Tuberculous aortitis in an human immunodeficiency virus-positive Ivorian migrant: A case report.

We report an unusual case of a 35-year-old Ivorian migrant with an abdominal mass and medical history relevant for human immunodeficiency virus-2 positivity with a CD4/CD8 ratio of 0.63; Mantoux and lymphocyte stimulation tests (QuantiFERON) were positive. 3D-CT images revealed a voluminous non-homogeneous retroperitoneal mass in the right abdominal region presenting no significant contrast impregnation. Thoraco-abdominal aorta presented diffuse-altered morphology with multiple ectasias throughout its course and an aneurysm at the level of the subrenal tract. The patient underwent vascular surgery. Mycobacterium tuberculosis complex was detected by polymerase chain reaction performed on intraoperative tissue specimens. Postoperative course was uneventful. After surgery, 3D-CT images showed no signs of malfunction of the prosthesis. At last, at 6-month follow-up, the patient was well. Cross-sectional imaging techniques, such as contrasted-CT, are essential and allow for making diagnosis, assessing disease activity, and evaluating post-treatment condition. 3D reconstruction permits an appropriate patient care by means of an excellent visualization and staging of the disease process.

Orbital metastases from breast cancer: A single institution case series.

BACKGROUND AND OBJECTIVES: Among orbital tumors, metastatic lesions have a prevalence of 1% to 13%; on the other hand, breast cancer is the most common malignancy causing orbital metastases. The aim of this study is to present our experience dealing with orbital metastases caused by breast cancer, to assess characteristics and clinic-pathological data of patients suffering from this rare occurrence and to find indexes related with their prognosis and survival. METHODS: Records of 28 patients diagnosed with orbital metastases from breast cancer at the Department of Ophthalmology, Humanitas Clinical and Research Centre of Milano over a 27-year period (1992-2018) were retrieved and analyzed. RESULTS: Mean patients' age at breast cancer diagnosis was 56.29 ± 14.63 years. Mean time interval between breast cancer diagnosis and orbital metastasis occurrence was 5 ± 4.17 years. All lesions were estrogen receptor-positive; 79% of patients harbored progesterone receptor-positive lesions. Interestingly, the majority of deceased patients presented orbital lesions with MIB-1 index >50% (P = .0265) and had concomitant lung metastases (P = .0452). CONCLUSIONS: The occurrence of orbital metastasis from breast cancer represents a challenging finding. Patients' clinical picture can include exophthalmos, edema, tumefaction, proptosis and/or diplopia. Significant symptomatic improvement can be achieved through surgery and other adjuvant treatments, such as radiation therapy and chemotherapy.

Open aortic arch surgery: how to reduce air embolism risk during antegrade cerebral perfusion.

Antegrade cerebral perfusion (ACP) is used widely, with the aim of obtaining cerebral protection during open aortic arch surgery. ACP is considered by many to be the reason for improvements in the clinical outcome of this type of surgery. However, perioperative cerebral complications may still occur. Cerebral complications during ACP are considered to be due mainly to embolic events rather than hypoperfusion. We believe that many of the embolic events during ACP may be due to air embolism rather than to vessel manipulation only. To reduce the risk of air embolism during ACP, we propose an easy technique, with the suggested steps to be followed in an exact sequence.

Aortic valve replacement by ministernotomy in redo patients with previous left internal mammary artery patent grafts.

OBJECTIVE: Aortic valve surgery with a patent left internal mammary artery (LIMA) on the left anterior descending (LAD) coronary artery is challenging in terms of myocardial protection and graft injury. Minimally invasive techniques may require minimal dissection of adhesions and may eventually decrease the risk of injuries. METHODS: Since 1997, more than 1000 ministernotomies have been performed by our surgical unit. Of these, 16 patients (14 males, 2 females, mean age: 68.7 years) had a patent LIMA graft on LAD. Fourteen underwent native aortic valve replacement, and in 2 a previously implanted prosthesis was replaced. A miniresternotomy was performed using either a "J" (15 patients) or a "reversed-T" method (1 patient). RESULTS: Cardiopulmonary bypass (CPB) was achieved by either femoral vein (12 patients) or right atrium (4 patients); arterial inflow was achieved either by ascending aorta (12 patients) or by femoral artery (4 patients). Mean CPB time was 119.7 ± 38.1 minutes (range: 50-235). Mean cooling body temperature was 27.4 °C. Antegrade cold crystalloid cardioplegia was delivered to all the patients. Mean aortic cross-clamp time was 72 ± 20 minutes (range: 45-125). No damage to LIMA occurred in any of the patients. No intra- or perioperative myocardial infarction (MI) occurred. Neither a conversion to full sternotomy nor a reoperation for bleeding was needed. Mean postoperative bleeding was 426 ± 474 ml (range: 120-1950). A blood transfusion was necessary in 7 patients. Mean postoperative ICU stay was 1.6 ± 1.1 days. Mean postoperative hospital stay was 7.5 ± 2.6 days. Postoperative course was totally uneventful in 10 patients (58.8%). Follow-up was complete for a total of 928 patient/months (range: 11-124), and there were four late deaths, two of which were related to cardiac problems. Nine of the 12 survivors are in NYHA CLASS I . II. Prosthesis-related morbidity did not occur either early or late during follow-up. CONCLUSIONS: This experience may represent the feasibility of an alternative surgical approach to a standard full-length median sternotomy in patients with previous coronary revascularization and with a patent LIMA on the LAD, requiring new surgery on the aortic valve.

Congenital musculoskeletal abnormalities associated with aortic, pulmonary and iliac aneurysms.

We present the case of a young patient with severe congenital musculoskeletal abnormalities. associated with different pathologies, with involvement of the arterial tree on both the systemic and pulmonary circulation, and involvement of the lungs due to thoracic hypoplasia. The presence of such extensive pathology raises the question of the suitability of such patients to undergo major corrective cardiac surgery procedures.

Reconstruction of anterior descending artery after removal of stents.

A 65-year-old man who had previously undergone multiple stenting on the coronary tree, was referred for urgent surgery. The left anterior descending coronary artery was found to be completely stented from the proximal to the distal portion. Open endarterectomy was required for removal of multiple thrombosed stents and reconstruction of the left anterior descending artery using left internal mammary artery. This highlights the need to spare the distal parts of coronary vessels for future surgery.

Treatment of malperfusion during surgery for type A aortic dissection.

During surgery for acute type A aortic dissection, malperfusion may occur during cardiopulmonary bypass. Retrograde perfusion trough femoral cannulation is considered a predisposing factor. However, this may occur even with antegrade perfusion, because of the presence of multiple flaps or compression of the true lumen by the false lumen. In this particular setting, the aim is to reach a perfusion of the true lumen of the dissected aorta. A technique of epicardial ultrasound-guided direct cannulation of the dissected aorta's true lumen by a Seldinger technique may help in those cases. We describe the technique with particular interest to the epicardial ultrasound control and the type of arterial cannula to be inserted by the Seldinger technique.

Aortic valve infective endocarditis: could multi-detector CT scan be proposed for routine screening of concomitant coronary artery disease before surgery?

Usefulness of the coronary artery study has been questioned in patients with infective valve endocarditis. Fatal events are reported in the literature due to embolization of endocarditic vegetations during cardiac catheterization. For this reason, many authors do not recommend preoperative invasive coronary studies in these patients. We report the case of a 56-year-old patient with prosthetic valve endocarditis with vegetations, and concomitant risk factors for coronary disease. We did preoperative coronary screening using multi-detector computed tomographic scan imaging, which may be useful for noninvasive imaging of the coronary arteries in these patients with high risk of embolization.