Surgical techniques using an attached patch for large left ventricular pseudoaneurysm after inferior acute myocardial infarction.

We report a case of large left ventricular pseudoaneurysm after inferior acute myocardial infarction. Patch repair is commonly performed; however, only a few studies have described specific surgical techniques for left ventricular pseudoaneurysm repair of the inferior left ventricular wall. As an optimal repair technique for left ventricular pseudoaneurysm of the inferior left ventricular wall is lacking, we believe our technique is safe and effective in repairing this pathology.

Fenestrated and covered frozen elephant trunk technique for management of chronic aortic dissection.

BACKGROUND: Reintervention for residual dissection after repaired type A aortic dissection remains challenging. When a frozen elephant trunk (FET) is used, the incidence of distal stent graft-induced new entry (d-SINE) is reportedly high in chronic dissection. AIMS: We report a case of successful redo arch repair using fenestrated and covered FET techniques for chronic residual aortic dissection. METHODS: After the arch was transected proximal to the left subclavian artery (LSCA), and a modified FET prosthesis, in which the distal edge of the FET was covered, was deployed. A fenestration was created in the FET on the LSCA aspect. RESULTS: The postoperative course was uneventful. DISCUSSION: The distal edge of the FET was covered to prevent d-SINE. Creation of a fenestration on the FET eliminates the need to reconstruct the LSCA. CONCLUSION: The fenestrated FET technique simplifies redo arch repair and the covered FET technique can potentially prevent d-SINE.

Effects of a frozen elephant trunk on postoperative renal dysfunction in acute type A aortic dissection extending into the renal artery.

BACKGROUND: We investigated the effects of frozen elephant trunk (FET) implantation on clinical outcomes in patients with acute type A aortic dissection (ATAAD) extending into the renal artery (RA). METHODS: Between May 2016 and April 2021, 136 patients underwent surgery for ATAAD at our hospital. Patients who died within 7 days postoperatively and those without preoperative contrast-enhanced computed tomography (CT) data were excluded from the study. The remaining 125 patients were included in this study. A preoperative CT-documented RA abnormality was found in 53 patients. Clinical outcomes, including renal dysfunction and CT findings, were compared between 29 patients with and 24 patients without the FET prosthesis. RESULTS: Among the 53 patients with RA abnormalities, origin of the RA from the false lumen was the most common type of abnormality. The percentage of men and rate of arch repair were higher, and the operation, cardiopulmonary bypass, and lower body hypothermic circulatory arrest times were longer in the FET than in the non-FET group. Early mortality rates were similar between groups. The incidence of postoperative acute kidney injury (AKI) was lower in the FET group (35% vs. 67%, p = 0.028). Multivariable analysis showed that FET implantation was associated with a low incidence of AKI (odds ratio: 0.28, 95% confidence interval: 0.08-0.96; p = 0.043). Among the 125 patients with or without RA abnormalities, no predictor of AKI was identified. CONCLUSION: FET implantation protected against postoperative AKI in patients with ATAAD extension into the RA.

Reconstruction of the left subclavian artery in arch repair: An end-to-side anastomosis technique.

BACKGROUND: The left subclavian artery (LSCA) is deeply located and difficult to visualize in some cases of total arch replacement. AIMS: We report an end-to-side anastomosis technique that enables safer and easier anatomical reconstruction of the LSCA. MATERIALS AND METHODS: Under Hypothermic circulatory arrest, the origin of the LSCA was ligated and pulled caudally. With clamping the distal LSCA, a graft was anastomosed to the anterior wall of the LSCA and antegrade cerebral perfusion to the LSCA was ensured through the anastomosed graft. Thereafter, distal anastomosis was performed proximal to the LSCA. RESULTS: The postoperative course was uneventful. DISCUSSION: Our reconstruction technique provides excellent exposure of the LSCA by pulling the origin of the LSCA caudally. Hemostasis after reconstruction is feasible, as the anastomosis in the anterior wall of the LSCA is easily visualized. CONCLUSION: The end-to-side anastomosis technique for LSCA reconstruction is a simple alternative in arch repair.

Covered frozen elephant trunk technique for prevention of distal stent graft-induced new entry.

Distal stent graft-induced new entry is not rare after frozen elephant trunk implantation. We report a case of covered frozen elephant trunk placement for prevention of distal stent graft-induced new entry. Coverage of the rigid distal stent edge using a graft reduces mechanical stress on the intima and radial force of the distal stent; therefore, this technique can potentially prevent distal stent graft-induced new entry.

Biliary Peritonitis Caused by Spontaneous Bile Duct Rupture in the Left Triangular Ligament of the Liver after Endoscopic Sphincterotomy for Choledocholithiasis.

Spontaneous bile duct rupture is a rare condition in adults, with only 70 cases reported. Increased bile duct wall pressure may lead to rupture and biliary peritonitis. In this patient, the bile duct ruptured in the hepatic left triangular ligament. A 91-year-old man underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and endoscopic retrograde biliary drainage (ERBD) placement. One week later, removal of the ERBD and common bile duct stones and an endoscopic sphincterotomy (EST) were performed. Four days later, the patient had abdominal pain, increased inflammatory reaction, and jaundice. Abdominal computed tomography showed ascites, bile duct dilatation and fluid collection under the liver (10 cm in diameter). Emergency surgery was performed to drain the fluid. On laparotomy, encapsulated biliary ascites was seen. To search for the site of the leak, after cholecystectomy, a tube (C-tube) was inserted into the common bile duct via cystic duct stump. Because of uncontrollable bleeding, after packing with surgical gauze, the operation was temporarily stopped. The next day, reoperation was performed. Intraoperative cholangiography with contrast dye revealed the perforation site in the left triangular ligament and a partial resection was performed. Bile excretion from the C-tube was subsequently observed, but the patient's jaundice did not improve. Although endoscopic retrograde cholangiopancreatography revealed that the EST site was normal, ERBD was placed again, and the jaundice gradually improved. Although EST was performed in this case, biliary peritonitis resulting from spontaneous bile duct rupture occurred. This case was very informative because biliary perforation may occur even after EST.

Laparoscopic Views of Obturator Hernia.

In this report, we highlighted the clinical manifestations of obturator hernia and focused on laparoscopic views. Given its rarity and vague symptoms, the early diagnosis of obturator hernia presents a challenge. Although delays in diagnosis cause high rates of morbidity and mortality, CT with multi-planar reformations provides an excellent means of preoperative diagnosis. Despite current progress of laparoscopic surgery, its indication is believed to be limited only in elective obturator hernia repairs because of technical difficulties associated with bowel strangulation followed by a resection anastomosis. However, in selected cases, laparoscopic techniques can provide a minimally invasive option for obturator hernia repairs. These laparoscopic views, together with CT imaging, allow a better understanding of spatial anatomy and abnormality surrounding an obturator hernia.