Ligation of symptomatic celiac artery aneurysm without vascular reconstruction: Utilizing the natural collateral circulation of the celiac axis: A case report.

INTRODUCTION: Celiac artery aneurysm is very rare visceral artery aneurysm. Symptomatic and ≥ 2.5 cm sized aneurysm requires treatment. Excision and revascularization is the most commonly employed procedure. CASE PRESENTATION: We report a case of ligation and excision of celiac artery aneurysm extending onto the splenic and hepatic arteries without vascular reconstruction. The patient was a 52 year old lady who was evaluated for abdominal pain and was found to have a celiac artery aneurysm involving the hepatic and splenic arteries. She was evaluated with computerized tomography and digital subtraction angiography of the abdominal vessels. These confirmed good natural collaterals from the branches of superior mesenteric artery supplying the liver, stomach and spleen. We performed ligation and excision of the aneurysm and ligation and division of hepatic, splenic and left gastric arteries as the aneurysm was extending on to these vessels, without any vascular reconstruction, utilizing the natural collaterals from the superior mesenteric artery. DISCUSSION: Ligation of celiac artery aneurysm without revascularization is often done in emergency situations. Excision and revascularization is the treatment of choice to ensure adequate blood supply to liver, spleen and stomach. We could utilize the natural collateral circulation of celiac artery from superior mesenteric artery avoiding a complex procedure of revascularization. CONCLUSION: We present this because of the rarity of the disease as well as rarity of the technique of not performing vascular reconstruction. We emphasize on the pre-operative and operative evaluation of collateral circulation with conventional angiography and intraoperative Doppler respectively.

Single-stage repair for multiple muscular septal defects: a single-centre experience across 16 years.

OBJECTIVES: Multiple muscular ventricular septal defects (VSDs) are surgically challenging and its management remains controversial. We present a technique of surgical repair for muscular VSDs, which includes surgical exposure and detection of these defects and has excellent clinical outcomes. METHODS: We have analysed consecutive patients who underwent surgical repair of isolated multiple muscular VSDs under cardiopulmonary bypass over a 16-year period (from January 2001 to November 2016) in a single centre from the southern part of India. These defects were accessed through the right atrium in most cases and closed directly; completeness of closure was confirmed by pressurizing the left ventricle with blood cardioplegia. There were no haemodynamically significant residual VSDs following repair. RESULTS: One hundred and two patients with an average time of follow-up of 4.1 years (1 month-12 years) were included. The mean age of our patients at the time of operation was 23.5 months (3 months-22 years) with a mean weight of 7.9 kg (2-55 kg). The mean cardiopulmonary bypass and cross-clamp time was 118.8 ± 39.2 min (mean ± SD) and 76.5 ± 29.4 min (mean ± SD), respectively. There were 10 (9.8%) hospital deaths and 3 late deaths in the entire study group. Permanent pacemaker was implanted in 2 patients. Seventy patients could be followed up after discharge. Postoperative pulmonary artery pressure was normal in 52% of the patients, mild-to-moderate hypertension in 27% and severe in 7% of the patients. The ejection fraction was >60% among the survivors, and there were no reoperations or reinterventions. CONCLUSIONS: This surgical approach to multiple muscular VSDs is safe and effective with minimal risk of complete heart block and diminution of ventricular function.

Postoperative management of pulmonary endarterectomy and outcome.

Pulmonary artery thromboendarterectomy (PTE) has been regarded as a promising, potentially curative surgical procedure. However, PTE is associated with specific postoperative complications, such as reperfusion pulmonary edema and right heart failure leading to a considerable mortality of 7-24%. Despite its limitations PTE is a better surgical alternative to lung transplantation which carries high morbidity and mortality. The aim of the study is to analyze the efficacy, safety, morbidity and survival associated in the postoperative period and quality of life after six months of PTE in Indian patients. Forty-one patients with surgically correctable chronic thromboembolic pulmonary hypertension underwent pulmonary endarterectomy. All patients were in New York Heart Association (NYHA) Class II, III or IV. Preoperative mean pulmonary artery pressure was 40.98 +/- 9.29 mmHg and mean pulmonary vascular resistance was 418.39 +/- 95.88 dynes/sec/cm(-5). All patients were followed up to six months and a telephonic survey was conducted using a standard questionnaire. They were assessed and classified as per NYHA grading. There was a significant reduction in the mean pulmonary artery pressure (from 40.98 +/- 9.29 mmHg to 24.13 +/- 7.36 mmHg, P < 0.001) and pulmonary vascular resistance (from 418.39 +/- 95.88 dynes/sec/cm(-5) to 142.45 +/- 36.27 dynes/sec/cm(-5), P < 0.001) with a concomitant increase in the cardiac index (from 1.99 +/- 0.20 L/min/m 2 to 3.28 +/- 0.56 L/min/m 2 , P < 0.001) during the postoperative period. The mortality rate in our study was 12.19% (five patients). Ninety per cent of the patients reported a significant improvement in the quality of life and exercise tolerance after surgery compared to the preoperative state. Pulmonary endarterectomy is an effective and potentially curative surgical treatment for patients with severe chronic thromboembolic pulmonary hypertension. The current techniques of operation make the procedure relatively safe and long-term survival, NYHA functional status and exercise capacity improve significantly.

Marsupialization of intramyocardial left anterior descending artery: a novel approach for easy access during revascularization.

The left anterior descending (LAD) artery is the most important vessel bypassed during coronary revascularization procedures. This artery usually runs a superficial course, making it easy for localization and grafting. However, many times it takes a course deep in the myocardium or is embedded in thick epicardial fat, which results in technical challenges to the surgeon for localization and grafting. So far, many techniques are described for overcoming these problems, but all require cardiopulmonary bypass (CPB), and in fact, intramyocardial LAD is considered a relative contraindication for off-pump coronary artery bypass grafting (OPCAB). In the present era of enhanced interest in OPCAB, these techniques are not as helpful as they are for conventional CABG with CPB. Here, we describe a novel approach of marsupialization of the LAD for revascularization of intramyocardial LAD that is useful for off-pump as well as conventional revascularization procedures and makes grafting simple and reproducible.