Malpositioned pedicle screw in spine deformity surgery endangering the aorta: report of two cases, review of literature, and proposed management algorithm.

STUDY DESIGN: Case reports and review of the literature with a proposed management algorithm. OBJECTIVES: To report two cases of a potential vascular complication due to an incorrectly placed pedicle screw (PS) during spine deformity surgery. Relevant literature regarding the management of vascular complications is reviewed, and an evidence-based management algorithm is proposed. Aortic lesions represent a rare but potentially life-threatening complications with spine deformity and revision surgery, significantly increasing the risk. A management algorithm for an aortic lesion in the case of a malpositioned PS has not yet been published. METHODS: Case 1: An 18-year-old female with proximal thoracic spinal non-instrumented fusion underwent a revision corrective procedure due to a progressive right-sided thoracolumbar compensatory curve. However, postoperative computed tomography (CT) performed to evaluate the position of the PS revealed malposition of the left T9 PS, which was abutting the descending aorta with CT angiography excluding the perforation of the aorta. Case 2: A 17-year-old male was scheduled for correction of Lenke 3-C-N adolescent idiopathic scoliosis. Postoperative routine evaluation with low-dose CT revealed a left T9 PS paravertebral malposition, and subsequent CTA demonstrated that the thread of the PS was in contact with the descending thoracic aorta and an unlikely hemodynamically significant vessel injury. RESULTS: Successful removal of both malpositioned PS was performed. In the first case, a cardiovascular surgeon attended the operation if an urgent thoracotomy was needed, and in the second case, additional video-assisted thoracoscopic control of the aorta was performed during PS removal. CONCLUSIONS: Preoperative imaging in spinal surgery is essential to avoid major vascular and other complications when placing PS, especially in thoracic deformities. When a potential major vessel complication emerges, an interdisciplinary approach and an appropriate management algorithm are mandatory to make the best clinical decisions. LEVEL OF EVIDENCE: 4.

Detection of peripheral arterial disease with an improved automated device: comparison of a new oscillometric device and the standard Doppler method.

In occidental countries, peripheral arterial disease (PAD) is an important health issue; however, most subjects are asymptomatic (~50%) and therefore undiagnosed and untreated. Current guidelines recommend screening for PAD in primary care setting using ankle brachial index (ABI) in all patients with cardiovascular risks. This is, however, not performed strictly because the standard Doppler method is cumbersome and time-consuming. Here, we evaluate the accuracy and reproducibility of ABI measurements obtained by an improved automated oscillometric device, the MESI ABPI MD(®) device, and the standard Doppler method. ABI was measured in random order in a general practice with Doppler probes by two operators separately (ABI_dop) and twice with the MESI ABPI MD device (ABI_mesi). ABI_dop was calculated dividing the highest systolic blood pressure from both tibial and dorsalis pedis arteries by the highest systolic blood pressure of both brachial arteries. ABI_mesi was obtained automatically with simultaneous measurements on three extremities. According to ABI_dop, PAD was present in 10% of the 136 screened subjects (68.2±7.4 years). Interoperator coefficient of variation was 5.5% for ABI_dop, while the intrasubject coefficient of variation for ABI_mesi was 3.0%. ABI_mesi was correlated with ABI_dop (R=0.61, P<0.0001). The difference between the two techniques was 0.06±0.14 with ABI_mesi providing slightly higher values (P<0.0001) and negligible bias across the range (R=0.19, P<0.0001). Therefore, ABI_mesi ≤1 had a sensitivity of 85% and specificity of 96% to detect ABI_dop ≤0.9 and hence PAD. Doppler measurements took seven times longer than MESI ABPI MD measurements to be performed. In conclusion, MESI improved automated oscillometric method and offered a faster and repeatable measurement of ABI with only a small, clinically irrelevant overestimation of ABI value. The tested MESI ABPI MD-improved oscillometric system can be used as a screening tool for patients in general practice and would enable family doctors to comply with current guidelines for PAD.

Percutaneous ventricular assist device support during off-pump surgical coronary revascularization.

Intraaortic balloon pump counterpulsation has been used for mechanical circulatory support in cardiogenic shock patients, but percutaneous left ventricular assist devices can provide superior circulatory support in the same group of patients. We describe the case of a patient in cardiogenic shock after a myocardial infarction. A percutaneous ventricular assist device was used to provide immediate active hemodynamic support, and, because the patient's condition necessitated surgical revascularization, percutaneous left ventricular assist device support was continued during off-pump coronary artery bypass.

Minimally invasive sternotomy for aortic valve replacement followed by a minilaparotomy for abdominal aneurysm repair.

Abdominal aortic aneurysms (AAAs) are commonly associated with severe coronary artery disease, but the incidence of associated aortic valve disease and AAAs in the general population is not known. The standard approach for surgical repair of AAAs is a laparotomy, and for aortic valve repair, a full sternotomy; results of both approaches are well documented. However, when AAAs and aortic valve disease occur concomitantly and both are symptomatic, they should be repaired during a combined procedure, with the aortic valve repair performed first. We describe the case of a 75-year-old patient with a symptomatic infrarenal AAA and severe aortic valve stenosis. To avoid an extensive surgical incision and shorten the recovery period, we performed a combined procedure in which we replaced the aortic valve through a ministernotomy and repaired the AAA through a minilaparotomy. The postoperative period was uneventful, and the patient was discharged home 6 days after surgery.

Sex difference in the effect of ACE-DD genotype on the risk of premature myocardial infarction.

In this association study the authors compared the insertion/deletion (I/D) angiotensin-I converting enzyme (ACE) gene polymorphism in females and males with premature myocardial infarction (MI). I/D ACE gene polymorphism was tested in 738 subjects: 302 patients with MI (151 men and 151 women) and 436 healthy subjects (207 men and 229 women). In women the ACE-DD genotype was not associated with MI (OR 1.1, 95% CI 0.6-2.1, p=0.6), whereas the ACE-DD genotype conferred a 2-fold independent risk for MI in men (95% CI=1.2-3.4; p=0.013) after adjustment for cardiovascular risk factors. The authors found evidence for the sex difference in the effect of the ACE-DD genotype on MI risk. The ACE-DD genotype conferred a 2-fold independent risk for premature MI in males.