Cor triatriatum with Raghib complex in partial atrioventricular septal defect and common atrium: a rare combination.

Persistent left superior vena cava draining into the left atrium in the absence of coronary sinus and atrial septal defect (Raghib complex) is an uncommon anomaly of systemic venous drainage. We present a unique case of simultaneous presentation of cor triatriatum and persistent left superior vena cava draining into the left atrium in an adult female with partial AV canal and common atrium. Complex intra-atrial baffling including a procedure to redirect flow from a proximal atrial chamber was successful.

Aortic Isthmus Narrowing after Endovascular Repair of Acute Traumatic Aortic Transection.

PURPOSE: The traumatic transection is located in the normal sized aortic isthmus where the angle is curved. We found a reversal of upper and lower blood pressure differences among patients who underwent thoracic endovascular aortic repair (TEVAR) for transection of the thoracic aorta. We investigated the isthmus stenosis in patients who underwent TEVAR for aortic injury using computed tomography. MATERIALS AND METHODS: Sixteen patients who underwent TEVAR for transection were divided in two groups: the aortic narrowing (AN) group and the non-aortic narrowing (NAN) group. AN was defined as stent graft folding more than 5 mm at the isthmus confirmed by computed tomography. The length of aorta at isthmus, pseudoaneurysm, and angle of isthmus were measured. RESULTS: AN was noted in five patients (31.3%). The area index in the NAN group (2.16±0.35 cm2/m2) was larger than that in the AN group (1.74±0.77 cm2/m2). The size of the pseudoaneurysm in the NAN group (31.9±4.2 mm) was smaller than that in the AN group (37.4±7.5 mm). The distance from the subclavian artery in the NAN group (15.7±9.3 mm) was longer than that in the AN group (8.4±3.2 mm) but not statistically significant. The angle of the isthmus in the NAN group (131±6 degrees) was larger than that in the AN group (107±3 degrees), and this was the only statistically significant difference (P=0.002). CONCLUSION: AN by stent graft folding should be considered when performing TE-VAR in aortic injury with an acute angle of the isthmus less than 110 degrees.

Thoracic Endovascular Repair for Acute Traumatic Transection of the Descending Thoracic Aorta and Postendovascular Remodeling Change.

BACKGROUND: The recently developed thoracic endovascular repair (TEVAR) technique seems to offer a good alternative for treating acute traumatic transection of the thoracic aorta (TTA). We reviewed our experience of TEVAR in cases of acute traumatic transection and analyzed the subsequent remodeling changes. METHODS: The medical records of 17 patients who underwent TEVAR for TTA were reviewed. The trauma mechanisms, anatomical characteristics of the transected aortas, technical details of TEVAR, and postprocedural results were reviewed. RESULTS: The overall mean injury severity score was 53 ± 12. On three-dimensional computed tomography (CT), the mean distance of transection from the left subclavian artery was 14 ± 9 (0-31) mm. Fifteen patients presented an aortic pseudoaneurysm and two patients had impending rupture. TEVAR was performed emergently under general endotracheal induction. Technical success was achieved and complete pseudoaneurysm sealing was confirmed with aortography in all 17 patients. Two patients (12%) died of hypovolemic shock and hyperkalemia; however, no late death or stent-related complication occurred during the 45 ± 32 (6-102) months of follow-up. During a mean CT follow-up of 35 months, the mean aortic diameter increased by 2 (0-5) mm and pseudoaneurysm lesions completely disappeared in all patients. CONCLUSIONS: TEVAR resulted in good early survival in patients with TTA. No late or stent graft-related event was encountered up to a maximum of 9 years after surgery. We recommend that patients with grade III or higher TTA should undergo emergency surgery. Moreover, we consider that long-term follow-up and blood pressure management are essential when the proximal aortic diameter is found to increase slightly after TEVAR on follow-up CT.

Critical Illness Neuromyopathy Complicating Cardiac Surgery.

Critical illness neuromyopathy (CINM) is a sporadically reported disease in the setting of an intensive care unit developing in the process of managing a critical illness. The disease primarily affects the motor and sensory axons and results in severe limb weakness rendering ventilator weaning extremely difficult. We report a case of CINM after cardiac valve surgery. Quadriplegia developed after the operation and resolved slowly over the following 2 months. The patient was discharged home free of neurologic symptoms.

Spontaneous Resolution of the Left Subclavian Artery Obstruction in Takayasu's Arteritis.

Spontaneous resolution of the arterial obstruction in Takayasu's arteritis is rarely reported. We reported a case of spontaneous resolution of an obstruction of the left subclavian artery in a young female. The patient underwent a bilateral coronary patch ostioplasty for both coronary ostial lesions complicated by Takayasu's arteritis at the age of 28. Concomitant left subclavian obstruction was seen at that time but left untreated. Surprisingly, the 10-year follow-up angiogram revealed complete resolution of the left subclavian artery obstruction. Meanwhile, no specific medical treatment was administered.

Thoracic Endovascular Stent Graft Repair of Middle Aortic Syndrome.

Middle aortic syndrome is a rare disease defined as a segmental narrowing of the distal descending thoracic or abdominal aorta. A thoracoabdominal bypass or endovascular treatment is the choice of treatment. Endovascular therapy consists of a balloon dilatation and stent implantation. Recently, thoracic endovascular aortic repair has been widely used in a variety of aortic diseases. We report a case of middle aortic syndrome treated with a thoracic endovascular stent graft.

Axillary Artery Cannulation in Acute Aortic Dissection: A Word of Caution.

Arterial cannulation into the right axillary artery is a commonly adopted perfusion strategy in the treatment of acute aortic dissection. Here we describe our experience of accidentally cannulating the axillary artery in a case of acute aortic dissection with an aberrant right subclavian artery, which was missed preoperatively because its proximal segment was malperfused by the dissection and thereby not enhanced. The rapid hemodynamics collapse at the start of the bypass was reversed by prompt switching to femoral perfusion. Postoperative follow-up computed tomographic angiography revealed a well-perfused right aberrant subclavian artery. Surgeons should be aware of an aortic arch anomaly whenever performing an axillary artery cannulation.

Metastatic Thymic Adenocarcinoma from Colorectal Cancer.

This report describes the case of a 57-year-old man with an anterior mediastinal tumor. Four years previously, he underwent laparoscopic anterior resection for sigmoid colon cancer. Thirty months after that procedure, bilateral pulmonary metastasectomy was performed. Twelve months later, follow-up computed tomography revealed a 1-cm pulmonary nodule on the upper lobe of the right lung and a solid mass on the anterior mediastinum, and the patient was also observed to have an elevated serum carcinoembryonic antigen (CEA) level. Repeated pulmonary nodule resection and total thymectomy were performed. Immunohistochemical staining of the anterior mediastinal tumor revealed adenocarcinoma, and his serum CEA level returned to normal after the operation. These findings strongly suggested metastatic thymic adenocarcinoma from a colorectal cancer.

Refractory vascular spasm associated with coronary bypass grafting.

Diffuse refractory vascular spasms associated with coronary bypass artery grafting (CABG) are rare but devastating. A 42-year-old male patient with a past history of stent insertion was referred for the surgical treatment of a recurrent left main coronary artery disease. A hemodynamic derangement developed during graft harvesting, necessitating a hurried initiation of cardiopulmonary bypass (CPB). Although CABG was carried out as planned, the patient could not be weaned from the bypass. An emergency coronary angiography demonstrated a diffuse spasm of both native coronary arteries and grafts. CPB was switched to the femorofemoral extracorporeal membrane oxygenator (ECMO). Although he managed to recover from heart failure, his discharge was delayed due to the ischemic injury of the lower limb secondary to cannulation for ECMO. We reviewed the case and literature, placing emphasis on the predisposing factors and appropriate management.

Massive rhabdomyolysis following cardiopulmonary bypass.

Here, we report a case of massive rhabdomyolysis following an uncomplicated repair of a ventricular septal defect in a five-month-old baby. Postoperatively, the patient was hemodynamically stable but metabolic acidosis continued, accompanied by fever and delayed mental recovery. The next day, he became comatose and never regained consciousness thereafter. The computed tomography of the brain revealed a diffuse brain injury. The patient followed a downhill course and eventually died on postoperative day 33. An unusually high level of creatine phosphokinase was noticed, peaking (21,880 IU/L) on postoperative day 2, suggesting severe rhabdomyolysis. The relevant literature was reviewed, and the possibility of malignant hyperthermia obscured by cardiopulmonary bypass and hypothermia was addressed.

Endovascular Treatment of Isolated Bilateral Common Iliac Artery Aneurysms Using Iliac Branched Stent Graft.

Endovascular treatment of isolated bilateral common iliac artery aneurysm (CIAA) requires salvage of at least one internal iliac artery to prevent complications such as ischemic buttock claudication. We treated a case of bilateral CIAAs using an internal iliac branched stent graft. We report a case of a 58-year-old man who presented with bilateral CIAAs. The left internal iliac artery was occluded with coil embolization. The right internal iliac artery was saved by using a branched stent graft. The aneurysms were excluded with conventional endovascular aneurysm repair. Completion angiography showed technical success. Follow up computed tomography angiogram at three months showed complete exclusion of bilateral CIAAs, no endoleaks, and patent right internal iliac artery. There was no pelvic ischemic complication. We treated successfully a case of isolated bilateral CIAAs using an iliac branched stent graft.

Quadrangular resection of the tricuspid valve.

Quadrangular resection is the gold standard technique for correction of the posterior leaflet prolapse in mitral valve disease. Prompted by the idea that the anterior leaflet of the tricuspid valve corresponds to the posterior leaflet of the mitral valve in its structure and function, we conducted a quadrangular resection of the anterior leaflet of the tricuspid valve in a case of tricuspid endocarditis. Tricuspid regurgitation was well corrected, and the durability of the repair was proven by the patient's freedom from cardiac events for the following 8 years.

Large cell neuroendocrine carcinoma of the thymus: a two-case report.

A large cell neuroendocrine carcinoma (LCNEC) of the thymus is a very rare malignant tumor that has a very poor prognosis. The detailed clinical features of LCNEC are still unknown, including the long term prognoses and the definitive modalities of the treatment for LCNEC of the thymus. We are reporting 2 cases of an enlarged LCNEC of the thymus, both of which were diagnosed and treated by surgical resection followed by postoperative adjuvant chemoradiation therapy. Although recurrences and metastases of the LCNEC were noticed 1 and 4 years postoperatively for each case, aggressive surgical resection and adjuvant chemoradiation therapy may be helpful for a patient's long term survival.

Pseudoaneurysm of the popliteal artery mimicking tumorous condition.

Diagnosing pseudoaneurysms of the popliteal artery is usually straightforward in physical examinations and imaging findings. However, when a pseudoaneurysm shows a soft tissue mass with adjacent osseous change, it can mimic a bone tumor or a soft tissue sarcoma. We present a case of a 65-year-old man who had a pseudoaneurysm of the popliteal artery showing soft tissue mass and insinuating into the intramedullary cavity of the tibia. This presented case emphasizes the importance of considering pseudoaneurysms in the differential diagnosis of an apparent soft tissue mass with pressure erosion in adjacent bone.

Thoracic EndoVascular Stent Graft Repair for Aortic Aneurysm.

BACKGROUND: The number of cases employing thoracic endovascular aortic repair (TEVAR) has been increasing due to lower morbidity and mortality compared to open repair technique. The aim of this study is to evaluate the outcome of TEVAR for thoracic aortic diseases. MATERIALS AND METHODS: Sixteen patients underwent TEVAR from October 2003 to April 2010. Mean age at operation was 59 years (20~78 years), and 11 were male. Indications for TEVAR were large aortic diameter (>5.5 cm) upon presentation in 6 patients, increasing aortic diameter during the follow-up period in 4, traumatic aortic rupture in 3, persistent chest pain in 2, and ruptured aortic aneurysm in one. The mean diameter, length and the number of the stents were 33 mm (26~40 mm), 12 cm (9.5~16.0 cm), and 1.25 (1~2), respectively. Aortography employing Multi-detector computerized tomography (MDCT) technique was performed at one week, and patients were followed up in the out-patient department at one month, 6 months, and one year postoperatively. RESULTS: Primary technical success showing complete exclusion of the aneurysm was achieved in 15 patients. One patient showed a small endo-leak (type 1). Four patients developed perioperative stroke: Three recovered without sequelae, and one showed mild right-side weakness. There was no operative mortality. Diameter of the thoracic aorta covered by stent graft changed within 10% range in 12 patients, decreased by more than 10% in 3, and increased by more than 10% in one during mean follow-up duration of 18 months (1~73 months). There was no recurrence-related death during this period. CONCLUSION: Intermediate-term outcome after TEVAR was encouraging. Indications for TEVAR could be extended for other thoracic aortic diseases.

Catheter-directed thrombolysis with conventional aspiration thrombectomy for lower extremity deep vein thrombosis.

PURPOSE: The purpose of this study is to evaluate treatment outcomes in patients with symptomatic deep vein thrombosis (DVT) who had undergone a catheter-directed thrombolysis with conventional aspiration thrombectomy for the treatment of lower extremity deep vein thrombosis. MATERIALS AND METHODS: The authors retrospectively reviewed the records of 74 patients (mean age 61 +/- 15) that underwent a catheter-directed thrombolysis with conventional aspiration thrombectomy. A retrieval inferior vena cava (IVC) filter was placed to protect against a pulmonary embolism in 60 patients (81%). Stenting and balloon angioplasty were performed in 37 patients (50%) under the left common iliac vein compression. RESULTS: Sixty-seven patients (91%) showed a clinical improvement within 48 hours, but seven patients (9%) showed no improvement. Multi detector computerized tomographic venography (MDCT venography) at discharge showed no thrombus in 15 patients (20%) and partial thrombus in 52 (70%). Twenty-eight patients (38%) developed post-thrombotic syndrome at 3.0 +/- 4.2 months postoperatively. Six patients (8%) were admitted due to DVT recurrence at a mean of 5.6 +/- 7.4 months postoperatively. Sixty-nine patients underwent follow up MDCT venography at 5.7 +/- 5.6 months. fifty (72%) of these showed no thrombus, 15 (22%) partial thrombus, and 4 (6%) showed obstruction. Twenty-eight of 61 (46%) were asymptomatic, twenty-eight (46%) had moderate improvement, and four (6%) were mildly improved by a telephone interview (81%) at 22.8 +/- 10.7 months postoperatively. CONCLUSION: Catheter-directed thrombolysis with conventional aspiration thrombectomy is an effective treatment for lower extremity deep vein thrombosis and produces satisfactory clinical results.

Patent ductus arteriosus closure in prematurities weighing less than 1 kg by subaxillary mini-thoracotomy.

The surgical closure of patent ductus arteriosus (PDA) is provided more frequently in extremely low birth weight babies who are usually deemed unsuitable for pharmacological closure. We have adopted subaxillary mini-thoracotomy in order to lessen surgical trauma in these babies; and its clinical results were analyzed. From April 2004 to August 2008, out of 50 babies at the neonatal intensive care unit who underwent the surgical closure of PDA, 22 premature babies weighing less than 1 kg at operation were included in the study. Eleven babies were males and mean gestational age was 27 weeks ranging from 23(+3) to 30(+2) weeks. Mean body weight at operation was 816 g ranging from 490 to 989 g and average age at operation was 17.9+/-11.9 days. Of them, 17 babies (72%) were ventilator dependent preoperatively, as compared with 13 out of 28 (46%) babies that weighed more than 1 kg (P<0.05). Four babies did not survive to discharge. Among 28 babies who were heavier than 1 kg, there were only one death. However, the mortality difference was not statistically significant (P=0.11). All mortalities were caused by inherent problems of prematurity and co-morbidities. Out of 17 babies who had been ventilator dependent preoperatively, 13 weaned off successfully at 17.0+/-23.9 days after the operation. The baby patients heavier than 1 kg weaned at 6.0+/-5.3 days (P=0.27). Surgical outcome of simple and less invasive subaxillary mini-thoracotomy was satisfactory; the surgery is highly recommended for ductal closure in extremely low weight premature babies.

Recurrent type B intramural hematoma progressed into type A acute aortic dissection in a young otherwise healthy woman: are there unknown background factors?

Intramural hematoma is reported with increasing frequency but the recurrence after complete resolution is rarely reported. We herewith describe a case of type B intramural hematoma in an otherwise healthy 39-year-old woman showing unusual clinical course in which acute aortic dissection developed three months after complete resolution of intramural hematoma. The case clearly reminded us of the potential of intramural hematoma for recurrence and progression to frank aortic dissection even after complete resolution.