Saphenous Vein Bypass Grafts Research Articles

Coronary Microembolization

Coronary microembolization from the erosion or rupture of a vulnerable atherosclerotic plaque occurs spontaneously in acute coronary syndromes and iatrogenically during percutaneous coronary interventions. Typical consequences of coronary microembolization are microinfarcts with an inflammatory response, contractile dysfunction, and reduced coronary reserve. Apart from transient elevations of creatine kinase and troponin, microemboli can be visualized by intracoronary Doppler and the resulting microinfarcts by late-enhancement nuclear magnetic resonance. Statins, antiplatelet agents, and coronary vasodilators protect against microembolization and microinfarction when started before percutaneous coronary interventions. Distal protection devices can retrieve atherothrombotic debris and prevent its embolization into the microcirculation, but their effect on clinical outcome has been disappointing so far, except for saphenous vein bypass grafts. Devices for aspiration of thrombi and thrombus-derived vasoconstrictor, thrombogenic, and inflammatory substances, however, reduce thrombus burden, improve perfusion, and provide protection in patients with acute myocardial infarction.

TCT-391: Percutaneous intervention on the Saphenous Vein Bypass graft- A Meta Analysis of Drug Eluting stents compared to the use of Bare metal stents

TCT-391: Percutaneous intervention on the Saphenous Vein Bypass graft- A Meta Analysis of Drug Eluting stents compared to the use of Bare metal stents

In vivo human lower extremity saphenous vein bypass grafts manifest flow mediated vasodilation

As in arteries, venous endothelium modulates vessel homeostasis and tone. The effect of an arterialized environment on venous endothelial function remains poorly understood. In particular, regulation of saphenous vein graft (SVG) blood flow and lumen caliber remains undefined. We hypothesized that mature SVGs would exhibit endothelium-dependent, flow-mediated vasodilation (FMD). We further hypothesized that endothelium-derived nitric oxide (NO) was an important mediator. Patients with femoral to popliteal artery SVGs that had maintained primary patency and were at least 1 year from surgery were enrolled. High-resolution, B-mode ultrasound scans were used to measure vein graft diameter before and 1 minute after reactive hyperemia (RH) to determine FMD. RH was created through application of 220 mm Hg to the calf for 5 minutes with a sphygmomanometric cuff. After a 10-minute recovery period, nitroglycerin-mediated, endothelium-independent vasodilation was measured 3 minutes after administration of nitroglycerin 0.4 mg sublingually. Brachial artery FMD was determined by validated techniques. L-N(G)monomethyl arginine (L-NMMA; 1 mg/kg infusion over 10 minutes) was used in a subset of patients (n = 6) to competitively inhibit endothelial NO synthase. Nineteen subjects were enrolled. The median age of the SVGs was 34.6 (21.0-49.7) months. SVG flow-mediated, endothelium-dependent vasodilation was measured at 5.28% +/- 3.1% mean change in lumen diameter (range, 1.99%-9.36%; P < .0001 for diameter change). Nitroglycerin-mediated vasodilation was 3.7% +/- 1.0%, (range, 16%-10.04%; P < .005). Intravenous administration of L-NMMA abolished SVG FMD (5.7 +/- 1.4% before L-NMMA vs 0.01 +/- 0.01% during L-NMMA infusion; P = .0088) and attenuated brachial artery FMD (7.54% +/- 1.0% vs 5.7 +/- 1.4; P = .05). SVGs manifest flow-mediated, endothelium-dependent, and nitroglycerin-mediated endothelium-independent vasodilation. Vein graft endothelium-dependent FMD is likely mediated by NO. Further investigation will be required to determine the role of endothelial function in vein graft patency.

Intervenção coronária percutânea em pontes de veia safena com uso de stents farmacológicos: resultados agudos e tardios dos pacientes incluídos no registro DESIRE

INTRODUÇÃO: Mesmo com o advento dos stents farmacológicos, a intervenção coronária percutânea em pontes de veia safena permanece desafiadora, com elevada incidência de complicações agudas e incerteza dos resultados tardios. Neste estudo, buscamos avaliar os resultados clínicos de pacientes com lesões em pontes de veia safena tratados com stents farmacológicos. MÉTODO: Entre maio de 2002 e janeiro de 2009, 151 pacientes com 196 lesões em pontes de veia safena foram consecutivamente submetidos a intervenção coronária percutânea com 211 stents farmacológicos e incluídos neste estudo. Os pacientes foram pré-tratados com enoxaparina, clopidogrel e ácido acetilsalicílico por 3 a 5 dias antes da intervenção coronária percutânea. A terapia antiplaquetária dupla (ácido acetilsalicílico + clopidogrel) foi prescrita por 12 meses. Objetivou-se determinar as taxas de eventos cardíacos adversos maiores (ECAM) no período hospitalar e na fase tardia. Seguimento clínico foi obtido com 1, 6 e 12 meses e, então, anualmente. RESULTADOS: A média de idade da população avaliada foi de 68,2 anos, com predominância do sexo masculino (89,1%). Diabetes melito foi observado em 30,7% dos casos e a média de idade dos enxertos venosos foi de 10,4 anos. Sucesso angiográfico foi obtido em 98,2% dos casos. Na fase hospitalar, a taxa de ECAM foi de 8,7%, sobretudo à custa de elevação enzimática pós-procedimento (7,1%). No primeiro ano de evolução, a taxa de ECAM elevou-se para 14,2%, com 3,9% de nova revascularização da lesãoalvo. No seguimento mais tardio (média de 2,6 anos), a taxa de ECAM atingiu 28,5%, com 6% de óbito cardíaco e 16,6% de infarto agudo do miocárdio. Nessa população, foram observados 5 casos de trombose (todos definitivos). CONCLUSÃO: Na presente subanálise do Registro DESIRE, o uso da terapêutica antitrombótica otimizada (ácido acetilsalicílico + tienopiridínico + heparina de baixo peso, por 3 a 5 dias pré-intervenção) e o uso de stents farmacológicos para o tratamento de pontes de veia safena correlacionaramse com excelentes desfechos clínicos imediatos e no primeiro ano pós-intervenção percutânea. No entanto, após o primeiro ano, tais resultados sofrem marcante deterioração, refletindo o caráter mais agressivo da doença vascular nos condutos venosos. As taxas de trombose podem ser consideradas baixas, favorecendo a segurança desses instrumentais em tão complexo cenário.

Management of traumatic brachial artery injuries: A report on 49 patients

BACKGROUND AND OBJECTIVE:The brachial artery is the most frequently injured artery in the upper extremity due to its vulnerability. The purpose of our study was to review our experience with brachial artery injuries over a 9-year period, describing the type of injury, surgical procedures, complications, and associated injuries.PATIENTS AND METHODS:Forty-nine patients with brachial artery injury underwent surgical repair procedures at our hospital, from the beginning of May 1999 to the end of June 2008. The brachial artery injuries were diagnosed by physical examination and Doppler ultrasonography. Depending on the mode of presentation, patients were either taken immediately to the operating room for bleeding control and vascular repair or were assessed by preoperative duplex ultrasonography.RESULTS:This study group consisted of 43 males and 6 females, ranging in age from 6 to 65 years with a mean (SD) age of 27.9 (6.7) years. The mechanism of trauma was penetrating in 45 patients and blunt in the remaining 4 patients. Stab injury was the most frequent form of penetrating trauma (24 of 45). Treatment included primary arterial repair in 5 cases, end-to-end anastomosis in 28 cases, interposition vein graft in 15 cases, and interposition-ringed polytetrafluoroethylene graft in 1 case. Associated injuries were common and included venous injury (14), bone fracture (5), and peripheral nerve injury (11). Fifteen patients developed postoperative complications. One patient underwent an above-elbow amputation.CONCLUSIONS:Prompt and appropriate management of the brachial artery injuries, attention to associated injuries, and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage.

Four-year safety and efficacy of the unrestricted use of sirolimus- and paclitaxel-eluting stents in coronary artery bypass grafts

Recently, concerns were raised about the relative long-term safety and efficacy of drug-eluting stents (DES) in saphenous vein bypass grafts (SVG). Our objective was to assess the 4-year relative safety and efficacy of the unrestricted use of drug-eluting stents (DES) as compared to bare metal stents (BMS) in saphenous vein bypass grafts (SVG). Between April 16, 2002 and December 2005 a total of 122 consecutive patients were treated with either sirolimus- or paclitaxel-eluting stents for saphenous vein graft disease. These patients were compared with 128 consecutive patients treated with BMS in the immediate preceding period (January 1, 2000 to April 2002). At 4-years the cumulative survival rate in the DES group was 77.5% versus 73.0% in the BMS group (adjusted HR 1.09; 95% CI 0.63-1.90, Logrank p=0.65). The cumulative survival free of major adverse cardiac events (MACE: death, myocardial infarction and target vessel revascularisation) was 61.5% vs. 46.8% in the DES and BMS groups respectively (adjusted HR 0.77, 95% CI; 0.51-1.16) due to a higher event free survival of clinically driven target vessel revascularisation in the DES group as compared to the BMS group (81.6% vs. 69.0%; adjusted HR 0.53; 95% CI 0.27-1.05). In the present study, the use of DES for SVG PCI was associated a similar safety profile and there was a trend towards lower rates of TVR and MACE at four years as compared to BMS.

The Impact of Diabetic Status on Coronary Artery Bypass Graft Patency

Despite worse outcomes in diabetics after coronary artery bypass grafting surgery, studies have not examined graft patency in this high-risk group. This study examined the impact of diabetes on graft patency, 1-year postcoronary artery bypass grafting, using data from a multicenter randomized trial. The Radial Artery Patency Study enrolled 561 patients undergoing coronary artery bypass grafting, comparing graft patency of the saphenous vein (SV) versus radial artery 1-year postcoronary artery bypass grafting. Angiographic follow-up was acquired for 440 patients (115 diabetics, 325 nondiabetics), each with a study radial artery and a control SV graft. Preoperative characteristics were similar. The proportion of small-sized target vessels was greater in diabetics (P=0.04). At 1 year, 33 of 230 study grafts (14.4%) were occluded in the diabetics versus 63 of 650 (9.7%) in the nondiabetics (P=0.052). Multivariable regression found diabetes to be a significant independent predictor of 1-year graft occlusion (relative risk, 1.45; 95% CI, 1.03 to 2.05; P=0.03) along with female gender, SV conduit, and small target-vessel size. A significantly higher proportion of SV grafts were occluded in the diabetics (19% versus 12%, P=0.04). Radial artery grafting was protective in the diabetic cohort (radial artery: 11 of 115 occluded [9.5%] versus SV: 22 of 115 occluded [19.1%], McNemar corrected P=0.05; relative risk, 0.42; 95% CI, 0.16 to 1.01) and nondiabetics (radial artery: 25 of 325 occluded [7.7%] versus SV: 38 of 325 occluded [11.7%], McNemar corrected P=0.11; relative risk, 0.63; 95% CI, 0.35 to 1.10). Coronary artery bypass grafting occlusions were more common among diabetics versus nondiabetics at 1-year angiography, mainly because of more frequent SV graft failure in diabetics. Radial artery, compared with SV grafting, is protective in both diabetic and nondiabetic patients.

Pathophysiology of Aortocoronary Saphenous Vein Bypass Graft Disease

Aortocoronary saphenous vein bypass grafting relieves anginal pain in patients with coronary artery disease. However, its effectiveness is limited due to graft failure; the 10-year patency rate is 50%-60%. Early, 1-year and late graft failure may be due to thrombosis, fibrointimal hyperplasia and atherosclerosis, respectively. There is general agreement that vein graft atherosclerosis differs from arterial lesions in terms of temporal and histological changes. Vein graft atherosclerosis is more rapid, with diffuse concentric changes and a less noticeable fibrous cap, making venous plaques more vulnerable to rupture and subsequent thrombus formation. Despite progress in understanding the pathophysiology, some aspects of vein graft atherosclerosis need to be clarified. This review focuses on the pathophysiologic aspects of this widespread, costly and disabling disease, with emphasis on late graft occlusion and distinctions between arterial and venous atherosclerosis in terms of histology, pathophysiology and risk factors.

Invited Commentary

Invited Commentary

TRAIL Stimulates Proliferation of Vascular Smooth Muscle Cells via Activation of NF-κB and Induction of Insulin-like Growth Factor-1 Receptor

TRAIL/Apo2L (tumor necrosis factor-related apoptosis-inducing ligand) is a multifunctional protein regulating homeostasis of the immune system, infection, autoimmune diseases, and apoptosis. However, its function in normal, nontransformed tissues is not clear. Here we show that TRAIL increases vascular smooth muscle cell (VSMC) proliferation in vitro, effects that can be blocked with neutralizing antibodies to TRAIL receptors DR4 and DcR1. In aortocoronary saphenous vein bypass grafts in vivo, TRAIL co-localizes with VSMC, proliferating cell nuclear antigen, and insulin-like growth factor type 1 receptor (IGF1R) expression but not active caspase-3. TRAIL is required for serum-inducible IGF1R expression, and antisense IGF1R inhibits TRAIL-induced VSMC proliferation. At 1 ng/ml, TRAIL stimulates IGF1R mRNA expression greater than insulin-like growth factor-1 and also activates the IGF1R promoter 7-fold. TRAIL-inducible IGF1R expression requires NF-kappaB activation. Consistent with this, ammonium pyrrolidine dithiocarbamate, a pharmacological inhibitor of NF-kappaB, blocks TRAIL-induced IGF1R expression, and p65 overexpression increases IGF1R protein levels. In addition, NF-kappaB binds a novel TRAIL-responsive element on the IGF1R promoter. Our findings suggest that the biological functions of TRAIL in VSMC extend beyond its role in promoting apoptosis. Thus, TRAIL may play an important role in atherosclerosis by regulating IGF1R expression in VSMC in an NF-kappaB-dependent manner.

Use of Drug‐Eluting Stents in Saphenous Vein Aortocoronary Bypass Graft Lesions: A Critical Appraisal

The use of drug-eluting stents (DES) in aortocoronary saphenous vein bypass grafts (SVGs) remains controversial. We reviewed 14 published studies that examined the outcomes after DES implantation in SVG lesions. All studies, except two, were retrospective, and reported follow-up for approximately 1 year or less. Ten of the 14 studies were single-center. Six studies (5 retrospective and 1 prospective), including a total of 711 patients, compared DES with bare metal stents: 2 studies included paclitaxel-eluting stents, 2 studies included sirolimus-eluting stents, and 2 studies included both. Four of five retrospective comparative studies showed lower incidence of major adverse cardiac events in the DES group during short-term follow-up (6-12 months), mainly due to a reduction in target vessel revascularization (TVR) (3 of 4 studies had high rates of follow-up angiography). In the only published prospective, randomized controlled study, patients receiving DES had lower incidence of TVR at 6 months, but during longer follow-up (median 32 months), they had similar incidence of TVR and higher mortality. A large, multicenter, randomized controlled clinical trial is needed to clarify the role of DES in the percutaneous treatment of SVG lesions.

Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome)

The results of treatment for subclavian vein effort thrombosis were assessed in a series of competitive athletes. A retrospective review was conducted of high-performance athletes who underwent multidisciplinary management for venous thoracic outlet syndrome in a specialized referral center. The overall time required to return to athletic activity was assessed with respect to the timing and methods of diagnosis, initial treatment, operative management, and postoperative care. Between January 1997 and January 2007, 32 competitive athletes (29 male and 3 female) were treated for venous thoracic outlet syndrome, of which 31% were in high school, 47% were in college, and 22% were professional. The median age was 20.3 years (range, 16-26 years). Venous duplex ultrasound examination in 21 patients had a diagnostic sensitivity of 71%, and the mean interval between symptoms and definitive venographic diagnosis was 20.2 +/- 5.6 days (range, 1-120 days). Catheter-directed subclavian vein thrombolysis was performed in 26 (81%), with balloon angioplasty in 12 and stent placement in one. Paraclavicular thoracic outlet decompression was performed with circumferential external venolysis alone (56%) or direct axillary-subclavian vein reconstruction (44%), using saphenous vein panel graft bypass (n = 8), reversed saphenous vein graft bypass (n = 3), and saphenous vein patch angioplasty (n = 3). In 19 patients (59%), simultaneous creation of a temporary (12 weeks) adjunctive radiocephalic arteriovenous fistula was done. The mean hospital stay was 5.2 +/- 0.4 days (range, 2-11 days). Seven patients required secondary procedures. Anticoagulation was maintained for 12 weeks. All 32 patients resumed unrestricted use of the upper extremity, with a median interval of 3.5 months between operation and the return to participation in competitive athletics (range, 2-10 months). The overall duration of management from symptoms to full athletic activity was significantly correlated with the time interval from venographic diagnosis to operation (r = 0.820, P < .001) and was longer in patients with persistent symptoms (P < .05) or rethrombosis before referral (P < .01). Successful outcomes were achieved for the management of effort thrombosis in a series of 32 competitive athletes using a multidisciplinary approach based on (1) early diagnostic venography, thrombolysis, and tertiary referral; (2) paraclavicular thoracic outlet decompression with external venolysis and frequent use of subclavian vein reconstruction; and (3) temporary postoperative anticoagulation, with or without an adjunctive arteriovenous fistula. Optimal outcomes for venous thoracic outlet syndrome depend on early recognition by treating physicians and prompt referral for comprehensive surgical management.

Percutaneous intervention on the saphenous vein bypass grafts—Long‐term outcomes

In this era of drug eluting stents (DES), the long-term outcome of percutaneous intervention (PCI) on saphenous venous grafts (SVG) is unknown. The objective of the study was to compare the long-term outcomes of DES versus bare metal stent (BMS) in this population and to determine the predictors of outcomes. We reviewed the medical records of all patients who had PCI performed during January 2003 to February 2005 to obtain data cardiac risk factors, medications at discharge, angiographic details and outcomes. One hundred and nine patient had PCI to SVG; of these, 37 patients received DES and the remaining had BMS. Over a mean follow-up of 33 months, the PCI using DES was associated with 30% restenosis, 35% target vessel revascularization (TVR) and major adverse cardiac event (MACE) rate of 46% versus 35% restenosis, 38% TVR and 50% MACE rate with BMS. There was no significant difference in long-term outcome with DES as compared to BMS. There was no difference in the long-term outcomes of PCI on SVG irrespective of the type of stent used.

Comparison of the Efficacies of Five Different Statins on Inhibition of Human Saphenous Vein Smooth Muscle Cell Proliferation and Invasion

Statins (HMG-CoA reductase inhibitors) exhibit beneficial effects on the vasculature independently of their cholesterol-lowering properties. These pleiotropic effects underlie the ability of statins to reduce intimal hyperplasia in saphenous vein (SV) bypass grafts by attenuating smooth muscle cell (SMC) invasion and proliferation. Although all statins can effectively lower cholesterol, the pleiotropic effects of individual statins may well differ. We therefore compared the concentration-dependent effects of 4 lipophilic statins (simvastatin, atorvastatin, fluvastatin, and lovastatin) and 1 hydrophilic statin (pravastatin) on the proliferation and invasion of SMC cultured from SV of 9 different patients undergoing coronary artery bypass grafting (CABG). The lipophilic statins inhibited SV-SMC proliferation over a 4-day period with an order of potency of fluvastatin > atorvastatin > simvastatin > lovastatin (IC50 range = 0.07 to 1.77 microM). Similarly, these statins also inhibited SV-SMC invasion through an artificial basement membrane barrier (fluvastatin > atorvastatin > simvastatin >> lovastatin; IC50 range = 0.92 to 26.9 microM). In contrast, the hydrophilic pravastatin had no significant effect on SV-SMC proliferation at concentrations up to 10 microM, nor did it attenuate SV-SMC invasion (up to 30 microM). Our data provide strong evidence that individual statins possess differential pleiotropic effects on SV-SMC function. This may be of clinical relevance in the selection of individual statins for the treatment of CABG patients.

Saphenous Vein Grafts Display Poor Endothelium-Dependent and Endothelium-Independent Dilation—Implications for the Pathogenesis of Vein Graft Atherosclerosis

As endothelial dysfunction has been implicated in the pathogenesis of late failure of saphenous vein grafts (SVG), we assessed endothelium-dependent and endothelium-independent vascular responses of SVG in humans. Subjects undergoing angiography after bypass grafting had selective infusions of acetylcholine (ACh, an endothelium-dependent dilator) and sodium-nitroprusside (SNP, an endothelium-independent dilator) into a non-obstructed vein graft. SVG diameters were measured by quantitative coronary angiography. Two matched groups of control subjects, with or without coronary artery disease (CAD), were studied after similar infusions into their femoral arteries. We assessed 10 subjects with SVG, 8 controls with and 8 without CAD. SVG dilatation to high-dose ACh was 5+/-3%, similar to the femoral arteries of subjects with CAD (10+/-5%), but significantly less than the ACh-related arterial dilatation in the non-CAD group (16+/-2%, p=0.02). Similarly, dilatation of SVG after SNP infusion was 9+/-3%, which was not significantly different from the nitrate responses of femoral arteries in the CAD group (21+/-5%), but significantly poorer than in the non-CAD subjects (27+/-5%, p=0.02). Saphenous vein bypass grafts display poor endothelium-dependent and endothelium-independent vascular responses in vivo, compared with healthy systemic arteries. This may contribute to the pathogenesis of accelerated atherosclerosis seen in SVG.

Peri-Stent Reference Segment Plaque Burden Is Associated With Disease Progression in Saphenous Vein Grafts (A Serial Intravascular Ultrasound Assessment)

We are aware of no studies of peri-stent disease progression or luminal compromise in saphenous vein graft (SVG) lesions. We used serial intravascular ultrasound (IVUS) to assess disease progression in peri-stent saphenous vein bypass graft reference segments. We studied 37 peri-stent SVG reference segments in 21 patients; 16 were proximal and 21 were distal to the stent. The same anatomic image slice was analyzed after the intervention and at follow-up; this site was 3.68 +/- 2.22 mm from the stent edge. Graft age was 10.1 +/- 5.4 years, and mean follow-up duration was 13 months (range 3 to 61). Overall, change in SVG area, change in lumen area, and change in plaque burden correlated with postintervention plaque burden (r = 0.448, p = 0.005; r = -0.584, p <0.001; and r = 0.507, p = 0.001, respectively). For the proximal edge, change in lumen area correlated with change in plaque area (r = -0.951, p <0.001), but not with change in SVG area (r = -0.337, p = 0.201). For the distal edge, change in lumen area correlated more strongly with change in plaque area (r = -0.982, p <0.001) than with change in SVG area (r = -0.624, p = 0.003). When peri-stent reference segments were divided into 2 groups according to postintervention plaque burden (>50% [n = 20] vs <50% [n = 17]), there was a greater decrease in lumen area (-1.12 +/- 0.81 vs -0.33 +/- 0.26 mm(2), p <0.001) and greater increases in SVG area (0.26 +/- 0.29 vs 0.09 +/- 0.09 mm(2), p = 0.027), plaque area (1.37 +/- 0.96 vs 0.42 +/- 0.30 mm(2), p <0.001), and plaque burden (8.2 +/- 5.6% vs. 2.8 +/- 1.6%, p <0.001) in segments with a plaque burden >50%. In conclusion, peri-stent reference segment SVG disease progression and lumen loss were more significant in segments with a greater postintervention plaque burden after implantation of a bare metal stent or drug-eluting stent.

Common hepatic artery as an inflow site for off-pump coronary artery bypass grafting

We used the common hepatic artery (CHA) as an inflow site for a saphenous vein graft bypass to the right coronary system during off-pump coronary artery bypass grafting. The CHA is a suitable inflow vessel to provide sufficient blood flow and a short-distance bypass in case both the ascending aorta and the gastroepiploic artery are considered inadequate.

Novel thromboresistant materials

The development of a clinically durable small-diameter vascular graft as well as permanently implantable biosensors and artificial organ systems that interface with blood, including the artificial heart, kidney, liver, and lung, remain limited by surface-induced thrombotic responses. Recent breakthroughs in materials science, along with a growing understanding of the molecular events that underlay thrombosis, has led to the design and clinical evaluation of a variety of biologically active coatings that inhibit components of the coagulation pathway and platelet responses by surface immobilization or controlled release of bioactive agents. This report reviews recent progress in generating synthetic thromboresistant surfaces that inhibit (1) protein and cell adsorption, (2) thrombin and fibrin formation, and (3) platelet activation and aggregation.

Giant fusiform aneurysm in an adolescent with PHACES syndrome treated with a high-flow external carotid artery–M3bypass

The acronym PHACES describes a rare neurocutaneous syndrome that comprises posterior fossa malformations, facial hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities, and sternal defects. Facial hemangiomas constitute the hallmark of this disorder. Giant intracranial aneurysms have not been previously reported in the literature as manifestations of PHACES syndrome and can present difficult therapeutic challenges. The authors describe a unique case of a 13-year-old adolescent boy with an incomplete phenotypic expression of PHACES syndrome who harbored diffuse cerebral angiodysplasia and a giant fusiform internal carotid artery (ICA) aneurysm extending from the distal cavernous segment to the supraclinoid segment. The aneurysm was successfully treated with a high-flow saphenous vein graft bypass from the external carotid artery to the distal middle cerebral artery followed by proximal ICA occlusion. This case represents a unique vascular manifestation of PHACES syndrome that required a complex management strategy. The authors review the literature on this rare disorder and emphasize the importance of considering the diagnosis of PHACES syndrome in child with a facial hemangioma.

Acute Aortic Dissection with Intimal Layer Prolapse into the Left Ventricle

34-year-old male presented with acute onset ofsearing chest pain and was preoperatively diagnosedwith a Type A dissection limited to the ascendingaorta and arch. His preoperative troponin levels werenot elevated. The patient was scheduled for urgentrepairofaTypeAascendingaortaandtransversearchdissection under hypothermic circulatory arrest usingselective antegrade cerebral perfusion. The intraopera-tive transesophageal echocardiogram (TEE) examina-tion was performed using the Philips 5500 ultrasoundmachine with a Philips OmniPlane III ultrasoundprobe.Multiple views of the left ventricle (LV) revealed alarge intimal flap, prolapsing several centimeters intothe LV outflow tract during diastole. Severe (4)aortic insufficiency (AI) was diagnosed with colorflow Doppler, but regurgitant flow was containedwithin the prolapsing, intimal “sock.” No evidence ofregurgitantflowbeyondtheprolapsedintimallayerinthe LV outflow tract was demonstrated (Fig. 1). TheLV was dilated with moderate, global hypokinesis. Noregional wall motion abnormalities were noted andthe ejection fraction was estimated at 40%.Careful comparison of the aortic valve (AV) inmidesophageal (ME) long axis, and ME AV short axis(SAX) views suggested functional, bicuspid leafletexcursion, mild thickening, and no significant leafletcalcification or stenosis. The aorta was 2.6 cm at theAV annulus, 4.8 cm at the sinus of Valsalva, 7.2 cm atthe sino-tubular junction, and larger than 7.5 cm in thevisualized portion of the ascending aorta.Surgical inspection confirmed the diagnosis of bi-cuspid AV. The left/right coronary cusp was partiallyfused with a congenital cleft from the midportion tothe free leaflet edge. The intima of the sinus ofValsalva was 80% circumferentially torn, with ananchor point surrounding the left main coronary ostia.The surgeon performed a valve-sparing aortic rootreplacement using the David V re-implantation tech-nique with 32-mm Gelweave Valsalva graft (VascutekUSA Inc). The valve annulus was reduced in circum-ference with an aortic valvuloplasty, and the AV cuspcleft was closed with interrupted sutures. A buttonre-implantation of the left coronary ostia into the graftwas possible. The right coronary ostium was partiallydisrupted, and a saphenous vein graft bypass wasperformed.The patient was successfully weaned after 304 minof cardiopulmonary bypass, including 27 min of deephypothermic circulatory arrest. Moderate inotropicsupport was required. The cardiac function was de-pressed from baseline to an estimated 30% ejectionfraction. No new-onset regional wall motion abnor-malities were demonstrated.The postcardiopulmonary bypass TEE examinationrevealed a functional bicuspid valve with good excur-sion of leaflets and no subsequent aortic insufficiency.Planimetry of the effective orifice area measured 2.10cm