Endovascular Therapy for Distal Superior Mesenteric Artery Mycotic Aneurysms due to Infective Endocarditis.

Purpose: To report 3 patients with infective endocarditis who underwent transcatheter arterial embolization for mycotic aneurysm of the distal superior mesenteric artery (SMA). Case Report: Three men (60, 64, and 65 years old) were diagnosed with infective endocarditis. Antibiotics were initiated immediately after admission and continued for several weeks to months. Distal SMA mycotic aneurysm was identified on computed tomography in the vicinity of the ileocolic artery at 33, 26, and 30 days after admission. In case 1, the ileal artery was occluded distal to the aneurysm, with collateral flow to the ileum. In case 2, the mycotic aneurysm was located below the ileocolic artery, which was stenosed distal to the lesion. In case 3, the aneurysm was located on a branch of the ileal artery. Transarterial embolization using microcoils was successfully performed in all patients. No complications associated with embolotherapy or relapse of infection were observed in these 3 patients at 60, 30, and 15 months, respectively. Conclusion: Transcatheter arterial embolization for distal SMA mycotic aneurysm could provide an alternative to open surgery. Anatomical assessment of collateral flow and preprocedure long-term antibiotic therapy could play important roles in preventing bowel ischemia and minimizing the risk of infection relapse.

Treatment of infected thoracic aortic aneurysm with combined abscess debridement and stent-graft wrapping using pedicled latissimus dorsi muscle flaps after thoracic endovascular aortic repair.

BACKGROUND: Open thoracic surgery (with infected lesion removal, prosthetic graft replacement, and pedicled tissue flap) has remained the main treatment for infected thoracic aortic aneurysms to date. Recent reports have highlighted good prognostic outcomes with thoracic endovascular aortic repair. However, thoracic endovascular aortic repair for infected thoracic aortic aneurysms is associated with an exacerbation of infection due to residual infected tissues. We discuss the control of refractory infections following endovascular treatment of infected thoracic aortic aneurysms. CASE PRESENTATION: An 81-year-old man, with a history of insulin-dependent diabetes mellitus and pancreaticoduodenectomy, presented to our emergency department with a fever. Blood tests revealed a markedly elevated leukocyte count, and contrast-enhanced computed tomography suggested a descending thoracic aortic pseudoaneurysm. We diagnosed the patient with an infected descending thoracic aortic aneurysm, and performed urgent thoracic endovascular aortic repair; he was started on an intravenous antibiotic treatment. Postoperatively, blood tests revealed a decreased leukocyte count and the patient remained afebrile. However, computed tomography revealed temporal enlargement of the abscess cavity; therefore, an abscess debridement and stent graft wrapping with pedicled latissimus dorsi muscle flaps were performed, which successfully controlled the infection. Six weeks after abscess debridement, the patient was switched to an oral antibiotic therapy. There was no evidence of recurrence of infection 8 months after the surgery. CONCLUSIONS: A combined abscess debridement and pedicled tissue flap approach is useful for patients with poor surgical tolerance in whom infection control is difficult after thoracic endovascular aortic repair for infected thoracic aortic aneurysms. Pedicled latissimus dorsi muscle flaps are useful when using the omentum for pedicled tissue flap is difficult.

Left brachiocephalic venous occlusion with spontaneous arteriovenous fistula presenting with severe edema in left upper extremity and face: A case report.

INTRODUCTION AND IMPORTANCE: The coexistence of central venous occlusion and arteriovenous fistulas (AVF) is rare among non-dialysis patients. Herein, we describe a case of left brachiocephalic venous occlusion with spontaneous AVF, presenting with severe edema in left upper extremity and face. CASE PRESENTATION: A 90-year-old woman presented to our hospital with gradually worsening edema in her left arm and face for eight years. Contrast-enhanced computed tomography revealed left brachiocephalic venous occlusion and severe edema in her left upper extremity and face. Computed tomography also revealed abundant collateral veins; thus, it seemed unnatural for severe edema to occur with such well-developed collateral pathways. Therefore, the presence of AVF was suspected. After careful re-examination of the patient, a continuous murmur was heard in the post-auricular region. Magnetic resonance imaging and angiogram revealed a dural AVF. Considering the patient's age and treatment difficulty for the dural AVF, we performed a stent insertion into the left brachiocephalic vein. After the procedure, edema in her left upper extremity and face improved dramatically. CLINICAL DISCUSSION: In cases of persistent swelling of the upper extremities or face, there could be a factor that increases venous inflow. Therefore, any condition that may increase venous inflow must be aggressively investigated and therapeutic interventions should be applied to treat such conditions. CONCLUSION: Central venous occlusion and AVF is a possible underlying cause for severe refractory edema in the upper extremity and face. Therefore, both AVF and brachiocephalic occlusion should be assessed for treatment indications under these conditions.

Aortic injury repair in a patient with situs inversus totalis and dextrocardia.

Situs inversus totalis (SIT) with dextrocardia is a rare autosomal recessive disorder. We herein describe a blunt thoracic aortic injury (BTAI) in a patient with SIT and dextrocardia. An 18-year-old girl who was injured by a fall presented to our hospital. Computed tomography (CT) revealed a traumatic pseudoaneurysm at the aortic isthmus. Open aortic repair was performed through a right thoracotomy. No abnormal findings were observed on CT 1 year after the surgery. Open aortic repair of BTAI can be safely performed through a right thoracotomy in patients with SIT and dextrocardia.

Diagnosis and treatment of isolated celiac artery dissection following blunt trauma: A case report.

INTRODUCTION: Celiac artery (CA) dissection due to blunt abdominal trauma is extremely rare and, as such, the clinical features of this potentially life-threatening injury have not been clearly defined, nor have treatment strategies been established. PRESENTATION OF CASE: We describe the case of a 61-year-old man who presented to our emergency department after a motor vehicle accident. Although the patient did not report abdominal pain, enhanced computed tomography (CT) revealed CA dissection. The patient was treated conservatively using antiplatelet therapy and was discharged from the hospital on day 8, without complications. DISCUSSION: As abdominal pain is not a common presenting factor of CA dissection after blunt trauma, it should be suspected as a potential injury in all affected patients and comprehensively assessed, with CT being the most useful diagnostic modality. CONCLUSION: In the absence of any signs of organ ischemia, changes in the CA aneurysm, and persistent, severe abdominal pain following blunt abdominal trauma, conservative treatment is indicated, with or without anticoagulation or antiplatelet therapy.

Coronary Artery Embolism Caused by BioGlue Surgical Adhesive After Type A Acute Aortic Dissection Repair.

Coronary artery embolism due to BioGlue surgical adhesive after repair of type A acute aortic dissection is a rare condition. We report a case of BioGlue coronary artery embolism after type A acute aortic dissection repair confirmed using intravascular ultrasound imaging and pathological examination. It was successfully treated with percutaneous coronary intervention. (Level of Difficulty: Advanced.).

Herniation of the transverse colon into the mediastinum after the use of an omental flap for mediastinitis.

We describe a rare complication, transverse colon herniation into the mediastinum, after the use of an omental flap. Adequate separation of the transverse colon from the omental flap and ensuring that the incision in the diaphragm is as small as possible are important preventive measures.

Successful transcatheter arterial embolization of a ruptured right gastroepiploic artery aneurysm: A case report.

BACKGROUND: Gastroepiploic artery aneurysms (GEAAs) are extremely rare. Ruptured GEAAs are related to high mortality and often treated by open surgery. We describe a case of a ruptured right GEAA that was successfully treated by transcatheter arterial embolization (TAE). PRESENTATION OF CASE: An 80-year-old woman presented to the emergency department with sudden abdominal pain. We diagnosed her as having a ruptured right GEAA based on the contrast-enhanced computed tomography finding. We performed TAE for the GEAA after resuscitation. The patient had an uneventful recovery and was discharged 10 days after TAE. DISCUSSION: A ruptured GEAA causes high mortality; thus, immediate and adequate treatment is mandatory. Previously, many cases of successful surgical resections of ruptured GEAAs have been reported. In our case, we decided that the patient was not suitable for surgery because of her advanced age and bronchiectasis; therefore, we performed TAE and had a good outcome. CONCLUSION: In patients at high risk for surgery, TAE can be an effective treatment for a ruptured GEAA.

Infective endocarditis associated with Bartonella henselae: A case series.

Organisms in the genus Bartonella are cause of blood culture-negative endocarditis. Bartonella infective endocarditis is being increasingly reported worldwide; however, reports from Japan are limited. Here, we report five cases of infective endocarditis associated with Bartonella henselae. All patients had a history of contact with cats or fleas; this information helped achieve an appropriate diagnosis.

Mitral valve replacement for Libman-Sacks endocarditis in a patient with antiphospholipid syndrome secondary to systemic lupus erythematosus.

Libman-Sacks endocarditis is a relatively rare sterile verrucous vegetative lesion observed in systemic lupus erythematosus (SLE)/antiphospholipid syndrome (APLS) patients. Most patients with this condition are asymptomatic. Here we report a case of a 46-year-old woman with APLS secondary to SLE complicated with frequent thromboembolic events due to a mitral valve mass. We performed minimally invasive mitral valve replacement with a mechanical prosthetic valve, and she was successfully discharged 14 days after surgery. Thus, Libman-Sacks endocarditis may be an indication for mitral valve replacement.

Primary aortoduodenal fistula: A case report and review of literature.

BACKGROUND: Primary aortoduodenal fistula (PADF) is an abnormal connection between the aorta and the duodenum and is a life-threatening condition. It is a very rare cause of gastrointestinal bleeding, which often leads to delay in its diagnosis. Prompt diagnosis and surgical treatment are crucial to improve the outcome of patients with PADF. PRESENTATION OF CASE: An 82-year-old man with a history of untreated abdominal aortic aneurysm (AAA) presented to the emergency department with hematemesis. Computed tomography (CT) revealed an AAA with air within the thrombus wall and disruption of the fat layer between the AAA and duodenum, indicating PADF. Emergent surgery, in situ aortic reconstruction using a Dacron graft, and omental coverage were performed. Although the patient needed another surgery for postoperative chylous ascites, he made good recovery and was discharged 86 days after initial surgery. DISCUSSION: In our case, the patient presented with hematemesis and a pulsatile abdominal mass on physical examination and had a history of untreated AAA, which helped in prompt diagnosis of PADF. CT findings suggesting PADF include disappearance of the fat plane between the aneurysm and duodenum, air in the retroperitoneum or within the aortic wall, and contrast enhancement within the duodenum. The recommended surgical approach for PADF consists of aortic reconstruction (in situ aortic reconstruction or extra-anatomical bypass) and duodenal repair. CONCLUSION: Our report affirms that CT and open surgery are effective diagnostic and treatment options, respectively, for PADFs.