Antegrade thoracic endovascular aneurysm repair via the ascending aorta.

PURPOSE: We performed antegrade thoracic endovascular aneurysm repair via the ascending aorta in selected high-risk patients scheduled for open surgery, in whom an iliofemoral or abdominal aortic approach was not feasible. We present our initial experience with this approach. METHODS: Of 16 consecutive patients who underwent antegrade endovascular aneurysm repair via the ascending aorta at our institution, 3 had an emergency intervention for rupture and 3 had an urgent intervention for impending rupture or complicated aortic dissection. The procedure was scheduled in 10 patients. The median patient age was 77 years. In 13 patients, one or more concomitant procedures were performed. In 6 patients, vascular access for endovascular aneurysm repair was obtained via a branch of the replacement graft. In 10 patients, direct cannulation of the ascending aorta was carried out using 2 pursestring sutures. RESULTS: The initial success rate was 100%. Early mortality occurred in 2 (12.5%) patients because of multiple organ failure in one and heart failure in the other. No patient required a second intervention during follow-up. The mean duration of follow-up was 19 months. CONCLUSION: The antegrade approach is a useful alternative in patients with no access suitable for endovascular aneurysm repair and who are not appropriate candidates for open conventional thoracic aortic surgery. This approach is applicable to selected patients.

Long-Term Survival After Coverage With Prevertebral Fascia for Abdominal Aortic Stump Closure.

Abdominal aortic graft-enteric fistula is an uncommon but grave complication. Acceptable early results of its management have been reported in recent years, but aortic stump disruption remains a dreaded problem in the remote period. This report describes a case of a 71-year-old male with graft-enteric fistula following after a distant abdominal aortic aneurysm repair. The patient underwent 1-stage operation with extra-anatomic bypass preceding the complete removal of the infected aortic graft and intestinal repair. For coverage of the aortic stump closure, the prevertebral fascia was harvested as a flap and was successfully used to buttress the closure. Additionally, omental wrap was secured around the stump and around the area after complete graft removal. Postoperative intravenous antibiotic with meropenem was administered for 8 weeks, followed by suppression with ongoing oral antibiotic with trimethoprim-sulfamethoxazole for 6 months. Although sigmoidectomy and the left ureteral reconstruction were required, the patient is doing well without recurrent infection and without stump disruption after 8 years of follow-up.

Meshless bubble filter using ultrasound for extracorporeal circulation and its effect on blood.

A bubble filter with no mesh structure for extracorporeal circulation using ultrasound was developed. Hemolysis was evaluated by measuring free hemoglobin (FHb). FHb in 120 mL of bovine blood was measured in acoustic standing-wave fields. With a sound pressure amplitude of 60 kPa at driving frequencies of 1 MHz, 500 kHz and 27 kHz for 15 min. FHb values were 641.6, 2575 and 8903 mg/dL, respectively. Thus, hemolysis was inhibited with higher driving frequencies when the same sound pressure amplitude was applied. An ultrasound bubble filter with a resonance frequency of 1 MHz was designed. The filtering characteristics of the flowing microbubbles were investigated with a circulation system using bovine blood with a flow rate of 5.0 L/min. Approximately 99.1% of microbubbles were filtered with 250 kPa and a flow of 5.0 L/min. Hemolysis decreased as the sound pressure decreased; FHb values were 225.8 and 490.7 mg/dL when using 150 and 200 kPa, respectively.

[Acute aortic dissection with anomalous coronary artery].

A 38-year-old man was diagnosed with acute type A aortic dissection and severe aortic regurgitation, and taken immediately to the operating room for repair of the ascending aorta using the Bentall procedure. The presence of the anomalous right coronary artery was revealed at the time of the procedure, and was repaired with single coronary button technique. Some case reports have described anomalous coronary artery in association with acute myocardiac infarction or angina pectoris. This report describes a case of anomalous coronary artery diagnosed during an emergency operation for aortic dissection.

Congestive heart failure due to coral reef thoracoabdominal aorta.

Acquired coarctation due to coral reefs is a rare and unique entity characterized by extensively calcified thrombus of the entire aorta. There are few reports of coral reef aorta resulting in severely congestive heart failure in the literature. We describe a 60-year-old female with acute heart failure. Computed tomography (CT)-scan and magnetic resonance imaging (MRI) revealed that the cause of the heart failure was cardiac after-load mismatch due to serious stenosis of the aorta. In order to prevent cardio-respiratory failure, an axillofemoral bypass was performed to release the cardiac after-load mismatch. This diminished the pressure gradient between upper and lower blood pressure that caused cardiac dysfunction.

[Application of partial median sternotomy in cardiac surgery in patients with tracheostoma].

Median full-sternotomy carries a risk of sternal infection and lethal mediastinitis in cardiac surgery. We performed open-heart surgery through partial median sternotomy in 5 patients with tracheostomy. Coronary artery bypass grafting (CABG) was performed in 3 patients, aortic valve replacement in 1, and mitral valve replacement in 1. No operative deaths or complications related to wound infection occurred. Partial sternotomy represents a safe alternative in cardiac surgery in patients with tracheostoma.

Aortoesophageal fistula due to esophageal ulcer.

Aortoesophageal fistula is a rare but fatal disease. Many such fistulas are caused by an aortic aneurysm, a previous operation, or esophageal disease. We report a case of aortoesophageal fistula due to an esophageal ulcer. A 66-year-old man suffered massive hematemesis; he was diagnosed as having an aortoesophageal fistula due to an esophageal ulcer after examination by upper endoscopy, computed tomography, and angiography. He had no aortic aneurysm, nor was there a history of a previous operation. An emergency operation was performed, but we could only accomplish closure because clamping of the aorta was impossible, and the source of the bleeding could not be established. He died 4 days later after sudden hemorrhage. Surgical outcome depends on early surgical intervention before massive hemorrhage occurs.

Antegrade selective cerebral perfusion with mild hypothermic systemic circulatory arrest during thoracic aortic surgery.

OBJECTIVE: Antegrade selective cerebral perfusion (ASCP) and retrograde cerebral perfusion (RCP) have proven to be reliable methods of brain protection during aortic surgery. These techniques are usually accompanied by systemic circulatory arrest with moderate hypothermia (24-28 degrees C) or deep hypothermia (18-24 degrees C). However, hypothermia can lead to various problems. The present study therefore reports results for thoracic aorta replacement using ASCP with mild hypothermic systemic arrest (28-32 degrees C). DESIGN: Between 1995 and 2003, 68 consecutive patients underwent repair of the ascending aorta and/or aortic arch. Mild hypothermic ASCP was utilized in 31 cases, moderate hypothermic ASCP in 20, and deep hypothermic RCP in 17. Various parameters were compared between the mild hypothermic ASCP, moderate hypothermic ASCP, and RCP. RESULTS: Hospital mortality was 10.3%, with no significant differences observed between any groups. Permanent neurological dysfunction was 8.8%, and no significant differences were observed between any groups. Mild hypothermic ASCP displayed significantly decreased transfusion volume, intubation time, and ICU stay. CONCLUSIONS: Use of ASCP with mild hypothermic systemic circulatory arrest during aortic surgery resulted in acceptable hospital mortality and neurological outcomes. ASCP with mild hypothermic arrest allows decreased transfusion volume and reduced duration of intubation and ICU stay.

Pericardial-peritoneal window for chronic exudative pericarditis using a subxiphoidal approach: report of three cases.

From August 1986 to February 2000, three patients were given a pericardial-peritoneal window using a subxiphoidal approach, for pericardial effusion associated with chronic exudative pericarditis. Complete drainage without recurrence was achieved in two patients with a large pericardial-peritoneal window (4 cm diameter) and effusion recurred in another with a small pericardial-peritoneal window (3cm diameter). No complications were encountered. The pericardial-peritoneal window, approached subxiphoidally, is a simple, safe, and effective procedure and applicable in most patients with non-infectious benign pericardial effusion. We herein describe our techniques, clinical characteristics, and the results for three patients undergoing this treatment.

Fenestrated stent-graft for traumatic juxtahepatic inferior vena cava injury.

PURPOSE: To report the use of a fenestrated stent-graft to manage a traumatic rupture of the juxtahepatic inferior vena cava (IVC). CASE REPORT: A 62-year-old man was involved in a traffic accident and hospitalized for severe right leg fractures. Computed tomography also uncovered liver contusion and retroperitoneal hematoma. The next day, he became hemodynamically unstable; a huge retroperitoneal hematoma had developed from a rupture of the juxtahepatic IVC. An emergent procedure to implant a self-expanding fenestrated stent-graft was successful in repairing the IVC injury and maintaining hepatic venous return. The patient recovered and continues in good health with a patent endograft 16 months after treatment. CONCLUSIONS: This experience supports the efficacy of fenestrated endograft implantation for emergent repair of IVC injuries, although proper facilities, an experienced interventional team, and an assortment of devices must be available.