Revascularization for controlling hypertension and improving cardiorenal failure in Leriche syndrome.

Leriche syndrome usually occurs when atherosclerotic obstructions result in luminal narrowing of the abdominal aorta or iliac arteries and leads to thrombosis; it rarely causes heart or renal failure. We report the case of a 58-year-old Asian man with heart and renal failure as the dominant clinical manifestations of renovascular hypertension caused by Leriche syndrome. We performed an aorto-bifemoral bypass and unilateral renal artery stenting. Post-operative echocardiography showed improved cardiac function, with the left ventricular ejection fraction increasing from 30% before surgery to 54.2% after surgery. Moreover, his heart rate and blood pressure became stable, and his serum creatinine and brain natriuretic peptide levels decreased from 3.46 to 1.08 mg/dL and 685 to 4 pg/mL, respectively. Our case report shows that aorto-bifemoral bypass and unilateral renal artery stenting can effectively treat heart and renal failure resulting from renovascular hypertension caused by Leriche syndrome.

Combination of endoscopic internal thoracic artery harvest and proximal anastomoses on the descending aorta in minimally invasive coronary artery bypass grafting.

Minimally invasive coronary artery bypass grafting is less invasive. Proximal anastomoses at the ascending aorta, in contrast, are technically difficult to perform because of the limited field of view. A man in his 60s undergoing haemodialysis required minimally invasive coronary artery bypass grafting for left anterior descending artery and circumflex arterial restenosis. We successfully performed minimally invasive coronary artery bypass grafting with a proximal graft anastomosis of the descending aorta. A thoracotomy was performed to extend the lateral approach to the descending aorta. We performed a minithoracotomy using three-dimensional endoscopy for internal thoracic artery harvesting. Endoscopic internal thoracic artery harvesting minimises incision length. The combination of endoscopic and lateral thoracotomy incisions in minimally invasive coronary artery bypass grafting enabled small and lateral thoracotomy incisions.

A Partial Clamp During Off-Pump Coronary Artery Bypass Grafting Can be Safely Used When Utilizing the Calcium Score with Computed Tomography For Evaluating The Ascending Aorta.

BACKGROUND: No previous study has shown that the volume of calcium score is useful for evaluating the aorta when performing a partial clamp (PC). The purpose of this study was to examine the effect of different clamping strategies during off-pump coronary artery bypass grafting (OPCAB), in terms of the incidence of postoperative stroke using the calcium score of the ascending aorta. METHODS: We retrospectively reviewed 339 patients, who underwent isolated OPCAB between August 2013 and March 2021. There were two groups of patients, depending on the procedure. A PC was used for proximal anastomoses in 130 (38.3%) patients. A clampless proximal facilitating anastomotic device (CFD) was used in 107 (31.5%) patients. We prescribed preoperative CT for all patients, and the Agatston score was used. RESULTS: The calcium score significantly was higher in the CFD group than in the PC group (29.7 ± 66.5 vs. 1819.8 ± 2391.5, < 0.001). The number of distal anastomoses and operative time were not significantly different between the two groups. There was no mortality and three strokes occurred at the 30-day follow up. Two strokes occurred in the PC group (1.5%) and one in the CFD group (0.9%), which was not significantly different (P = 0.98). CONCLUSION: A PC does not increase postoperative stroke incidence compared with a CFD, when utilizing calcium score evaluation in OPCAB.

Stent graft in abdominal aortic aneurysm collapsed suddenly after thoracic endovascular aortic repair.

Stent graft collapse due to aortic dissection is an extremely rare event. Although endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) are increasingly being performed, various complications can occur. We report a case of collapse of a stent graft, which was used to repair an abdominal aortic aneurysm (AAA) after TEVAR for thoracic aortic aneurysm (TAA). A 72-year-old man with a 77 mm AAA and 60 mm TAA underwent EVAR and a TEVAR 2 months later, respectively. CT performed after the TEVAR showed thoracic aorta dissection with associated AAA stent graft collapse. The graft collapsed was due to superior mesenteric artery obstruction. An emergency TEVAR was performed, and the procedure improved the collapsed graft; however, the endoleak of the AAA stent graft persisted. The AAA expanded over several days, warranting an open repair. Our case provides an insight into the cautionary indications for endovascular therapy.

Endoscopic Internal Thoracic Artery Harvesting with Changes in Scope Position.

Although minimally invasive direct coronary artery bypass (MIDCAB) is a less invasive procedure, internal thoracic artery (ITA) harvesting is difficult. A 65-year-old woman was advised to undergo MIDCAB for recurrent in-stent restenosis. We harvested the ITA using three-dimensional endoscopy without robotics and determined the scope position using enhanced computed tomography. We changed the camera installation between the wound and the camera port, according to the harvesting site with a harmonic scalpel using the skeletonized technique. We harvested the ITA from the subclavian vein level superiorly to the xyphoid process level inferiorly.

Late-onset total anomalous pulmonary venous connection in a 70-year-old woman.

Total anomalous pulmonary venous connection (TAPVC) is a rare congenital cardiac anomaly. There are a few reports of untreated TAPVC diagnosed in patients older than 60 years. Herein, we report the successful surgical treatment of TAPVC in a 70-year-old woman. A 70-year-old woman with TAPVC presented with symptoms of acute heart failure. We closed an atrial septal defect and performed tricuspid annuloplasty and commissurotomy of the pulmonary valve. Postoperative CT showed no residual shunt, and the pulmonary veins drained into the left atrium. She had an uneventful postoperative course. This report describes the case of the oldest known patient who underwent surgical treatment for TAPVC. Surviving into adulthood with little or no symptoms is uncommon in patients with TAPVC, and cases of late-onset TAPVC, such as our case, are rare. Nevertheless, close vigilance is necessary to prevent misdiagnosis in patients with this clinical presentation.

Herniation of the transverse colon into the mediastinum after the use of an omental flap for mediastinitis.

We describe a rare complication, transverse colon herniation into the mediastinum, after the use of an omental flap. Adequate separation of the transverse colon from the omental flap and ensuring that the incision in the diaphragm is as small as possible are important preventive measures.

Bioprosthetic tricuspid valve stenosis: a case series.

BACKGROUND: Bioprosthetic tricuspid valve stenosis is a late sequela of tricuspid valve replacement (TVR); however, detailed information regarding its clinical picture is lacking. CASE SUMMARY: Thirty-one patients with bioprosthetic TVR (mean age: 60.5 ± 16.6 years, male/female: 11/20) were followed-up for 79.5 ± 49.1 months (14-188 months). Eleven patients developed bioprosthetic tricuspid valve stenosis (mean tricuspid gradient >5 mmHg) at a median interval of 96 months (interquartile range: 61-114 months). The mean tricuspid gradient at the time of tricuspid valve stenosis diagnosis was 10.9 ± 3.9 mmHg. Although the mid-term tricuspid valve stenosis-free survival was favourable (92.4% at 60 and 78.7% at 84 months), it had declined steeply to 31.5% by 120 months. Ten out of 11 tricuspid valve stenosis patients showed signs of right heart failure (RHF) as manifested by oedema and elevated jugular venous pressure, requiring moderate-to-high doses of diuretics. Diastolic rumble was audible in 10 patients. Five of the 11 tricuspid valve stenosis patients required redo TVR as a result of refractory RHF. Examination of the five excised bioprostheses showed pannus in four, fusion of the commissure in three, native valve attachment in two, and sclerosis in one. Detailed clinical pictures and pathology of the explanted valves in three cases that underwent surgery are presented in this case series. DISCUSSION: Bioprosthetic tricuspid valve stenosis is not uncommon after 8 years. Tricuspid valve replacement performed at the second surgery was associated with a higher incidence of bioprosthetic tricuspid valve stenosis.

Endovascular Therapy for Distal Superior Mesenteric Artery Mycotic Aneurysms due to Infective Endocarditis.

Purpose: To report 3 patients with infective endocarditis who underwent transcatheter arterial embolization for mycotic aneurysm of the distal superior mesenteric artery (SMA). Case Report: Three men (60, 64, and 65 years old) were diagnosed with infective endocarditis. Antibiotics were initiated immediately after admission and continued for several weeks to months. Distal SMA mycotic aneurysm was identified on computed tomography in the vicinity of the ileocolic artery at 33, 26, and 30 days after admission. In case 1, the ileal artery was occluded distal to the aneurysm, with collateral flow to the ileum. In case 2, the mycotic aneurysm was located below the ileocolic artery, which was stenosed distal to the lesion. In case 3, the aneurysm was located on a branch of the ileal artery. Transarterial embolization using microcoils was successfully performed in all patients. No complications associated with embolotherapy or relapse of infection were observed in these 3 patients at 60, 30, and 15 months, respectively. Conclusion: Transcatheter arterial embolization for distal SMA mycotic aneurysm could provide an alternative to open surgery. Anatomical assessment of collateral flow and preprocedure long-term antibiotic therapy could play important roles in preventing bowel ischemia and minimizing the risk of infection relapse.

Successful transcatheter arterial embolization of a ruptured right gastroepiploic artery aneurysm: A case report.

BACKGROUND: Gastroepiploic artery aneurysms (GEAAs) are extremely rare. Ruptured GEAAs are related to high mortality and often treated by open surgery. We describe a case of a ruptured right GEAA that was successfully treated by transcatheter arterial embolization (TAE). PRESENTATION OF CASE: An 80-year-old woman presented to the emergency department with sudden abdominal pain. We diagnosed her as having a ruptured right GEAA based on the contrast-enhanced computed tomography finding. We performed TAE for the GEAA after resuscitation. The patient had an uneventful recovery and was discharged 10 days after TAE. DISCUSSION: A ruptured GEAA causes high mortality; thus, immediate and adequate treatment is mandatory. Previously, many cases of successful surgical resections of ruptured GEAAs have been reported. In our case, we decided that the patient was not suitable for surgery because of her advanced age and bronchiectasis; therefore, we performed TAE and had a good outcome. CONCLUSION: In patients at high risk for surgery, TAE can be an effective treatment for a ruptured GEAA.

Primary aortoduodenal fistula: A case report and review of literature.

BACKGROUND: Primary aortoduodenal fistula (PADF) is an abnormal connection between the aorta and the duodenum and is a life-threatening condition. It is a very rare cause of gastrointestinal bleeding, which often leads to delay in its diagnosis. Prompt diagnosis and surgical treatment are crucial to improve the outcome of patients with PADF. PRESENTATION OF CASE: An 82-year-old man with a history of untreated abdominal aortic aneurysm (AAA) presented to the emergency department with hematemesis. Computed tomography (CT) revealed an AAA with air within the thrombus wall and disruption of the fat layer between the AAA and duodenum, indicating PADF. Emergent surgery, in situ aortic reconstruction using a Dacron graft, and omental coverage were performed. Although the patient needed another surgery for postoperative chylous ascites, he made good recovery and was discharged 86 days after initial surgery. DISCUSSION: In our case, the patient presented with hematemesis and a pulsatile abdominal mass on physical examination and had a history of untreated AAA, which helped in prompt diagnosis of PADF. CT findings suggesting PADF include disappearance of the fat plane between the aneurysm and duodenum, air in the retroperitoneum or within the aortic wall, and contrast enhancement within the duodenum. The recommended surgical approach for PADF consists of aortic reconstruction (in situ aortic reconstruction or extra-anatomical bypass) and duodenal repair. CONCLUSION: Our report affirms that CT and open surgery are effective diagnostic and treatment options, respectively, for PADFs.

Infective endocarditis associated with Bartonella henselae: A case series.

Organisms in the genus Bartonella are cause of blood culture-negative endocarditis. Bartonella infective endocarditis is being increasingly reported worldwide; however, reports from Japan are limited. Here, we report five cases of infective endocarditis associated with Bartonella henselae. All patients had a history of contact with cats or fleas; this information helped achieve an appropriate diagnosis.

Transcatheter aortic valve insertion in patients with hostile ascending aorta calcification.

OBJECTIVE: Calcification of the ascending aorta complicates aortic valve replacement. Transcatheter aortic valve replacement is an alternative procedure in this situation, but it requires manipulation through the hostile area in the ascending aorta. We reviewed our transcatheter aortic valve insertion experience to better understand the surgical mortality risk of valve insertion in patients with extensive calcification of the ascending aorta. METHODS: We retrospectively reviewed the records of 665 consecutive patients who received transcatheter aortic valve insertion from November 2008 through December 2015. We defined a hostile ascending aorta on the basis of preoperative computed tomography scan documenting significant aortic calcification that the surgeon believed precluded safe aortic cross-clamp application. There were 36 patients (5%) who met our definition of a hostile ascending aorta (hostile aorta group) and 629 (95%) who did not (control group). RESULTS: Surgical mortality occurred in 2 patients (6%) in the hostile aorta group and in 18 (3%) in the control group (P = .296). There were no strokes in the hostile aorta group, whereas there were 15 (2%) in the control group (P = 1.00). There was no difference in mortality at 3 years for patients in the hostile aorta (48.5% ± 9.0%) and control groups (35.9% ± 2.3%; P = .484). Alternative access was associated with an increased risk of mortality (hazard ratio, 1.41; 95% confidence interval, 1.09-1.82; P = .009). CONCLUSIONS: Transcatheter aortic valve insertion can be performed with low procedure-related morbidity and mortality in patients with hostile calcification of the ascending aorta. Our data support a transfemoral-first paradigm in this patient population.

Mitral valve replacement for Libman-Sacks endocarditis in a patient with antiphospholipid syndrome secondary to systemic lupus erythematosus.

Libman-Sacks endocarditis is a relatively rare sterile verrucous vegetative lesion observed in systemic lupus erythematosus (SLE)/antiphospholipid syndrome (APLS) patients. Most patients with this condition are asymptomatic. Here we report a case of a 46-year-old woman with APLS secondary to SLE complicated with frequent thromboembolic events due to a mitral valve mass. We performed minimally invasive mitral valve replacement with a mechanical prosthetic valve, and she was successfully discharged 14 days after surgery. Thus, Libman-Sacks endocarditis may be an indication for mitral valve replacement.