Endovascular Aortic Repair for Thoracic Aortic Compression Resulting From Chance Fracture of the Thoracic Spine.

Blunt aortic injury is a serious condition with a high mortality rate. Although rare, blunt aortic injury associated with spinal fracture has also been reported, and appropriate management of aortic disease is key to a good outcome. This report is a case of a 78-year-old man who was found to have a transverse fracture (Chance fracture) in the ninth thoracic vertebra, with a sharp bone fragment compressing the thoracic aorta. Early spinal surgery was needed; however, there was concern about the possibility of bleeding from the aorta and surrounding small arteries associated with the bone fragment during spinal surgery. Therefore, thoracic endovascular aortic repair was performed before spinal surgery. The next day after thoracic endovascular aortic repair, posterior spinal instrumentation was performed, and the postoperative course was uneventful. Because aortic injury associated with vertebral fracture can lead to massive bleeding and spinal cord injury, endovascular repair before spinal surgery is reasonable.

Pleural Approach to Aberrant Right Subclavian Artery in Aortic Surgery.

An aberrant right subclavian artery usually arises from the aortic arch just distal to the left subclavian artery and crosses behind the esophagus on its way to the right axillary artery. Several reconstructive techniques of this artery in aortic surgery have been reported but mostly resulted in troublesome procedures. Here, we describe an alternative strategy presenting the occlusion of the aberrant right subclavian artery through the right pleural approach followed via extraanatomical axillary artery bypass. This surgical approach might be a simple and safe option for the aberrant right subclavian artery.

Surgery for Bacterial Endocarditis Complicated by Diffuse Alveolar Hemorrhage.

Diffuse alveolar hemorrhage is a very rare but potentially lethal condition resulting from various disorders. We report the case of a patient who suffered diffuse alveolar hemorrhage subsequent to bacterial endocarditis and survived aortic valve replacement, which was applied after improvement in respiratory distress. We believe that the strategy of respiratory functional recovery by aggressive rehabilitation is essential for the achievement of a successful surgical outcome in patients with alveolar hemorrhage.

Adjunctive Ischemic Lower-Limb Perfusion during Aortic Repair with Cardiopulmonary Bypass Prevents Fatal Reperfusion Injury.

Acute aortic dissection can be complicated by malperfusion syndromes, including ischemia of the lower limbs. In some cases, delayed correction of leg ischemia leads to reperfusion injury, potentially resulting in renal failure. We describe the case of a 64-year-old woman who presented with acute aortic dissection manifesting itself as lower-limb ischemia. During and after aortic surgery with cardiopulmonary bypass, the patient developed myonephropathic metabolic syndrome. Hyperkalemia was corrected and acute kidney injury was prevented by infusing large volumes of intravenous fluids and administering human atrial natriuretic peptide. Peripheral bypass surgery was unnecessary. This case suggests that restoring blood flow to an ischemic leg by means of adjunctive perfusion during aortic repair with cardiopulmonary bypass is a viable way to overcome the biochemical instability associated with prolonged ischemia, especially hyperkalemia in the early phase of reperfusion.

Concealed Left Ventricle to Right Atrium Fistula Complicating Infective Endocarditis.

We report a case of aortic prosthetic valve endocarditis presenting with subaortic stenosis without perivalvular leakage and vegetations in the left ventricular outflow and right atrium, the latter being attached to the atrioventricular septum. Intraoperatively, an abscess that had formed on the aortic annulus and perforated to the right atrium was unexpectedly found, the fistula being occluded by vegetations. Even when no left-to-right shunts are detected by imaging, vegetations adjacent to the atrioventricular septum may conceal a left ventricle-right atrium fistula, resulting in prosthetic valve endocarditis presenting clinically as subaortic stenosis without perivalvular leakage.

Successful Treatment of Iatrogenic Subclavian Artery Pseudoaneurysm by Ultrasound-Guided Thrombin Injection.

Ultrasound-guided thrombin injection has been well described as a safe and effective treatment for pseudoaneurysms of the femoral artery. However, cases for subclavian artery pseudoaneurysm are rare. An 82-year-old man developed an iatrogenic right subclavian artery pseudoaneurysm. The pseudoaneurysm, which was partially thrombosed, was successfully treated by ultrasound-guided percutaneous thrombin injection. A trial injection with saline under color Doppler ultrasonography was helpful for confirming that the tip of the needle was in the sac with blood flow in the partially thrombosed pseudoaneurysm. Ultrasound-guided thrombin injection can be the first treatment of choice to treat subclavian artery pseudoaneurysm.

Successful resection of a huge metastatic liposarcoma in the pericardium resulting in improvement of diastolic heart failure: a case report.

Although liposarcoma often metastasizes to various organs, cardiac metastasis, including to the pericardium, is rare. We present a case of a third recurrence of pericardial metastasis from the thigh, which required surgical resection because of cardiac failure. Surgery was effective for improving cardiac function and reintroducing chemotherapy. This is the first reported case of metastatic pericardial liposarcoma, which was successfully resected three times. We believe that aggressive surgical treatment, when it can resolve cardiac impairment, potentially leads to a more favorable prognosis.

Early and Long-term Effects of the Autologous Peripheral Stem Cell Implantation for Critical Limb Ischemia.

OBJECTIVE: Therapeutic angiogenesis by peripheral blood mononuclear cells (PB-MNCs) implantation has been shown to be a safe and effective treating for critical limb ischemia (CLI). We herein report our investigation of the long-term efficacy of implantation of granulocyte-colony stimulating factor (G-CSF)-induced PB-MNCs to treat patients with CLI for which surgical bypass and/or percutaneous transluminal angioplasty are not possible. Methods and Methods : Eleven cases were enrolled in this study. Following an injection of G-CSF (250 ug/day) for 3 days, PB-MNCs (1.1 ± 0.5 × 10(10) including 1.5 ± 0.2 × 10(7) CD34-positive cells) were harvested by apheresis and then injected into 13 ischemic limbs. RESULTS: Resting pain either diminished or improved in 10 cases (91%) at 4 weeks, and ulcer formation was cured in 6 out of 10 limbs (60%) after treatment. The time required to enhance the arteries at the level of foot-joint by angiography which was performed in the abdominal aorta was shortened by 1 month (10 ± 4 seconds) and 6 months (12 ± 1) compared with the pretreatment time (15 ± 5). Three patients died after treatment, and the actuarial survival rate at 3 years was 73%. Freedom from major amputation at 3 years was 92%. CONCLUSION: The local injection of G-CSF-induced PB-MNCs showed striking early and long-term effects.

Sharp rib fragment threatening to lacerate the aorta in a patient with flail chest.

A 50-year-old man who was the victim of an accident during work was taken to the hospital. His chest radiograph and computed tomography (CT) scan showed pulmonary contusion, multiple rib fractures (left 5th to 1lth ribs), hemopneumothorax, and splenic rupture. On the fourth posttrauma day, CT showed bone particles of the ninth rib migrating to the thoracic aorta. These bone particles were threatening to penetrate the thoracic aorta. He underwent operation to repair the flail chest by approximating the left ribs and partial lung resection. After the operation the flail chest improved, enabling extubation the first day after the operation. He was mobile and was discharged on the 17th postoperative day. A literature review revealed cases of sudden death when such rib fragments lacerated the aorta. We therefore propose an early operation for patients who have multiple bone fractures in the left chest.

Cardiac tamponade due to spontaneous rupture of large coronary artery aneurysm.

A 70-year-old woman admitted with chest pain went into shock due to cardiac tamponade; 1000 mL of blood was drained from her pericardium. Enhanced computed tomography showed massive pericardial effusion and a coronary artery aneurysm in front of the main pulmonary artery. Coronary angiography revealed a coronary artery-pulmonary artery fistula and 3 giant saccular coronary artery aneurysms. Emergency surgical repair was successful.

Long-term effectiveness of total arch replacement for type A aortic dissection.

BACKGROUND: With recent improvements in cerebral protection during aortic arch repair, total aortic arch replacement has become an accepted surgical method for acute type A aortic dissection involving the aortic arch. Our surgical strategy is to perform total arch replacement with a branched graft using antegrade selective cerebral perfusion for the patients with type A aortic dissection involving the aortic arch. The objective of this study is to evaluate the effectiveness of this strategy on late outcome. METHODS: From October 1988 to April 2003, 46 patients underwent total arch replacement for acute type A dissection involving the aortic arch. Operations were performed with hypothermic cardiopulmonary bypass, antegrade selective cerebral perfusion during the arch repair, and open distal anastomosis. RESULTS: Hospital mortality was 6.5% (3 patients), and permanent neurologic dysfunction was observed in 1 patient. During the follow-up period (mean, 5.4 years; range, 13 months to 15.6 years), 2 patients died, but the causes were not related to the aorta or aortic valve. Survival rates at 5 and 10 years postoperatively were 89.6% +/- 5.2% and 82.7% +/- 8.2%, respectively. Of the 41 survivors, 3 patients underwent successful reoperation for the distal thoracic aorta. Freedom from reoperation was 93.6% +/- 4.6% and 88.7% +/- 6.5% at 5 and 10 years, respectively. The residual false lumen in the thoracic aorta was frequently thrombosed (76.2%). CONCLUSIONS: Total arch replacement for acute type A dissection may decrease the risk of late complications related to the false lumen and lead to excellent long-term survival.

Haemostatic profile of small children during and following cardiopulmonary bypass.

OBJECTIVE: We evaluated changes of the haemostatic system during pediatric cardiac surgery during and after cardiopulmonary bypass (CPB). METHOD: Twenty-five children under 15 kg of body weight undergoing open-heart surgery were divided into three groups; 9 patients (Group A), no bank blood was used throughout the surgery; 8 patients (Group B), packed red cells were used in the priming of CPB circuit; 8 patients (Group C) in cyanotic condition, for whom surgery was performed without bank blood. CPB caused a significant decrease of platelet counts in all three groups, the levels of which remained similar next morning. RESULTS: Platelet counts decreased more significantly in Group C (59+/-27 k/mm3) than in Group A (119+/-42 k/mm3) and B (104+/-27 k/mm3). Platelet function-platelet activating factor test (HemoSTATUS) did not significantly decrease throughout the perioperative period in Group A. HemoSTATUS value decreased during CPB and recovered after CPB in Group B and C. Prothrombin time international ratio (PT-INR) and activated partial thromboplastin time were significantly prolonged just after CPB and recovered until next morning in all three groups. PT-INR was more prolonged in Group C (2.92+/-0.62) than in Group A (2.08+/-0.27) and B (2.42+/-0.42). There was no significant difference in postoperative bleeding for the first 12 hours among the three groups. CONCLUSION: Although extreme hemodilution during CPB significantly impairs the coagulation and platelet system, these changes are usually transient and tolerable with minimal postoperative hemorrhage. However, a prolonged CPB and preoperative cyanotic condition may induce a critical decrease of platelet counts and increase postoperative bleeding.

Evidence-based infection control in thoracic surgery.

OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) continues to pose a major threat to the lung and cardiovascular surgery patients. We propose evidence-based infection control (EBIC) against MRSA. METHODS: We conducted a basic study comparing genotyping to cluster analysis using minimal inhibition concentration on 17 drugs for 21 MRSA strains. With or without EBIC using cluster analysis and global evidence, we compared the incidence of postoperative MRSA infection. Notably, we eliminated tweezers stands and emesis basins. RESULTS: Cluster analysis showed a typing sensitivity of 72%. The use of EBIC decreased MRSA cross-infection in the recovery room. A lung surgery series showed an MRSA incidence of 1/190 before and 0/200 after EBIC was introduced. For a cardiovascular surgery series, the MRSA incidence was 2/169 before and 0/84 after EBIC was introduced. Across wards, MRSA among Staphylococcus aureus in patient fell from 68% in 1999 to 57% in 2000. CONCLUSIONS: EBIC consisting of global guidelines and cluster analysis was useful in controlling MRSA in lung and cardiovascular surgery patients.