Atypical and rare cause of myocardial infarction: coronary subclavian steal syndrome (CSSS) treated by a carotid-subclavian bypass in a 71-year-old female patient.

BACKGROUND: The coronary subclavian steal syndrome (CSSS) is a rare complication after coronary arterial bypass graft operations (CABG) using the left or right internal mammary artery ((L/R)IMA). It results from a retrograde blood flow from the IMA into the subclavian artery (SA) due to a stenosis or occlusion of the SA proximal to the IMA origin. This "steal phenomenon" leads to a decreased blood flow in the IMA and may result in myocardial ischemia (MIS) and even myocardial infarction (MIN). Treatment options include interventional and surgical therapy. CASE PRESENTATION: We report the case of a 71-year old woman, who suffered from an acute non-ST elevation myocardial infarction (NSTEMI) 11 years after LIMA-CABG surgery and who was treated successfully with a carotid-subclavian bypass (CSB) after failed interventional therapy. CONCLUSION: CSB may be regarded as a viable treatment option for patients suffering CSSS in the case of MIS and even an acute MIN/NSTEMI, especially in the case of missing or failed interventional therapy attempts. Specialists in cardiothoracic and vascular surgery should be aware of possible CSSS conditions and know about appropriate diagnostic and therapeutic options.

Intraoperative use of transit time flow measurement improves patency of newly created radiocephalic arteriovenous fistulas in patients requiring hemodialysis.

BACKGROUND: The autologous arteriovenous fistula is the primary choice to establish hemodialysis access without high failure rates. Intraoperative ultrasound flow measurements of newly created autologous arteriovenous fistulas represent a possibility of quality control and may therefore be a tool to assess their functionality. The aim of our study was to correlate intraoperative blood flow with access patency. METHODS: Between March 2012 and March 2015, intraoperative transit time flow measurements were collected on 89 patients. Measurements were performed 5-10 min after the creation of a standardized anastomosis using 3-6 mm flow probes. To examine the correlation between intraoperative blood flow and access patency, groups of patients with high (> 200 mL/min) versus low flow (< 200 mL/min) were enrolled. Patients were assessed clinically and with ultrasound every 3 months. Data were analyzed retrospectively. RESULTS: In the current short-term follow-up, including 89 patients (age 62 ± 3 years), 61 (68.5%) of the autologous arteriovenous fistulas were currently being used in an observation period ranging from 3 months to 3 years (mean observation period 546 ± 95 days) postoperatively. The intraoperative blood flow in patients with functioning autologous arteriovenous fistula (78) was significantly higher than that of patients without functioning autologous arteriovenous fistulas (407 ± 25 vs 252 ± 42 mL/min, respectively; p < 0.005) (11). CONCLUSION: The intraoperative measurement of blood flow is a useful tool to predict the outcome of maturation in autologous arteriovenous fistula. With this method, technical problems can be detected and corrected intraoperatively. Routine implementation of intraoperative flow measurements has to be examined by prospective controlled trials.

Successful Management of an Infected Aortic Stent Graft in a Liver Transplanted Patient.

We report on a 57-year-old female liver transplanted patient who underwent endovascular aneurysm repair because of an infrarenal abdominal aortic aneurysm. Two months later, she developed an infection, and positron emission tomography computed tomography detected a paraprosthetic abscess. Explantation of the endoprosthesis and aortic reconstruction with a Y-shaped silver graft was made. The patient was discharged on the 12th postoperative day and shows up regularly in our outpatients department in a good clinical condition. After meticulous research of the current literature, this is the first published case of the successful management of an infected endovascular aortic stent in a liver transplanted patient.

Vascular and nerval damage after intraoperative radiation therapy of the liver hilum in a large animal model.

It has been demonstrated that intraoperative radiotherapy is a therapeutic option for patients suffering from perihilar cholangiocarcinoma. Aim of our study was to investigate vascular and nerve damages after irradiation of the liver hilum in a pig model. Twenty-four pigs underwent central bile duct resection followed by biliodigestive anastomosis. Nine pigs underwent this surgical procedure alone (group 1). Ten pigs were treated with additional intraoperative radiation therapy (IORT) of 20Gy to the liver hilum (group 2). And five pigs received operation and IORT with 40Gy to the area of anastomosis (group 3). Six weeks after operation and treatment the animals were sacrificed and histopathological examination was performed. Histology showed no vascular or nerve damage in non-irradiated perihilar tissue. Significant changes of nerve structures occurred, as well as vascular damage in large and even more in small hilar arteries in the irradiated neighboring liver tissue. In detail for small hilar arteries: intima proliferation (p ≤ .0001), endothelial swelling (p ≤ .0001), fibrinoid arterial wall necrosis (p ≤ .0001), and arterial thrombosis (p = .0079) were detected. Venous vessels did not show significant dose dependant cell damage. Overall, 20Gy as a single dose application during operation showed similar damage to vessels and nerves compared to 40Gy. A radiation dosage of 20Gy seems to be sufficient to induce necrosis due to vascular and nerve damage in potential malignant liver tissue with acceptable damage to surrounding tissue. Perineural invaded tumor cells might be diminished due to IORT.