Thoracic endovascular aortic repair of a severely angulated aorta using a double-wire technique.

When endovascular treatment is performed, angulation of the access route for a device can make the operative procedure difficult. We encountered a case in which we successfully completed thoracic endovascular aortic repair (TEVAR) in a patient with severely angulated aorta by applying 'double-wire technique'. The patient was an 80-year-old woman. An aneurysm with a 71-mm diameter was observed in the descending aorta. We performed TEVAR. Device delivery could not be achieved by a conventional procedure using one guide wire since the peripheral aorta was severely angulated. Therefore, in addition to a guide wire for main body, a stiff wire and a stiff sheath were introduced to straighten the angulation. The device was successfully introduced and TEVAR was completed. We used the Relay Plus(®) that facilitates tracking through the angulation. The device has a dual structure consisting of a hard sheath and a flexible sheath. We performed TEVAR successfully.

Contrast Medium Induced Nephropathy after Endovascular Stent Graft Placement: An Examination of Its Prevalence and Risk Factors.

Endovascular stent graft placement has become a major treatment for thoracic and abdominal aneurysms. While endovascular therapy is less invasive than open surgery, it involves the use of a contrast medium. Contrast media can cause renal impairment, a condition termed as contrast-induced nephropathy (CIN). This study sought to evaluate the incidence and risk factors of CIN following endovascular stent graft placement for aortic aneurysm repair. The study included 167 consecutive patients who underwent endovascular stent graft placement in our hospital from October 2013 to June 2014. CIN was diagnosed using the European Society of Urogenital Radiology criteria. Patients with and without CIN were compared. Chi-squared tests, t-tests, and multivariate logistic regression analyses were performed. Thirteen patients (7.8%) developed CIN. Left ventricular dysfunction and intraoperative blood transfusion were significantly more frequent in the CIN group (P = 0.017 and P = 0.032, resp.). Multivariate analysis showed that left ventricular dysfunction had the strongest influence on CIN development (odds ratio 9.34, P = 0.018, and 95% CI = 1.46-59.7). Patients with CIN also experienced longer ICU and hospital stays. Measures to improve renal perfusion flow should be considered for patients with left ventricular dysfunction who are undergoing endovascular stent graft placement.

Management of partial anomalous pulmonary venous connection in single ventricle.

We herein report a case of a hypoplastic left heart syndrome variant complicated with partial anomalous pulmonary venous connection to the left innominate vein. We left the vertical vein at the time of the bidirectional Glenn procedure, and ligated the vertical vein at the time of the total cavopulmonary connection procedure, without reconnecting the vertical vein to the left atrium. Because of the development of an interlobar vein draining from the left upper lung into the lower lung after the bidirectional Glenn procedure, the circulation of the left upper lung was preserved after the total cavopulmonary connection procedure.

Development of Delirium in the Intensive Care Unit in Patients after Endovascular Aortic Repair: A Retrospective Evaluation of the Prevalence and Risk Factors.

Delirium is an acute form of nervous system dysfunction often observed in patients in the intensive care unit. Endovascular aortic repair (EVAR) is considered a minimally invasive surgical treatment for abdominal aortic aneurysm. Although the operation method is widely used, there are few investigations of the rate and risk factors of delirium development after the operation. In this study, we retrospectively examined the rate of delirium development in the intensive care unit (ICU) after EVAR, as well as the associated preoperative risk factors and effects on the lengths of ICU and hospital stays. We examined the 81 consecutive patients who underwent elective EVAR between November 2013 and August 2014. The Intensive Care Delirium Screening Checklist was used to diagnose delirium. Twenty patients (24.7%) were diagnosed with delirium in this study. The ICU and hospital length of stays of patients with delirium were 3.3 ± 2.4 days and 14.5 ± 11.9 days, respectively, the latter of which was significantly longer than that of patients without delirium (p = 0.019). Additionally, renal dysfunction, preoperative benzodiazepine use, and intraoperative transfusion were found to be risk factors for the development of delirium after elective EVAR.

A Case Report on the Successful Treatment of Streptococcus pneumoniae-Induced Infectious Abdominal Aortic Aneurysm Initially Presenting with Meningitis.

Infectious abdominal aortic aneurysms often present with abdominal and lower back pain, but prolonged fever may be the only symptom. Infectious abdominal aortic aneurysms initially presenting with meningitis are extremely rare; there are no reports of their successful treatment. Cases with Streptococcus pneumoniae as the causative bacteria are even rarer with a higher mortality rate than those caused by other bacteria. We present the case of a 65-year-old man with lower limb weakness and back pain. Examination revealed fever and neck stiffness. Cerebrospinal fluid showed leukocytosis and low glucose levels. The patient was diagnosed with meningitis and bacteremia caused by Streptococcus pneumoniae and treated with antibiotics. Fever, inflammatory response, and neurologic findings showed improvement. However, abdominal computed tomography revealed an aneurysm not present on admission. Antibiotics were continued, and a rifampicin soaked artificial vascular graft was implanted. Tissue cultures showed no bacteria, and histological findings indicated inflammation with high leukocyte levels. There were no postoperative complications or neurologic abnormalities. Physical examination, blood tests, and computed tomography confirmed there was no relapse over the following 13 months. This is the first reported case of survival of a patient with an infectious abdominal aortic aneurysm initially presenting with meningitis caused by Streptococcus pneumoniae.

A successful patch angioplasty with auto-pulmonary wall for congenital coronary left main trunk occlusion in a young child.

Congenital occlusion of the left main coronary trunk is a life-threatening abnormality, and its optimal management remains controversial. This report describes a case of successful patch angioplasty with auto-pulmonary artery for a 12-year-old boy with congenital left main trunk occlusion. We divided the main pulmonary artery, harvested a pulmonary artery wall strip, and performed patch angioplasty of the occluded left main trunk ostium. We were able to clearly expose the left main trunk behind the pulmonary artery because the obstruction was divided for the patch material. The postoperative course was uneventful, and coronary angiography at 4 months after surgery showed excellent patency of the left main trunk. The auto-pulmonary arterial wall was easy to handle during angioplasty, and its favorable durability has been established both in the Ross procedures and in an arterial switch procedure. Therefore, we conclude that patch angioplasty using a piece of the pulmonary arterial wall represents a good alternative to conventional coronary artery bypass grafting.

Surgical outcome of Fontan conversion and arrhythmia surgery: Need a pacemaker?

BACKGROUND: Atrial tachyarrhythmias are frequent complications in the late period after the Fontan procedure, and important risk factors for a poor prognosis. The impact of Fontan conversion and arrhythmia surgery in failed Fontan patients has been described in many reports. OBJECTIVE: We evaluated our experience with Fontan conversion procedures, concomitant arrhythmia surgery, and pacemaker implantation. METHODS: We reviewed the hospital records of 25 consecutive patients who underwent a Fontan conversion procedure from January 2004 to March 2012. Twenty-four patients had arrhythmia surgery using cryoablation and radiofrequency ablation at the time of conversion. A bilateral atrial maze procedure was performed in 6 patients, right-side maze in 15, and isthmus block in 3. Three patients with a diagnosis of corrected transposition of the great arteries underwent simultaneous pacemaker implantation electively. RESULTS: There was no early death and one late death during a mean follow-up period of 21.2 months. Three tachyarrhythmia recurrences developed, and there were 4 occurrences of sinus bradycardia. Five of these patients required postoperative pacemaker implantation. CONCLUSION: The mid-term results of Fontan conversion and arrhythmia surgery in our institute were satisfactory. The occurrence of unexpected postoperative pacemaker requirement was high in the patients who underwent a right atrial or bilateral atrial maze procedure. Pacemaker or lead implantation is recommended for patients planned to undergo a right-side or full maze procedure.

[Association of lung volume with shunt size in Starnes' procedure in neonates with severe Ebstein's anomaly].

Our modification of Starnes' procedure reduces right ventricular volume using only "suture plication" to improve surgical outcomes. However, shunt size in the procedure varies widely between patients. As this may be related to small lung volume, we estimated lung volume in each patient using computed tomography (CT).Since 2007, we have performed Starnes' procedure in 4 patients. Preoperative cardiothoracic ratio was 89±4.5%. Age and body weight at operation were 4.3±2.6 days and 2.6±0.2 kg, respectively. Anatomic slices 3 mm thick were acquired in transverse planes by CT. Total lung volume was calculated by accumulating those slices. Total lung volume and lung volume/body weight were 97.2±34.1 ml, 36.8±11.5 ml/kg, respectively. In one patient, a 3 mm prosthetic graft was needed to place a clip to regulate blood flow. Another patient required an additional shunt. The patient with the smallest lung volume required treatment with an extracorporeal lung-assistance device. Chest X-rays of neonates with severe Ebstein's anomaly usually show a "wall-to-wall" heart. However, lung volume varies widely between patients. Estimation of lung volume using CT is useful. In patients with smaller lung volume, a larger shunt than usual may be required to obtain the necessary pulmonary blood flow.

Spontaneous disappearance of a saphenous vein graft pseudoaneurysm after coronary artery bypass grafting.

A saphenous vein graft pseudoaneurysm is a rare complication of coronary artery bypass grafting. Its natural course is largely unknown because there have been few observational studies of medically observed patients. We herein report a case of spontaneous regression of a saphenous vein graft pseudoaneurysm in the early postoperative period, which has never been described, to our knowledge, in the previous literature.