Single-stage transmediastinal replacement of the ascending, arch, and descending thoracic aorta.

BACKGROUND: Aneurysms of the ascending, arch, and descending thoracic aorta are typically managed with two operations. The first stage involves replacement of the ascending and arch aorta leaving a segment of graft in the proximal descending aorta with a mortality and stroke risk of 8%. The second stage involves replacement of the descending aorta with a mortality of 5% and a paraplegia risk of 5% to 10%. Some patients refuse surgical completion and others are at increased risk to undergo the second stage thoracotomy, leaving them with untreated descending thoracic aortic aneurysms vulnerable to rupture. A single-stage transmediastinal operation used in 14 patients is described. METHODS: Under circulatory arrest, the descending thoracic aorta is opened. A wire is passed up to the arch and a graft is brought down and secured excluding the descending thoracic aneurysm. The arch vessels are attached as a single patch and the graft is brought forward, replacing the ascending aorta. RESULTS: Fourteen patients have undergone single-stage replacement of the ascending, arch, and descending aorta with a 14% mortality rate and 14% incidence of paraplegia. CONCLUSIONS: Patients with aneurysms of the ascending, arch, and descending thoracic aorta can be managed with a single operation with comparable mortality and morbidity of the two-stage approach.

Intraoperative diagnosis of aortic pseudoaneurysm with transesophageal echocardiography.

A pseudoaneurysm of the ascending aorta is a rare complication of aortic valve endocarditis that requires prompt diagnosis. Several imaging strategies can be used; however, transesophageal echocardiography (TEE) has been utilized more frequently due to its superior resolution in detection of aortic valve complications. This case presents a patient with prosthetic valve dysfunction in which intraoperative TEE was used to diagnose a previously undetected aortic pseudoaneurysm, thus leading to a change in surgical management.

Colon perforation after lung transplantation.

BACKGROUND: Colon perforation has been previously described after solid organ transplantation. Since the inception of the lung transplant program at the University of Colorado 60 isolated lung transplantations have been performed. Four of these patients have suffered spontaneous colonic perforation. METHODS: The case history of each lung transplant patient with a colon perforation and the literature were reviewed. RESULTS: An increased incidence of colon perforation in lung transplant patients was identified. Diverticulitis was found to be the predominant cause, and an association with steroids was noted. The two deaths in this series were in patients receiving high-dose steroids in whom invasive Aspergillus infections developed. CONCLUSIONS: Careful screening of the gastrointestinal tract before transplantation is advocated. A steroid-sparing immunosuppressive regimen is recommended. All lung transplant patients with abdominal complaints require an aggressive work-up, and surgeons should have a low threshold for laparotomy. Conservative surgical principles, including resection of the perforated segment of colon and proximal end-colostomy rather than primary anastomosis, are necessary for the optimal outcome.