Internal thoracic artery pseudoaneurysm after redo aortic root replacement.

Pseudoaneurysm of the internal thoracic artery (ITA) or bleeding from the ITA is an extremely rare complication after cardiovascular surgery via a median sternotomy. Early treatment is needed in the case of massive haemorrhage or a rapidly enlarging pseudoaneurysm. Herein, we present a rare case of a delayed large pseudoaneurysm of the right ITA in a 49-year-old woman with Marfan syndrome who underwent redo aortic root replacement via re-median sternotomy and pacemaker implantation. Diagnostic selective angiography revealed the origin of the pseudoaneurysm, and simultaneous transcatheter embolisation of the ITA was successfully performed. Follow-up computed tomography imaging showed no evidence of contrast media extravasation from the ITA and recurrent extra-pleural haemorrhage. Our findings suggest that postoperative management of patients who have undergone median sternotomy, including cardiovascular surgeries, should also focus on the prevention or early detection of pseudoaneurysm of the ITA to avoid life-threatening conditions.

An Unusual Cause of Intraoperative Hemodynamic Instability Complicating Elective Mastectomy With Immediate Free Flap Reconstruction: A Case Report.

Extrinsic compression of the heart consequent to intrapleural fluid is a rare cause of cardiac tamponade. Cases of massive hemothorax resulting in external cardiac tamponade due to injury of the internal thoracic artery (ITA) following blunt or penetrating trauma have been described in the literature. Here, we present a case of iatrogenic injury to the right ITA complicating mastectomy and deep inferior epigastric perforator flap reconstruction. It manifested as hemodynamic instability that persisted despite aggressive fluid resuscitation. Investigation with an intraoperative transesophageal echocardiogram demonstrated cardiac tamponade secondary to a massive hemothorax which resolved following surgical placement of an intercostal drain.

Left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome: A review of literature on therapy, intervention, and management.

Coronary artery anomalies (CAA) are anatomical aberrations in the origin, structure, and course of the epicardial arteries. Literature has detailed common anomalies or fistulas formed because of coronary artery bypass grafting (CABG) manipulation of intrathoracic vessels. Despite the commonality of the CABG procedure, there are a few CAA and fistula findings which remain extremely rare. We present a case of left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome that presented symptomatically as a malignant arrhythmia. Following a literature review of therapy, intervention, and management we recommend a team based approach when faced with this extremely rare case presentation. The goal of management should to reduce symptoms, and ischemia, by reducing or stopping flow through the fistula and out of the coronary blood supply.

Is internal thoracic artery resistant to reperfusion injury? Evaluation of the storage of free internal thoracic artery grafts.

OBJECTIVES: The in situ internal thoracic artery (ITA) is recognized as the best conduit for coronary artery bypass surgery. The ITA-if it is used as an in situ graft-has a much higher late patency rate than any other arterial graft, including a free ITA graft. We sought to determine if the use of the ITA as an in situ/free graft and its storage in preservation solutions, have an effect on endothelial function. METHODS: The ITA was harvested as either a free or in situ graft in a porcine model. Free grafts were stored in different preservation solutions (saline, Custodiol and Tiprotec [both Köhler Chemie GmbH, Bensheim, Germany]). The ITA was anastomosed off pump to the left anterior descending artery (as in situ/free graft). Freshly harvested ITA served as a control. After 2 hours of reperfusion, the implanted grafts were harvested. The assessment of endothelial function, histopathological analysis, and gene expression were performed. RESULTS: Endothelial function and integrity were severely impaired after reperfusion in the free ITA groups, however, it was partially preserved in the Tiprotec group. Reperfusion injury resulted in increased nitro-oxidative stress, DNA breakage, vascular cell adhesion protein 1, intercellular adhesion molecule-1, and caspase-3 scores, and a decreased endothelial nitric oxide synthase score in the free ITA groups. The in situ ITA graft showed no signs of injury. mRNA levels were significantly altered among the groups. CONCLUSIONS: An early, severe endothelial dysfunction of the stored, free ITA as described, could be completely prevented by the use of an in situ ITA graft. Tiprotec might be a feasible option for storage of free arterial grafts during coronary artery bypass grafting.

Cirugía videoasistida en traumatismo de tórax / Video assisted thoracic surgery in thoracic trauma

El objetivo es discutir el manejo del hemotórax traumático con cirugía videoasistida (VATS) y una revisión de sus principales indicaciones. Se presenta el caso de un paciente con hemotórax por traumatismo penetrante. Inicialmente manejado con pleurostomía, evoluciona con persistencia del sangrado, por lo que se explora. Como hallazgo se encuentra una lesión de arteria torácica interna que se controla con clips de VATS. El paciente evoluciona estable, sin dolor, por lo que se da de alta al tercer día. El manejo quirúrgico preferido del traumatismo de tórax clásicamente ha sido la toracotomía, pero los abordajes mínimamente invasivos han ganado espacio gracias a su menor morbilidad asociada. Algunos de sus beneficios son el menor dolor en el posoperatorio, menor sangrado y menor tiempo operatorio. Algunas indicaciones validadas son el hemotórax retenido y la persistencia del sangrado, siempre que el paciente se encuentre hemodinámicamente estable y no haya sospecha de lesión cardíaca o de grandes vasos. Se concluye que la VATS es una técnica apropiada en casos seleccionados de hemotórax traumático, pero el abordaje de elección sigue siendo la toracotomía tradicional.

The objective is to discuss the use of video assisted thoracic surgery (VATS) in thoracic trauma and to review the most common indications. A young male with a hemothorax due to penetrating trauma is seen at the emergency department. Initial management with a pleural tube revealed persistence of bleeding so surgical exploration was performed. A lesion of the internal thoracic artery was found and controlled with VATS using laparoscopic clips. The patient had an uneventful postoperative course and was discharged home on the third day posterior to surgery. Usually, surgical management of thoracic trauma has been thoracotomy, but minimally invasive procedures have gained terrain in this area thanks to their lower morbility. Some benefits of these are less postoperative pain, less bleeding, and shorter surgical time. Its validated indications include retained hemothorax and persistent bleeding, but only if the patient is hemodinamically stable and cardiac or large vessel lesions are not suspected. As a conclussion, VATS is an appropriate technique for selected cases of traumatic hemothorax, but thoracotomy still remains as the prefered surgical approach.

Safety and effectiveness of transcatheter embolization in the treatment of internal mammary artery injuries.

PURPOSE: Demonstrate the role of endovascular management in the treatment of internal mammary artery (IMA) injuries using transcatheter embolization reviewing our 7-year experience. MATERIALS AND METHODS: Our retrospective analysis of cases consists of a total of 12 patients (8 M and 4 F; mean age 52 years) who underwent angiographic studies and transcatheter embolization for IMA injuries. Causes of vascular injury were divided in high-energy trauma (n = 6), iatrogenic (n = 3) and penetrating injuries (n = 3). Type of trauma, associated injury, imaging findings, treatments and complications were assessed. Imaging findings included active haemorrhage, pseudoaneurysm and focal dissection. RESULTS: Embolization was performed with microcoils in all patients; complete thrombosis was obtained in four patients by additional injection of Spongostan pledgets and in two patients with 300-500 µm particles. The technical success rate was 100%. No patient died as a direct result of vascular injury; one died of myocardial contusion and one for severe multiorgan failure related to high-energy trauma. No major and minor complications were registered. No patient required emergency surgery or subsequent surgical treatment. CONCLUSION: Transcatheter embolization offers an effective, efficient and safe alternative to conventional surgical management of IMA injuries.

Internal mammary artery-to-pulmonary vasculature fistula: Systematic review of case reports.

The formation of a fistula between the internal mammary artery and the pulmonary vasculature (IMA-to-PV) is a rare anomaly. The etiology can be congenital; however, most recent cases have been associated with coronary artery bypass grafting, trauma, inflammatory conditions, chronic infections, or neoplasia. The knowledge base on the formation of these fistulas is derived primarily from case reports. To our knowledge, no systematic reviews or guidelines are available that provide information on how to manage these cases, and the treatment of an IMA-to-PV fistula is controversial. To our knowledge, this report is the first to review 80 cases of IMA-to-PV fistulas reported in the literature. We describe the etiologies, clinical presentation, and management of these fistulas.

Successful deployment of polytetrafluoroethylene-covered stent to seal left internal mammary artery graft perforation due to guide catheter extension system.

Coronary artery bypass graft perforation during percutaneous coronary intervention is a rare complication. Perforation of a left internal mammary artery (LIMA) graft due to a guide catheter extension system has not been described. We report the successful deployment of a polytetrafluoroethylene (PTFE)-covered stent to seal the LIMA graft perforation due to the guide catheter extension system. Percutaneous coronary intervention was performed for a culprit lesion of the distal left circumflex via the LIMA graft. A balloon catheter failed to be delivered because the LIMA graft was very long and tortuous. The guide catheter extension system was introduced, and the balloon was delivered and inflated. However, the LIMA graft perforation with continuous extravasation was caused by the edge of deeper intubated guide extension catheter when a coronary stent was attempted to be delivered to the culprit lesion. A long balloon inflation was performed, but the perforation was not completely sealed. The PTFE-covered stent was successfully deployed and sealed the LIMA graft perforation. This case describes that the rapid deployment of PTFE-covered stent is effective to treat severe coronary artery bypass graft perforation due to the guide catheter extension system.

[The radial access approach in complex coronary anatomy: case report and literature review]. / L'accesso arterioso radiale nell'anatomia coronarica complessa: caso clinico e revisione della letteratura.

The radial artery approach has been accepted as an alternative to the traditional femoral approach in both diagnostic and interventional procedures, including treatment of complex coronary lesions such as chronic total occlusions. Catheterization of the left internal mammary artery (LIMA) graft is frequently performed through this route in order to limit catheter manipulation and avoid dissection of the subclavian and mammary artery, a dramatic event rarely reported in the literature. Nonetheless, indication for this approach should be carefully evaluated, especially if an unfavorable angle of origin of the mammary artery is present. We report the case of a patient who, following iatrogenic dissection of the LIMA during catheterization through the left radial artery, was electively treated with percutaneous coronary angioplasty on a complex anatomy, rather than with high-risk redo coronary artery bypass surgery. Using a combined radial and femoral approach, retrograde disobstruction of the left anterior descending artery, followed by plaque debulking with rotational atherectomy through the struts of a previously implanted stent in the left main-left circumflex artery, was performed. Although the radial approach might be considered even for the treatment of complex coronary anatomy subsets, appropriate use in diagnostic and interventional settings should always be carefully evaluated.

Left Internal Mammary Artery Dissection: Use of Dual Balloon Angioplasty in Treatment of Ostial Dissection Involving Subclavian Artery.

The left internal mammary artery (LIMA) is the preferred arterial graft to be used for the left anterior descending (LAD) artery for coronary artery bypass graft (CABG) due to high graft patency rate. LIMA dissection is a rare, but dreadful complication of graft angiography and may lead to serious complications including death, myocardial infarction (MI), and re-do CABG. Transcatheter management of LIMA dissection involves multiple stenting. However, this may leave a dissection flap at the ostium of the LIMA that may extend to the left subclavian artery jeopardizing flow to the left arm and vertebral artery. We present a case of LIMA dissection where a dual balloon angioplasty was used for the first time offering better "sealing" of the dissection flap at the level of the ostium of the LIMA graft/subclavian artery.

Unusual Vascular Complications Associated with Transradial Coronary Procedures Among 10,324 Patients: Case Based Experience and Treatment Options.

OBJECTIVES: We aimed to present our experience regarding the unusual vascular complications and specific treatment strategies in patients who underwent transradial coronary procedure (TRC). BACKGROUND: Transradial access provides lower vascular access site complication rates compared with transfemoral access. However, there is lack of data obtained from large study populations concerning the incidence and treatment strategies of hemorrhagic and vascular complications following a TRC in the literature. METHODS: 10,324 patients (2,652 patients with percutaneous coronary intervention and 7,672 patients with a diagnostic transradial coronary angiography) who underwent a TRC from February 2010 to December 2014 were reviewed to identify cases of large hematoma, perforation, arteriovenous fistula, and pseudoaneurysm. RESULTS: The observed incidence was 0.44% (45 patients) for all unusual vascular and hemorrhagic complications. Of these 45 patients; 32 patients (0.31%) presented with large hematoma (≥6 cm), 8 patients (0.08%) presented with perforation, 4 patients (0.04%) presented with arteriovenous fistula (AVF), and only 1 case (0.009%) presented with radial artery pseudoaneurysm. Forty-one of forty-five patients were managed with mechanical compression. Surgery was performed in only 3 cases; a patient with a brachial artery perforation leading to compartment syndrome, a patient with AVF resulting in limb ischemia, and a patient with radial artery pseudoaneurysm. A right internal mammarian artery perforation resulting in huge breast hematoma was treated via endovascular graft stent implantation. CONCLUSIONS: Hemorrhagic and vascular complications are rarely seen during TRC. However, majority of these complications could be managed conservatively without a requirement for surgical reconstruction.

Pseudoaneurysm of a branch of left internal mammary artery: a late and potentially fatal complication after redo-sternotomy.

Post-sternotomy pseudoaneurysms of the internal mammary arteries (IMAs) and their branches are rare and often present with rupture-associated haemothorax and haemodynamic instability. In those cases, urgent surgical correction or embolization can be the treatment of choice. Traumatic chest injuries might lead to IMA branch injury as well; after cardiac surgery, injuries to these branches during sternal closure can be an extremely rare cause of pseudoaneurysm. We describe the case of a 78-year old lady with a left IMA branch pseudoaneurysm, arising from left sternal edge a few weeks after redo-sternotomy for mitral valve surgery. We also describe its non-surgical successful repair.

Avoiding vessel laceration in thoracentesis: a role of vascular ultrasound with color Doppler.

Thoracentesis is considered a relatively safe and well-established procedure commonly done at the bedside with minimal risk of complication. Thoracentesis-related hemothorax is uncommon; however, it may be life-threatening. We describe a case of a 19-year-old woman with persistent fever and pleural effusion, in which thoracentesis resulted in tension hemothorax due to intercostal artery laceration. It is important for proceduralists to understand not only the tortuosity of the intercostal artery covering 25% to 50% of the intercostal space, but also the presence of traversing collateral arteries. Herein, we discuss the potential benefit of vascular ultrasonography with color Doppler during thoracentesis, with the goal of avoiding vessel injury and hemorrhage.

Endovascular treatment of posttraumatic pseudoaneurysm of the internal mammary artery.

Pseudoaneurysm of the internal mammary artery is an unusual complication of wounds to the chest. We report a case of a 41-year-old man who sustained a stab chest wound and posttraumatic pseudoaneurysm of the internal mammary artery, resulting in hemomediastinum and hemothorax. The patient was successfully treated using emergency endovascular coil embolization. Because this injury is extremely rare, the literature is reviewed, and several principles are suggested to improve the management.

Coil embolization of a symptomatic left internal mammary arteriovenous fistula.

Internal mammary artery (IMA) arteriovenous fistulae (AVF) are exceedingly rare. There have been a few case reports documenting incidences of IMA AVFs arising from traumatic, iatrogenic, and congenital causes. Recommendations for management of IMA AVFs vary from open surgical ligation-excision to transcatheter embolization to observation. We present an unusual case of a patient who presented with ventricular arrhythmias and heart failure symptoms due to a left IMA AVF that formed after open heart surgery. The patient ultimately underwent percutaneous embolization of the fistulous connection.