Multifaceted surgical approach of combined thoracoretroperitoneal incision and midline abdominal incision for a secondary aortoenteric fistula.

BACKGROUND: We report a one-stage surgery to the case of secondary aortoenteric fistula (sAEF) after prosthetic reconstruction of abdominal aortic aneurysm, by multifaceted approach. CASE PRESENTATION: A 63-year-old male was admitted to our unit under diagnosed of sAEF after prosthetic reconstruction of abdominal aortic aneurysm, and a pseudoaneurysm of thoracoabdominal aorta due to infection. The patient underwent emergency operation. Firstly, we placed the patient in a modified right lateral decubitus position and performed thoracoabdominal aortic replacement with retroperitoneal approach by thoracoretroperitoneal incision which combined thoracotomy and pararectal incision, and secondly, we changed to a supine position and performed closure of the duodenal fistula and omental flap transposition by midline abdominal incision. The patient was doing well without complications. CONCLUSIONS: A one-stage, multifaceted surgical approach covering both prosthetic reconstruction of thoracoabdominal aorta and closure of sAEF with omentopexy is reasonable and useful strategy.

Total arch replacement with frozen elephant trunk technique for Kommerell's diverticulum with a right-sided aortic arch and aberrant left subclavian artery.

BACKGROUND: Kommerell's diverticulum with a right-sided aortic arch and aberrant left subclavian artery is uncommon. We perforemed a single-stage procedure with the frozen elephant trunk technique. CASE PRESENTATION: A 62-year-old man underwent aortic dissection a year ago, and computerized tomographic angiography performed at that time revealed a right aortic arch, Kommerell's diverticulum (42 mm), and an aberrant left subclavian artery. We performed one-stage repair through median sternotomy. The cervical branches were exposed during the operation, and a deep hypothermic circulatory arrest with antegrade cerebral perfusion was established. The aorta was transected distally to the origin of the left carotid artery. We inserted a stent graft into the aorta, followed by peripheral anastomosis using a premade 5-branch Dacron graft. The right subclavian artery and the aorta were reconstructed, and the remaining cervical branches were reconstructed after the cross-clamp had been released. CONCLUSIONS: Total arch replacement through median sternotomy was performed for the right aortic arch, Kommerell's diverticulum, and aberrant left subclavian artery. The frozen elephant trunk technique is allowed to perform a one-stage operation safely.

Priming and replenishment in cardiopulmonary bypass with hydroxyethyl starch 130/0.4 decreases fluid overbalance without renal dysfunction or bleeding in adult valve surgery.

The best priming and replenishment solution in cardiopulmonary bypass remains unknown, and the efficacy and drawbacks of artificial colloid are controversial. We retrospectively compared consecutive patients undergoing elective adult valve surgery in cases wherein cardiopulmonary bypass was primed and replenished with hydroxyethyl starch 130/0.4 (n = 12) or crystalloid solution (n = 11). The fluid overbalance during cardiopulmonary bypass was much lower in the hydroxyethyl starch 130/0.4 group (mean ± standard deviation, + 95 ± 1241 mL) than in the crystalloid solution group (+ 2921 ± 1984 mL) (P < 0.001). Renal function, intraoperative and postoperative bleeding, and blood products did not deteriorate with the use of hydroxyethyl starch 130/0.4. The postoperative intubation time was shorter in the hydroxyethyl starch 130/0.4 group (16.0 ± 2.6 h) than in the crystalloid solution group (18.7 ± 2.6 h) (P = 0.018). Although prospective randomized trials are needed to verify our findings, the impact of fluid balance differences requires serious consideration.

Efficacy of Glutaraldehyde-Treated Leaflets for Mitral Valve Repair to Treat Active Infective Endocarditis: A Case Report.

We report the use of glutaraldehyde (GA) in a case of valve repair for mitral valve prolapse associated with active infective endocarditis. GA scrubbed at the site of infection decontaminates and reinforces infected fragile tissue, avoids excessive debridement, and strengthens the edges of valve leaflets to facilitate suturing.

De-airing an open stent graft to potentially reduce spinal cord injury.

We have occasionally observed a bubble leaving the suture line of an open stent graft; hence, we hypothesized that de-airing an open stent graft could potentially reduce spinal cord injury. Postoperative computed tomography often showed residual air in thoracic aortic aneurysms, confirmed by the presence of a certain amount of air in an open stent graft in a dry lab. We filled CO2 in the sterilized package of an open stent graft and subsequently filled it with saline, which absorbed the CO2 and entered into the gap of the graft. The clinical benefit of de-airing an open stent graft to reduce the incidence of spinal cord injury needs to be evaluated.

Pitfalls for the "Sandwich technique" via a right ventricular incision to repair post-infarction ventricular septal defects.

BACKGROUND: We have reported "sandwich technique," via a right ventricular incision, to treat a post-infarction ventricular septal defect (VSD). This technique involves the placement of patches on both the left and right sides of the septum, pinching the VSD sealed with surgical adhesive between the two patches. In this study, we analyzed factors influencing 1-year mortality to determine the pitfalls in our procedure. METHODS: We evaluated 24 consecutive patients with post-infarction VSD who underwent the "sandwich technique" via a right ventricular incision. One-year survival and major residual leak were used as the criteria for the analysis of survival and technical success, respectively. In protocol 1, clinical variables were evaluated as predictors of one-year mortality. In protocol 2, surgical techniques were evaluated as predictors of major residual leak, which was found to be related to one-year mortality in protocol 1. RESULTS: In protocol 1, the one-year mortality was higher in patients with major residual leak (75 %, 3/4) than in those without (15 %, 3/20) (p = 0.035). In protocol 2, the patients with major residual leak had smaller patches than those without (41.9 ± 3.8 vs. 47.8 ± 4.8 mm, p = 0.031) and a smaller size difference between the patches and the VSD (22.5 ± 6.5 vs. 30.0 ± 5.7 mm, p = 0.028). CONCLUSION: For the "sandwich technique" via a right ventricular approach to treat post-infarction VSD, the choice of patch size according to VSD size is an important variable for reducing major residual leak.

Constrictive pericarditis caused by immunoglobulin G4-related disease.

An 81-year-old man with congestive heart failure was admitted to our hospital. Computed tomography of the chest revealed pericardial thickening without calcification. Ultrasonic echocardiography and cardiac magnetic resonance imaging demonstrated diastolic dysfunction. Cardiac catheterization showed bilateral elevation of ventricular end-diastolic pressure with a square root sign. The preoperative serum immunoglobulin G4 (IgG4) level was abnormally high. Pericardiectomy and pericardiotomy were considered to be indicated and were performed. Histopathologic examination revealed tissue infiltration by IgG4-positive plasma cells, and constrictive pericarditis caused by IgG4-related disease was diagnosed. Postoperatively, the patient received additional corticosteroid therapy. The latest cardiac magnetic resonance image showed further improvement in diastolic function.

Congenital aortopulmonary artery fistulas combined with bilateral coronary artery fistulas.

We describe an extremely rare case of "congenital aorto-pulmonary artery fistulas" combined with bilateral coronary artery fistulas associated with clinically significant left-to-right shunt. A multi-detector row computed tomographic scan revealed that tortuous anomalous vessels arising from the aortic arch, left anterior descending coronary artery, diagonal branch, and right coronary artery were connected to the main pulmonary trunk. After surgical intervention, the systemic-to-pulmonary flow ratio nearly normalized from 2.02 to 1.05. We describe the case and speculate as to the embryological pathogenesis of these unique fistulas.

[Chemotherapy with linezolid for chronic synthetic graft infection].

Infection of thoracic synthetic grafts is a serious problem, potentially leading to septicemia. Total removal of infected grafts might be too invasive for patients in poor general condition or who have long synthetic grafts. Effective and safe chemotherapy regimens are needed to control infection. A 75-year-old man with infected synthetic grafts of the ascending aorta, aortic arch, descending aorta, and thoracoabdominal aorta caused by methicillin-resistant Staphylococcus aureus was admitted to our hospital because of septicemia. He had previously received vancomycin for about 1 year at an outpatient clinic. The blood culture after admission was positive for vancomycin-intermediate Staphylococcus aureus. Linezolid was effective against septicemia, but caused side effects, such as blurred vision, severe diarrhea, and thrombocytopenia. Intermittent oral treatment with linezolid (1,200 mg/day) was then given for 7 days every 2 weeks. This treatment decreased the incidence of the side effects and had a beneficial effect on the infection.

Long-term outcomes using vascular grafts sealed with fragmented autologous adipose tissue for aortoiliac occlusive disease.

The aim of this study was to test the safety and efficacy of fragmented autologous adipose tissue (FAT) grafts for revascularization in aortoiliac occlusive disease. Twenty-seven patients with atherosclerotic aortoiliac occlusive disease underwent surgical treatment using FAT grafts. A piece of adipose connective tissue was obtained from the operative wound, cut into small pieces, and pressed into the wall of a fabric vascular prosthesis. Cumulative primary patency rates were 92% at 1 year, 92% at 3 years, and 86% at 6 years. Cumulative secondary patency rates were 96%, 96%, and 90% for the same intervals. In this clinical study, the FAT grafts demonstrated good long-term patency rates and no particular problems. This is the first clinical report of long-term outcomes using FAT grafts for aortofemoral or aortoiliac bypasses. FAT grafts are thus safe for revascularization in aortoiliac occlusive disease.

Surgical case of isolated pulmonary Takayasu's arteritis.

Involvement of the pulmonary arteries is common in systemic Takayasu's arteritis, but pulmonary arteritis alone is very rare. A 67-year-old woman had severe right pulmonary artery stenosis and left pulmonary arterial obstruction caused by Takayasu's arteritis. Surgical treatment was successfully performed with extracorporeal circulation, without transection of the ascending aorta and the right pulmonary artery was enlarged with an autologous pericardial patch.

Using fascia lata to treat infective aortic false aneurysm.

In patients with infective aortic false aneurysms, repair using artificial materials is in danger of becoming an additional focus for infection. We used harvested autologous fascia lata as a vascular patch in such operations on 2 patients with infected mediastinal false aneurysm after coronary artery bypass surgery. These patients have not had any recurrences of mediastinitis and false aneurysm for 4 to 6 years after the operations.

Experience with expanded polytetrafluoroethylene (ePTFE Gore-Tex) surgical membrane for coronary artery grafting: does ePTFE surgical membrane predispose to postoperative mediastinitis?

The advantage of completely closing the pericardium after a coronary artery bypass grafting is the avoidance of injury of the heart and grafts during a re-operation. However, it would obviously be counterproductive to close the pericardium with a substitute that is predisposed to infection. This study was designed to evaluate the safety of ePTFE surgical membrane in comparison to native pericardium or autologous tissue. Between January 1992 to March 2003, 695 coronary artery bypass graftings were performed. The hearts and grafts were covered with ePTFE surgical membrane (474 cases: ePTFE group), or autologous pericardium and/or other autologous tissue (221 cases: non-ePTFE group). Often, a bilateral dissection of the internal thoracic artery was performed, which lengthened the surgery, the cardiopulmonary bypass, and the aortic clamp, in the ePTFE group. But there was no difference between the ePTFE group (2.1%) and the non-ePTFE group (3.2%) in the development of postoperative mediastinitis. There was also no difference between the two groups in the organism type of the infection. Methicillin resistant Staphylococcus aureus (MRSA) is the most common organism cultured from sternal wound infections; there were five cases in the ePTFE group, and four cases in the non-ePTFE group. In the ePTFE group, the hospital mortality due to postoperative mediastinitis was zero, and there was also no significant difference between the ePTFE group and the non-ePTFE group in time from the drainage operation to discharge; 74.3 days in the ePTFE group, and 81.0 days in the non-ePTFE group. The clinical use of ePTFE surgical membrane for a coronary artery bypass grafting does not appear to be a risk factor for mediastinitis.

Anastomotic pseudoaneurysm occurred at long time after surgery for atherosclerotic thoracic aortic aneurysm.

We encountered two cases of ruptured anastomotic pseudoaneurysms 47 and 77 months after surgery for atherosclerotic thoracic aortic aneurysms. Autopsy was performed in one case and emergency re-operation was performed in the other case. We gained some interesting findings in the autopsy and the re-operation. The anastomotic sites were sustained by sutures only, and there was no evidence of tissue supplementation at the anastomotic sites in macroscopic observation. Microscopic findings demonstrated endothelium healing on the internal side of the prosthesis near the anastomotic site. There was no tissue connection between the prostheses and the native aortic walls, although over four or six years had passed after the previous anastomoses. Anastomotic pseudoaneurysms may occur even in a long time after surgery. Careful operative procedures and long-term computed tomography or magnetic resonance imaging follow-up are crucial.

Flow dynamics in internal thoracic artery grafts 10 years after coronary artery bypass grafting.

BACKGROUND: Flow dynamics in internal thoracic artery grafts 10 years after surgery are not known. METHODS: Doppler examination was performed in native internal thoracic arteries as a control (n = 8) and in internal thoracic artery grafts to the left anterior descending coronary artery 6 months postoperatively (group A, n = 25), at 5 years (group B, n = 14), and at 10 years (group C, n = 11). RESULTS: Each graft group showed a diastolic to systolic peak velocity ratio of less than 1.0 at the proximal end, and more than 1.0 at the distal end, but the control group showed a ratio of less than 1.0 throughout the length of the artery. The diastolic peak velocity of the graft groups was significantly faster than that of the control group at the distal end (versus group A, p < 0.01; versus group B, p < 0.005; and versus group C, p < 0.05). The systolic peak velocity of the graft groups was significantly lower than that of the control at the proximal end (versus group A, p < 0.0001; versus group B, p < 0.005; and versus group C, p < 0.0005). There were no significant differences of flow velocities among the graft groups and graft diameter among the four groups. CONCLUSIONS: Although the internal thoracic artery is systolic predominant, when native artery is used as graft, it changes its hemodynamics to diastolic predominance, especially at the distal end. Even after 10 years, graft flow dynamics are unchanged. This hemodynamic character may be one of the factors related to the superior long-term patency.