Treatment of Infected Aneurysms of the Abdominal Aorta and Iliac Artery with Endovascular Aneurysm Repair and Percutaneous Drainage.

Infected aneurysm remains one of the most challenging diseases for vascular surgeons. We describe the successful treatment of 2 cases of infected aneurysms with endovascular aneurysm repair and percutaneous computed tomography-guided drainage. This strategy may be an effective alternative to open surgical repair in selected patients.

Type A Aortic Dissection After Thoracic Endovascular Aortic Repair.

BACKGROUND: Type A aortic dissection (TAAD) is a rare complication associated with thoracic endovascular aortic repair (TEVAR). Although TAAD can result in catastrophic outcomes, the pathology of the condition has not been thoroughly clarified yet. METHODS: We retrospectively reviewed details from the medical records of 546 patients with diseases of the thoracic aorta (thoracic aortic aneurysm, n = 362; aortic dissection, n = 178; and fistula between the descending thoracic aorta and esophagus, n = 6) who underwent TEVAR in five hospitals from May 1997 through February 2015 to identify patients in whom TAAD developed during or after TEVAR. RESULTS: TEVAR-associated TAAD developed in 12 patients (2.2%). Pathologies originally treated with TEVAR were aortic dissection in 10 patients (83%) and true thoracic aortic aneurysm in 2 (17%). Type A aortic dissection developed during hospitalization in 4 patients (33%), within 1 year in 5 (42%), and more than 1 year later in 3 (25%). The entry tear was located in the ascending aorta or the aortic arch away from the edges of stent grafts in 8 patients (67%), whereas it was found just at the proximal edges of stent grafts in 4 patients (33%). Nine patients underwent ascending aortic replacement with or without concomitant aortic arch replacement, and 3 patients underwent medical management. Overall, 2 patients (17%) died during hospitalization. CONCLUSIONS: Type A aortic dissection can develop during TEVAR or even years after TEVAR. Careful operative procedures and follow-up should be mandatory for patients with aortic dissection as TAAD seems to occur more frequently among these patients.

Upside down use of Gore Excluder or Cook Zenith legs.

PURPOSE: Endovascular aneurysm repair is becoming increasingly popular. This technical note describes the usefulness of the upside-down technique of Gore Excluder or Cook Zenith legs. METHODS: Four patients with iliac or abdominal aortic aneurysms were treated. Three patients with isolated iliac artery aneurysms and one patient with an abdominal aortic aneurysm, in which the neck diameters were unfit for commercially available stent-grafts, were treated using an Excluder or a Zenith leg in an upside-down technique. RESULTS: The aneurysms were completely excluded and no endoleak occurred. There were no serious adverse events. CONCLUSIONS: The upside-down technique using an Excluder leg or a Zenith leg is both feasible and effective.

Improve morbidity and mortality in coronary artery bypass graft surgery for severe atherosclerosis.

OBJECTIVES: Atherosclerosis has been identified as a risk factor for both morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). To investigate outcomes following CABG for severe atherosclerosis, and to determine whether different surgical techniques can reduce the risk of neurologic events in these patients. METHODS: We studied 225 consecutive patients who underwent elective isolated CABG. Routine preoperative and intraoperative examinations identified patients with severe atherosclerosis. We compared the outcomes between patients with (group A; 42 ceses) and those without (group N; 183 cases) severe atherosclerosis. RESULTS: 36 patients (85.7%) in group A and 176 (96.2%) in group N underwent off-pump coronary artery bypass (OPCAB); 6 (14.3%) in group A and 7 (3.8%) in group N underwent on-pump beating CABG. Three patients in group A suffered deep sternal infection (7.1%), and one suffered stroke (2.4%) compared with none in group N. No cerebral infarction or neurologic events occurred in patients who underwent OPCAB (n = 212, 94.2%). CONCLUSIONS: Prevalence of complications was significantly greater among patients with severe atherosclerotic disease who underwent OPCAB than in those without atherosclerotic disease. Careful selection of surgical strategies can prevent perioperative stroke and reduce mortality.

Aortic valve destruction and pseudoaneurysm of the sinus of Valsalva associated with infective endocarditis.

We report the successful surgical treatment of a case of aortic valve destruction and pseudoaneurysm of the sinus of Valsalva associated with infective endocarditis (IE) in an 80-year-old woman. Multidetector-row computed tomography revealed an abnormal cavity in the left posterior aortic root. We had made the diagnosis of the aortic valve destruction and saccular pseudoaneurysm of the sinus of Valsalva associated with IE. Aortic valve replacement and patch plasty of the left sinus of Valsalva was performed successfully. A histopathologic examination of the resected aortic valve leaflet revealed inflammatory changes consistent with IE. We describe the surgical technique used in this rare case of pseudoaneurysm of the sinus of Valsalva resulting from IE.

A ball-shaped thrombus of the tricuspid valve after VSD closure.

We report successful surgical management of a 26-year-old man with a ball-shaped thrombus of the tricuspid valve. He had been treated with prednisolone for IgA nephropathy and undergone surgical closure of an isolated ventricular septal defect (VSD). No symptoms, coagulative disorders, or pulmonary embolisms were found. Preoperative echocardiography showed a ball-shaped mass that had originated from the anterior leaflet of the tricuspid valve; it also revealed a small residual VSD. A histological examination revealed the mass to be an organized thrombus with no tumor components. This was a rare case of excision of an organized thrombus of the tricuspid valve. The findings suggest that the thrombus formation may have been associated with the small shunt and/or prednisolone.

Surgical removal of a left ventricular thrombus associated with cardiac sarcoidosis.

We report successful surgical management of a 31-year-old man with a left ventricular thrombus following heart failure due to cardiac sarcoidosis. Preoperative echocardiography showed diffuse hypokinesis and a mobile ball-like thrombus in the left ventricle. Computed tomography revealed a left ventricular tumor and bilateral hilar lymphadenopathy, while MRI of the brain showed small infarctions in the occipital lobe. Postoperative pathologic examination of a specimen from the left ventricular free wall and a mediastinal lymph node revealed non-caseating granulomas consistent with cardiac sarcoidosis. The patient was referred to a cardiologist for further treatment with prednisolone. This is a rare case of surgical removal of a left ventricular ball-like thrombus in a patient with cardiac sarcoidosis.

Report of takotsubo cardiomyopathy occurring during cardiopulmonary bypass.

On weaning from cardiopulmonary bypass, a 59-year-old Japanese woman with mitral valve plasty suddenly showed a greatly increased heart rate, and an electrocardiogram revealed elevated ST-segments. There was also abnormal wall motion in the inferior region and apical ballooning of the left ventricle. We diagnosed the condition as takotsubo cardiomyopathy (acute left ventricle apical ballooning syndrome), possibly caused by catecholamine release and regional stress-induced ischemia. We believe this to be the first case report of takotsubo cardiomyopathy observed during heart surgery. We hypothesize that the condition was mediated by regional myocardial stunning and that it could be prevented by administration of angiotensin converting enzyme inhibitors before surgery and by the use of superior biocompatible cardiopulmonary bypass components. Once takotsubo cardiomyopathy occurs, we recommend mechanical circulatory assistance during weaning from the bypass.

New intraluminal coronary shunt tube for off-pump coronary artery bypass grafting.

PURPOSE: In cooperation with JMS Co., Ltd. (Hiroshima, Japan), we have developed a new intraluminal coronary shunt tube to allow easier, safer, and more accurate off-pump coronary artery bypass grafting (OPCABG). DESCRIPTION: Between September 2000 and July 2002, the new shunt tube was used in 100 consecutive patients undergoing OPCABG. Patient characteristics, experimental data, and clinical results for our new shunt tube are provided. EVALUATION: Our new coronary shunt tube was easily implanted in nearly all (97.2%) target vessels during reconstructions. All 100 cases were performed completely during off-pump operation. Early postoperative coronary angiography was performed in all 100 cases, demonstrating excellent patency in arterial grafts (99.5%) and venous grafts (96.2%). The shunt tube displayed good flow rates under experimental conditions according to diameter, and effectively prevented ischemia during coronary arterial reconstructions in all cases. No target vessels were injured on insertion or removal of shunt tubes. Neither perioperative complications nor hospital deaths were encountered. CONCLUSIONS: This new shunt tube improves the safety, accuracy, and ease of OPCABG surgery.

Usefulness of preoperative intraaortic balloon pump therapy during off-pump coronary artery bypass grafting in high-risk patients.

BACKGROUND: In off-pump coronary artery bypass grafting (OPCABG) surgery, the most critical complication is hemodynamic deterioration, which can occur during displacement of the heart to expose the target vessels. Preoperative intraaortic balloon pump (IABP) therapy improves cardiac performance and facilitates access to the target coronary artery while maintaining hemodynamic stability, especially in high-risk patients. METHODS: One hundred thirty-three consecutive patients who underwent OPCABG through sternotomy between April 2000 and July 2003 were studied. We compared the clinical results of 32 patients who underwent preoperative IABP placement (group 1) with those of 101 patients who did not have IABP placement (group 2). Of the 32 patients satisfying the insertion criteria, 15 had critical left main artery disease, 20 had unstable angina, 5 had acute myocardial infarction, and 5 had left ventricular dysfunction. RESULTS: There were no significant differences in the average number of distal anastomoses performed between group 1 and group 2 (3.1 +/- 0.8 versus 3.3 +/- 0.9, p = not significant). The complete revascularization rate was 95% in both group. There was no conversion to on-pump surgery in either group. There was no operative death in group 1 and only 1 death in group 2. In group 1, the number of patients who required prolonged ventilatory support (longer than 48 hours) was higher (3 versus 1, p = 0.036), and there was a higher incidence of low cardiac output syndrome (1 versus 0, p = 0.074). There were no IABP-related complications in group 1. CONCLUSIONS: Preoperative IABP therapy for high-risk coronary patients is very effective in preventing hemodynamic instability and providing surgical results comparable with those in moderate- to lower-risk patients.

Our experiences for off-pump coronary artery bypass grafting to the circumflex system.

BACKGROUND: Complete revascularization has been difficult in off-pump coronary artery bypass grafting (OPCAB). Hemodynamic deterioration often prevents access to the circumflex territory. This study presents instrumentation for accessing the circumflex territory, and our clinical experience. METHODS: From August 1999 through December 2002, 140 patients underwent OPCAB via sternotomy in our institution. The 114 requiring reconstruction of the circumflex artery are the subjects of this study. There were no exclusion criteria. A series of techniques and instruments were developed to provide access to the circumflex area while hemodynamic stability was preserved, including the left pericardial traction technique, compression of the right pericardium, a right sternal retractor, and a type of shunt tube. RESULTS: Patients received an average of 3.2 grafts (range, 2 to 6). Complete revascularization was achieved in 95% of the cases. Complications included respiratory insufficiency (0.8%), renal dysfunction (7%), and sternal wound infection (0.8%). Blood transfusions were required in 10 patients (8%). No patient suffered perioperative myocardial infarction or stroke. No operation was converted to cardiopulmonary bypass. There was no operative death. Predischarge angiography demonstrated a 99% patency rate. CONCLUSIONS: With our techniques and instruments, off-pump coronary revascularizaion of the circumflex area may be performed safely to achieve complete revascularization. Early clinical results are excellent, but long-term longitudinal follow-up is required to assess the future effectiveness of OPCAB procedure with our techniques.