Hybrid repair of a very late, post-aortic coarctation surgery thoracic aneurysm: a case report

ABSTRACT: INTRODUCTION: Local aneurysms after surgical repair of coarctation of the aorta occur mainly in patients surgically treated by Dacron patch plasty during adulthood. The management of these patients is always problematic, with frequent complications and increased mortality rates. Percutaneous stent-graft implantation avoids the need for surgical reintervention. CASE PRESENTATION: We report a case involving the hybrid treatment by stent-graft implantation and transposition of the left subclavian artery to the left common carotid artery of an aneurysmal dilatation of the thoracic aorta that occurred in a 64-year-old Caucasian man, operated on almost 40 years earlier with a Dacron patch plasty for aortic coarctation. Our patient presented to our facility for evaluation with back pain and shortness of breath after minimal physical effort. A physical examination revealed stony dullness to percussion of the left posterior thorax, with no other abnormalities. The results of chest radiography, followed by contrast-enhanced computed tomography and aortography, led to a diagnosis of giant aortic thoracic aneurysm. Successful treatment of the aneurysm was achieved by percutaneous stent-graft implantation combined with transposition of the left subclavian artery to the left common carotid artery. His post-procedural recovery was uneventful. Three months after the procedure, computed tomography showed complete thrombosis of the excluded aneurysm, without any clinical signs of left lower limb ischemia or new onset neurological abnormalities. CONCLUSIONS: Our patient's case illustrates the clinical outcomes of surgical interventions for aortic coarctation. However, the very late appearance of a local aneurysm is rather unusual. Management of such cases is always difficult. The decision-making should be multidisciplinary. A hybrid approach was considered the best solution for our patient.     

A giant pseudoaneurysm becoming apparent after cardiac resynchronisation therapy

A 57-year-old male patient with coronary artery disease developed a pseudoaneurysm after an inferior infarct in 1997. He underwent coronary bypass surgery and resection of the pseudoaneurysm located at the inferior wall. Unfortunately, the pseudoaneurysm recurred due to dehiscence of the patch, necessitating a second surgical intervention. After six years he developed progressive heart failure due to severe left ventricular dysfunction. He was referred to our institution for cardiac resynchronisation therapy (CRT) because of drug refractory heart failure which was associated with a left bundle branch block, ejection fraction of 12%, and a NYHA class IV status. After successful implantation of a biventricular pacemaker, a remarkable clinical recovery was observed. Left ventricular function improved and echocardiography now demonstrated that the pseudoaneurysm at the inferior wall had recurred for the third time. This diagnosis could not be established by preoperative echocardiography.     

Iatrogenic ascending aortic dissection following cannulation for arterial return and for infusion of cardioplegic solution: Prevention and repair

Two patients are presented in whom dissection of the ascending aorta resulted from cannulation for arterial return and from the infusion of cardioplegic solution. The dissections were recognized promptly. Following dissection in the first patient, the femoral artery was used to reestablish systemic perfusion. The aortic valve and dissected ascending aorta were replaced, and three vessels were grafted. In the second patient, the dissected anterior wall of the ascending aorta was excised and replaced with a low-porosity Dacron patch into which the proximal aortocoronary anastomoses were inserted. Predisposing factors are discussed, along with preventive measures and methods of repair.     

THE DIFFICULT PROXIMAL CORONARY ANASTOMOSIS

Two patients are presented in whom severe calcific aortitis made performance of satisfactory proximal coronary anastomosis impossible. Endarterectomy of the ascending aorta after aortic valve replacement, combined with aortocoronary bypass prior to performance of the proximal anastomoses, was successfully employed in one patient. The second patient underwent resection of an anterior segment of aorta, which was replaced by a woven Dacron patch into which the vein grafts were sewn.     

Anatomical correction of complete transposition of the great arteries and ventricular septal defect in infancy.

Two patients, aged 8 weeks and 5 years, with D transposition of great arteries and large ventricular septal defect were treated by transection of both aorta and pulmonary arteries and reattaching them to the appropriate ventricles. This included the origins of the coronary arteries. The ventricular septal defect was closed through a transverse ventriculotomy using a Dacron patch. The younger child was operated on as an emergency because of cyanosis and severe heart failure resistant to intensive medical treatment. The older child had had previous banding of the pulmonary artery at the age of 1 year. In both patients pulmonary artery pressure dropped to below half systemic pressure immediately after the operation. Postoperative progress was satisfactory with relief of cyanosis and heart failure. Early anatomical correction of transposition of the great arteries and ventricular septal defect is feasible and should play an important part in the management of these patients.     

Aortic aneurysm formation following coarctation repair by Dacron patch aortoplasty

We describe the finding of an aortic aneurysm in an asymptomatic 43-year-old male, who was managed by Dacron patch aortoplasty for native coarctation of the aorta 25 years before. The role of magnetic resonance angiography as standard imaging technique in lifelong postoperative surveillance is discussed subsequently. (Neth Heart J 2010;18:376-7.)     

Combination of two pseudoaneurysms in a patient 6 years after ascending aorta and aortic valve replacement

BACKGROUND: We report successful treatment of a patient 6 years after ascending aorta and aortic valve replacement suffering from a combination of two pseudoaneurysms. The first of them originated from the coronary ostial suture line and the second pseudoaneurysm originated from the distal suture line. METHODS: We performed re-replantation of the left main trunk to the prosthesis and then we resected the pseudoaneurysm originating from the distal suture line and we replaced the entire aorta by a vascular graft. RESULTS: The postoperative convalescence was uneventful, the patient was discharged two weeks after the surgery. The patient is currently in a very good condition one year after the surgery. CONCLUSIONS: Coronary ostial pseudoaneurysm in patients after ascending aorta and aortic valve replacement with the use of "button technique" is a quite rare situation. The combination of two pseudoaneurysms originating from different suture lines in one patient seems to be unique in literature reviews.     

Ascending aorta to common femoral artery bypass: An unusual but successful method for revascularization of the lower extremity: Report of case

A 61-year-old woman presented with symptoms and signs of severe ischemia in the left leg. Rest pain was present, and the leg was pulseless. The patient reported a complicated history of repeated strokes. Complete evaluation revealed mitral valve disease, atrial fibrillation, and occlusion of the distal aorta and left iliac and femoral arteries. Corrective surgery consisted of mitral valve replacement and concomitant ascending aorta to left common femoral and femoral graft to right femoral artery bypass. Recovery was uneventful. The cardiac and vascular prostheses functioned well and provided complete relief of ischemia.     

"Mushroom cloud": a giant left ventricular pseudoaneurysm after a myocardial infarction due to myocardial bridging – a case report

Left ventricular pseudoaneurysm is an uncommon complication after transmural myocardial infarction, occurring when a free wall rupture is contained by adhesions of the overlying pericardium preventing acute tamponade. In this report, an unusual case of a 61 year-old male with a giant apical left ventricular pseudoaneurysm after an unnoticed myocardial infarction is presented. On coronary angiogram myocardial bridging of the distal left anterior descending artery was judged to be the infarct related lesion. The echocardiographic diagnosis allowed for a timely surgical intervention which resulted in the patient's full recovery.     

Combined treatment of traumatic aortic transection and Kommerell diverticulum

We present the case of a 41-year-old male trauma patient admitted to the emergency department after being struck in a pedestrian versus a motor vehicle accident. Computed tomography revealed a traumatic transaction of the descending aorta with pseudoaneurysm and an aberrant right subclavian artery with Kommerell diverticulum. Surgical correction was accomplished with bilateral subclavian carotid bypass, with occlusion of both subclavian arteries followed by the placement of endovascular stent grafts to repair the aortic injury.     

The Treatment of Multiple Coronary Occlusions by Internal Mammary Artery Implantation and Omental Graft: Report on Two Human Cases

The importance of triple coronary artery disease was evident in 125 patients undergoing internal mammary artery implantation, when some patients died from right coronary artery occlusion. This occurred even when the internal mammary artery was patent and revascularizing the left ventricle.In 1961 the free omental graft operation was developed to revascularize both right and left ventricles. In animals this operation has proved most effective in preventing death after application of Ameroid constrictors to all three coronary arteries. Arteriolar or larger-sized vessels rapidly formed between the aorta and omentum and the pericardium and omentum and the heart and omentum.Two patients with triple coronary artery disease underwent internal mammary artery implantation and free omental graft early in December 1962. Postoperative convalescence was uneventful. They have returned home and appear to be improved. Wrapping the entire heart with the free omental graft has produced little reaction, suggesting that, as in the animal, the grafts are surviving.     

改良Nikaidoh 手术治疗合并肺动脉瓣狭窄的右室双出口

目的:总结改良Nikaidoh手术治疗右心室双出口(DORV)患者的临床经验,以提高手术疗效。方法:2例先天性心脏病右心室双出口伴肺动脉瓣狭窄行改良Nikaidoh手术,游离主动脉根部及冠状动脉,重建左心室流出道,以带单瓣牛心包片补片重建肺动脉及右心室流出道。结果:术后患者紫绀消失,复查心脏彩超仅有轻度肺动脉瓣关闭不全,未发现左、右心室流出道梗阻,康复出院。结论:采用改良Nikaidoh手术治疗伴肺动脉瓣狭窄的右室双出口,术后可获得良好的血流动力学效果,早期临床结果满意。     

Dacron fabric-enveloped hydroxyapatite prosthesis for sternal tumor defect: an autopsy report

A 38-year-old housewife with solitary plasmacytoma of the manubrium who underwent a subtotal sternectomy treated by resection of the lesion is reported. This was followed by replacement with a Dacron fabric-enveloped hydroxyapatite prosthesis. The Dacron fabric was sutured to the surrounding tissues, and then the clavicle was passed through the cylindrical-shaped Dacron fabric to form a sternoclavicular joint capsule. The patient returned to her daily life 3 months after the operation. She had no trouble in her daily living, without any dislocation of the sternoclavicular joints or any displacement of the artificial sternum. The autopsy examination about 1 year after the operation showed that the Dacron fabric enveloping the artificial sternum became stronger with time. The sternoclavicular joint also was stably fixed, and the Dacron fabric fulfilled its function as an artificial articular capsule and biologic fixation of the surrounding supporting tissues.     

Bronchiectasis and hoarseness of voice in takayasu arteritis: a rare presentation

ABSTRACT: BACKGROUND: Takayasu arteritis is a large vessel vasculitis occurring in young females. We report a rare presentation of Takayasu arteritis in a Sri Lankan woman. She presented with bronchiectasis and left recurrent laryngeal nerve palsy prior to the onset of vascular symptoms. This case illustrates an atypical presentation of this disease and the diagnostic dilemma that the physician may be faced with. CASE PRESENTATION: A 39-year-old woman presented with chronic cough, haemoptysis and hoarseness of voice. She had left recurrent laryngeal nerve palsy and high inflammatory markers on investigation. CT thorax revealed aortic wall thickening and traction bronchiectasis. 2 D echocardiogram revealed grade 1 aortic regurgitation compatible with aortitis. She did not have weak peripheral pulses or a blood pressure discrepancy and did not meet American College of Rheumatology (ACR) criteria for diagnosis of Takayasu arteritis at this stage. Tuberculosis, syphilis and sarcoidosis was excluded. While awaiting angiography, she developed left arm claudication and a pericardial effusion. Angiography revealed evidence of Takayasu arteritis and absence of flow in the left subclavian artery. Takayasu arteritis was diagnosed at this stage after a period of eight months from the onset of initial symptoms. She is currently on prednisolone, azathioprine and aspirin. CONCLUSION: Bronchiectasis and recurrent laryngeal nerve palsy is a rare presentation of Takayasu arteritis. Atypical presentations can occur in Takayasu arteritis prior to the onset of vascular symptoms. Elevation of inflammatory markers are an early finding. A high degree of suspicion is needed to identify these patients in the early course of the disease.     

改良Nikaidoh手术治疗合并肺动脉瓣狭窄的右室双出口

目的：总结改良Nikaidoh手术治疗右心室双出口（DORV）患者的临床经验,以提高手术疗效。方法：2例先天性心脏病右心室双出口伴肺动脉瓣狭窄行改良Nikaidoh手术,游离主动脉根部及冠状动脉,重建左心室流出道,以带单瓣牛心包片补片重建肺动脉及右心室流出道。结果：术后患者紫绀消失,复查心脏彩超仅有轻度肺动脉瓣关闭不全,未发现左、右心室流出道梗阻,康复出院。结论：采用改良Nikaidoh手术治疗伴肺动脉瓣狭窄的右室双出口,术后可获得良好的血流动力学效果,早期临床结果满意。     

Left main stem disease in a patient with Takayasu’s arteritis

Takayasu’s arteritis is a chronic vasculitis of unknown aetiology involving the aorta and its main branches, the pulmonary and coronary tree. Women are affected more often than men (80 to 90% of the cases) with an age onset between 10 and 40 years. This case report demonstrates the limitations of exercise testing and stress echocardiography in diagnosing the extent of coronary artery disease in patients with inflammatory disease in the left main stem coronary artery. (Neth Heart J 2007;15:260-2.)     

两种早期心衰大鼠模型的建立和心功能的比较

目的比较两种不同方法建立大鼠心衰模型心功能的特点,寻找大鼠模型早期心衰阶段。方法用冠脉结扎法及腹主动脉结扎法建立不同的心衰模型,用血流动力学及心脏称重的方法比较其心功能的各项指标。结果冠脉结扎组术后2周没有心功能的改变,2周后收缩和舒张功能均下降,4周达最低。腹主动脉结扎组术后14周没有心功能的下降,16周出现了舒张功能的衰竭。结论冠脉结扎法及腹主动脉结扎法均可以造成早期心衰,冠脉结扎法术后2周为早期心衰阶段,2周后同时出现收缩和舒张功能衰竭,腹主动脉结扎法术后14周为早期心衰阶段,14周后出现了舒张功能衰竭。     

Variations in the extracranial origin of the human vertebral artery

The aim of this study is to demonstrate a case of a cadaver in which both left and right vertebral arteries had an abnormal origin. On the left, the artery arose directly from the arch of the aorta. On the right, a double-originating vertebral artery was seen. The literature on the variations of the artery is reviewed and a detailed morphometric study of the artery was carried out because of its importance for neurosurgeons.     

Operations on large arteries; application of recent advances

With the use of anticoagulants to prevent recurrence of thrombosis it is now possible to open a major artery which has been occluded by a thrombus, remove the thickened lining with the clot and restore the continuity of the vessel. Free vein grafts have been used successfully to replace arterial segments in the extremities. Vein inlay grafts are preferred in dealing with aneurysms of the abdominal aorta. The aneurysmal wall can be used to support the venous segments. It has been possible to by-pass aneurysms of the abdominal aorta by anastomosing the splenic artery to the left iliac artery. The use of the left superficial femoral artery as a by-pass to supply blood to the right leg is described.     

OPERATIONS ON LARGE ARTERIES—Application of Recent Advances

With the use of anticoagulants to prevent recurrence of thrombosis it is now possible to open a major artery which has been occluded by a thrombus, remove the thickened lining with the clot and restore the continuity of the vessel. Free vein grafts have been used successfully to replace arterial segments in the extremities. Vein inlay grafts are preferred in dealing with aneurysms of the abdominal aorta. The aneurysmal wall can be used to support the venous segments.It has been possible to by-pass aneurysms of the abdominal aorta by anastomosing the splenic artery to the left iliac artery. The use of the left superficial femoral artery as a by-pass to supply blood to the right leg is described.