Cardiovasc Surg Research Articles

Coil Embolization of an Aneurysmal Type B Dissection Persistent False Lumen after Visceral Hybrid Repair

Complex aortic dissections with subsequent dilatation may be managed by using a visceral hybrid approach. In some cases, however, there is substantial retrograde blood flow into the false lumen, leaving a pressurized aneurysmal segment. The authors describe a novel treatment method whereby successful seal of a distal type 1 endoleak was achieved with coil embolization and a liquid injectable embolic agent. The patient was followed up for 2 years without further aortic dilatation or complications.

Left Internal Mammary Artery Atherosclerosis: Twenty-Three Years After Repair of Aortic Coarctation

Atherosclerosis of the internal mammary artery is a rare disease. We describe a case in which a 41-year-old man underwent coronary artery bypass surgery 23 years after repair of aortic coarctation. The diseased mammary artery was used to graft the left anterior descending coronary artery after intraoperative confirmation of good patency. Early graft occlusion occurred a few days after the operation. This case demonstrates that atherosclerosis affects mammary arteries after long-term repair of aortic coarctation. Such conduits should not be used, even in the presence of good blood flow.

Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

Endovascular Treatment of Acute Type B Dissection and Kommerell’s Diverticulum

A 59-year-old man presented with severe hypertension and resistant interscapular pain. Transesophageal echocardiography and computed tomographic angiogram demonstrated acute type B dissection associated with aberrant right subclavian artery with 3.5 cm Kommerell's diverticulum. Open repair was deemed to be high risk to elevate perioperative mortality and morbidity of this surgical technique. Therefore the patient was managed with an endovascular procedure after 14 days of medical therapy because of resistant thoracic pain. We did not observe intraoperative or perioperative mortality and right arm ischemia or symptomatic subclavian steal.

Complicated acute type B aortic dissection with involvement of an aberrant right subclavian artery and rupture of a thoracoabdominal aortic aneurysm, Crawford type I: Successful emergency endovascular treatment

Although an aberrant right subclavian artery (ARSA) is the most common abnormality of aortic arch development, it is an unusual entity to encounter associated with thoracic aortic dissection. We report the successful endovascular treatment of this association in a critically ill patient. An 80-year-old man was referred to our institution with the diagnosis of an acute aortic Stanford type B dissection (Figure 1, A). The computed tomographic scan images also showed a thoracoabdominal aortic aneurysm extending from an ARSA (Figure 1, B) to the esophageal hiatus (Crawford type I). Because of persistent back pain despite correct intravenous treatment, a new computed tomographic scan was repeated 8 hours later, revealing progression of the aortic dissection and the appearance of a left-sided hemothorax. Blood analysis also showed a fall of 10 points in the hematocrit value. Because of the patient’s critical status and high surgical risk, emergency endovascular treatment was indicated. Notwithstanding, the procedure was technically demanding, because the endograft had to be deployed while avoiding occlusion of the ARSA. However, the diameter of the aortic aneurysm distal to the origin of the ARSA was greater than 46 mm, which is the maximum diameter amenable for the standard Medtronic Valiant thoracic endograft (Medtronic, Inc, Santa Rosa, Calif). Therefore, the deployment of the endoprosthesis was adjusted to the origin of the ARSA, where the thoracic aneurysm had a neck of 42 mm. A Valiant endograft, 160 mm in length and 46 mm in diameter, was deployed at the level of ARSA origin, so that its floppy FreeFlo straight portion (Figure 2, A), which is fenestrated, allowed blood flow through the artery. In this way, the flow through the aberrant artery was preserved (control computed tomographic scans, Figure 2, A and B). There were no significant variations of invasive radial pressure (<10 mm Hg) between the two arms. The patient was discharged from the hospital 6 days later. Aberrant subclavian artery, also called arteria lusoria, was first described by Bayford in 1794. It is the most common form of aortic arch anomaly and has a reported incidence of 0.5% to 2%. It results from regression of the right fourth aortic arch between the carotid and subclavian arteries.1Felson B. Cohen S. et al.Anomalous right subclavian artery.Radiology. 1950; 54: 340-349PubMed Google Scholar The association of aortic dissection and ARSA is rarely encountered; however, it has very important implications in treatment, either surgical or endovascular. A number of surgical techniques have been proposed for treatment of this pathologic condition. These include transposition or bypass of the distal portion of the aberrant artery into the adjacent carotid artery, resection of the origin of the aneurysm from the descending thoracic aorta, and repair of the aortic dissection/aneurysm with the elephant trunk technique.2Borst H.G. Walterbusch G. Schaps D. Extensive aortic replacement using “elephant trunk” prosthesis.Thorac Cardiovasc Surg. 1983; 31: 37-40Crossref PubMed Scopus (483) Google Scholar The use of partial or total cardiopulmonary bypass, hypothermia, and circulatory arrest is normally necessary. Nevertheless, endovascular therapy has revolutionized this surgery. Complex open surgical procedures may be replaced by endovascular treatment, which is associated with a lower perioperative morbidity and mortality.3Kouchoukos N.T. Masetti P. Aberrant subclavian artery and Kommerell aneurysm: surgical treatment with a standard approach.J Thorac Cardiovasc Surg. 2007; 133: 888-892Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar In this case, the very high surgical risk of the patient led us to choose an endovascular treatment. We decided to use the Valiant system, which is a third-generation endoprosthesis designed specifically for the exclusion of thoracic aortic disease.4Brooks M. Loftus I. Morgan R. Thompson M. The Valiant thoracic endograft.J Cardiovasc Surg (Torino). 2006; 47: 269-278PubMed Google Scholar Its floppy FreeFlo straight portion allowed us to deploy the endograft without occluding the ARSA and, therefore, without compromising either the right arm blood supply or the right vertebral artery flow. Dr Mosquera

Evaluation of preservation solutions by ESR-spectroscopy: Superior effects of University of Wisconsin over Histidine–Tryptophan–Ketoglutarate in reducing renal reactive oxygen species

Despite the causative role of oxidative stress in renal ischemia-reperfusion (I-R) injury effects of preservation solutions on reactive oxygen species (ROS) release have not been sufficiently evaluated. We compared the effects of most common solutions in kidney transplantation, University of Wisconsin (UW) and Histidine-Tryptophan-Ketoglutarate (HTK). ROS formation in isolated perfused rat kidney was detected by electron spin resonance spectroscopy using spin label 1-hydroxy-3-methoxycarbonyl-2,2,5,5-tetramethyl-pyrrolidine. Donor kidneys from Lewis rats were pretreated with saline (controls), in therapeutic groups, kidneys underwent 18 h of cold storage (CS) preserved by HTK or UW solution. Experimental protocol included a stabilization period followed by additional I-R. Kidneys preserved by HTK produced highest ROS values in the control period after CS, whereas levels in UW and control group did not vary significantly. A peak release induced by additional I-R was also significantly highest in HTK kidneys, and UW did not differ from controls. During reperfusion, levels in HTK exceeded control and UW values. Renal vascular resistance, caspase-3-activity, and tissue hydration were enhanced in HTK compared with UW group, whereas ATP concentration was less reduced in UW-preserved tissue. These data show the greater antioxidative potential of UW solution, which also attenuated organ impairment after CS in the early reperfusion period.

Triple thymoma with different histologic types

Clinical Summary A 72-year-old man was admitted to our university hospital after screening because three discrete masses in the anterior mediastinum were noted on his chest computed tomographic scans (Figure 1). The patient was symptom free. Results of physical and laboratory examinations, including the serum level of anti–acetylcholine receptor antibodies, were normal. Total thymectomy with removal of the three tumors was performed through a median sternotomy. The largest firm tumor (Tumor A), measuring 40 30 16 mm and adherent to the mediastinal pleura, was found at the right lower portion of the thymus. Far from it, the second tumor (Tumor B), measuring 17 17 12 mm was noted in the right upper portion, and the remaining one (Tumor C), measuring 12 12 8 mm, was detected in the left lobe of the thymus. No additional tumor was disclosed during the operation. The pathologic examinations of the resected specimens revealed that all three tumors were thymomas with histologic types that were different from each other, according to the World Health Organization classification. Tumor A had invaded the capsule of the thymoma, and the histologic finding of a proliferation of epithelial cells with relatively large and vesicular nuclei with distinct nucleoli among a heavy population of lymphocytes was compatible with type B2 thymoma. Tumor B was encapsulated, and the histologic feature was predominant lymphocytic forms with scattered plump and round to oval epithelial cells (type B1). Tumor C was also encapsulated and comprised rich lymphocytes and spindle-shaped epithelial cells without nuclear atypia (type AB). Moreover, a focus of thymic epithelial cell hyperplasia was observed in the resected thymus. No adjuvant therapy was performed, and the patient has been well without recurrence for 7 months after surgery.

Tension pneumopericardium and pneumothorax during spontaneous ventilation

Tension pneumopericardium and pneumothorax during spontaneous ventilation

Guidelines for the treatment of arterial insufficiency ulcers

1. Co-chaired panel 2. University of Utah, Salt Lake City, UT 3. University of Texas, San Antonio, TX 4. Sinai Hospital/Johns Hopkins Medical Institutions, Baltimore, MD 5. GKT School of Medicine, King’s College, London, UK 6. University of Texas Health Science Center at Houston, TX 7. Sequoia Hospital, Redwood City, CA 8. Maricopa Medical Center, Phoenix, AZ 9. Tufts-New England Medical Center, Boston, MA 10. Southampton University Hospitals Trust NHS, Southampton, UK 11. Penrose–St. Francis Health Services, Colorado Springs, CO 12. Beverly Surgical Associates, Beverly, MA 13. Saint Francis Memorial Hospital, San Francisco, CA 14. Northbay Center for Wound Care, Vacaville, CA, and 15. University of California, San Francisco, CA

Invited commentary

Invited commentary

Use of Nitric Oxide for Treatment of Pulmonary Hypertensive Crisis in a Child After Protamine Administration

PROTAMINE ADMINISTRATION may cause systemic hypotension, pulmonary hypertension, anaphylactic shock, and cardiovascular collapse. 1 Horrow J.C. Protamine: A review of its toxicity. Anesth Analg. 1985; 64: 348-361 Crossref PubMed Google Scholar , 2 Carr J.A. Silverman N. The heparin-protamine interaction A review. J Cardiovasc Surg. 1999; 40: 659-666 PubMed Google Scholar These adverse reactions are more commonly reported in adults than in children. In one recent pediatric study, 3 Seifert H.A. Jobes D.R. Ten Have T. et al. Adverse events after protamine administration following cardiopulmonary bypass in infants and children. Anesth Analg. 2003; 97: 383-389 Crossref PubMed Scopus (35) Google Scholar the only adverse reaction noted was systemic hypotension. Because severe pulmonary hypertension has rarely been noted in children after heparin reversal, the authors report a pulmonary hypertensive crisis in a child after protamine administration, which was successfully treated with nitric oxide (NO).

Lower extremity compartment syndrome after off-pump aortocoronary bypass

Lower extremity compartment syndrome after off-pump aortocoronary bypass

Combined Severe Pectus Excavatum Correction and Aortic Root Replacement in Marfan’s Syndrome

A 23-year-old man with Marfan's syndrome was admitted for repair of annulo-aortic ectasia and severe pectus excavatum. A submammary skin incision approach followed by bilateral subperichondrial resection of abnormal costal cartilages was performed. The left intercostal muscles and perichondrial sheaths were divided 2 inches lateral to the sternum in a parasternal fashion to place the retractor. The aortic root was replaced with a 23-mm St. Jude's composite graft (St. Jude Medical, Inc, St. Paul, MN). Chest wall reconstruction was completed with a high sternal osteotomy and support of the sternum was made with Gortex strips (W.L. Gore & Associates, Inc, Flagstaff, AZ). The patient made an uneventful recovery.

Off-Pump Repair of a Giant Pseudoaneurysm of a Distal Saphenous Vein Bypass Graft

Pseudoaneurysm of a saphenous vein bypass graft is a rare occurrence after coronary artery bypass grafting but may have lethal consequences. We treated a giant pseudoaneurysm of a saphenous vein graft to the right coronary artery in an 80-year-old male Jehovah's Witness who had undergone coronary artery bypass grafting 4 and a half years earlier. His history revealed a recurrent sternal wound infection. By using a venous patch to close the damaged graft, we were able to perform a successful surgical repair without the need for extracorporeal circulation.

Surgical management of acute carotid thrombosis after carotid stenting: A report of three cases

We report three cases of symptomatic acute carotid thrombosis occurring after carotid artery stenting (CAS). CASE 1: A patient presented with crescendo transient ischemic attacks on the second day after CAS. Ultrasound images demonstrated incomplete in-stent thrombosis due to plaque protrusion. The urgent surgical procedure consisted of stent removal and carotid thromboendarterectomy. CASE 2: A case of complete thrombosis of a carotid stent occurred 4 days after implantation in a patient with essential thrombocythemia diagnosed by chance. The surgical strategy included stent removal and carotid thromboendarterectomy. CASE 3: Cardiac multiple embolisms in a patient with chronic atrial fibrillation caused concomitant leg ischemia and acute carotid stent occlusion 2 hours after CAS. Cerebral reperfusion was established by embolectomy, without removing the stent. At the same time, the right leg ischemia was resolved by a thromboembolectomy with a Fogarty catheter. These three cases demonstrate that acute thrombosis after carotid stenting can be managed successfully with emergent surgical intervention. Thromboendarterectomy with stent removal or in selected cases, simple thromboembolectomy, can minimize neurologic sequelae in patients suffering from acute post-stenting carotid thrombosis.

Iliac artery thrombosis after aortic balloon counterpulsation: Treatment with intraarterial Tirofiban, manual thrombectomy and stenting

Vascular complications after aortic balloon pumping include vascular thrombosis, arterial dissection, arterial perforation, and acute inferior limb ischemia [ [1] Sirbu H. Busch T. Aleksic I. Friedrich M. Dalichau H. Ischaemic complications with intra-aortic balloon counter-pulsation: incidence and management. Cardiovasc Surg. 2000; 8: 66-71 Crossref PubMed Scopus (34) Google Scholar ].

Endoluminal repair of an acute aorto-left renal vein fistula

A 64-year-old man with hypertension presented with acute left-sided abdominal and chest pain. Notable laboratory studies included a creatinine of 2.6 mg/dL. Noncontrast computed tomography (CT) scan revealed an 8.5-cm infrarenal abdominal aortic aneurysm (AAA) with perianeurysmal stranding extending into the left renal space and a large retroaortic left renal vein. In the operating room, percutaneous transfemoral access was obtained. Aortography revealed extravasation of contrast as well as brisk filling of the inferior vena cava via a fistula to a retroaortic left renal vein (Fig, A). Exclusion of the aneurysm and the aorto-left renal vein fistula (ALRVF) was achieved after successful deployment of a 26 × 160 mm Gore Excluder bifurcated endoprosthesis with a 14.5 × 140 mm contralateral limb (Fig, B) (W.L. Gore & Associates Inc, Falstaff, Ariz). After complete exclusion of the aneurysm, the patient's hemodynamics improved immediately, with a decrease in the central venous pressure (CVP) from 42 to 20 mm Hg, an increase in blood pressure from 95/40 to 135/60, and a decrease in heart rate from 100 to 84 beats per minute. Percutaneous mechanical closure devices (Prostar XL, Perclose; Abbott Laboratories Co, Redwood City, Calif) were used to close both common femoral arteriotomies. Postoperatively, the patient was observed in the intensive care unit overnight and was discharged home the next day with a CVP of 7 mm Hg and a creatinine of 1.3 mg/dL. Follow-up imaging will include a CT scan at one month, six months, and then annually. 1 Eskandari M.K. Yao J.S.T. Pearce W.H. Rutherford R.B. Veith F.J. Harris P. et al. Surveillance after endoluminal repair of abdominal aortic aneurysms. Cardiovasc Surg. 2001; 9: 469-471 Crossref PubMed Scopus (22) Google Scholar

Anesthetic implications of surgical repair of an aortocaval fistula

Arteriovenous fistulas (AVF) deprive the surrounding tissues of blood supply and nutrients, produce venous hypertension and localized edema, and by overloading the heart can cause congestive heart failure. Clinical manifestations of the AVF depend on its size, its locality, and the presence or absence of concomitant cardiac disease. Aortocaval fistula (ACF) is a recognized complication of an abdominal aortic aneurysm (AAA). 1 Brewster DC Cambria RP Moncure AC et al. Aortocaval and iliac arteriovenous fistulas: Recognition and treatment. J Vasc Surg. 1991; 13: 253-265 Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar Numerous studies published in the surgical journals document significant hemodynamic changes in the presence of ACF. These are a significant reduction in systemic vascular resistance (SVR), <500 dynes.sec.cm−5; a remarkable increase in the cardiac output up to 12 to 15 L/min; and a significant increase in cardiac filling pressures. 2 Ghilardi G Scorza R Bortolani E et al. Rupture of abdominal aortic aneurysms into the major abdominal veins. J Vasc Surg. 1993; 34: 39-47 Google Scholar , 3 Salo JA Verkkala K Ketonen P et al. Diagnosis and treatment of spontaneous aortocaval fistula. J Cardiovasc Surg. 1987; 28: 180-183 PubMed Google Scholar These hemodynamic alterations are reversed by the surgical or endovascular repair of the fistula. 4 Sharma ML George KA Gamble JAS Anesthetic implications of endovascular repair of aortocaval fistula. Anaesthesia. 2000; 55: 697 Crossref PubMed Scopus (5) Google Scholar This sudden normalization of the afterload, 500 dynes.sec.cm−5 to 1,200 dynes.sec.cm−5, and the mobilization of edema fluid can further compromise the already stressed heart. A review of the literature revealed no detailed information on the anesthetic management of patients with ACF. The authors report management of a patient with ACF who presented for its repair.

Clinical microbiological case: an 81-year-old woman with fever and a cervical mass

Clinical microbiological case: an 81-year-old woman with fever and a cervical mass

Intraoperative OctreoScan and Management of Bronchial Carcinoid

We read with interest the article of Rodriguez et al (March 2002), 1 Rodriguez JA Meyers MO Jacome TH et al. Intraoperative detection of a bronchial carcinoid with a radiolabeled somatostatin analog. Chest. 2002; : 985-988 Abstract Full Text Full Text PDF Scopus (26) Google Scholar in which they pointed out the importance of 111In-diethylenetriamine pentaacetic acid pentetreotide (OctreoScan; Mallinckrodt-Tyco; St. Louis, MO) scintigraphy in the preoperative diagnosis and intraoperative management of bronchial carcinoid. In 1997, we 2 Oliaro A Filosso PL Bello M et al. Use of 111In-DTPA-octreotide scintigraphy in the diagnosis of neuroendocrine and non-neuroendocrine tumors of the lung: preliminary results. J Cardiovasc Surg. 1997; 38: 313-315 PubMed Google Scholar published our preliminary results about our experience with OctreoScan in the preoperative diagnosis and postoperative follow-up of neuroendocrine and nonneuroendocrine tumors of the lung. OctreoScan is effective in detecting both primary neuroendocrine bronchial tumors and their mediastinal metastases with higher accuracy than thoracic CT scan. Positive scintigraphy results in nonneuroendocrine lung tumors (especially in undifferentiated large cell carcinomas) are probably due to the presence of activated lymphocytes surrounding the surface of the tumor. 2 Oliaro A Filosso PL Bello M et al. Use of 111In-DTPA-octreotide scintigraphy in the diagnosis of neuroendocrine and non-neuroendocrine tumors of the lung: preliminary results. J Cardiovasc Surg. 1997; 38: 313-315 PubMed Google Scholar We demonstrated how OctreoScan was effective in the diagnosis of liver metastases of resected atypical carcinoid with carcinoid syndrome 3 Filosso PL Ruffini E Rena O et al. Long-term survival of atypical bronchial carcinoids with liver metastases, treated with octreotide. Eur J Cardiothorac Surg. 2002; 21: 913-917 Crossref PubMed Scopus (80) Google Scholar ; a positive OctreoScan result can, in addition, influence medical therapy with octreotide or lanreotide (two current generations of somatostatin analogs) because of the expression of the tumor tissue receptors for somatostatin. 3 Filosso PL Ruffini E Rena O et al. Long-term survival of atypical bronchial carcinoids with liver metastases, treated with octreotide. Eur J Cardiothorac Surg. 2002; 21: 913-917 Crossref PubMed Scopus (80) Google Scholar