Bronchial Artery Aneurysm Treated Using Aortic Stent Graft Alone: A Case Report.

A 72-year-old woman with a history of malignant lymphoma was referred to our hospital for the treatment of a bronchial artery aneurysm. Computed tomography (CT) scan showed a round, 30 mm-diameter fusiform aneurysm with two tortuous inflow arteries. We deployed thoracic stent grafting to cover the orifice of the two inflow arteries without transcatheter bronchial arterial embolization. Postoperative CT scan revealed complete thrombosis of the aneurysm. Although further follow-up is mandatory, this may be considered a viable treatment option in cases wherein the bronchial artery aneurysm is anatomically difficult to treat.

Endovascular Surgery for Traumatic Thoracic Aortic Injury: Our Experience with Five Cases, Two of Whom were Young Patients.

OBJECTIVES: We present our experience of endovascular surgery for traumatic aortic injury and the results of our procedures. MATERIALS AND METHODS: From January 2009 to December 2013, we performed endovascular repairs of traumatic thoracic aortic injury on 5 male patients 16-75 years old (mean, 50.8), two of whom were young. Three of the patients had multiple organ injuries. The mean interval time to the operation is 22.0 hours (range, 10-36). All patients underwent endovascular repair with heparinization. The isthmus regions were seen in three cases and all of them were needed left subclavian artery (LSA) coverage. In the two young patients, the deployed stent graft was 22 mm (22.2% oversizing for diameter of aorta) and 26 mm (36.8% oversizing), respectively. RESULTS: The procedures were successful in all patients, with no early mortality, paraplegia or stroke. During 3-63 months (mean, 30.8) follow-up period, no one experienced stent graft-related complications. One patient with LSA coverage experienced arm ischemia but the symptom improved with time. CONCLUSION: Endovascular surgery for traumatic thoracic aortic injury can be performed safely with low mortality or morbidity even in young small aorta. Accumulation of clinical experience and evaluation of long-term outcomes are necessary.

[Arch aneurysm and ruptured innominate artery aneurysm with acute occlusion of trachea].

We reported on a case of 80-year-old woman who suffered from severe acute respiratory failure. A chest computed tomography (CT) revealed arch aneurysm and innominate artery pseudoaneurysm, which severely compressed main bronchus and trachea. After tracheal intubation in the emergency room, respiratory status improved rapidly. We immediately performed total arch replacement using deep hypothermia, circulatory arrest and the arch first technique. The postoperative course was uneventful, and stenosis of trachea resolved. Arch aneurysm associated with acute trachea occlusion is very rare and employing deep hypothermia, circulatory arrest and the arch first technique is useful for such atypical arch aneurysms.

[Two-stage repair of the transposition of great arteries with interruption/coarctation of the aorta].

We report on 10 patients who underwent two-stage repair of transposition of the great arteries (TGA) with interruption (IAA) or coarctation (CoA) of the aorta. First, an operation for aortic arch reconstruction was performed: Blalock-Park with pulmonary artery banding (PAB) for IAA (5 patients), subclavian flap with PAB for CoA (4 patients) and end-to-end anastomosis without PAB (1 patient). All survived the first operation and had no significant pressure gradient with good growth of the ascending aorta, except for the 1 case without PAB. Half of the 8 patients who underwent PAB developed migration of the PAB. The arterial switch operation (ASO) was performed 0.7-12.6 (5.6+/-4.7) months after the first surgery. One patient with an abnormal coronary artery tract was lost after ASO. Five developed pulmonary artery stenosis and 1 developed supra-aortic stenosis late after ASO. Two patients need reoperation, 1 for supra-aortic stenosis, and the other for reCoA. Two-stage repair for TGA with IAA/CoA is still a useful method with a good operative result. However, strict follow-up is necessary because of the high frequency of late morbidity.

Comparison of pulsatile and non-pulsatile cardiopulmonary bypass on regional renal blood flow in sheep.

OBJECTIVE: The purpose of the present study was to evaluate the effects of pulsatile cardiopulmonary bypass (CPB) on sheep regional renal blood flow by comparing pulsatile and non-pulsatile perfusion at two different flow rates. DESIGN: Seven female Suffolk sheep were used and the animals were perfused with pulsatile and non-pulsatile CPB at flow rates of 60 and 100 ml/min/kg. Regional renal blood flow was measured by the colored microsphere method. General linear model ANOVA was performed to analyze the data. RESULTS: Regional renal blood flow was significantly higher in both outer and middle cortices of pulsatile CPB compared with non-pulsatile CPB (outer cortex: pulsatile CPB, 381+/-192 ml/min/100 g, non-pulsatile CPB, 255+/-151 ml/min/100g, p=0.002; middle cortex: pulsatile CPB, 239+/-114 ml/min/100 g, non-pulsatile CPB, 176+/-80 ml/min/100 g, p=0.02). The increase of flow rate from 60 to 100 ml/min/kg improved renal cortical blood flow significantly. CONCLUSION: The regional renal blood flow was significantly higher in both outer and middle cortices of pulsatile CPB compared with the non-pulsatile CPB.

Usefulness of low-priming-volume cardiopulmonary bypass circuits and dilutional ultrafiltration in neonatal open-heart surgery.

In neonate open-heart surgery, cardiopulmonary bypass (CPB) with extreme hemodilution induces an increased capillary permeability and accumulation of extravascular fluid, resulting in organ dysfunction. We evaluated the effects of a reduced priming volume for CPB and dilutional ultrafiltration (DUF) during neonatal open-heart surgery. Nineteen consecutive neonates with complete transposition of the great arteries who underwent an arterial switch operation were retrospectively assigned into two groups: the high-priming-volume circuit group (group A, n = 9) and the low-priming-volume circuit group (group B, n = 10). Patients in group B underwent surgery with a miniaturized CPB circuit and using the DUF technique. The priming volume of group B was nearly two-thirds that of group A. The water balance value after CPB and surgery was significantly lower in group B (-126 +/- 118 ml, -116 +/- 116 ml) than in group A (88 +/- 218 ml, 83 +/- 165 ml). Systolic blood pressure just after CPB was higher in group B (67.9 +/- 9.1 mmHg) than in group A (55.4 +/- 10.3 mmHg). Postoperative ventilatory support was shorter in group B (45 +/- 19 h) than in group A (68 +/- 27 h). In neonatal cardiac surgery, low-priming-volume CPB circuits and DUF improve the water balance during surgery and may attenuate any inflammatory reaction, which would help preserve postoperative organ function.

Haemostatic profile of small children during and following cardiopulmonary bypass.

OBJECTIVE: We evaluated changes of the haemostatic system during pediatric cardiac surgery during and after cardiopulmonary bypass (CPB). METHOD: Twenty-five children under 15 kg of body weight undergoing open-heart surgery were divided into three groups; 9 patients (Group A), no bank blood was used throughout the surgery; 8 patients (Group B), packed red cells were used in the priming of CPB circuit; 8 patients (Group C) in cyanotic condition, for whom surgery was performed without bank blood. CPB caused a significant decrease of platelet counts in all three groups, the levels of which remained similar next morning. RESULTS: Platelet counts decreased more significantly in Group C (59+/-27 k/mm3) than in Group A (119+/-42 k/mm3) and B (104+/-27 k/mm3). Platelet function-platelet activating factor test (HemoSTATUS) did not significantly decrease throughout the perioperative period in Group A. HemoSTATUS value decreased during CPB and recovered after CPB in Group B and C. Prothrombin time international ratio (PT-INR) and activated partial thromboplastin time were significantly prolonged just after CPB and recovered until next morning in all three groups. PT-INR was more prolonged in Group C (2.92+/-0.62) than in Group A (2.08+/-0.27) and B (2.42+/-0.42). There was no significant difference in postoperative bleeding for the first 12 hours among the three groups. CONCLUSION: Although extreme hemodilution during CPB significantly impairs the coagulation and platelet system, these changes are usually transient and tolerable with minimal postoperative hemorrhage. However, a prolonged CPB and preoperative cyanotic condition may induce a critical decrease of platelet counts and increase postoperative bleeding.

Ventricular energetics in endoventricular circular patch plasty for dyskinetic anterior left ventricular aneurysm.

BACKGROUND: The endoventricular circular patch plasty (Dor procedure) applies to patients with a left ventricular dysfunction due to an ischemic dilated ventricle. In the present study, we analyzed left ventricular energetics in patients who underwent the Dor procedure. METHODS: We measured left ventricular contractility (end-systolic elastance; Ees), afterload (effective arterial elastance; Ea), and efficiency (ventriculoarterial coupling; Ea/Ees, and the ratio of stroke work and pressure-volume area; SW/PVA) based on the cardiac catheterization data before and after the Dor procedure in 8 patients with a postinfarction dyskinetic anterior left ventricular aneurysm. Concomitant procedures included coronary artery bypass grafting in all patients, mitral valve repair in one patient, and cryoablation in one patient. End-systolic elastance (Ees) and Ea were approximated as follows: Ees = mean arterial pressure/minimal left ventricular volume, and Ea = maximal left ventricular pressure/(maximal left ventricular volume-minimal left ventricular volume), and thereafter Ea/Ees and SW/PVA were calculated. The left ventricular volume was normalized with the body surface area. RESULTS: End-systolic elastance (Ees) increased after the Dor procedure (from 1.15 +/- 0.60 to 1.86 +/- 0.84 mm Hg x m2 x mL(-1), p < 0.01), thus resulting in an improvement in Ea/Ees and SW/PVA (from 2.94 +/- 1.11 to 1.64 +/- 0.49, p < 0.01, and from 0.426 +/- 0.110 to 0.559 +/- 0.082, p < 0.01, respectively), even though Ea did not substantially change (from 2.96 +/- 0.78 to 2.74 +/- 0.55 mm Hg x m2 x mL(-1), p = 0.4). CONCLUSIONS: Left ventricular contractility and efficiency improves after the Dor procedure in patients with a dyskinetic anterior left ventricular aneurysm. However, afterload does not change. The use of appropriate afterload-reducing therapy thus plays an especially important role in the management of patients who undergo the Dor procedure.