Sizing the Frozen Elephant Trunk Based on Aortic Pathology and the Importance of Pre-Operative Imaging.

The frozen elephant trunk is a formidable tool for the aortovascular surgeon. An appreciation of how to size the graft in different pathologies is key in achieving optimal results. Herein, we demonstrate worked examples of how imaging can be used to plan for a frozen elephant trunk and discuss the nuisances and uncertainties of sizing using three index cases: Type A aortic dissection, distal thoracic aortic aneurysm and chronic dissection.

Double right coronary artery: a plea for a standardized nomenclature.

BACKGROUND: Double coronary artery is a rare anomaly with just a few cases reported in the literature. This anomaly started being reported recently with the wide use of coronary angiography. Before the advent of advanced imaging and catheterization facilities most of the available data came from the work of anatomists. Two patients were recently operated in our department. In the first patient the preoperative coronary angiography showed two right coronary arteries. In the second patient a double ostium of the right coronary artery was encountered intraoperatively. We wanted to know the incidence of this anomaly and the available data in the literature. METHODS: A PubMed research was conducted by using the term 'double right coronary artery'. More than 50 case reports and small case series were identified. RESULTS: The review of the literature revealed a lot of controversy and debate. When using the term 'double right coronary artery' authors do not always refer to the same entity. Different definitions and classifications have proposed without, however, gaining wide acceptance. In fact, there is a lot of confusion in the literature and cases that are rather common are presented as being 'extremely rare'. CONCLUSIONS: Even though the real incidence could be over or underestimated due to variability in coronary angiography interpretation, clinicians must be aware of this entity in order to avoid troubleshooting during percutaneous coronary interventions and cardiac surgery. There is need for a close collaboration between interventional cardiologists, anatomists and cardiac surgeons in order to standardize the nomenclature.

Single stage repair for aortic root aneurysm in a patient with coexisting coarctation incorporating the Cabrol technique: a case report.

BACKGROUND: A 44 year old man who presented with a history of chest pain and dyspnoea was found to have an aneurysm of the aortic root, aortic valve insufficiency, and coarctation of the aorta. CASE PRESENTATION: The patient underwent a single stage procedure to treat the aortic root, valve and coarctation with a composite valved conduit and extra-anatomic bypass of the coarctation. The modified Cabrol technique was necessary to attach the coronary buttons due to grossly abnormal anatomy. The patient made a remarkable recovery and was discharged on the 8th post-operative day. CONCLUSION: This case report highlights the feasibility and efficacy of performing a single stage procedure on complex coarctation with associated cardiac defects. To the best of our knowledge, this is the first report of the modified Cabrol technique being used in this particular setting.

Spontaneous Coronary Artery Dissection in a Woman: Surgical Treatment and Angiographic Follow-Up.

Spontaneous coronary artery dissection constitutes a rare entity that affects mostly women, especially those less than 40 years of age. Treatment of choice is a matter of discussion. It is suggested by many that the therapeutic strategy should be individualized based on each patient's clinical and angiographic manifestations. We present the case of a young woman who underwent surgical revascularization for dissection of the left main stem by using both internal thoracic arteries. Angiographic follow-up revealed resolution of the dissection, obstruction of the right internal thoracic artery graft, and reverse flow in the left internal thoracic artery graft.

Ascending Aorta to Hepatic and Mesenteric Artery Bypassing, in Patients with Chronic Mesenteric Ischemia and Extensive Aortic Disease-A Case Report and Review of the Literature.

Chronic mesenteric ischemia (CMI) is a rare disorder caused by severe stenosis of the mesenteric arterial supply that results in postprandial pain and weight loss. Treatment options are surgical or endovascular. Surgical bypass can be performed in an antegrade fashion from the supraceliac abdominal aorta (AA) or the distal descending thoracic aorta or in a retrograde fashion from the infrarenal aorta or the common iliac artery. However, in some patients with disease of the descending thoracic aorta or the AA, another site for the proximal anastomosis needs to be found. In this article, we report the case of a 69-year-old man with a thoracoabdominal aortic aneurysm and CMI in whom we performed bypass grafts to the hepatic and superior mesenteric arteries using the ascending aorta as the site for the proximal anastomoses via a median sternolaparotomy. In addition, we performed a literature review of all similar cases and provide an analysis of this technique and an assessment of the success rates.

A review of the surgical management of right-sided aortic arch aneurysms.

Aneurysms and dissections of the right-sided aortic arch are rare and published data are limited to a few case reports and small series. The optimal treatment strategy of this entity and the challenges associated with their management are not yet fully investigated and conclusive. We performed a systematic review of the literature to identify all patients who underwent surgical or endovascular intervention for right aortic arch aneurysms or dissections. The search was limited to the articles published only in English. We focused on presentation and critically assessed different management strategies and outcomes. We identified 74 studies that reported 99 patients undergoing surgical or endovascular intervention for a right aortic arch aneurysm or dissection. The median age was 61 years. The commonest presenting symptoms were chest or back pain and dysphagia. Eighty-eight patients had an aberrant left subclavian artery with only 11 patients having the mirror image variant of a right aortic arch. The commonest pathology was aneurysm arising from a Kommerell's diverticulum occurring in over 50% of the patients. Twenty-eight patients had dissections, 19 of these were Type B and 9 were Type A. Eighty-one patients had elective operations while 18 had emergency procedures. Sixty-seven patients underwent surgical treatment, 20 patients had hybrid surgical and endovascular procedures and 12 had totally endovascular procedure. There were 5 deaths, 4 of which were in patients undergoing emergency surgery and none in the endovascular repair group. Aneurysms and dissections of a right-sided aortic arch are rare. Advances in endovascular treatment and hybrid surgical and endovascular management are making this rare pathology amenable to these approaches and may confer improved outcomes compared with conventional extensive repair techniques.

Surgical management of infected cardiac implantable electronic devices.

The growing use of cardiac implantable electronic devices (CIED) has led to infections requiring intervention. These are traditionally managed using a percutaneous transvenous approach to fully extract the culpable leads. Indications for such strategies are well-established and range from simple traction to the use of powered extraction tools including laser sheaths. Where such attempts fail, or if there are further complications, then there may be need for a cardiothoracic surgical approach. Limited evidence is currently available on the merits of individual strategies, and these are mainly drawn from case reports or series. Most utilise cardiopulmonary bypass, cardioplegic arrest and entry within the right atrium to allow direct visualisation of any vegetation and safely explant all CIED components whilst avoiding perforation, valvular and paravalvular damage. In this review, we describe a number of these and the unique challenges faced by surgeons when attempting to extract CIED. It is clear that future work should concentrate on creating clear consensus and guidelines on indications, risks and measures of efficacy outcomes for various surgical techniques.

Left ventricular post-infraction pseudoaneurysm mimicking mitral valve endocarditis.

In this report we present a patient who was initially diagnosed as suffering from mitral valve endocarditis. The proper use of diagnostic modalities revealed a pseudo aneurysm of the left ventricle which was mimicking mitral valve vegetations. This allowed better planning of the subsequent operation. The optimal preoperative diagnostic studies are discussed along with the proper surgical treatment.

Intimal aortic sarcoma mimicking ruptured thoracoabdominal type IV aneurysm. A rare case report and review of the literature.

Primary intimal aortic sarcoma represents a very rare and highly lethal medical entity. Diagnosis is made either by embolic events caused by the tumor or by surrounding tissue symptoms such as pain. Herein we report an extremely rare case of a 51-year-old man previously operated for ascending aortic aneurysm, who presented with clinical and radiological findings suggestive of a ruptured thoracoabdominal type IV aneurysm. The patient underwent radical resection of the aorta and surrounding tissue with placement of a composite 4-branched graft. The diagnosis was made by frozen section and regular histopathologic examination of the specimen and the patient received adjuvant chemotherapy. Nine months after surgery the patient is still alive and has no signs of recurrence. We review the literature and discuss the option of postoperative chemotherapy.