Aneurysmectomy and Revascularization of Anterior Tibial Artery Aneurysm: Case Report.

An 86-year-old man presented with a pulsatile mass in the anterior compartment of the right lower leg. He had become aware of it two months earlier. Computed tomography angiography revealed a fusiform 3.2×5 cm aneurysm of the anterior tibial artery. Mural thrombosis in the aneurysm was absent. Peripheral pulse was normal. We performed aneurysmectomy and revascularization using a saphenous vein graft. Histological findings revealed that the mass was a true aneurysm. The clinical course was good, and the graft has remained patent for six months.

Optimization of thromboelastography-guided platelet transfusion in cardiovascular surgery.

OBJECTIVES: Platelet dysfunction is a major cause of bleeding complications in patients undergoing cardiovascular surgery under cardiopulmonary bypass (CPB). Thromboelastography (TEG) can be used to assess post-CPB coagulopathy, but its utility in guiding platelet transfusion (PT) after CPB is unclear. This study assessed the utility of a TEG-guided PT protocol in patients undergoing cardiovascular surgery under CPB. METHODS: The platelet count and TEG maximum amplitude (MA) was measured in 100 patients undergoing valvular or thoracic aortic surgery under CPB. PTs were guided by an empiric protocol in 50 patients (group C) and by a TEG-guided protocol (MA <35 mm, platelet count <7 × 10(4)/mm(3)) in the other 50 patients (group T). RESULTS: PT was utilized significantly less in group T (11 patients; 22%) than in group C (24 patients; 48%) (P < 0.01). The difference in PT utilization was particularly marked in patients undergoing aortic arch aneurysm repair (20% in group T vs. 100% in group C; P < 0.01), yet there was no difference in bleeding complications between these two groups. CONCLUSIONS: Use of a TEG-guided transfusion protocol dramatically reduced PT after CPB, particularly in patients undergoing aortic arch aneurysm repair.

A papillary fibroelastoma of the aortic valve that presented with repeated chest pain.

A 70-year-old woman without any previous history of heart disease was referred to our hospital for repeated chest discomfort. She had experienced temporary hemiparesis because of a cerebral infarction of unknown etiology. Clinical evaluations were all within normal limits except for echocardiography. There was a mobile tumor in her ascending aorta, about 15 mm in diameter, adhering to a part of the right coronary cusp on its aortic side. Urgent surgery was performed. The tumor was attached to the edge of the right coronary cusp and excised with a part of the right coronary cusp, which was then repaired. Histological examination revealed the tumor to be a papillary fibroelastoma. The chest discomfort responsible for admission disappeared after the operation. In patients with events that may be embolic in nature and are not explained by other cardiovascular or neurological diseases, a cardiac source of emboli should be considered.

Successful surgical treatment of tricuspid valve endocarditis associated with vertebral osteomyelitis.

Right-sided endocarditis is relatively rare and can occasionally be complicated by vertebral osteomyelitis (VO). We describe successful treatment, including valve repair for tricuspid endocarditis associated with VO. A 77-year-old man presented with back pain and high fever. Magnetic resonance imaging demonstrated VO. Despite 2 months of intravenous antibiotics, the infectious signs persisted and both legs became edematous. Enterococcus faecalis was isolated from blood cultures, and echocardiography showed severe tricuspid regurgitation with large vegetations attached to the anterior leaflet (AL). A series of echocardiographic assessments revealed that the antibiotic therapy did not affect the tricuspid lesions. In surgery, the infection was extended to some chordae and over half of the AL was resected. The AL was repaired with autologous pericardium and artificial chordae. Antibiotic therapy was continued for 2 months after surgery, and the infections did not reoccur. Follow-up echocardiography showed mild regurgitation of the tricuspid valve. The patient remains free from endocarditis at 2 years after surgery.

[Efficacy of vacuum-assisted closure therapy for various non-healing wounds after cardiovascular and thoracic surgery].

Vacuum-assisted closure (VAC) therapy is an efficacious modality for treating chronic and difficult wounds. We present 3 cases that responded well to VAC therapy after cardiovascular and thoracic surgery: 1 methicillin-resistant Staphylococcus aureus (MRSA) wound infection after Stony's incision, 1 inguinal lymphorrhea, and 1 empyema after a traffic accident The duration of VAC therapy was 9, 18, and 90 days, respectively, and all 3 wounds healed completely. Familiar equipment and supplies available on the hospital ward were used, and patients were able to leave their beds. In this report, the efficacy of VAC therapy, the problems encountered, and the steps that could be taken to address them are discussed.

Video-assisted transaortic left ventricular thrombectomy and coronary artery bypass grafting.

A 59-year-old man with cardiac dysfunction was admitted to our hospital because of thrombus formation in the left ventricle 10 days following acute myocardial infarction. Echocardiography revealed evidence of two mobile thrombi, each measuring about 2 cm in diameter. Urgent coronary artery bypass grafting and video-assisted transaortic thrombectomy were performed without making a left ventricular incision to preserve his cardiac function. Endoscopy was useful for visualizing the anatomical structures in the left ventricular cavity.

Preoperative respiratory physiotherapy for a patient with severe respiratory dysfunction and annuloaortic ectasia.

A 23-year-old man with Marfan syndrome, who had undergone surgery for pectus excavatum and scoliosis and who had severe respiratory dysfunction, was referred for surgical repair of annuloaortic ectasia. The preoperative pulmonary function test revealed severe obstructive and restrictive respiratory dysfunction, with forced expiratory volume in one second of 650 ml and vital capacity of 1,220 ml. These parameters improved after 4 months respiratory physiotherapy. A modified Bentall's procedure was performed after respiratory physiotherapy. A tracheostomy made on the 7th postoperative day (POD) appeared to improve respiratory condition and he was weaned off mechanical ventilation on the 14th POD. The lower limits of pulmonary function for open heart surgery have not been established clearly; however, our case will help elucidate these limits of respiratory function for open heart surgery. Preoperative respiratory physiotherapy improved parameters of pulmonary function test and may decrease the morbidity of postoperative pulmonary complications in a patient with severe respiratory dysfunction.

Intraoperative transesophageal sonographic monitoring of tumor thrombus in the inferior vena cava during radical nephrectomy and thrombectomy for renal cell carcinoma.

We report the case of a 58-year-old woman with renal cell carcinoma in whom real-time transesophageal sonographic monitoring of the tumor thrombus in the inferior vena cava provided dynamic information, allowing us to determine the appropriate operative procedure to use. Observation of the thrombus throughout the operation showed that mobilization of the liver resulted in compression of the inferior vena cava against the spine, increasing the risk of migration of the tumor thrombus and reinforcing the need to maintain adequate positioning of the liver to prevent such compression. The surgery was completed successfully, and the patient's postoperative course was uneventful. We recommend the use of real-time transesophageal sonographic monitoring of the tumor thrombus during such surgical procedures.