Stent Graft Collapse after Zone 0 Landing Thoracic Endovascular Aortic Repair.

A zone 0 landing thoracic endovascular aortic repair was performed on a 69-year-old man with a saccular aortic arch aneurysm. Seven days after the surgery, the patient experienced diminished consciousness and lower limb paralysis. Stent graft collapse was seen on a computed tomography scan. Thereafter, the patient underwent total arch replacement and emergency stent graft removal.

Brachial plexus injury and upper rib fracture after median sternotomy in cardiac surgery.

OBJECTIVES: Sternal retractors utilized during open-heart surgeries through median sternotomy can cause upper rib fractures which sometimes further leads to brachial plexus injury. We aimed to investigate the incidence of brachial plexus injury and upper rib fractures in open-heart surgeries and how these injuries are associated with each other. METHODS: We investigated 1050 cases during the past five years. The incidence of brachial plexus injury and upper rib fractures after median sternotomy was assessed in all patients and the patients who sustained were evaluated for the affected side, the level of paralysis. RESULTS: Ten cases (0.95%) exhibited brachial plexus injury after median sternotomy. Nine cases developed paralysis on left upper extremity. In all ten cases, sensory and motor nerve impairment were exhibited in the lower plexus. Rib fractures were observed in 35.0% of cases after median sternotomy and the usage of asymmetric sternal retractors to harvest left internal thoracic artery (LITA) significantly affected the side of fracture. CONCLUSION: Sternal retractors utilized during open-heart surgeries through median sternotomy may cause rib fractures and brachial plexus injury, so operators should be aware of these complications.

Endovascular Therapy for Isolated Brachiocephalic Pseudoaneurysm.

In this study, we present a successful endovascular therapy using a small-diameter stent graft for a 73-year-old man who developed asymptomatic pseudoaneurysm of the brachiocephalic artery. An 8F sheath was placed in the brachial artery, and a stiff guidewire was advanced to the descending aorta. The stent graft was delivered to the brachiocephalic artery via the brachial approach. After the initial dilatation, the stent graft was post-dilated to maximum diameter. Final digital subtraction angiography confirmed no endoleak. We believed that endovascular for a brachiocephalic pseudoaneurysm using a small-diameter stent graft might be a minimally invasive and simple method useful in clinical practice.

Complete post-operative resolution of "temporary" end-stage kidney disease secondary to aortic dissection without static renal artery obstruction: a case study.

BACKGROUND: Acute kidney injury (AKI), which may progress to end-stage kidney disease (ESKD), is a potential complication of aortic dissection. Notably, in all reported ESKD cases secondary to aortic dissection, imaging evidence of static obstruction of the renal arteries always shows either renal artery stenosis or extension of the dissection into the renal arteries. CASE PRESENTATION: We present the case of a 58-year-old man with hypertension who was diagnosed with a Stanford type B aortic dissection and treated with medications alone because there were no obvious findings indicative of dissection involving the renal arteries. He had AKI, which unexpectedly progressed to ESKD, without any radiological evidence of direct involvement of the renal arteries. Thus, we failed to attribute the ESKD to the dissection and hesitated to perform any surgical intervention. Nevertheless, the patient's hormonal levels, fractional excretion values, ankle brachial indices, and Doppler resistive indices seemed to indirectly suggest kidney malperfusion and implied renal artery hypo-perfusion. However, abdominal computed tomography imaging only revealed progressive thrombotic obstruction of the false lumen and compression of the true lumen in the descending thoracic aorta, despite the absence of anatomical blockage of renal artery perfusion. Later, signs of peripheral malperfusion, such as intermittent claudication, necessitated surgical intervention; a graft replacement of the aorta was performed. Post-operatively, the patient completely recovered after 3 months of haemodialysis, and the markers that had pre-operatively suggested decreased renal bloodstream normalised with recovery of kidney function. CONCLUSIONS: To the best of our knowledge, this is the first report of severe AKI, secondary to aortic dissection, without direct renal artery obstruction, which progressed to "temporary" ESKD and was resolved following surgery. This case suggests that only coarctation above the renal artery branches following an aortic dissection can progress AKI to ESKD, despite the absence of radiological evidence confirming an obvious anatomical blockage. Further, indirect markers suggestive of decreased renal blood flow, such as ankle brachial indices, renal artery resistive indices, urinary excretion fractions, and hormonal changes, are useful for evaluating concomitant AKI and may indicate the need for surgical intervention after a Stanford type B aortic dissection.

Effects of pharmacist participation in chronic kidney disease (CKD) network and CKD manual distribution on drug-related kidney injury.

PURPOSE: Renin-angiotensin system (RAS) inhibitors carry a risk of normotensive ischemic acute kidney injury in dehydration and concurrent nonsteroidal anti-inflammatory drug (NSAID) use. Although the estimated number of patients with chronic kidney disease (CKD) is 20 000, Fujieda, Japan, has only three nephrologists. On 25 March 2016, we reorganized the CKD network to include pharmacists and distributed a CKD manual. We assessed effects of pharmacist participation in the CKD network and CKD manual distribution on patient hospitalizations because of drug-related kidney injury. METHODS: Changes in the prevalence of RAS inhibitor-related estimated glomerular filtration rate (eGFR) declines of greater than or equal to 30% and hyperkalemia of greater than or equal to 6.0 mEq/L in 129 hospitalized CKD patients, drug prescriptions of 14 150 hospitalized patients, and annual medical checkup data in 36 042 citizens were investigated before and after pharmacist participation. RESULTS: After pharmacist participation, patient hospitalizations due to RAS inhibitor-related eGFR declines decreased (71.4% to 38.1%, P = .03) and hyperkalemia declined (38.1% to 9.5%, P = .03). Pharmacist participation influenced the decrease in RAS inhibitor-related eGFR declines (P = .03). NSAID prescriptions decreased (13.4% to 11.8%, P = .003) and acetaminophen prescriptions increased (6.6% to 8.0%, P = .002) among 14 150 hospitalized patients, whereas RAS inhibitor prescriptions decreased (43.2% to 39.4%, P = .002) among 6930 hospitalized patients with eGFR less than 60 mL/min/1.73 m2 . A significant number of citizens shifted from CKD stage G3a-3b to G1-2. CONCLUSIONS: Pharmacist participation in the CKD network and CKD manual distribution decreased both hospitalizations due to RAS inhibitor-related kidney injury and citizens with CKD stage G3a-3b.

[Treatment of Mediastinitis after Open Heart Surgery Using Negative Pressure Wound Therapy with Irrigation].

Mediastinitis occurs after open heart surgery in a small number of cases. When it occurs, early diagnosis and treatment are important. A 69-year-old male patient suffered from mediastinitis after total aortic arch replacement. He has cured completely by negative pressure wound therapy (NPWT) with irrigation method. The vacuum-assisted closure( VAC) method is very useful for wound repair and has recently been used to treat mediastinitis. However, the use of VAC alone does not always result in complete cure. NPWT with irrigation is a very useful infection control method. Performing NPWT before VAC might contribute to improving the outcomes of mediastinitis treatment. However, it is difficult to decide when to switch from NPWT with irrigation to VAC.

[Superior vena cava thrombosis in a case with low serum factor XII].

The present case is 74 years old man who was hospitalized to treat lung tumor suspected of malignancy. Because the superior vena cava thrombus was also revealed by radiological examination, he was performed lobectomy and thrombectomy at the same time. He has past history of intravenous hyperalimentation for 15 days, and we supposed the event to be the cause of the thrombus. Venous thrombus has developed again in the left subclavian vein in spite of the anticoagulant therapy at the early postoperative period. The level of serum factor XII turned out to be low by the precise examination, of which possible contribution to thrombus formation was suspected.

Intimal sarcoma of aortic arch treated with proton therapy following surgery.

Management of a rare case of intimal sarcoma of the aortic arch is reported, which was diagnosed unexpectedly after total arch replacement for pseudoaneurysm. The prognosis for this condition is poor, with death usually within a few months from diagnosis. The newly developed proton-beam radiation therapy was applied to treat a local recurrence of the sarcoma following surgery. Positron-emission tomography/computed tomography revealed complete remission of the lesion.

Primary cardiac angiosarcoma resection combined with right coronary artery bypass grafting.

A 41-year-old woman presented with symptoms of cardiac tamponade. Diagnosis of a primary malignant tumor in the right atrium without distant metastasis was made by echocardiography, computed tomography and coronary angiography. Aggressive surgery consisting of resection of the tumor including the right atrial wall together with the right coronary artery and sinus node was performed. This was followed by coronary artery bypass grafting with myocardial electrode implantation for reconstruction of the right atrial wall using an equine pericardium. Final diagnosis was of angiosarcoma by pathological examination. Consequently, the patient underwent additional radiotherapy and was discharged. She is currently in good health with no recurrence 1.5 years after surgery.

Occlusion of the left superficial femoral artery during hepatic arterial infusion of chemotherapy for liver metastases from colon cancer 18 months after the implantation of a port system: a case report.

We report a case of complication of a catheter port system. A 67-year-old male who had undergone left hemicolorectomy and partial hepatectomy for liver metastases from colon cancer underwent hepatic arterial infusion (HAI) of chemotherapy by a percutaneously implanted catheter port system to prevent recurrence. Eighteen months after the implantation of a port system he complained of intermittent claudication. Intravenous digital subtraction angiography (IV-DSA) showed occlusion of the left superficial femoral artery. The catheter was removed and a femoro-popliteal bypass with an artificial graft was constructed. Thrombus was found around the indwelling catheter at the insertion site. After the operation his complaint disappeared and has been alive without recurrence for 6 years.