Anterolateral thoracotomy with partial sternotomy: a feasible approach for treating the complex pathology of the aortic arch.

OBJECTIVES: Our goal was to review our surgical experiences in patients with complex pathologies of the aortic arch who have undergone anterolateral thoracotomy with a partial sternotomy (ALPS). METHODS: From October 2019 to November 2023, a total of 23 patients underwent one-stage repairs of complex pathologies of the aortic arch through the ALPS approach. The mean age was 61.9 ± 16.7 years old. The aortic pathologies were as follows: aorta-related infection in 11 (aorto-oesophageal fistula: 4, graft infection: 6, native aortic infection: 1); aortic dissection in 9 including shaggy aorta in 2, non-dissecting aneurysm in 1, and coarctation of the aorta (CoA) in 2. RESULTS: Eighteen patients underwent aortic replacement from either the sinotubular junction or the ascending aorta to the descending aorta; 1 patient underwent it from the aortic root to the descending aorta (redo Bentall procedure and extensive aortic arch replacement); 3 patients underwent it from the aortic arch between the left carotid artery and left subclavian artery to the descending aorta; and 1 patient underwent a descending aortic replacement. Ten patients underwent omentopexy, latissimus dorsi muscle flap installation or both procedures. The hospital mortality rate was 13.0% (3/23). The overall survival and freedom from aortic events were 73.3%±10.2% and 74.1%±10.2%, respectively, at the 3-year follow-up. There was an absence of aorta-related deaths, and no recurrent infections were identified. CONCLUSIONS: The short-term outcomes using the ALPS approach for the treatment of complex pathologies of the aortic arch were acceptable. Further studies will be required to determine the long-term results.

[On-pump Beating Pulmonary Embolectomy for Acute Pulmonary Thromboembolism].

BACKGROUND: Acute massive pulmonary embolism is a life-threatening disease and the reported rate of mortality is 52%.It is often treated with anticoagulation therapy or thrombolysis, but in case of critically ill patients with shock or cardiac arrest, its effect is limited. Surgical embolectomy is a treatment option for patients with hemodynamic instability. We studied the outcomes of our patients who underwent on-pump beating pulmonary embolectomy for acute pulmonary embolism. METHOD: We evaluated eight consecutive patients who underwent on-pump beating pulmonary embolectomy for acute pulmonary embolism since May 2012 to September 2016. Our surgical indications were hemodynamic instability, but one patient underwent pulmonary embolectomy without hemodynamic instability because the patient had floating thrombus in the right heart. Three patients experienced cardiac arrest, and two patients were treated with extracorporeal membrane oxygenation (ECMO). Four patients were treated with thrombolysis before surgical embolectomy. RESULT: All patients underwent on-pump beating pulmonary embolectomy. One patient could not be weaned from cardiopulmonary bypass, and was treated with ECMO after pulmonary embolectomy. The patient died due to low output syndrome, while the other seven patients were rescued. One patient had gastrointestinal bleeding after surgery, but the other patients had developed no major complication including thrombosis, hemorrhage, and prolonged respiratory failure during follow-up of 11.4±16.1 months. CONCLUSION: Pulmonary embolectomy is effective treatment for acute massive pulmonary embolism. On-pump beating pulmonary embolectomy is useful surgical procedure. Acute pulmonary embolism is often treated with anticoagulation therapy or thrombolysis, but in critically ill patients, surgical pulmonary embolectomy should be considered.

Aortic Mural Thrombus Associated with Congenital Protein C Deficiency in an Elderly Patient.

Thrombophilia increases the risk of venous thrombosis, but is rarely responsible for aortic thrombosis. Aortic mural thrombus (AMT) may be associated with a protein C deficiency. However, it is necessary to determine whether the protein C deficiency is congenital/hereditary or secondary/acquired (consumption of protein C during the process of thrombus formation). This study describes a 77-year-old Japanese woman with incidentally diagnosed AMT, who had a protein C deficiency (activity 54%, antigen 42%). Sequencing of the protein C gene revealed a heterozygous mutation of c.1268delG, p.Gly423Valfs＊82 in exon 9, indicating a congenital protein C deficiency. These findings indicate that very late onset AMT can occur in an adult with congenital protein C deficiency.