Migratory Azygos Lobe: A Case Report.

The azygos vein sometimes merges abnormally across the right upper lobe of the lung and it hangs at the lower edge of a membranous septum, called the meso-azygos. The septum invaginates the lobe and makes a fissure. The smaller medial part of the right upper lobe is called an azygos lobe. A 16-year-old male patient was diagnosed with right-sided pneumothorax, and a closed thoracostomy was done in the emergency room. During elective wedge resection including the bulla, the meso-azygos, abnormal azygos vein, and azygos lobe were detected. We reviewed the computed tomography images and found that the azygos lobe had re-expanded laterally, not medially, to the meso-azygos after the closed thoracostomy in the emergency room. The patient had been diagnosed with left-sided pneumothorax a year ago, and no one noticed the azygos lobe at that time. We report the intraoperative findings and comparative images of a migratory azygos lobe.

The Influence of Unfavorable Aortoiliac Anatomy on Short-Term Outcomes after Endovascular Aortic Repair.

BACKGROUND: Endovascular aortic repair (EVAR) is widely performed to treat infrarenal abdominal aortic aneurysms (AAAs), and related techniques and devices continue to be developed. Although continuous attempts have been made to perform EVAR in patients with unfavorable aortic anatomy, the outcomes are still controversial. This study examined the short-term outcomes of EVAR for the treatment of infrarenal AAAs in patients with a 'hostile' neck and unfavorable iliac anatomy. METHODS: Thirty-eight patients who underwent EVAR from January 2012 to December 2017 were enrolled in this study. A hostile neck was defined based on neck length, angulation, the presence of an associated thrombus, or a conical shape. Unfavorable iliac anatomy was considered to be present in patients with a short common iliac artery (<15 mm) or the presence of aneurysmal changes. RESULTS: No perioperative mortality was recorded. No significant differences were found depending on the presence of a hostile neck, but aneurysmal sac shrinkage was significantly less common in the group with unfavorable iliac anatomy (p=0.04). A multivariate analysis performed to analyze the risk factors for aneurysmal progression revealed only unfavorable iliac anatomy to be a risk factor (p=0.02). CONCLUSION: Patients with unfavorable aortic anatomy showed relatively satisfactory short-term outcomes after EVAR. No difference in the surgical outcomes was observed in patients with a hostile neck. However, unfavorable iliac anatomy was found to inhibit the shrinkage of the aneurysmal sac.

Volume of mural thrombus plays a role in the elevation of inflammatory markers after endovascular aortic repair.

BACKGROUND: Although systemic inflammatory responses are common after endovascular aortic repair (EVAR), its etiology remains uncertain. It is normally well tolerated and has a benign course. This study was undertaken to investigate the possible etiology of post-EVAR inflammation by measuring volumes of chronic mural thrombus and fresh thrombus. METHODS: The subjects of this study included 34 patients who underwent EVAR from February 2012 to July 2017. Inflammatory markers in all the patients were evaluated before surgery, using the highest value among the laboratory data up to 5 days after surgery, and postoperative computed tomographic angiography (CTA) was taken for all of them before their discharging. Volumes of mural thrombus and fresh thrombus were calculated by CTA. The mean interval from surgery to immediate postoperative CTA was estimated as 6.8 ± 4.0 days. RESULTS: After undergoing EVAR, white blood cell (WBC) (p < 0.01), C-reactive protein (CRP) (p < 0.01) and erythrocyte sedimentation rate (ESR) (p = 0.01) were significantly elevated. Two groups were defined according to the post-implantation syndrome (PIS) by the criteria of systemic inflammatory response syndrome (SIRS);no significant differences were observed in any factors between the two groups. Classification of two groups by the criteria of increasing WBC and CRP revealed that inflammatory markers were significantly enhanced as the volume of mural thrombus increased (p = 0.03). However, no significant risk factor was found in view of aneurysmal growth after EVAR. CONCLUSION: Volume of mural thrombus is an important risk factor for the elevation of inflammatory markers after EVAR.

Acute Type A Aortic Dissection with Iliac Malperfusion in a Patient with Scimitar Syndrome.

We encountered a 35-year-old male patient with scimitar syndrome, acute type A aortic dissection, and severe iliac malperfusion. He presented with pain and weakness of the left lower extremity and underwent ascending aorta replacement through sternotomy and right anterior thoracotomy. Left iliac artery flow was recovered after the operation and the patient was discharged on the tenth day without any complication. The purpose of this report is to discuss the considerations in aortic surgery in patients with scimitar syndrome, and the surgical principles for treatment of aortic dissection with critical limb ischemia.

Left atrial thrombus due to transseptal catheterization simulating solid mass of right atrium.

BACKGROUND: Transseptal catheterization has been popularized through ongoing advances in percutaneous procedures, but related complications are known to occur. CASE PRESENTATION: A 72 year-old female was admitted with left-sided weakness. In the course of various exams, a rounded and smooth-surfaced solid mass of right atrium was identified. However, a septal aneurysm associated with left atrial mural thrombus was evident intraoperatively. Given that percutaneous transseptal mitral valvotomy had been done 7 years previously, a causal relationship is likely. CONCLUSIONS: Prior cardiac intervention should be considered in patients presenting with mass lesions of interatrial septum.

Delayed Type III Endoleak Caused by Fabric Erosion after Endovascular Repair of an Abdominal Aortic Aneurysm.

A 74-year-old patient presented with recurrent aneurysms in the infrarenal abdominal aorta and right common iliac artery 6 years after endovascular aortic repair using endografts in the same location. The patient underwent an aorto-bi-iliac replacement with removal of the stent graft. Two holes measuring 2 mm each were found in the removed graft, and they appeared to have been caused by wear from continuous friction between the endograft and the aortic wall.

Clinical outcome analysis of 47 patients with advanced head and neck cancer with preoperative suspicion of carotid artery invasion.

BACKGROUND: The purpose of this study was to retrospectively analyze the feasibility of the surgical management of the carotid artery in advanced head and neck cancer with preoperative suspicion of carotid artery invasion. METHODS: A total of 47 patients were retrospectively analyzed. Twenty-one patients (44.7%) received surgery as initial treatment, and 26 patients (55.3%) had salvage surgical treatment for recurrences. Intraoperative dissection and preservation of the carotid artery was achieved in 39 patients (83%). Eight patients underwent carotid resection with/without reconstruction (17%). RESULTS: The cumulative 2-year and 5-year overall survival rates were 40.4% and 34%, and the disease-specific survival rates were 59.5% and 55.3%, respectively. The overall perioperative mortality rate was 6.4%. Carotid blowout developed in 6 patients. CONCLUSION: Surgical treatment of the carotid artery in selected patients can provide locoregional control and the possibility of prolonged disease-free survival with acceptable morbidity. © 2015 Wiley Periodicals, Inc. Head Neck 38: E287-E292, 2016.

Prognostic role of p53 and Ki-67 immunohistochemical expression in patients with surgically resected lung adenocarcinoma: a retrospective study.

OBJECTIVE: p53 mutations and the Ki-67 protein are frequently observed in various types of human cancer; the abnormal expression of p53 and Ki-67 in the tumor is associated with poor survival of lung cancer patients. We aimed to assess the prognostic role of immunohistochemical (IHC) expression of p53 and Ki-67 in lung adenocarcinoma tissue. METHODS: Tumor samples from 136 patients who had undergone surgical resection for lung adenocarcinoma were retrospectively evaluated for p53 and Ki-67 expression by immunohistochemistry. Associations of clinical and pathologic variables with p53 and Ki-67 were determined using the χ(2) test. After excluding two patients (follow-up loss), 134 cases were evaluated for associations between p53, Ki-67, clinical and pathologic variables, and survival by using the Cox proportional hazards regression model and Kaplan-Meier method. RESULTS: In the 136 patients, p53 was positive in 71.0% (93/131), and Ki-67 showed high in 49.2% (61/124). Unlike p53, Ki-67 was associated with male sex, smoking, and poor tumor differentiation (P=0.004, P=0.001 and P=0.006). Of these, poor tumor differentiation strongly was correlated with high level of Ki-67 expression (P=0.008). Neither p53 nor Ki-67 was associated with increased risk of death (P=0.318, P=0.053); however, age ≥60 years and lymph node involvement were significant predictors of death (P=0.039 and P=0.042). The log-rank test revealed a significant association between Ki-67 and lower survival in all patients (χ(2)=5637; P=0.018); however, the risk was limited to stage III cases (χ(2)=5.939; P=0.015). Unlike p53, patients with high level of Ki-67 expression showed lower 3-year actuarial survival than those without (log-rank test, χ(2)=4.936; P=0.026). CONCLUSIONS: IHC expression of Ki-67 in lung adenocarcinoma tissue shows stronger association with poor tumor differentiation, and negatively affects patients' survival in advanced-stage lung cancer; however, the role of p53 on patient outcome needs further study.

Long-term results of surgical angioplasty for left main coronary artery stenosis: 18-year follow-up.

BACKGROUND: The aim of this study was to determine the long-term outcomes of surgical angioplasty for left main coronary artery (SA-LMCA) stenosis. METHODS: We retrospectively analyzed data from 24 consecutive patients (mean age, 55 years; male/female, 12/12) who underwent a surgical angioplasty for the left main coronary artery (LMCA) stenosis at our institution between 1995 and 2002. We used autologous pericardium in 7 patients and bovine pericardium in 17 patients as a patch. We evaluated the late mortality and major adverse cardiac events (MACE) rate. RESULTS: There was no operative mortality. Control coronary angiography exhibited wide open and funnel-shaped LMCA in all patients. One patient was lost to follow-up. During the mean follow-up of 167 months, there were 3 sudden cardiac deaths, 4 non-cardiac related deaths, and 9 MACE with one death at reoperation. The Kaplan-Meier method identified freedom from cardiac death in 95.7, 87.0, and 82.4% of the patients, and freedom from MACE in 91.3, 69.6, and 57.7% of the patients at 5, 10, and 15 years, respectively. CONCLUSIONS: This study demonstrated that the long-term outcomes of SA-LMCA with a pericardial patch are acceptable compared to those of coronary artery bypass grafting, despite the controversy over the indications and the patch material used.

Primary mucosa-associated lymphoid tissue lymphoma of the esophagus, manifesting as a submucosal tumor.

We report a case of primary mucosa-associated lymphoid tissue (MALT) lymphoma in the esophagus that manifested as a large submucosal tumor (SMT). Primary esophageal lymphoma is very rare, occurring in less than 1% of all patients with gastrointestinal lymphoma. Only a few cases of MALT lymphoma in the esophagus have been reported in the English literature. A 53-year-old man was referred to Dongguk University Ilsan Hospital (Goyang, Korea) in July 2012 for further evaluation and treatment of an esophageal SMT. Endoscopy showed a cylindrically elongated submucosal mass with normal overlying mucosa in the mid esophagus, 25-30 cm from the incisor teeth. He underwent surgery to confirm the diagnosis. Pathologic findings showed diffuse small atypical lymphoid cells which were stained with Bcl-2, CD20, but not with CD3, CD5, CD23, Bcl-6, or cyclin D1. These cells showed a positive monoclonal band for immunoglobulin heavy chain gene rearrangement. Based on the pathological, immunohistochemical, and molecular biological features, the esophageal mass was diagnosed as extranodal marginal zone B-cell lymphoma of the MALT type.

Multidetector computed tomography findings of a papillary fibroelastoma of the aortic valve: a case report.

Papillary fibroelastoma is a rare benign cardiac tumor that represents 10% of all primary cardiac tumors. Diagnosis is accomplished incidentally by echocardiography that is usually performed for another purpose. Most papillary fibroelastomas are asymptomatic, but the lesions are recognized as a cause of embolisms. To the best of our knowledge, there has been no case report of computed tomography findings of a papillary fibroelastoma. We report a case of a papillary fibroelastoma in a 78-yr-old woman who had dyspnea and chest tightness. Echocardiography revealed a small lobulated mobile echogenic mass attached to the aortic valve, and CT demonstrated a lobulated soft tissue density mass with a thin stalk at the sinotubular junction of the aortic valve.

Primary pulmonary rhabdomyosarcoma in an adult with neurofibromatosis-1.

Rhabdomyosarcomas arising in various tissues associated with neurofibromatosis type 1 have been sporadically described in children and young adults. We report a unique case of primary pulmonary rhabdomyosarcoma in an adult with neurofibromatosis type 1. A right lower lobectomy was performed. The Intergroup Rhabdomyosarcoma Study IV postsurgical grouping classification was 1A. The patient is scheduled for chemotherapy without adjuvant radiation therapy as per standard pediatric protocol.

Simultaneous rupture of the mitral and tricuspid valves with left ventricular rupture caused by blunt trauma.

To date, we believe that only 8 patients with simultaneous rupture of the mitral and tricuspid valves caused by blunt chest trauma have been reported. The correct diagnosis of this condition during the initial assessment is difficult and often delayed. Surgical experience with this condition has been quite limited. We present a unique case of atrioventricular valve rupture, combined with left ventricular rupture and a brief review of the relevant literature.