[Stanford Type A Acute Aortic Dissection with Acute Myocardial Infarction due to Compression of Left Main Coronary Artery:Report of a Case].

A 58-year-old man was admitted to our institution with sudden onset of hypotension and acute ischemia of left lower extremity. Electrocardiography showed ST segment elevation in leads V1~V6 and a transthoracic echocardiogram revealed antero-septal wall hypokinesis. He was given a diagnosis of acute myocardial infarction caused by left main coronary artery compression due to acute aortic dissection by enhanced computed tomography. We implanted a stent in the left main coronary artery and performed right external iliac-left femoral arterial bypass under general anesthesia. We performed a conventional total arch replacement and frozen elephant trunk and mitral valve repair at day 16. His postoperative course was good. Implantation of a left main trunk stent is an effective strategy for Stanford type A acute aortic dissection with left main coronary arterial occlusion before surgical repair.

[Infectious Thoracic Aortic Aneurysm and Purulent Pericarditis due to Staphylococcus aureus:Report of a Case].

The objective of this case report is to highlight a rare case of infectious thoracic aortic aneurysm and purulent pericarditis simultaneously in a 56-year-old woman. The patient complained of left anterior chest pain and contrast computed tomography (CT) revealed infectious thoracic aortic aneurysm and purulent pericarditis accompanied by massive pericardial effusion. She underwent a pericardial drainage immediately, and antibiotic treatment was initiated. Methicillin-sensitive Staphylococcus aureus was detected in blood and pericardial fluid cultures. On day eight of hospitalization, contrast CT scan showed enlargement of the aortic aneurysm. Therefore, total arch replacement was performed on day 10 using rifampicin-soaked graft. After surgery, antibiotic treatment was continued, till inflammatory markers became negative. She was discharged on day 66 without developing anastomotic pseudoaneurysms nor constrictive pericarditis.

A Case Series of Secondary Aortoenteric Fistula after Open Aortic Aneurysm Repair: Timing and Technique of Surgery.

Secondary aortoenteric fistula (sAEF) is a rare but serious complication after open aortic aneurysm repair (OAR). Although there is no consensus on the treatment strategy for sAEF, acute management of bleeding and infection control greatly affect the outcome. We report five cases of sAEF following OAR from 2016 to 2021. One patient died of sepsis following graft infection, whereas the others had relatively good outcomes. No recurrence of infection or fistula has been observed over an average follow-up period of 29.8 months. Timely management of bleeding and infection with surgical intervention resulted in favorable outcomes in our patients.

[Right branch pulmonary artery stenosis with supravalvar aortic stenosis as a complication of Lecompte maneuver for tetralogy of Fallot associated with absent pulmonary valve].

The patient was diagnosed with tetralogy of Fallot associated with absent pulmonary valve syndrome and a low birth weight of 1,912 g. He suffered from respiratory distress on day 14 and received non-invasive positive pressure ventilation. At 5 months of age and 4.1 kg, he underwent intracardiac repair including right ventricular outflow repair with a monocusp patch, patch closure of the ventricular septum defect and right pulmonary transposition to the anterior of the ascending aorta following the Lecompte maneuver for airway decompression. He was subsequently discharged to home and exhibited an uneventful clinical course with non-invasive positive pressure ventilation for 5 months postoperatively. However, right pulmonary artery and supra-aortic stenosis was noted 2 years after the operation. Computed tomography (CT) and angiography showed ascending aorta strangulation by the right pulmonary artery with right ventricular outflow regurgitation. Right pulmonary artery reconstruction using polytetrafluoroethylene graft interposition and repeat right ventricular outflow repair with bicuspid hand-sewn valves was therefore performed;the postoperative course was uneventful. Pre- and post-operative management using non-invasive positive pressure ventilation and airway decompression with pulmonary artery translocation is a useful strategy in patients exhibiting symptomatic tetralogy of Fallot associated with absent pulmonary valve syndrome in the neonatal period.

Splenic artery aneurysm of the hepatosplenomesenteric trunk.

We herein report the case of a splenic artery aneurysm with a hepatosplenomesenteric trunk that presented in a pregnant woman. Catheter embolization was not performed due to the wide neck of the aneurysm and its close location to the trunk indicates a high risk of mesenteric trunk thrombosis. We instead performed surgical resection of the aneurysm after successful delivery of the infant by Caesarian section. The splenic artery was reconstructed by side-to-end anastomosis with the common hepatic artery.

Complete rupture of the anterolateral papillary muscle complicated with acute myocardial infarction due to diagonal branch occlusion.

It is well known that post-infarction papillary muscle rupture of the anterolateral papillary muscle is less frequent than that of the posteromedial papillary muscle. This is thought to be due to a difference in blood supply (single vs dual) of the papillary muscles. Recently, we had two cases in which occlusion of the diagonal branch of the left anterior descending artery was found to be the culprit lesion of acute myocardial infarction leading to complete rupture of the anterolateral papillary muscle. Herein, we report on these two rare successful surgical cases with some review of the literature.

Two-staged treatment strategy in patients with severe carotid or cerebrovascular diseases undergoing coronary artery bypass grafting.

PURPOSE: There is no clear consensus on how to treat patients undergoing coronary artery bypass grafting (CABG) who have severe concomitant carotidcerebral artery stenosis. The aim of this study was to evaluate our surgical results in patients with severe carotid and/or cerebrovascular disease undergoing CABG. METHODS: Between October 2003 and April 2009, a total of 47 such patients were treated at our institution with the following strategies: (1) protective carotid artery stenting for severe carotid stenosis performed either before (n = 20) or after (n = 5) CABG or (2) a superficial temporal artery-middle cerebral artery anastomosis procedure followed by CABG if indicated (n = 4). Off-pump CABG was performed in 75% of the patients. RESULTS: There were no major perioperative strokes or in-hospital deaths; however, three patients had transient ischemic attacks and two had minor strokes during the early post-CABG period. All of the patients with postoperative cerebrovascular events had had unilateral carotid artery occlusion. There were no late deaths during the follow-up period (up to 6 years, with a mean of 27 months). However, major adverse cardiocerebrovascular events (MACCE) occurred in seven patients (14.9%). The rates of freedom from MACCE at 1 and 3 years were 92% and 74%, respectively. CONCLUSION: It appears that our two-staged approach is safe and may reduce the risk of postoperative cerebrovascular events.

Aortic regurgitation due to perforation of the right coronary cusp 10 years after implantation of a freestyle stentless bioprosthesis.

Valve deterioration following aortic valve replacement using the Freestyle stentless bioprosthesis is related to cusp tear, operative injury, or infection. We report a patient with aortic regurgitation due to perforation of the right coronary cusp 10 years after implantation of a Freestyle stentless bioprosthesis in the absence of endocarditis.

Treatment of prosthetic valve endocarditis complicated by destruction of the aortic annulus.

PURPOSE: It has been reported that surgical treatment for prosthetic valve endocarditis complicated by destruction of the aortic annulus is associated with high mortality and morbidity. The aim of this study was to evaluate the efficacy of our surgical strategy for this situation. METHODS: Between October 2003 and April 2009, eight patients (mean age 68.6 years) with prosthetic valve endocarditis complicated by destruction of the aortic annulus were surgically treated at our hospital. We use a relatively simple procedure consisting of a patch plasty of the abscess cavity in addition to complete removal of the infected tissue of the abscess cavity followed by standard aortic valve replacement. All patients had active endocarditis and were in New York Heart Association functional class III or IV. Preoperative echocardiography revealed that four patients had moderate or severe aortic regurgitation, and two had mitral valve endocarditis as well. RESULTS: There were no operative deaths (≤30 days). Cardiac complications included paroxysmal atrial fibrillation in three patients and transient atrioventricular block in one. One patient died of multiple organ failure 66 days after the surgery. The overall in-hospital mortality was 12.5%. Patients were followed-up for 6-49 months (mean 31 months). There was no recurrent prosthetic valve endocarditis. One patient required reoperation (mitral annuloplasty and redo aortic valve replacement). There were two late deaths: lung cancer in one and multiple organ failure related to pneumonia after the aforementioned redo operation in the other. CONCLUSION: Our simple procedure for complicated prosthetic valve endocarditis yielded excellent early and midterm outcomes.

Predictors of success of the modified maze procedure using radiofrequency device.

The modified maze procedure using radiofrequency devices has become an increasingly common surgical option for patients with atrial fibrillation. Several lesion sets have been proposed and tested, but it remains unclear which yields the best results. We studied 61 patients who underwent the modified maze procedure using radiofrequency devices from March 2005. The pulmonary veins were isolated separately on both sides, and a connecting lesion was made inferiorly in the early series of 30 patients (group 1). In 31 patients (group 2) treated from May 2007, we added a superior connecting lesion between both pulmonary veins (completing a box lesion), and also performed coronary sinus ablation from the epicardial side, using a monopolar device. At 6 months postoperatively, maintenance of sinus rhythm with and without antiarrhythmic medications was 70% and 63%, respectively in group 1, and 94% and 90% in group 2 (both p<0.05). Multivariate analysis indicated that the box lesion with coronary sinus ablation was an independent predictor of the maintenance of sinus rhythm at 6 months. These 2 lesions should not be eliminated from the modified maze procedure.

[Rupture of mycotic arch aneurysm due to Salmonella in an elderly patient].

An 80-year-old woman was admitted to the hospital for treatment of infected aortic arch aneurysm. Her C-reactive protein (CRP) was elevated to 24.2 mg/dl. We decided to operate after improvement of inflammatory reaction and physical status. However, sudden loss of consciousness occurred 9 days after admission. Chest X-ray revealed effusion and bleeding in the left pleural cavity. She was diagnosed with rupture of the aortic arch aneurysm and an emergency operation was performed. The aneurysm was treated by debridement of the infected aortic tissue, and total aortic arch replacement with a tube-graft was performed. Bacterial culture of the aneurysmal wall demonstrated Salmonella. Her postoperative course was uneventful. The patient remained well without any sign of wound infection.

Ex vivo gene delivery of ephrin-B2 induces development of functional collateral vessels in a rabbit model of hind limb ischemia.

OBJECTIVE: In this study, we delivered ephrin-B2 to the ischemic hind limb of rabbits using an ex vivo method of gene transfer and evaluated whether the in vivo application of ephrin-B2 contributed to the development of functional collateral vessels. Ephrin-B2 is a transmembrane ligand of several Eph receptors and bidirectional signaling between ephrin-B2 and Eph-B4 is considered to be essential in angiogenesis and the development of arteries and veins. METHOD: The left femoral artery of male Japanese White rabbits was excised to induce limb ischemia, and a primary culture of autofibroblasts was obtained from a skin section. Nineteen days later, the gene expressing ephrin-B2 (ephrin group) or beta-galactosidase gene (control group) was adenovirally transfected to the cultured auto-fibroblasts (5 x 10(6) cells); then 48 hours later, the gene-transduced cells were injected through the left internal iliac artery of the same rabbit. At 28 days after injection, the development of collateral vessels and their function were assessed (control group, n = 12; ephrin group, n = 10). RESULTS: The gene expressing ephrin-B2 was successfully transferred to the rabbit autofibroblasts, and ephrin-B2, expressed on the cell membrane, possessed binding ability with its receptor, Eph-B4. Calf blood pressure ratio (control group: 0.523 +/- 0.047 vs ephrin group: 0.658 +/- 0.049, P < .0001), angiographic score (0.344 +/- 0.091 vs 0.525 +/- 0.109, P = .0006), in vivo blood flow of the left internal iliac artery (rest: 11.963 +/- 2.806 vs 17.202 +/- 3.622 mL/min, P = .0014; maximum: 27.652 +/- 10.377 vs 43.400 +/- 7.108 mL/min, P = .0007), collateral conductance (32.740 +/- 7.408 vs 54.489 +/- 18.809 mL/min/100 mm Hg, P = .0097), and capillary density of the left thigh muscle (118.517 +/- 18.669 vs 167.400 +/- 31.271, P = .0002) showed significant improvement in the ephrin-B2 group compared with controls. CONCLUSION: These findings suggest that auto-fibroblasts expressing ephrin-B2 potentially promote arteriogenesis as well as angiogenesis in the adult vasculature, resulting in the development of functional collateral vessels to an ischemic lesion.

Recovery of cardiomegaly after treatment of traumatic popliteal arteriovenous fistula.

Circulatory distress can occur in the long term after the formation of a traumatic arteriovenous fistula (AVF), but cardiac failure rarely occurs in a patient with an AVF in the lower extremity. The present patient underwent surgery to treat a traumatic popliteal AVF 9 years after sustaining the injury. Although the patient was asymptomatic with regard to cardiac circulation, cardiomegaly was noted and it resolved promptly after the surgical treatment. Cardiac insufficiency should be borne in mind even when a patient is asymptomatic because young patients have a high tolerance for cardiac overload.

Coated prostheses are associated with prolonged inflammation in aortic surgery: a cost analysis.

This prospective study was conducted to compare inflammatory responses between patients receiving coated and uncoated vascular prostheses, and to examine their effect on length of stay and cost of patients undergoing abdominal aortic aneurysmectomy. Patients undergoing elective vascular reconstruction of an abdominal aortic aneurysm were assigned randomly to coated-graft or uncoated-graft groups (n = 20, for each group). Interleukin (IL)-6, granulocyte elastase, white blood cell count, C-reactive protein (CRP), and body temperature (BT) were prospectively recorded preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. In-hospital stay and hospitalized costs were also analyzed. IL-6 and CRP concentrations in the coated-graft group were higher than those in the uncoated-graft group (P = 0.01 and 0.05). BT was more frequently elevated >37 degrees C at POD 14 in the coated-graft group than in the uncoated-graft group (P =0.03). Discharge was delayed, and overall hospitalization cost was higher in the coated-graft group than in the uncoated group (17.6 vs. 13.5 days, and 2 010 000 vs. 1 780 000 yen, P = 0.006 and P = 0.002, respectively). Coated vascular prosthesis demonstrated more profound inflammatory reaction than noncoated prosthesis, postoperatively.

Treatment of abdominal malignancy invading the vena cava: a report of seven cases.

Retroperitoneal tumors and other abdominal malignancies invading the inferior vena cava can be treated surgically when no metastases are present. We resected four retroperitoneal tumors, two renal cell carcinomas, and one gastrointestinal stromal tumor with a concomitant caval resection. Although meticulous care is required when manipulating the major vessels, long-term survival with an improvement in the quality of life was achieved. These cases are described, with particular focus on the management of the major vessels.

Large saphenous vein graft aneurysm with a fistula to the right atrium.

We report on a case of a 65-year-old man who was admitted for anterior chest pain on effort. He had received coronary artery bypass grafting (CABG) surgery 20 years ago with saphenous vein grafts (SVGs) to the left anterior descending artery (LAD) and right coronary artery (RCA). An angiography demonstrated large aneurysmal dilatation of both grafts and a fistulous communication between the middle portion of the right SVG and the right atrium (RA). The aneurysm was excised surgically, and the fistula was closed with the right atrial wall with additional bypass grafts of the left internal thoracic artery (LITA) and gastroepiploic artery (GEA).