Successful Percutaneous Closure of a Large Saphenous Vein Graft Aneurysm With Vascular Plug 4, Optimal Percutaneous Device Selection.

Saphenous vein graft (SVG) aneurysm is one of the late unusual complications of coronary artery bypass grafting (CABG). We report a case of a very large SVG aneurysm successfully treated with a vascular plug 4. A 94-year-old man was referred to our hospital for an expanding aortic aneurysm. The patient had undergone CABG 24 years prior, with three SVGs to the left anterior descending (LAD) artery, left circumflex arteries (LCX) artery, and right coronary artery (RCA). A computed tomography scan of the chest demonstrated an 8.8 cm × 6.5 cm aneurysm arising from an ascending aortic wall. Coronary angiography revealed an aneurysm arising from the proximal segment of the SVG to the RCA. The distal graft anastomosis of the SVG to the RCA and LCX was occluded. Another SVG to the LAD was widely patent. From a radial approach, a 5-Fr catheter (Tempo, Cardinal Health, OH) was advanced into its cavity, and a 7-mm Amplatzer vascular plug 4 (AVP-IV, AGA Medical Corporation, MN) was successfully delivered. Contrast CT confirmed a thrombus development in the cavity. The patient was discharged home. However, interventions utilizing vascular plug insertion are limited to cases of graft occlusion. We report a case of the successful treatment of a large SVG aneurysm using the Amplatzer vascular plug 4.

Total Arch and Descending Aorta Replacement for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Replacement for Complicated Type B Aortic Dissection.

Retrograde type A aortic dissection (RTAD) is a severe complication of thoracic endovascular aortic repair (TEVAR). In this regard, we present our unique surgical methods for total arch and descending aorta replacement for RTAD after TEVAR for complicated type B aortic dissection (TBAD). A 52-year-old man with a history of distal arch large aneurysm was diagnosed with TBAD. Because he had sustained chest pain and his aneurysm diameter was 67 mm, TEVAR was urgently performed. After a right axillary-left axillary artery bypass, a stent graft was deployed in the descending aorta via the right femoral artery. Coil embolization was performed in the left subclavian artery. After the condition of the stent graft was checked by angiography, no Type 1 endoleak and backflow from the re-entry was observed. However, seven days after the operation, he experienced chest pain suddenly. Computed tomography (CT) revealed forward blood flow in the descending aorta (type IA endoleak) and thrombosed aortic dissection in the ascending aorta. The distal arch diameter exceeded 70 mm. A decision was taken to immediately perform an operation. Total aortic arch and descending aorta replacement were performed through a median sternotomy with left 5th interspace thoracotomy. The operation was performed under deep hypothermic circulatory arrest, and selective antegrade cerebral perfusion was accomplished. As a result of the exploration of the aortic arch, it was found that the intimal injury by the bare stent caused RTAD. The patient was successfully extubated after the operation and was discharged without any complications. RTAD can present as an early complication after descending stent grafting because of aortic instability or due to the strength of bare stents. Aortic arch and descending aorta replacement after TEVAR via a clamshell incision can be safely performed if RTAD is diagnosed early.

Daily transient discontinuation of extracorporeal LVAD to prevent thromboembolism of mechanical aortic valve prosthesis.

Patients with mechanical aortic valves are generally contraindicated for left ventricular assist device (LVAD) insertion because the prosthetic valve often becomes fixed in closed position. A 41-year-old woman with mechanical aortic valve prosthesis experienced sudden chest pain and developed cardiogenic shock. A paracorporeal pulsatile LVAD and a monopivot centrifugal pump as a right VAD (RVAD) were implanted. The mechanical aortic valve was intentionally left in place. Soon after the operation, LVAD support was discontinued daily for few seconds to allow the mechanical aortic valve to open and to avoid thrombus formation. The patient was successfully weaned off RVAD and received anticoagulation therapy with warfarin. On postoperative day 141, she was transferred to a university hospital where a HeartMate II LVAD was implanted, and the aortic valve was successfully replaced with a bioprosthetic valve. The patient is currently awaiting heart transplantation.

[Reconstruction of Unilateral Absent Pulmonary Artery Using Ringed Prosthetic Graft;Report of a Case].

We have repaired a unilateral absent pulmonary artery(UAPA) using a prosthetic graft with a ring. Case 1 was a 1-month old girl. The right pulmonary artery(RPA) was anti-anatomically reconstructed with a 4 mm ePTFE graft. In postoperative year 1, however, the graft became stenosed due to compression by the ascending aorta. We reversed the stenosis with a 6 mm stent by percutaneous transluminal angioplasty. Case 2 was 6-year old boy. His RPA was anatomically reconstructed with a ringed 5 mm ePTFE graft when he was 5-months old. In postoperative year 6, he needed the graft exchanged because of the relatively decreased pulmonary flow due to body growth. Therefore, we exchanged the graft with an anti-anatomically ringed 12 mm ePTFE graft. No graft stenosis was observed during the perioperative course. Using a prosthetic graft with a ring may be a good solution to avoid compression from the ascending aorta.

[Surgical Treatment of Large Muscular Ventricular Septal Defect nearby the Moderator Band Using the Sandwich Method;Report of a Case].

We describe the rare case of a 1-year-old girl who had large muscular ventricular defect (VSD) nearby the moderator band. We experienced the patch closure using sandwich method. A 1-month-old girl was referred to our institution for treatment of muscular VSD. At the age of 2 month, she underwent the pulmonary artery banding to control the pulmonary high flow. After follow up, the patient have reached 70 cm tall and weighed 7 kg. One year after the "sandwich operation", cardiac catheterization revealed the tiny residual shunt. Nevertheless, the cardiac function was good and the growth was in fine fettle. Sandwich method is a useful surgical technique to close the muscular VSD without resect the right ventricular trabeculation.

Successful treatment of a patient with purulent pericarditis by daily intrapericardial washouts.

Purulent pericarditis in adults is rare, but once it develops, it carries a high mortality rate. Adequate pericardial drainage and proper antibiotic treatment are essential in the successful management of purulent effusions, for which percutaneous catheter drainage is the most commonly performed technique. We herein report the case of a 75-year-old woman with purulent pericarditis attributable to methicillin-resistant Staphylococcus aureus. Although percutaneous pericardial drainage by catheter was used, the drainage was insufficient because of hyperviscous effusion. We performed surgical subxiphoid pericardial drainage, and a piece of a purulent stone was found in the pericardial cavity with purulent effusion. Additionally, daily intrapericardial washouts with physiologic saline alone were used as adjunct therapy. Five weeks later, the patient had a decreasing inflammatory reaction and symptom relief. She was discharged with no complications such as constrictive pericarditis.

Rupture of chronic type B aortic dissection in a Jehovah's Witness: successful surgical repair without blood transfusion.

The patient, a 55-year-old female Jehovah's Witness who had suffered type B aortic dissection since the age of 53 years, presented with enlargement of the false lumen in the distal aortic arch and was subsequently admitted to our hospital. While hospitalized, her enlarged false lumen ruptured and she underwent replacement of the distal aortic arch and descending thoracic aorta without blood transfusion. Blood conservation strategies for this patient included the following: 1) meticulous hemostasis when incising muscle or soft tissue, 2) minimal use of gauze and discard suckers, 3) exclusive use of a cell salvage device "from skin to skin," 4) low-prime cardiopulmonary bypass, 5) minimal laboratory blood sampling, and 6) preoperative and postoperative erythropoietin treatment. Hemoglobin (Hb) values were 12.5, 15.5, 10.0, and 9.7 g/dL on admission, before rupture, after rupture, and just after the operation, respectively. The patient had an uneventful postoperative course, except for prolonged rehabilitation. The postoperative lowest Hb value was 5.2 g/dL on postoperative day 5, and the Hb value at hospital discharge (postoperative day 55) was 11.0 g/dL. Our experience with blood conservation surgery on this Jehovah's Witness patient suggests that ruptured chronic type B aortic dissection can be safely repaired on bypass through a left thoracotomy with no blood transfusion if the preoperative Hb value is >10.0 g/dL.

Acute occlusion of the abdominal aorta with concomitant internal iliac artery occlusion.

Acute aortic occlusion is a rare but catastrophic pathology with high mortality even after revascularization. We describe four patients who underwent thrombectomy or bypass surgery for acute aortic occlusion with concomitant internal iliac artery occlusion. Two patients (82- and 75-year-old men), who had insufficient reperfusion of bilateral internal iliac arteries after treatment (thrombectomy alone and axillobifemoral bypass, respectively), died on postoperative day three of uncontrollable hyperkalemia and multiple organ failure, respectively (mortality: 50%). The third patient (74-year-old man), in whom the left internal iliac artery was reperfused after an axillobifemoral bypass, underwent right lower limb amputation but survived. The fourth patient (63-year-old man) with sufficient internal iliac artery reperfusion bilaterally after aortobifemoral and right internal iliac artery reconstruction, had an uneventful postoperative course. Elevated creatine phosphokinase and myoglobinuria levels were observed in all four patients but were notably higher in the two patients with no reperfusion in either of the internal iliac arteries. Our results suggest that reperfusion of one or more internal iliac arteries may be a crucial factor in reducing mortality in revascularization treatment of acute aortic occlusion with concomitant internal iliac artery occlusion.

Intermediate and long-term outcomes after treating symptomatic persistent sciatic artery using different techniques.

Persistent sciatic artery (PSA) is a rare congenital vascular malformation. In this article, we have described the case of a 66-year-old woman presenting with a pulsatile mass in the left buttock and bilateral lower limb ischemia, who underwent surgical therapy. Preoperative computed tomography scanning showed a left thrombosed PSA aneurysm (PSAA) with concomitant occlusion of bilateral iliac, bilateral common femoral, and left popliteal arteries. After recanalization of the left common femoral artery occlusion with a systemic heparin treatment, the patient underwent bypass surgery (left femoropopliteal bypass, right iliofemoral bypass) and PSAA exclusion. Postoperative computed tomography scanning 20 months after surgery revealed that the excluded PSAA was thrombosed with no refilling collateral flow, and that the bypass grafts were patent in both legs. In addition to this case report, a literature review of PubMed articles published between 1965 and 2009 that included the treatment and intermediate/long-term management of symptomatic PSAs was conducted. We found 45 articles (67 limbs), of which 24 (29 limbs) described the intermediate/long-term outcomes in patients treated for symptomatic PSA. Regardless of the method of arterial reconstruction or PSAA repair, intermediate/long-term outcomes of different treatments for lower limb ischemia and PSAAs were satisfactory, and the patients were asymptomatic during the follow-up period which ranged from 2 months to 10 years.

Bilateral retroperitoneal approach to repairing a ruptured right iliac artery aneurysm in a patient who has undergone transperitoneal abdominal surgery.

An 84-year-old woman with a history of surgery for cholangiocarcinoma presented to Akita University Hospital with severe right lower abdominal pain, respiratory distress, and hypotension. Computed tomography scanning revealed a ruptured right common iliac artery aneurysm with a massive right retroperitoneal hematoma and a right internal iliac artery aneurysm. Under the bilateral retroperitoneal approach, we preformed an in-situ repair of an aneurysm rupture from the aorta to the left common and right external iliac arteries using a bifurcated knitted Dacron graft, and then we ligated the right internal iliac artery. The postoperative course of the patient was uneventful. The patient was discharged from hospital 52 days after surgery. In conclusion, a bilateral retroperitoneal approach may be a safe and useful strategy for in-situ repair of a right iliac artery aneurysm rupture in patients with peritoneal adhesions after transperitoneal abdominal surgery.

Long-term outcomes of open surgical repair for ruptured iliac artery aneurysms.

BACKGROUND: Rupture of an iliac artery aneurysm is rare but could be catastrophic unless it is treated with an appropriate strategy. We reviewed our 10-year institutional experience in treating iliac artery aneurysms to elucidate the effectiveness of open surgical repair strategies for ruptured iliac artery aneurysms in terms of short- and long-term postoperative results. METHODS: A total of 26 patients (men/women = 22/4), with a mean age of 72 years, underwent open repair of iliac artery aneurysm with or without rupture (unruptured/ruptured = 15/11) between January 2001 and April 2010. There was no difference in the distribution of aneurysm morphology between the unruptured and ruptured groups, and 20 (76.9%) of the 26 patients had aneurysms involving unilateral or bilateral internal iliac arteries. Long-term event-free survival rates and freedom from secondary intervention were analyzed using the Kaplan-Meier method (follow-up: 55 ± 39 and 40 ± 25 months in the unruptured and ruptured groups, respectively). RESULTS: There was no difference in the time of surgery between the two groups (351 ± 118 and 348 ± 152 minutes in the unruptured and ruptured groups, respectively), but the ruptured group showed greater blood loss/min (time of surgery) and transfusion volume than the unruptured group. The early postoperative mortality was 6.7% in the unruptured group and 0% in the ruptured group (p = 0.557). There was no difference in the number of postoperative morbidities between the two groups, but the ruptured group showed significantly greater C-reactive protein, lactate dehydrogenase, and total bilirubin levels than the unruptured group. The cardiovascular event-free survival rate at 5 years was 93.3% and 100.0% in the unruptured and ruptured groups, respectively. The secondary intervention-free rate at 5 years was 100.0% and 90.0% in the unruptured and ruptured groups, respectively. CONCLUSIONS: The short- and long-term postoperative mortality rates after open repair for iliac artery aneurysms were satisfactorily low and similar in unruptured and ruptured groups. This suggests that open repair strategies remain as a reliable treatment option to obtain successful postoperative results in patients with rupture of an iliac artery aneurysm.

Aneurysm of a right-sided descending thoracic aorta with a left-sided aortic arch and aberrant right subclavian artery.

We describe a rare case of an arteriosclerotic aneurysm in the right-sided descending thoracic aorta with a left-sided aortic arch and concomitant aberrant right subclavian artery. A 76-year-old woman, who was found to have an aneurysm of the right-sided descending thoracic aorta, was referred to our hospital for surgical treatment. Contrast computed tomography scan revealed a left-sided aortic arch with an aberrant right subclavian artery, a descending thoracic aorta passing downward behind the esophagus, and an aneurysm of the right-sided and distal (level between the 8th and 10th vertebral bodies) descending thoracic aorta. With a right posterolateral thoracotomy, the patient underwent descending thoracic aorta replacement using an 18-mm woven Dacron prosthesis. The patient had an uneventful postoperative course and was discharged 24 days after surgery. Histological microscopic examination of the resected aneurysmal wall revealed an arteriosclerotic aneurysm. The postoperative computed tomography scan 18 days after surgery revealed no anastomotic aneurysm or abnormal fluid collection.

Acute aortic occlusion due to false-lumen expansion after repair of abdominal aortic rupture in type B acute aortic dissection.

We describe a patient with aortic occlusion due to false-lumen expansion after repair of abdominal aortic rupture in acute type B aortic dissection. A 70-year-old man presented to a nearby hospital with severe lower back pain, and was subsequently referred to our hospital with a diagnosis of abdominal aortic rupture. Computed tomography scanning on admission revealed type B aortic dissection with concomitant false-lumen rupture at the level of pre-existing infrarenal abdominal aortic aneurysm. The patient underwent abdominal aortic replacement with the true lumen reconstructed using a bifurcated knitted Dacron graft. On postoperative day 2, the patient developed severe lower body ischemia. Computed tomography scanning revealed complete true-lumen occlusion at the renal artery level because of false-lumen expansion. The patient underwent open fenestration by opening the bulging flap with a transverse graftotomy distal to the proximal graft anastomosis. After fenestration, the patient developed severe metabolic complications (i.e., myonephropathic-metabolic syndrome) and died a day later of cardiac arrest resulting from hyperkalemia. Abdominal aortic replacement with true-lumen reconstruction in patients with abdominal aortic rupture in type B acute aortic dissection could also lead to acute aortic occlusion due to re-dissection or true-lumen compromise accompanying retrograde propagation of false-lumen thrombosis. This lethal sequela after true-lumen reconstruction might be prevented by an adjuvant procedure such as concomitant fenestration.

Right retroperitoneal approach for repair of an abdominal aortic aneurysm involving bilateral iliac arteries in a patient with a left-side stoma after abdominoperineal resection.

A 78-year-old woman, who had a history of abdominoperineal resection with the associated left-side stoma for rectal cancer, was diagnosed with an infrarenal abdominal aortic aneurysm involving both common and right internal iliac arteries. She underwent in situ graft (bifurcated Dacron) replacement through a right retroperitoneal approach because of limited accessibility to the aorta and iliac arteries due to the left-side stoma. The distal anastomosis of the bifurcated graft was placed to the right external iliac artery and left femoral artery, and the left common iliac artery was excluded by ligating the branching arteries. The patient had an uneventful postoperative course, and the computed tomography scanning at 13 months after surgery revealed thrombosed occlusion of the excluded left common iliac aneurysm. In conclusion, a right retroperitoneal approach may be an option for abdominal aortic aneurysm patients who had a history of transperitoneal abdominal surgery and an associated left-side stoma.

Ligation-and-bypass technique through the posterior approach for bilateral popliteal aneurysms.

A 56-year-old man with a painful, progressively enlarging pulsatile mass in the bilateral popliteal fossae was diagnosed with a bilateral popliteal artery aneurysm (PAA) and referred to our hospital to undergo surgical therapy. Computed tomographic scanning demonstrated a large, middle-type PAA with a rich mural thrombus in the bilateral popliteal arteries. Following aneurysm exclusion posteriorly, the patient underwent bypass surgery using a ringed polytetrafluoroethylene graft bilaterally. This procedure was chosen to prevent nerve injury caused by mobilization of the adherent nerves and aneurysmal resection. The patient had a satisfactory postoperative course. This procedure may be recommended for large, middle-type PAAs because (1) the adherent tibial nerve trunk and its branch nerves can be protected by aneurysm exclusion with arterial branch ligation and (2) frequently occurring postexclusion expansion of the aneurysm caused by insufficient branch ligation using the medial approach can be avoided.

In situ replacement with equine pericardial roll grafts for ruptured infected aneurysms of the abdominal aorta.

We describe surgical in situ replacement using an equine pericardial roll to treat ruptured infected abdominal aortic aneurysms (AAA) in two patients. A 78-year-old man diagnosed with ruptured infected (Bacteroides fragilis) AAA underwent in situ replacement of the abdominal aorta using a bifurcated equine pericardial roll graft with concomitant omentum flap wrapping. A 50-year-old man diagnosed with ruptured infected (Streptococcus agalactiae) AAA underwent the same procedure, except the graft was straight. Computed tomography of this patient revealed no graft dilation or surrounding fluid accumulation at 48 months after surgery. We therefore suggest that in situ replacement of the abdominal aorta using equine pericardium with concomitant omental flap wrapping may be an option of treating ruptured infected AAAs.