Multiple deep femoral artery aneurysms with Loeys-Dietz syndrome.

A 60-year-old man with Loeys-Dietz syndrome (LDS) underwent surgery for multiple left deep femoral artery aneurysms (DFAAs). An intraoperative graft replacement was performed from the common femoral artery to the distal DFAAs; the superficial femoral artery was sutured to the graft. DFAAs in association with LDS and the occurrence of multiple DFAAs are rare. To the best of our knowledge, no studies have reported their coexistence. Graft replacement was decided as the optimal treatment for our patient. However, treatment should be considered on a patient-by-patient basis. Therefore, a lower limb arterial examination should accompany the screening of patients with LDS.

Left Coronary Cusp with Fenestration Adherent to the Aortic Wall.

An aortic valve with a coronary cusp adherent to the aortic wall is a rare anomaly. Furthermore, an adherent coronary cusp with fenestration is even rarer. Here, we report a case of aortic valve regurgitation with an adherent and fenestrated left coronary cusp. A 45-year-old man with complaints of dyspnea on exertion was hospitalized. Clinical examination revealed severe aortic valve regurgitation associated with poor cardiac function. He had a history of cardiac murmur present since childhood; however, the details of his cardiac history are unknown. During surgery, a fenestrated left coronary cusp adherent to the aortic wall was observed. Following resection of all aortic cusps, we performed an aortic valve replacement with a mechanical valve. The postoperative recovery was uneventful. In this case, the left coronary artery was perfused by a small fenestration in the adherent coronary cusp. In such cases, the adherent coronary cusp should be released to alleviate the possibility of sudden death and ischemic myocarditis.

Mechanical Thrombectomy for Postoperative Stroke in a Patient with Acute Aortic Dissection Type A.

Mechanical thrombectomy has been proposed to expand the treatment time window and enhance revascularization. However, it is unclear whether its use can be extended to patients with occlusions in acute aortic dissection, especially the thoracic aorta. A 55-year-old man underwent graft replacement for acute aortic dissection type A. On postoperative day 2, he developed stroke and computed tomography showed occlusion of the right middle cerebral artery. Mechanical thrombectomy was performed by transbrachial approach. Although successful recanalization was achieved, he suffered hemorrhagic stroke. Since there is no other effective treatment and the neurologic outcome with conservative management is poor, we consider mechanical thrombectomy to be a viable therapeutic option for the treatment of postoperative stroke in patients with acute aortic dissection type A. However, further study is warranted regarding the safety of this technique.

A Case of Traumatic Retrograde Type A Aortic Dissection Accompanied by Multiorgan Injuries.

A 75-year-old woman was involved in a traffic accident and suffered retrograde type A aortic dissection, multiple rib fractures, and grade II hepatic injury accompanied by intraperitoneal bleeding. We performed total arch replacement using an open stent graft with cardiopulmonary bypass and circulatory arrest. This procedure requires anticoagulation and hypothermia, which are principally contraindicated in severe trauma patients. However, this situation was resolved by managing the patient non-operatively for 7 days, confirming the stabilization of other injured organs, and then performing the surgery. She required prolonged postoperative rehabilitation; however, she recovered steadily.

Pseudoaneurysm fistulated into the right atrium after double valve replacement.

We discuss a rare case of an ascending aorta pseudoaneurysm fistulating into the right atrium following prior aortic and mitral valve replacement. Transthoracic echocardiography and computed tomography revealed a pseudoaneurysm of the ascending aorta attached to the right atrium with fistulous communication. The pseudoaneurysm arose from the center of the former aortotomy. Emergency remedian sternotomy was performed without aneurysmal injury and with exposure of the left femoral artery and femoral vein. Aneurysmal resection and ascending aorta repair were performed without complication. Exposing peripheral vessels, and initiating cardiopulmonary bypass only after reentry, might be effective in resternotomy to approach ascending aorta pseudoaneurysms.

Early and midterm results of transapical and right axillary artery cannulation for acute aortic dissection.

BACKGROUND: We combined transapical cannulation and right axillary artery cannulation in the repair of acute type A aortic dissection in order to reduce mortality and morbidity in the presence of risk of malperfusion. Early and midterm outcomes were evaluated. METHODS: Between October 2009 and March 2012, 23 aortic dissection patients (age, 54.3 ± 13.5 years) received graft replacement using a combination of transapical and right axillary artery cannulation. Preoperative malperfusion was present in 16 patients (69.6%). Cardiopulmonary bypass was initiated with axillary artery cannulation applied via the right axilla and right atrial drainage, then aotric cannulation applied via the left ventricular apex. We retrospectively investigated mortality and morbidity as well as cardiac function, which were evaluated echocardiographically during hospitalization and once a year postoperatively. RESULTS: All patients received total arch replacement. In-hospital mortality was 4.3%, and no patient developed intraoperative malperfusion. Intraoperative stroke occurred in one patient (4.3%), and three patients (13.0%) suffered from delayed stroke (10-24 days). These delayed strokes might have resulted from cardiogenic thrombus, although no intracardiac thrombus was found. Mean ejection fraction was 66.1 ± 10.9% in the early postoperative period and 73.1 ± 8.7% midterm. There was no left ventricular asynergy or intracardiac thrombus seen on either early or midterm echocardiography. CONCLUSION: Transapical cannulation with right axillary artery cannulation is a safe and effective procedure that can reduce operative risk associated with aortic dissection. Although transapical cannulation does not appear to impair cardiac function, it may confer a risk of delayed stroke.

[Left atrium thrombus after mitral valve replacement presented with syncope; report of a case].

Left atrial free ball thrombus (LABT) after mitral valve replacement (MVR) is very rare, and sudden death may occur by thrombus impaction to the mitral valve orifice. A 81-year-old woman who underwent MVR and tricuspid annuloplasty ten years ago presented with syncope. She was admitted to a hospital, and echocardiography revealed a LABT. When she took sitting position, she fainted. The free ball thrombus possibly impacted mitral valve orifice. She was transferred to our hospital and an emergent operation was performed. There was a LABT of 4 cm in diameter, which was removed. Postoperative course was uneventful. There are 12case reports which described LABT after MVR, and anticoagulant therapy was insufficient in most of those cases. Strict anticoagulant therapy is important to prevent left atrial thrombus after MVR.

Pericoronary pseudotumor caused by helicobacter cinaedi.

Cardiac tumors and tumor-like lesions are uncommon; most are true neoplasms. We here report a case of a pericoronary tumor-like lesion surrounding the right coronary artery in a 39-year-old man who presented with fever and chest pain. Although clarithromycin was administered for 1 week, his fever persisted. Helicobacter cinaedi (H. cinaedi) was isolated from blood cultures and found to be sensitive to ceftriaxone. A computed tomography scan showed a tumor-like lesion with no (18)F-fl uorodeoxyglucose uptake surrounding the right coronary artery. After administration of ceftriaxone, the tumor-like lesion diminished in size according to meticulous computed tomography examinations. We therefore concluded that it was caused by H. cinaedi infection. The patient has been followed up closely for 1 year and remains asymptomatic.

Delayed esophageal perforation secondary to thoracic aortic aneurysm rupture in a patient with human immunodeficiency virus infection.

A 65-year-old man infected with human immunodeficiency virus underwent emergency surgery for rupture of a mycotic descending thoracic aneurysm. The aneurysm was replaced with a prosthetic graft wrapped with omentum. Esophageal perforation occurred 3 weeks after surgery. The patient's condition remained stable, and we adopted a conservative treatment. The esophageal fistula had not healed completely and a biopsy of the scar revealed gastric cancer. We performed a distal gastrectomy, Roux-Y reconstruction, and enterostomy for enteral feeding. Follow-up endoscopy revealed healing of the fistula, and the patient was eventually discharged. We managed this potentially fatal complication with minimally invasive treatment.

Surgical outcomes of acute type A aortic dissection in elderly patients.

BACKGROUND: Age is still considered a risk factor in the repair of acute type A aortic dissection. Instead of total arch replacement, we performed hemiarch or partial arch replacement with intimal tear exclusion to reduce death in elderly patients and evaluated early-term and midterm outcomes. METHODS: From January 2004 to April 2012, 59 patients older than 70 years (mean age, 77.0±4.3 years) underwent emergency operations for acute type A aortic dissection at our institution. We performed hemiarch, partial arch, or total arch replacement, according to the location of the primary entry tear. The characteristics, surgical procedures, and early-term and midterm outcomes of these patients were reviewed. RESULTS: We performed hemiarch replacement in 47 patients, partial arch replacement in 4, and total arch replacement in 8. The primary entry site was excluded in 56 of 59 patients (94.9%). In-hospital mortality was 6.8%, and neurologic impairment occurred in 25.4%. We obtained midterm outcomes for 55 of 59 patients, with a mean follow-up period of 43.9±23.7 months. Fourteen patients died, two of these of aortic-related causes. One patient required repeat aortic operation for rupture of a pseudoaneurysm. Follow-up computed tomography imaging was done in 28 of 55 patients during the 12 months after the operation. No significant difference was noted in the increase in maximal aortic diameter between patients with and without residual dissection. CONCLUSIONS: In-hospital mortality was 6.8%; relatively low compared with previous reports. Hemiarch and partial arch replacement with entry tear exclusion may reduce deaths associated with acute type A aortic dissection repair in elderly patients, without increasing the risk of reoperation and aortic-related death.

Tracheo-Bronchial Obstruction and Esophageal Perforation after TEVAR for Thoracic Aortic Rupture.

A 67-year-old man was referred to our hospital for an ascending aortic aneurysm, thoracoabdominal aortic aneurysm and aortic regurgitation. Graft repair of the thoracic aortic arch and aortic valve replacement was given priority and completed, however he developed descending aortic rupture before the second scheduled surgery, and endovascular stent grafting was performed. He subsequently developed tracheobronchial obstruction and esophageal perforation. The patient underwent urgent esophagectomy and enterostomy with continuity later reestablished. However, he died of sepsis 5 months after surgery. Despite the less invasive nature of endovascular treatment, esophageal perforation can nevertheless occur and postoperative vigilance is well warranted.

Innovative application of available stent grafts in Japan in aortic aneurysm treatment-significance of innovative debranching and chimney method and coil embolization procedure.

OBJECTIVE: We here describe our experience with innovative uses of these devices. PATIENTS AND METHODS: We reviewed treatment outcomes of 310 endovascular abdominal aortic repair (EVAR) and 83 thoracic endovascular aortic repair (TEVAR) cases performed between August 2007 and February 2012. We separately assessed results in elderly and high-risk patients who had a novel procedure. This group included 94 patients who underwent EVAR with IIA embolization, 10 patients who had EVAR and a renal artery chimney procedure for a short aortic neck, 20 patients who had two de-branching TEVAR or Chimney method for thoracic aortic aneurysms (TAA) and 3 patients who had debranching TEVAR for thoracic abdominal aortic aneurysms (TAAA). RESULTS: Of the 393 patients given stent grafts (SGs), 3 (0.8%) died in the hospital, including 1 patient with pneumonia who underwent EVAR and IIA embolization and 1 patient with a cerebral infarction who had TEVAR. Four patients (4.3%) who were treated with EVAR with internal iliac artery (IIA) embolization presented with residual buttock claudication 6 months postoperatively, and 3 patients (3.2%) had onset of ischemic enteritis; however, in all 7 patients, the condition resolved without additional intervention. In the 10 patients who had EVAR and a renal artery chimney method, the landing zone (LZ) was ≤10 mm, but neither endoleak nor renal artery occlusion was observed perioperatively or during midterm follow-up. Of the 20 patients who had a 2-debranching TEVAR, including 9 in whom the chimney method was used with the LZ in zone 0, 1 (5%) had a residual endoleak. In 3 patients with TAAA, we used SGs to cover 4 abdominal branches and bypassed the visceral artery; the outcomes were good, with all patients being ambulatory at hospital discharge. CONCLUSION: Among innovative SGs treatments, the debranching procedure and the chimney method using catheterization and the coil-embolization technique provided good outcomes, as used in addition to surgical procedures. Aortic aneurysm treatment will become increasingly noninvasive with the continuing development of more innovative ways to use the SGs currently available in Japan. (English Translation of Jpn J Vasc Surg 2012; 21: 165-173).

Early bioprosthetic valve calcification with alfacalcidol supplementation.

We report a case of early bioprosthetic valve calcification in a 76 year-old woman who had received supplementation with alfacalcidol, an analogue of vitamin D, for 3 years after her initial valve replacement. She underwent aortic valve replacement at the age of 71 and subsequently complained of shortness of breath. Ultrasonic cardiography revealed severe aortic stenosis and we performed a second aortic valve replacement with a bioprosthesis. Histopathologic and x-ray examination showed calcification on the explanted valve. She had not presented with any known risk for early bioprosthetic calcification, suggesting that vitamin D supplementation may accelerate calcification of bioprosthetic valves.

Mediastinal mature teratoma with rupture into pleural cavity due to blunt trauma.

We report a rare case of mediastinal mature teratoma with rupture due to blunt trauma. A 15-year-old boy had received a strong head-butt in the left upper chest wall and was admitted with the sudden onset of left-sided severe chest pain and dyspnea. Chest computed tomography (CT) scan on admission revealed a heterogeneous mass lesion in the anterior mediastinum. The contrast-enhanced CT scans obtained 2 days after admission showed not only mediastinal mass lesion but also left pleural effusion. On the radiologic finding at 5 months later, the lesion became larger and was thought to be a typical mediastinal mature teratoma. The patient underwent extirpation of the tumor. Microscopically, the tumor was typically composed of adult-type tissues and was confirmed to be mature teratoma.

Indicators of survival after open repair of ruptured abdominal aortic aneurysms and an index for predicting aneurysmal rupture potential.

BACKGROUND: The aims of this study were to assess variables associated with survival in patients undergoing ruptured abdominal aortic aneurysm (RAAA) repair and to develop an index other than the aneurysmal diameter to predict rupture potential. METHODS: This study included 43 consecutive patients who underwent open surgery for RAAAs. RESULTS: The mortality rate was 18.6% (8/43). The ratio between the maximum aneurysmal diameter and the length (along the central axis) from the aneurysmal neck to the point at which the diameter was three-fourth of the maximum aneurysmal diameter was used as an index to predict aneurysmal rupture potential. The index score was 2.7 ± 1.2 in the RAAA and 1.9 ± 0.9 in the EAAA (p = 0.018). For aneurysms of ≤ 6-cm diameter, the index score was 3.0 ± 1.0 in the RAAA and 1.8 ± 0.9 in the EAAA (p = 0.03). All patients in the EAAA except one had an index score of < 2.3 and 6 of the 7 patients with RAAA had a score of > 3. CONCLUSIONS: The results suggest that patients with AAA having scores of > 3 are at high risk of rupture. This index would be useful for decision making regarding repair of AAA, especially in the borderline cases.

Upregulation of the apoptosis-related inflammasome in cardiac allograft rejection.

BACKGROUND: Inflammation is a major factor in cardiac allograft rejection. Accumulating reports have demonstrated an important role of the inflammation-induced adaptor complex, called the inflammasome, in the field of immunology. The apoptosis-associated, speck-like protein containing a caspase recruitment domain (ASC) is an adaptor protein that forms the inflammasome and regulates caspase-1-dependent generation of inflammatory cytokines. The aim of the present study was to determine how ASC is associated with the development of cardiac allograft rejection. METHODS: We used a murine heterotopic cardiac transplantation model between fully incompatible strains. Donor hearts (n = 9 for each time-point) were harvested for examination on Days 1, 4, 7 and 12 after transplantation. Histopathologic findings of cardiac grafts were evaluated using rejection scores. The expression of ASC and inflammatory cytokines in cardiac grafts were analyzed by immunohistochemistry and real-time reverse transcript-polymerase chain reaction (RT-PCR). RESULTS: Expression levels of both ASC and IL-1 beta were higher in the myocardial interstitium of allografts in parallel to the progress of cardiac rejection during the acute phase after transplantation. In contrast, expression of ASC and IL-1 beta remained low in isografts. Cardiac allografts treated with tacrolimus showed decreased expression of both ASC and IL-1 beta similar to that seen in isografts. Real-time RT-PCR demonstrated similar alteration of ASC and IL-1 beta mRNA expression in cardiac grafts during the acute phase. CONCLUSIONS: Our results demonstrate a novel finding showing that upregulation of ASC is closely associated with the inflammation induced in cardiac grafts after transplantation in the mouse.