (class III-IV of NYHA and CCS) were found to be the determinants of mortality. However, by multivariate analysis only older age and class III-IV of NYHA and CCS were detected as predictors of mortality. CONCLUSION: The low mortality and morbidity rates as well as postoperative improvements in functional capacity and in LVEF support the use of CABG without the need of any viability assessment in patients with left ventricular dysfunction. Advanced age, severe angina and functional symptom status seem to be the predictors of poor prognosis in these patients after CABG.

Adverse effects of cell saver in patients undergoing ruptured abdominal aortic aneurysm repair.

A retrospective analysis of 56 patients undergoing ruptured abdominal aortic aneurysm (AAA) repair was performed to find out if cell saver had any impact on postoperative morbidity and mortality. All patients but one were male. The mean age was 68 +/- 8 years (35-85 years). Cell saver was used in 40 patients (CS group) and was not used in 16 patients (NCS group). We compared the incidences of respiratory, renal, and gastrointestinal complications; reoperation; transfusion requirement; length of hospital stay; and mortality between the groups. This study demonstrated that intraoperative cell saver usage significantly increased the incidence of respiratory complications and the need for blood and fresh frozen plasma transfusion, and prolonged the hospital stay in patients with ruptured AAA, but did not have any impact on mortality. Postoperative complications were more prominent in patients who received >3000 mL cell saver blood.