Combined cerebral and lower-limb revascularization.

Brachiocephalic atherosclerosis and aortoiliac occlusive disease are often encountered concomitantly, The authors report a technique of combined brachiocephalic and femoral revascularization in which a single transthoracic approach is used.

Gadolinium-based coronarography in a patient with renal failure: first clinical report.

This article reports the use of gadolinium to perform a coronarography in a patient with renal insufficiency, unstable angina, and peripheral vascular disease. The examination was well tolerated and the images obtained of good quality. Cathet Cardiovasc Intervent 2001;54:68-69.

Substernal goitre: a rare cause of pulmonary hypertension and heart failure.

Benign substernal goitres usually extend into the upper anterior mediastinum and are easily extractable through a cervical approach. Very infrequently these tumours extend into the thoracic cavity causing compression of mediastinal structures. The authors report a case of pulmonary hypertension and severe cardiac failure secondary to a long-standing substernal goitre, and support the surgical management of this disease.

Effects of cardioplegic solutions on the vasoreactivity of the internal mammary artery.

BACKGROUND: During free internal mammary artery grafting, cardioplegia administration can be performed through the internal mammary artery. The present study examined whether cardioplegic solutions produce arterial graft constriction and functional endothelial damage. METHODS: Forty internal mammary artery segments from 10 patients were incubated in Krebs solution (n=10), University of Wisconsin solution (n=10), Broussais Hospital solution (n=10), or blood cardioplegia (n=10). RESULTS: There was a significant difference in sensitivity to norepinephrine between segments in Krebs solution and those in University of Wisconsin solution or Broussais Hospital solution but not segments in blood cardioplegia. There was a significant difference in relaxation to acetylcholine between segments in Krebs solution and those in the three other cardioplegic solutions and between those in blood cardioplegia and segments in University of Wisconsin solution or Broussais Hospital solution. There was no significant difference in relaxation to sodium nitroprusside between segments in any of the solutions. CONCLUSIONS: These experiments suggest that storage in the different cardioplegic solutions studied does not preserve the initial vasoreactivity of the internal mammary artery. However, blood cardioplegia appears to be less deleterious in regard to endothelial and myogenic vascular function.

Mycotic aneurysm of the popliteal artery secondary to tuberculosis. A case report and review of the literature.

Mycotic aneurysms of the popliteal artery are rare; 33 cases have been reported in the literature. The treatment of choice is a large excision with extra-anatomic revascularization. In situ revascularization is sometimes possible. To the best of our knowledge, tuberculosis has never been reported as a causal factor of mycotic aneurysms of the popliteal artery. We report a case of a recurrent tuberculous false aneurysm of the popliteal artery. After 2 attempts at in situ revascularization, the femoral artery was ligated with no distal ischemia.

Renal artery pseudoaneurysm after blunt abdominal trauma.

Renal artery pseudoaneurysms are rare after blunt abdominal trauma; only 11 cases have been previously reported. Pseudoaneurysms are caused by decelerating injuries of the renal artery after major falls or automobile accidents. Patients may be asymptomatic for many years, and the pseudoaneurysm may expand and rupture before diagnosis or treatment. The patients in four untreated cases died. The diagnosis of renal artery pseudoaneurysm can be made by Doppler sonography, computerized tomography, renal perfusion imaging, or contrast angiography. Treatment requires either surgical or percutaneous intervention. Renal salvage was possible in five of the seven patients treated. We report two additional patients with successful outcomes after surgical intervention.

Concomitant cerebral, brachiocephalic trunk, and cardiac revascularization. An unusual case.

Extensive transthoracic brachiocephalic revascularization is rarely performed. Instances of this operation performed concomitantly with cardiac revascularization and carotid endarterectomy have been reported in fewer than 10 cases in the literature. We report the case of a patient requiring complex brachiocephalic revascularization associated with coronary bypass grafting and a left carotid endarterectomy.

Aberrant right subclavian artery aneurysm--a surgical review.

Aneurysms of an aberrant subclavian artery are rare. They are usually secondary to atherosclerosis. Dysphagia is the most common presenting symptom. The diagnosis of the lesions is easily established by CT scan or MRI. Biplane arteriography is necessary in order to clearly analyse the aortic arch and its branches. Surgical resection is usually indicated. We treated a patient who suffered from an aneurysm of an aberrant subclavian artery. The surgical technique is detailed as well as a review of all the surgical cases of the literature.

Successful surgical treatment of a coronary artery mycotic aneurysm.

Mycotic aneurysms of the coronary artery are rare. We report the case of a mycotic aneurysm of the left anterior descending artery. Surgical treatment consisted of simultaneous resection of the aneurysm and revascularization using a venous graft. Thirteen cases of mycotic aneurysms of the coronary arteries have been reported in the literature, and we review these cases.

Long-term effects of dynamic aortomyoplasty.

Aortomyoplasty consists of wrapping the latissimus dorsi muscle (LDM) around the ascending aorta and electrostimulating it during diastole. The ascending aorta will act as an ectopic neo-ventricle compressed during diastole, thus reproducing the effects of long-term diastolic counterpulsation. In 5 goats, the right LDM was transferred to the thoracic cavity after removal of the second rib. The ascending aorta was enlarged by a pericardial patch and wrapped with the LDM. Postoperative electrostimulation was delivered in a counterpulsating manner. Hemodynamic studies were performed at 12 and 24 months postoperatively. Percent increase in the subendocardial viability index (diastolic pressure-time index/systolic tension-time index) was calculated using unassisted and assisted cardiac cycles with the stimulator off versus the stimulator on at a 1:1 ratio in the basal state and after acute heart failure was induced by the administration of high doses of propranolol hydrochloride. Diastolic counterpulsation of the ascending aorta resulted in significant improvement in the subendocardial viability index long term, both in basal state conditions and after induced cardiac failure. During heart failure, aortomyoplasty increased the cardiac output and decreased systemic vascular resistance. Histopathologic studies up to 24 months showed preservation of the histologic structure of the aortic wall and no evidence of thromboembolism. Tight adhesions developed between the aortic wall (including the pericardial patch) and the LDM. The diameters of the enlarged aortas showed no significant differences compared with diameters immediately postoperatively. In conclusion, aortomyoplasty produces chronic diastolic augmentation with preservation of aortic structure. After induction of heart failure, aortomyoplasty offers efficient circulatory support.

Combined coronary and femoral revascularization using an ascending aorta to bifemoral bypass.

OBJECTIVE: Coronary artery and aortoiliac disease frequently coexist. In rare instances simultaneous procedures may be required. This study reports our experience with ascending aorta to bifemoral bypass. DESIGN: Prospective consecutive sample study. PATIENTS: Ten male patients who underwent concomitant aortoiliac and coronary revascularization with the ascending aorta as the source of inflow to the femoral arteries between 1989 and 1991. RESULTS: One hospital death was unrelated to the surgical technique. All survivors displayed an uneventful recovery and were free of symptoms. Follow-up was obtained in all nine cases, they all stayed asymptomatic in terms of coronary artery disease and peripheral vascular disease. Echo-doppler studies showed perfect patency of the aorto-femoral grafts in all cases. CONCLUSIONS: This study shows that the ascending aorta to bifemoral bypass constitutes an interesting alternative in selected cases mainly those with severe ischemia coronary and leg ischemia. It offers the following advantages: (1) it is easy to perform, (2) does not require an intraperitoneal procedure, (3) the graft's position behind the muscles of the abdominal wall is not compressible, (4) the ascending aorta is the source of inflow, and (5) it allows a shorter duration of hospital stay.

Spontaneous cholesterol embolization. A rarely reported entity.

Cholesterol embolization sometimes occurs after invasive procedures involving manipulation of the aorta or its major branches, and less commonly occurs after thrombolytic therapy for acute myocardial infarction. Rarer still is spontaneous cholesterol embolization, a case of which we now report. Our patient experienced peripheral embolization, the origin of which was traced to the infrarenal aortic segment and the common iliac vessels. Aortoiliac reconstruction was successful; we believe that surgical management of this condition should be performed in selected cases.

Vasoreactivity of the radial artery. Comparison with the internal mammary and gastroepiploic arteries with implications for coronary artery surgery.

BACKGROUND: Recently, satisfactory results were obtained in a series of patients in whom the radial artery was used as a conduit for coronary artery bypass. However, spasm of this conduit was observed in 4% of patients. The aim of this study was to analyze the vasoreactive properties of the radial artery and to compare them with those of the internal mammary and the gastroepiploic arteries. METHODS AND RESULTS: Human radial (56 from 15 patients), internal mammary (77 from 20 patients), and gastroepiploic (41 from 12 patients) artery ring segments were mounted on a strain gauge in oxygenated, normothermic Krebs' solution at optimal resting tension. With KCl (100 mM) serving as the control, the dose-response curves to norepinephrine, serotonin, and thromboxane A2 mimetic were obtained, permitting assessment of force of contraction and sensitivity. Functional endothelium was assessed with acetylcholine. Smooth muscle-dependent relaxation was assessed with sodium nitroprusside. The radial artery had stronger contractions to KCl than the other vessels. The radial and the gastroepiploic arteries with endothelium presented a higher contraction force than the internal mammary artery in response to norepinephrine and serotonin. The three vessels had equal sensitivities to norepinephrine and serotonin. The gastroepiploic artery had a lower sensitivity to thromboxane A2 mimetic than the two other vessels. CONCLUSIONS: This increased reactivity of the radial artery explains its propensity to spasm and emphasizes the need for antispastic drugs and platelet inhibitors when the radial artery is used for coronary artery bypass.

Left ventricular outflow tract obstruction after mitral valve repair. Results of the sliding leaflet technique.

BACKGROUND: Left ventricular outflow tract obstruction (LVOTO) occurs in 4% to 5% of patients after prosthetic ring mitral valve repair. Major anatomic factors incriminated in the genesis of LVOTO include degenerative mitral valve insufficiency with excess leaflet tissue, nondilated left ventricular cavity, and narrow mitro-aortic angle. We have previously reported a 14% incidence of LVOTO after prosthetic ring mitral valve repair in this high-risk group of patients. Serial echo Doppler studies demonstrated an overlapping and/or inversion of the left ventricular functional compartments generating systolic anterior motion of the posterior leaflet and paradoxical opening (eversion) of the anterior leaflet. In an attempt to eliminate LVOTO after mitral valve repair, a new surgical procedure was developed in 1988 by Carpentier: the sliding leaflet technique, which reduces the height of the posterior leaflet. The purpose of this study was to analyze the results of the new technique in terms of the occurrence of LVOTO: METHODS AND RESULTS: Eighty-two patients undergoing prosthetic ring mitral valve repair between 1988 and 1991 and identified as high risk for LVOTO were operated on using the sliding leaflet technique. There were 52 men and 30 women. Ages ranged from 28 to 75 years. The surgical techniques used included prosthetic ring annuloplasty (n = 82), leaflet resection (n = 82), chordal shortening or transposition (n = 36), and other (n = 19). Intraoperative and/or immediate postoperative echo Doppler studies were obtained in all cases. Two patients (2.4%) died, and 2 (2.4%) required reoperation. Nonsignificant LVOTO was identified in 2 cases (2.4%), in whom instantaneous maximal subaortic gradients were 20 and 18 mm Hg, respectively. CONCLUSIONS: This study was not done on a concomitant series of patients but on patients with the same type of pathology. It demonstrates that (1) the sliding leaflet technique eliminates significant LVOTO in the high-risk patients; (2) the sliding leaflet technique is associated with a low mortality; and (3) no reoperations for mitral insufficiency were required in this series.

Cardiac hemangiomas.

Cardiac hemangiomas are rare benign vascular tumors of the heart. To date, 23 cases have been reported. Symptoms are usually due to compression of cardiac structures or obstruction of outflow tracts. Echocardiography usually directs the diagnosis toward a cardiac mass. Enhanced-contrast computed tomographic scan or magnetic resonance imaging establishes the diagnosis of hypervascularized cardiac tumor. Coronary arteriography establishes the diagnosis by showing the characteristic tumor blush. Surgical resection is done using cardiopulmonary bypass. Long-term outcome is favorable.

Percutaneous embolization of an arteriovenous fistula of the internal mammary pedicle following sternal wire insertion.

A case of traumatic arteriovenous fistula and false aneurysm of the internal mammary artery was encountered following sternal wire insertion during cardiac surgery. The diagnosis was suspected by echo-doppler and confirmed by arteriography allowing percutaneous embolization using cyanoacrylate in the same setting.

[Mitral valvuloplasty during the acute phase of endocarditis]. / Plasties mitrales au cours de la phase aiguë de l'endocardite.

Thirty-five patients were operated in the acute phase of mitral valve endocarditis between 1986 and 1991. The surgical indications were hemodynamic (22), echocardiographic (9), embolic (2) and infectious (2). There were pre-existing valve lesions in 45% of cases. The causal organism was identified in 90% of cases: streptococcus (19), staphylococcus (9) and Gram negative bacilli (4). Preoperative antibiotic therapy was prescribed for an average of 18 days. The aortic valve was infected in 9 patients and tricuspid valve in 1 patient. The mitral lesions were: abscess (11), vegetations (11), perforations (16), and ruptured chordae tendinae (22). All patients underwent Carpentier's mitral valvuloplasty. The operative mortality was 5.7% (2 patients). Early reoperation was required in 1 case. Follow-up was possible in 96% of cases for an average of 23 months. No recurrences of endocarditis were observed. One patient was reoperated and 3 died. All the others were in Classes I and II of the NYHA. None had significant mitral regurgitation or stenosis. These results show that mitral valvuloplasty is possible in the acute phase of endocarditis in 90% of cases. The mortality and morbidity are low and long-term results are stable.

Spontaneous cholesterol embolization--a rare clinical entity.

Embolization of cholesterol crystals from atheromatous plaques is a rare entity most often seen after invasive procedures involving manipulation of the aorta. Spontaneous CE has been reported in very rare cases. Peripheral signs include livedo reticularis, muscle pain and palpable pulses. Depending on the site of the responsible plaque, emboli may involve visceral organs and produce a systemic illness. Diagnosis is confirmed using skin, muscle and/or renal biopsies. Surgery is recommended when the atheromatous disease is localized to a unique segment which can be replaced.