Internal thoracic artery as main blood supply to the lower limbs. Case report.

A 70-year-old male patient was admitted with symptoms of unstable angina pectoris and claudication. He presented critical left main and right coronary artery disease and juxtarenal aortic occlusion at the same time. Internal thoracic artery increased in diameter with many collateral branch arteries distally. Coronary artery bypass graft operation was performed immediately. Saphenous veins were used for conduit. Internal thoracic artery was let intact to avoid any ischemic problem of the lower extremities. DSA performed postoperatively showed that the internal thoracic artery was the unique blood supply to the leg. In the absence of emergency of peripheral revascularization two staged surgical approach (CABG first and aortobifemoral bypass some months later) was considered. However, in patients with severe peripheral vascular disease or even in patients whom intraaortic balloon-pump indicated postoperatively, combined surgical approach is necessary. In all coronary artery disease patients with Leriche syndrome, ITA dependent lower extremity circulation should be thought preoperatively. Extra-anatomic peripheral bypass is a reasonable alternative choice in combined procedures with low morbidity, especially in elderly patients having coexisting disease.

Chylomediastinum following tracheal surgery.

Chylomediastinum is a rare but serious complication following thoracic procedures. A 70-year-old woman underwent tracheal resection through median sternotomy. Sternal dehiscence and chylous drainage appeared on the second postoperative week. Oral intake was stopped and total parenteral nutrition was started. Drainage stopped after two weeks. The region was ligated with a purse string suture during revision of sternotomy. A minimal lymph leakage was determined on control Tc-99 lymphoscintigraphy, which indicated injury of the thoracic duct. The patient has been problem-free for 9 months.

Management of a large pseudo-aneurysm secondary to balloon angioplasty for aortic coarctation.

Balloon dilation of native aortic coarctation has been employed safely and effectively in selected patients and with good results during follow-up. However, pseudo-aneurysm formation at the site of dilatation occurs in about 2%-8% of patients. Although the majority of these aneurysms remain stable, they occasionally may increase in size during follow-up, raising concerns in regard to potential rupture, massive bleeding, and death. We report a case of aneurysm formation after balloon dilation of native coarctation of the aorta, treated successfully with the interposition of a tube graft.

Implantation of the coronary arteries after reconstruction of the neoaorta by using pericardial or pulmonary hood techniques. A significant impact on the outcome of arterial switch operations.

AIM: Coronary artery anomaly and techniques used for their transfer are the major risk factors for the arterial switch operation. Although various methods have been described, torsion and stretching of the coronary arteries continue to trouble surgeons. Especially, in cases in which there is a size mismatch between the aorta and the pulmonary artery, the true coronary implantation points can change. METHODS: We studied the incidence of myocardial ischemia in 40 patients who underwent a Jatene procedure from January 1997 to August 2000 at Istanbul Medical Faculty of Istanbul University. In all cases; firstly, the neo-aortic anastomosis was performed. After filling the neo-aorta by removing the aortic cross-clamp, we aimed to identify the exact coronary implantation points. In 26 cases, direct re-implantation or trap-door techniques were the method of choice used for the implantation. In 14 cases, we used pericardial or pulmonary hood augmentation techniques. In 12 of these 14 cases, we used directly pericardial or pulmonary hood for the maintenance of the exact coronary geometry because of the unfavorable anatomy. In the remaining 2 patients, because of the determination of ischemic changes on the electrocardiogram during the rewarming phase, we should revise the coronary anastomosis by a pericardial hood. RESULTS: One patient with intramural course of the coronary arteries died from of myocardial ischemia. In the remaining 39 patients, we did not see postoperative morbidity and mortality because of the myocardial ischemia. CONCLUSION: The use of pericardial or pulmonary hood augmentation techniques is very helpful for the maintenance of the exact coronary geometry. Reconstruction of the neoaorta prior to coronary anastomosis allows a more accurate determination of the true coronary implantation points; especially, if there is an abnormal relationship and size mismatch between the great vessels. By this innovative technique, the more accurate geometry and angulation of the coronary arteries can be achieved.

A new technique for abdominal heart transplantation in rats.

Experimental studies in animals play a major role in the progress of medicine. Different surgical techniques have been described for heterotopic heart transplantation in rats. In this study we introduce a new technique for heart transplantation in the abdominal cavity of rats. Fifteen Sprague Dawley rats have been used as recipients and 15 others as donors. Following preparation of recipient abdominal aorta and left renal vein, the donor heart including proximal arcus aorta was harvested. Donor aorta was anastomosed to the recipient's aorta; donor pulmonary artery was anastomosed to the left renal vein of the recipient using continuous suture technique. Graft function was evaluated daily by palpation of the rat abdomen. The mean operating time was 38.46+/-2.66 min and the mean ischemia time was 23.93+/-2.11 min. One death was seen because of bleeding of the aorto-aortic anastomosis. In this study we evaluated advantages and disadvantages of our technique and compared it to other techniques. This modification provides a more anatomical position, reduces exploration time, has a low incidence of morbidity and mortality. We conclude that, this implantation technique is more suitable for heterotopic heart transplantation in rats.

Primary aortoduodenal fistula complicated by abdominal aortic aneurysm.

A 74-year-old male patient was operated in Vakif Gureba Hospital for aortoduodenal fistula developing from abdominal aortic aneurysm. The patient was diagnosed as abdominal aortic aneurysm after physical examination and computed tomography in another center. Appearing of melena and hematemesis gastroduodenoscopy and radionuclide scanning was performed as diagnosis. After 6 days gastrointestinal bleeding recurred in massive haemorrhage and the patient was operated with a diagnosis of aortoenteric fistula as emergency. A midline laparotomy was performed. There was a fistula between infrarenal abdominal aortic aneurysm (with diameter 8x10 cm) and the 3rd portion of the duodenum. The duodenum was resected segmental and the fistula was disconnected. Following aneurysmotomy a prosthetic graft was placed in the aortobiiliac position. The patient was discharged at the 42nd postoperative day. Primary aortoenteric fistula is a very rare consequence of untreated abdominal aortic aneurysm. The segments of intestine most frequently involved in aortoenteric fistula are the 3rd and 4th portions of the duodenum. Clinical presentation is recurrent episodes of gross gastrointestinal haemorrhage. These cases have high mortality and morbidity unless evaluated as quickly as possible and appropriate surgical intervention performed.