Endovascular Therapy for Distal Superior Mesenteric Artery Mycotic Aneurysms due to Infective Endocarditis.

Purpose: To report 3 patients with infective endocarditis who underwent transcatheter arterial embolization for mycotic aneurysm of the distal superior mesenteric artery (SMA). Case Report: Three men (60, 64, and 65 years old) were diagnosed with infective endocarditis. Antibiotics were initiated immediately after admission and continued for several weeks to months. Distal SMA mycotic aneurysm was identified on computed tomography in the vicinity of the ileocolic artery at 33, 26, and 30 days after admission. In case 1, the ileal artery was occluded distal to the aneurysm, with collateral flow to the ileum. In case 2, the mycotic aneurysm was located below the ileocolic artery, which was stenosed distal to the lesion. In case 3, the aneurysm was located on a branch of the ileal artery. Transarterial embolization using microcoils was successfully performed in all patients. No complications associated with embolotherapy or relapse of infection were observed in these 3 patients at 60, 30, and 15 months, respectively. Conclusion: Transcatheter arterial embolization for distal SMA mycotic aneurysm could provide an alternative to open surgery. Anatomical assessment of collateral flow and preprocedure long-term antibiotic therapy could play important roles in preventing bowel ischemia and minimizing the risk of infection relapse.

Treatment of infected thoracic aortic aneurysm with combined abscess debridement and stent-graft wrapping using pedicled latissimus dorsi muscle flaps after thoracic endovascular aortic repair.

BACKGROUND: Open thoracic surgery (with infected lesion removal, prosthetic graft replacement, and pedicled tissue flap) has remained the main treatment for infected thoracic aortic aneurysms to date. Recent reports have highlighted good prognostic outcomes with thoracic endovascular aortic repair. However, thoracic endovascular aortic repair for infected thoracic aortic aneurysms is associated with an exacerbation of infection due to residual infected tissues. We discuss the control of refractory infections following endovascular treatment of infected thoracic aortic aneurysms. CASE PRESENTATION: An 81-year-old man, with a history of insulin-dependent diabetes mellitus and pancreaticoduodenectomy, presented to our emergency department with a fever. Blood tests revealed a markedly elevated leukocyte count, and contrast-enhanced computed tomography suggested a descending thoracic aortic pseudoaneurysm. We diagnosed the patient with an infected descending thoracic aortic aneurysm, and performed urgent thoracic endovascular aortic repair; he was started on an intravenous antibiotic treatment. Postoperatively, blood tests revealed a decreased leukocyte count and the patient remained afebrile. However, computed tomography revealed temporal enlargement of the abscess cavity; therefore, an abscess debridement and stent graft wrapping with pedicled latissimus dorsi muscle flaps were performed, which successfully controlled the infection. Six weeks after abscess debridement, the patient was switched to an oral antibiotic therapy. There was no evidence of recurrence of infection 8 months after the surgery. CONCLUSIONS: A combined abscess debridement and pedicled tissue flap approach is useful for patients with poor surgical tolerance in whom infection control is difficult after thoracic endovascular aortic repair for infected thoracic aortic aneurysms. Pedicled latissimus dorsi muscle flaps are useful when using the omentum for pedicled tissue flap is difficult.

Left brachiocephalic venous occlusion with spontaneous arteriovenous fistula presenting with severe edema in left upper extremity and face: A case report.

INTRODUCTION AND IMPORTANCE: The coexistence of central venous occlusion and arteriovenous fistulas (AVF) is rare among non-dialysis patients. Herein, we describe a case of left brachiocephalic venous occlusion with spontaneous AVF, presenting with severe edema in left upper extremity and face. CASE PRESENTATION: A 90-year-old woman presented to our hospital with gradually worsening edema in her left arm and face for eight years. Contrast-enhanced computed tomography revealed left brachiocephalic venous occlusion and severe edema in her left upper extremity and face. Computed tomography also revealed abundant collateral veins; thus, it seemed unnatural for severe edema to occur with such well-developed collateral pathways. Therefore, the presence of AVF was suspected. After careful re-examination of the patient, a continuous murmur was heard in the post-auricular region. Magnetic resonance imaging and angiogram revealed a dural AVF. Considering the patient's age and treatment difficulty for the dural AVF, we performed a stent insertion into the left brachiocephalic vein. After the procedure, edema in her left upper extremity and face improved dramatically. CLINICAL DISCUSSION: In cases of persistent swelling of the upper extremities or face, there could be a factor that increases venous inflow. Therefore, any condition that may increase venous inflow must be aggressively investigated and therapeutic interventions should be applied to treat such conditions. CONCLUSION: Central venous occlusion and AVF is a possible underlying cause for severe refractory edema in the upper extremity and face. Therefore, both AVF and brachiocephalic occlusion should be assessed for treatment indications under these conditions.

Aortic injury repair in a patient with situs inversus totalis and dextrocardia.

Situs inversus totalis (SIT) with dextrocardia is a rare autosomal recessive disorder. We herein describe a blunt thoracic aortic injury (BTAI) in a patient with SIT and dextrocardia. An 18-year-old girl who was injured by a fall presented to our hospital. Computed tomography (CT) revealed a traumatic pseudoaneurysm at the aortic isthmus. Open aortic repair was performed through a right thoracotomy. No abnormal findings were observed on CT 1 year after the surgery. Open aortic repair of BTAI can be safely performed through a right thoracotomy in patients with SIT and dextrocardia.

Diagnosis and treatment of isolated celiac artery dissection following blunt trauma: A case report.

INTRODUCTION: Celiac artery (CA) dissection due to blunt abdominal trauma is extremely rare and, as such, the clinical features of this potentially life-threatening injury have not been clearly defined, nor have treatment strategies been established. PRESENTATION OF CASE: We describe the case of a 61-year-old man who presented to our emergency department after a motor vehicle accident. Although the patient did not report abdominal pain, enhanced computed tomography (CT) revealed CA dissection. The patient was treated conservatively using antiplatelet therapy and was discharged from the hospital on day 8, without complications. DISCUSSION: As abdominal pain is not a common presenting factor of CA dissection after blunt trauma, it should be suspected as a potential injury in all affected patients and comprehensively assessed, with CT being the most useful diagnostic modality. CONCLUSION: In the absence of any signs of organ ischemia, changes in the CA aneurysm, and persistent, severe abdominal pain following blunt abdominal trauma, conservative treatment is indicated, with or without anticoagulation or antiplatelet therapy.

Unilateral Left Pulmonary Edema Caused by Contained Rupture of the Ascending Aortic Dissection.

Unilateral pulmonary edema (UPE) is a rare entity and is usually associated with severe mitral regurgitation and more frequently occurs in the right lung. We herein report a case of unilateral left pulmonary edema caused by external compression of the right pulmonary artery and left pulmonary vein caused by the presence of hematoma due to type A acute aortic dissection (AAD), resulting in asymmetrically increased inflow and decreased outflow in the left pulmonary circulation. Physicians caring for patients with UPE should be aware that AAD leading to the external compression of the heart may be a possible underlying mechanism.

Coronary Artery Embolism Caused by BioGlue Surgical Adhesive After Type A Acute Aortic Dissection Repair.

Coronary artery embolism due to BioGlue surgical adhesive after repair of type A acute aortic dissection is a rare condition. We report a case of BioGlue coronary artery embolism after type A acute aortic dissection repair confirmed using intravascular ultrasound imaging and pathological examination. It was successfully treated with percutaneous coronary intervention. (Level of Difficulty: Advanced.).

Early onset bioprosthetic tricuspid valve stenosis in a case with cardiac sarcoidosis: Pathological findings based on autopsy.

A 60-year-old woman with cardiac sarcoidosis developed recurrent and refractory right heart failure 26 months after tricuspid valve replacement. Echocardiography revealed thickened and immobile cusp with increased diastolic tricuspid gradient of 8-10 mmHg, consistent with bioprosthetic tricuspid stenosis (TS). Prolonged intravenous injection of dobutamine and carperitide, with intermittent intravenous furosemide, was necessary at multiple times. Despite treatment, the patient died of refractory right heart failure. The explanted tricuspid bioprosthesis on autopsy revealed marked pannus formation, resulting in stiff and immobile cusps while the same mitral bioprosthesis, which was implanted on the same day, was normal. Sarcoid granulomas were not present either in tricuspid or mitral bioprostheses. Chronic valve inflammation associated with prolonged use of intravenous drugs and multiple episodes of line-associated bacteremia may have caused early onset bioprosthetic TS. Learning objectives:1Early onset bioprosthetic tricuspid stenosis (TS) is rare.2Elevated jugular venous pulse and pan-diastolic rumble with the Rivero-Carvallo sign are keys to the diagnosis of TS which is confirmed using echocardiography.3Repeated episodes of bacteremia associated with prolonged infusion of intravenous drugs might have contributed to the development of early onset bioprosthetic TS.

Acute Aortic Dissection Masquerading as Acute Pericarditis.

We herein report 3 cases of acute aortic dissection (AAD) in which the initial 12-lead electrocardiogram showed typical ST elevation consistent with acute pericarditis. All patients exhibited small pericardial effusion but did not suffer from rupture into the pericardium or clinical tamponade. Slow leakage or exudate stemming from the dissecting hematoma appeared to have caused inflammation, resulting in pericarditis. Therefore, we highlight the fact that AAD may masquerade as acute pericarditis. Physicians should be aware of the possibility of type A AAD as an important underlying condition, since the early diagnosis and subsequent surgical treatment may save patients' lives.

Herniation of the transverse colon into the mediastinum after the use of an omental flap for mediastinitis.

We describe a rare complication, transverse colon herniation into the mediastinum, after the use of an omental flap. Adequate separation of the transverse colon from the omental flap and ensuring that the incision in the diaphragm is as small as possible are important preventive measures.

Aorto-right pulmonary venous fistula after mitral valve replacement for prosthetic mitral valve infective endocarditis: a case report.

BACKGROUND: Aorto-cavitary fistula is a rare condition, and the most common underlying aetiology is infective endocarditis (IE) of the native or the prosthetic aortic valve. We report a case of aorto-right inferior pulmonary venous fistula following redo mitral valve replacement (MVR) for prosthetic mitral valve IE. CASE SUMMARY: A 74-year-old woman underwent urgent redo MVR for prosthetic mitral valve IE. The post-operative course was complicated with heart failure and mediastinal haematoma compressing the left atrium. The haematoma was surgically removed and laceration of the left atrial wall was suture ligated; this was attributed to the surgical trauma dissection of the adhesive tissues. One-week post-operatively, a continuous murmur emerged, which prompted an evaluation of the left to right shunt. Transthoracic echocardiography revealed an echolucent area posterior to the aorta, with continuous flow on colour Doppler. Three-dimensional computed tomography showed a fistula between the aorta and the right inferior pulmonary vein. There was a high risk involved in surgical management; therefore, she was managed medically. Fortunately, the continuous murmur and echolucent space disappeared after 6 months. The fistula was considered to be obstructed by spontaneous thrombus formation in the narrowed segment of the fistula tract. DISCUSSION: The cause of fistula was attributed to possible surgical trauma in the presence of infection. The present case was unique, as it showed spontaneous healing of an aorto-cavitary fistula, which is very rare. The patient was alive with good health status, 6 years after the MVR.

Factors Associated with Secondary Functional Patency After Percutaneous Transluminal Angioplasty of the Early Failing or Immature Hemodialysis Arteriovenous Fistula.

PURPOSE: To evaluate the efficacy of percutaneous transluminal angioplasty for early failing hemodialysis arteriovenous fistulas (AVFs) and predictors of secondary functional patency (FP). METHODS: A review of our endovascular registry database showed that 61 patients with early failure after a surgically created AVF underwent endovascular intervention between 2011 and 2016. Median time from AVF creation to first intervention was 5.6 weeks. Median duration of follow-up was 14 months. Items related to the technical success rate and primary and secondary FP, and factors associated with secondary FP were analyzed. RESULTS: Technical success was achieved in 55 (90%) of 61 patients. The primary and secondary FP rates were 42% and 65% at 12 months, respectively. Multivariate analysis showed that lesion length (HR; 1.15, P = 0.001) and lesions including juxta-AVF (the portion of fistula vein within 2 cm of the arteriovenous anastomosis, HR; 6.23, P = 0.008) were factors associated with reduced secondary FP. ROC curve analysis indicated lesion length with cutoff value ≥ 9 cm as a risk factor for reduced secondary FP. Secondary FP at 12 months for patients with no risk factors, with 1, and with 2 was 86%, 65%, and 0%, respectively. There was a significant difference in secondary FP rates among these groups (P = 0.001). CONCLUSIONS: A lesion length and juxta-AVF lesion are the risk factors for reduced secondary FP. The secondary FP rate at 12 months is acceptable in patients without risk factors.

Bioprosthetic tricuspid valve stenosis: a case series.

BACKGROUND: Bioprosthetic tricuspid valve stenosis is a late sequela of tricuspid valve replacement (TVR); however, detailed information regarding its clinical picture is lacking. CASE SUMMARY: Thirty-one patients with bioprosthetic TVR (mean age: 60.5 ± 16.6 years, male/female: 11/20) were followed-up for 79.5 ± 49.1 months (14-188 months). Eleven patients developed bioprosthetic tricuspid valve stenosis (mean tricuspid gradient >5 mmHg) at a median interval of 96 months (interquartile range: 61-114 months). The mean tricuspid gradient at the time of tricuspid valve stenosis diagnosis was 10.9 ± 3.9 mmHg. Although the mid-term tricuspid valve stenosis-free survival was favourable (92.4% at 60 and 78.7% at 84 months), it had declined steeply to 31.5% by 120 months. Ten out of 11 tricuspid valve stenosis patients showed signs of right heart failure (RHF) as manifested by oedema and elevated jugular venous pressure, requiring moderate-to-high doses of diuretics. Diastolic rumble was audible in 10 patients. Five of the 11 tricuspid valve stenosis patients required redo TVR as a result of refractory RHF. Examination of the five excised bioprostheses showed pannus in four, fusion of the commissure in three, native valve attachment in two, and sclerosis in one. Detailed clinical pictures and pathology of the explanted valves in three cases that underwent surgery are presented in this case series. DISCUSSION: Bioprosthetic tricuspid valve stenosis is not uncommon after 8 years. Tricuspid valve replacement performed at the second surgery was associated with a higher incidence of bioprosthetic tricuspid valve stenosis.

Successful transcatheter arterial embolization of a ruptured right gastroepiploic artery aneurysm: A case report.

BACKGROUND: Gastroepiploic artery aneurysms (GEAAs) are extremely rare. Ruptured GEAAs are related to high mortality and often treated by open surgery. We describe a case of a ruptured right GEAA that was successfully treated by transcatheter arterial embolization (TAE). PRESENTATION OF CASE: An 80-year-old woman presented to the emergency department with sudden abdominal pain. We diagnosed her as having a ruptured right GEAA based on the contrast-enhanced computed tomography finding. We performed TAE for the GEAA after resuscitation. The patient had an uneventful recovery and was discharged 10 days after TAE. DISCUSSION: A ruptured GEAA causes high mortality; thus, immediate and adequate treatment is mandatory. Previously, many cases of successful surgical resections of ruptured GEAAs have been reported. In our case, we decided that the patient was not suitable for surgery because of her advanced age and bronchiectasis; therefore, we performed TAE and had a good outcome. CONCLUSION: In patients at high risk for surgery, TAE can be an effective treatment for a ruptured GEAA.

Mitral valve replacement for Libman-Sacks endocarditis in a patient with antiphospholipid syndrome secondary to systemic lupus erythematosus.

Libman-Sacks endocarditis is a relatively rare sterile verrucous vegetative lesion observed in systemic lupus erythematosus (SLE)/antiphospholipid syndrome (APLS) patients. Most patients with this condition are asymptomatic. Here we report a case of a 46-year-old woman with APLS secondary to SLE complicated with frequent thromboembolic events due to a mitral valve mass. We performed minimally invasive mitral valve replacement with a mechanical prosthetic valve, and she was successfully discharged 14 days after surgery. Thus, Libman-Sacks endocarditis may be an indication for mitral valve replacement.

Infective endocarditis associated with Bartonella henselae: A case series.

Organisms in the genus Bartonella are cause of blood culture-negative endocarditis. Bartonella infective endocarditis is being increasingly reported worldwide; however, reports from Japan are limited. Here, we report five cases of infective endocarditis associated with Bartonella henselae. All patients had a history of contact with cats or fleas; this information helped achieve an appropriate diagnosis.

Primary aortoduodenal fistula: A case report and review of literature.

BACKGROUND: Primary aortoduodenal fistula (PADF) is an abnormal connection between the aorta and the duodenum and is a life-threatening condition. It is a very rare cause of gastrointestinal bleeding, which often leads to delay in its diagnosis. Prompt diagnosis and surgical treatment are crucial to improve the outcome of patients with PADF. PRESENTATION OF CASE: An 82-year-old man with a history of untreated abdominal aortic aneurysm (AAA) presented to the emergency department with hematemesis. Computed tomography (CT) revealed an AAA with air within the thrombus wall and disruption of the fat layer between the AAA and duodenum, indicating PADF. Emergent surgery, in situ aortic reconstruction using a Dacron graft, and omental coverage were performed. Although the patient needed another surgery for postoperative chylous ascites, he made good recovery and was discharged 86 days after initial surgery. DISCUSSION: In our case, the patient presented with hematemesis and a pulsatile abdominal mass on physical examination and had a history of untreated AAA, which helped in prompt diagnosis of PADF. CT findings suggesting PADF include disappearance of the fat plane between the aneurysm and duodenum, air in the retroperitoneum or within the aortic wall, and contrast enhancement within the duodenum. The recommended surgical approach for PADF consists of aortic reconstruction (in situ aortic reconstruction or extra-anatomical bypass) and duodenal repair. CONCLUSION: Our report affirms that CT and open surgery are effective diagnostic and treatment options, respectively, for PADFs.

Dynamic left ventricular outflow obstruction in situs inversus with levocardia.

A 69-year-old man with situs inversus, levocardia and inverted great arteries developed severe dynamic left ventricular outflow tract (LVOT) obstruction with systolic anterior motion of the anterior mitral leaflet. There was no asymmetric septal hypertrophy. A possible mechanism of the LOVT obstruction in the present case may have been related to an abnormally long and bent outflow tract resulting from overriding of the right ventricle over the LVOT due to a congenital malposition of the heart. Mitral valve replacement with septal myectomy was performed in order to eliminate systolic anterior motion. The postoperative course has been excellent.

Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room.

BACKGROUND: Initial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD. METHODS: We conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test. RESULTS: An IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01-6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14-36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39-9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001). CONCLUSIONS: WI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.