Traumatic rupture of the aortic valve and ascending aorta diagnosed by transesophageal echocardiography

The most common site for rupture of the aorta as a consequence of blunt chest trauma is at the level of the isthmus. Rupture of the aortic valve with concomitant rupture of the ascending aorta is an uncommon entity and only relatively few patients sustaining such an injury survive to surgery. Early diagnosis of such injuries are critical to facilitate timely intervention. We report a case of a 17-year old male who sustained a rupture left coronary cusp and ascending aorta in a road traffic accident. The diagnosis was preoperatively made by transesophageal echocardiography and he underwent successful surgical repair with primary apposition of the torn cusp and closure of the aorta with a pericardial patch. Preoperative diagnosis of this rare combination of injury has hitherto not been made by transesophageal echocardiography.     

Aortic pseudoaneurysm after endarterectomy for small aorta syndrome

IntroductionSmall Aorta Syndrome (SAS) or hypoplastic aorto-iliac syndrome is a rare pathology of the aorta that affects almost exclusively young or middle-aged women and is characterized by smaller dimension of the aorta and iliac axes. Etiopathogenesis is unclear and many factors have been invoked. The smaller caliber of the aorta and iliac arteries may predispose to aorto-iliac occlusive disease development.In the past aorto-iliac endarterectomy (AE) with patch closure was utilized as an alternative to surgical bypass in order to correct steno-obstructive syndromes affecting carriers of SAS. Little is known about long term outcomes of this type of surgery.Presentation of the caseDuring investigations for acute colecystitis, an aortic pseudoaneurysm (PA) was diagnosed by ultrasound in a 73 old year woman. She was submitted twenty-two years ago for SAS with disabling claudication to aortic endarterectomy (AE) with patch graft insertion. Considering all the vascular options available she was submitted to open surgery with replacement of the aortic bifurcation.DiscussionAortic PA is a relatively common complication after bypass surgery but is rarely observed after AE. It requires prompt intervention to prevent subsequent complications such as rupture, thrombosis, distal embolism or aorto-enteric fistula.ConclusionEndovascular treatment for aortic PA should be always considered the treatment of choice but the open surgical option was preferred in this particular case because of the small diameters of the iliac accesses, making them unsuitable for an endovascular approach.     

A case of Pott's disease of the spine eroding into the suprarenal aorta

Spinal tuberculous osteomyelitis eroding into the aorta is an extremely rare entity. The case of an 80-year-old man with a large proximal anastomotic pseudoaneurysm above an aortobiiliac prosthesis involving the suprarenal aorta is reported. A periaortic and perigraft fluid collection was found to be contiguous with an osteolytic process of the anterior bodies of the T12 and L1 vertebrae. Staged extraanatomic axillobifemoral bypass, graft excision, and viscerorenal revascularization with superficial femoral popliteal veins were performed. The pathologic diagnosis of spinal tuberculous osteomyelitis was made. The rare entity of Pott's disease of the spine involving the suprarenal aorta and an aortic prosthesis presented significant challenges in resection and revascularization. The use of the deep veins of the legs as large-diameter autogenous conduit facilitated visceral and renal arterial bypass in an infected field. (J Vasc Surg 1996;24:482-6.)     

Abdominal aortic injuries associated with chance fractures in pediatric patients

Injury to the abdominal aortic artery from blunt trauma is an infrequent event with few cases reported in either the adult or the pediatric literature. Injury to the thoracic aorta after blunt abdominal trauma is more common. It has been estimated that 95% to 99% of all aortic disruptions are in the thoracic region. Injury to the abdominal aorta is rarely seen in association with fractures of the lumbar spine secondary to seat belt use in motor vehicle accidents; there are few cases in the literature of these injuries in pediatric patients. Nevertheless, the overall mortality rate of this injury has been reported to be between 18% and 37%. It is therefore important to be aware of the possible association to allow prompt diagnosis and management of multitraumatized patients because extensive injuries to the abdominal viscera may mask aortic dissection and prognosis is significantly improved with early intervention.     

Inflammatory Aneurysm of the Ascending Aorta: Report of a Case

Inflammatory aortic aneurysms are found most commonly in the infrarenal abdominal aorta. We report the case of a 78-year-old man with an inflammatory aortic aneurysm of the ascending aorta, which is extremely unusual. Surgery revealed that the ascending aorta was adherent to the superior vena cava and pulmonary artery, but a dissection membrane was not found. The wall of the ascending aorta was up to 20 mm thick with perianeurysmal fibrosis. Pathologic examination revealed an inflammatory aneurysm with adventitia remarkably thickened by fibrotic tissue and infiltrated by lymphocytes and plasma cells. Our search of the literature found only seven other cases of an inflammatory ascending aortic aneurysm. Preoperative diagnosis was very difficult in most of these cases; however, improved scanning techniques using multidetector row computed tomography may allow the differential diagnosis of this clinical entity.     

Management of suspected mycotic suprarenal aortic aneurysm

Mycotic aortic aneurysm is an uncommonly encountered entity. The diagnosis and management are challenging problems. Involvement of the visceral aorta creates additional problems in management. Experience with a patient having this diagnosis and the dilemma in treatment forms the basis of this report.     

Endovascular stent-graft placement for nonaneurysmal infrarenal aortic rupture: a case report and review of the literature

Penetrating atheromatous ulceration of the infrarenal aorta is a rare entity. There are few reported cases of this lesion, and most of the published data is in regards to the thoracic aorta. Spontaneous rupture of a nonaneurysmal noninfected atherosclerotic infrarenal aorta is a rare event. We report the eleventh case of this occurrence and present the first reported case of endovascular stent-graft placement in treating this entity. We review the literature regarding ulcerative disease of the aorta and specifically discuss the published data on spontaneous rupture of the nondilated, noninfected infrarenal aorta secondary to penetrating atheromatous ulceration.     

Pneumococcal aortitis: a difficult preoperative diagnosis

Primary infections of the aorta are rare. We recently treated a patient who was given a diagnosis of noninfectious aortitis after an extensive work-up, but after clinical deterioration, was found to have a pneumococcal mycotic aneurysm at the time of surgery. The difficulty in distinguishing microbial aortitis from noninfectious chronic periaortitis is discussed as well as the need for frequent surveillance imaging of the aorta if immunosuppression is used to treat the latter entity. The infected aortoiliac segment was ultimately repaired with autologous femoral veins.     

Síndrome neuroléptico maligno en paciente postoperada: a propósito de un caso

Neuroleptic malignant syndrome is a rare medical emergency associated with the use of antipsychotics and other antidopaminergic drugs. There is no specific test, and diagnosis is based on high clinical suspicion and good differential diagnosis.A clinical picture consistent with hyperthermia, muscle rigidity, altered level of consciousness, together with signs of rhabdomyolysis in analytical studies and a history of taking neuroleptic drugs are the key elements in the detection of this entity.Due to its low incidence and potential mortality, it is essential to publish case reports of neuroleptic malignant syndrome in order to raise awareness of this entity and facilitate diagnostic suspicion when encountering a patient with compatible symptoms.The following is the case of a 79 year old patient with chronic alcohol consumption as the only history of interest, who was given a single dose of haloperidol after an episode of delirium in the postoperative period of conventional trauma surgery. She subsequently developed a picture of progressive deterioration of the level of consciousness, diaphoresis, generalized muscle rigidity, hyperthermia, together with severe metabolic acidosis, hyperlacticaemia, rhabdomyolysis, hypertransaminasemia and hypocalcemia. After ruling out other entities compatible with the clinical picture, neuroleptic malignant syndrome was given as the main diagnostic hypothesis. Diagnosis was confirmed after clinical and analytical improvement following treatment with dantrolene. The patient was discharged from hospital with no sequelae a few days after onset of the condition.     

Hypoplasias of the thoracic and abdominal aorta: presentation of two cases, with evaluation 11 and 20 years after surgical management

Two cases of hypoplasia of the thoracic and abdominal aorta are reported, diagnosed in two individuals, a girl 13 years old and a boy aged 16 years. The malformation involved the upper abdominal aorta and the visceral arteries in the first case, and simply the descending thoracic aorta in the remainder. Arterial hypertension was the principal manifestation who lead to the diagnosis, which was confirmed through the conventional angiography. Both patients underwent surgical management, which consisted in the aortic revascularization associated to complete visceral revascularization in the first case, and in the single aortic revascularization in the second patient. Surgical therapy course was uneventful in both cases and blood pressure returned to normal values following the operation. Reviewed 11 and 20 years after the procedure, they were found in good condition, with normal blood pressure without any medication; angio CT studies disclosed the prosthetic grafts working in excellent condition. The main features of etiopathogeny, clinical presentation, diagnosis and surgical management are subjected to a discussion, based on an extensive review of the literature dedicated to this clinical entity.     

Use of the BioMedicus centrifugal pump in traumatic tears of the thoracic aorta

Traumatic blunt thoracic aortic injury is a clinical entity of increasing incidence. After the diagnosis of traumatic tear of the aorta is made, there is some controversy over whether the aorta should be repaired using cardiopulmonary bypass, a heparinized shunt, or cross-clamping and graft interposition without a shunt or bypass. At Allegheny General Hospital, 19 patients were treated for traumatic tears of the thoracic aorta between July 1, 1977, and June 30, 1983. They can be divided into two groups: Group 1 (July 1, 1977, through October 31, 1981), in which no shunt or bypass or only a heparinized shunt was used, and Group 2 (November 1, 1981, through June 30, 1983), in which left atrium-femoral artery bypass was performed using a BioMedicus heparinless pump and tubing. Among the 10 patients in Group 1, 4 died and 2 had paraplegia postoperatively. Among the 9 patients in Group 2, 1 died and none experienced paraplegia following operation. We believe that the BioMedicus centrifugal pump is a simple, safe means of perfusing the lower body, kidneys, and spinal column without necessitating heparinization in a patient with multiple injuries or the placement of a cumbersome heparinized shunt. Because of the simplicity and the reliability demonstrated, this pump should be considered for use in all patients with traumatic tears of the thoracic aorta.     

Successful repair of supravalvular aortic stenosis using Steinberg 3 sinuses reconstruction; report of a case

Steinberg method is a modification of Doty extended aortoplasty for supravalvular aortic stenosis (SAS). This modification entails placement of an additional patch in the left coronary sinus. A 3-year-old boy was diagnosed as SAS with aortic valvular stenosis. He was noticed a systolic murmur from 1 month after his birth. Echocardiography showed left ventricular hypertrophy, and pressure gradient of 80 mmHg was measured between the ascending aorta and the left ventricle. Cardiac catheterization revealed severe aortic stenosis at the sino-tubular (ST) junction. We adopted Steinberg 3 sinuses reconstruction. After this operation, there was no pressure gradient at ST junction although aortic valvular stenosis remained and mild aortic valve regurgitation newly developed. As this method can produce a symmetric aortic root, it may reduce aortic valve deformity especially on the left coronary cusp.     

Radial, renal and craniofacial anomalies: Baller-Gerold syndrome

The Baller-Gerold syndrome is a rare syndrome with very few cases published in literature. Craniosynostosis and radial aplasia are striking features, easy to diagnose. However, there are many differential diagnoses. Often, the question raised is whether the Baller-Gerald syndrome is a distinct entity. We report a patient with findings of craniosynostosis and radial aplasia consistent with the diagnosis of the Baller-Gerold syndrome. Genotypic heterogeneity could possibly underlie the phenotypic variability exhibited by these cases.     

Primary Aortoenteric Fistula: Computed Tomographic Diagnosis of an Atypical Presentation

A primary aortoenteric fistula is a potentially devastating complication of untreated aortic aneurysmal disease. The clinical presentation can be confusing, leading to a delay in diagnosis. Computed tomography (CT) can greatly assist in establishing the diagnosis. An unusual case of a primary aortoenteric fistula with an atypical presentation is described. The patient presented with symptoms indicating an exacerbation of recurrent nephrolithiasis. No clinical history of an abdominal aortic aneurysm or previous history of gastrointestinal hemorrhage was reported. A CT scan demonstrated extravasation of arterial contrast into the duodenum. The aorta was repaired with an in-line prosthetic graft. A review of the literature regarding this rare entity and surgical options are presented.     

Asthma and Sleep Apnea in Patients with Morbid Obesity: Outcome after Bariatric Surgery

Background: Asthma and sleep apnea syndrome (SAS) are frequently reported in obese patients. The authors determined the prevalence of asthma and SAS in morbidly obese patients and the effect of biliopancreatic diversion with duodenal switch (BPD-DS) on these conditions. Methods: 398 patients were evaluated for bariatric surgery in a university-affiliated tertiary care center. All patients completed a written questionnaire on asthma and SAS before BPD-DS. In addition, 139 patients also completed a questionnaire on their general health status, including asthma and SAS, 2 years after the procedure. Results: For the cohort of 398 patients, the prevalence of self-reported asthma was 30.4% and that of SAS, 32.2%. No significant association was found between asthma and SAS diagnosis (P =0.10). Significant relationships were observed between the diagnosis of asthma and age, hip circumference, waist/hip ratio, weight and BMI of the patients as well as between a diagnosis of SAS and gender, waist circumference, hip circumference, waist/hip ratio, weight and BMI. 2 years after surgery (mean BMI was reduced from 51.4 to 30.5 kg/m²), asthma was reported improved in 79.3% of patients and SAS was improved in all but one with this condition; among 29 SAS patients using CPAP before surgery, only 4 were still using this treatment after 2 years. Conclusion: The prevalence of asthma and SAS is high in the morbidly obese population and is associated with markers of obesity. We found no association between the diagnosis of asthma and SAS diagnosis in this population. BPD-DS improved self-reported severity of asthma and SAS symptoms.     

Congestive heart failure due to coral reef thoracoabdominal aorta

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

Massive Hemorrhage Caused by Major Pulmonary Vessel-Cutaneous Fistula in the Late Postoperative Period: Report of Two Cases

Sudden life-threatening hemorrhage caused by erosion of the wall of a thoracic blood vessel such as the aorta, pulmonary artery, or pulmonary vein, in the late postoperative period is extremely rare and presents a challenging emergency. We report the cases of two patients whose only clinical manifestation was a hemorrhagic cutaneous chest wall fistula. Both patients were treated by emergency surgery. The diagnosis and management of this clinical entity requires a high index of suspicion and innovative therapeutic solutions.     

Inflammatory aneurysms of the abdominal aorta, complicated by hydronephrosis and anuria. Surgical management

In this paper the clinical condition of two male patients, aged 58 and 65 years are presented, after being admitted as a consequence of a rare complication of an inflammatory aneurysm of the abdominal aorta, which is an ureteral compression, with hydronephrosis, anuria and acute renal failure. After having an urgent haemodialysis session, the etiology of the process was diagnosed by echography and abdominal CT-scans, followed by ureteral catheterization, restoration of diuresis and normalization of renal function. Conventional surgery was performed later, in elective conditions, and the post operative course was normal, without complications. The main features of this clinical entity, its diagnosis and multidisciplinary management are presented and discussed.     

Transverse incision for appendectomy

A brief review of the subject of dissecting aneurysms of the aorta due to trauma has been presented as a result of interest aroused by the postmortem diagnosis of a case following death from injuries received in an automobile accident. From the fact that the rôle of trauma in the production of aneurysms of the aortic arch is so incompletely discussed in medical literature, it is concluded that the condition is a rare variety of a relatively rare pathological entity and that complete clinical facts of such a case will therefore be of interest. That this fatal condition may be present after an automobile accident even when the aorta was previously normal becomes an important consideration for any physician who handles such accidents and who may at any time be involved in the resulting litigation.     

Gastrointestinal Neuroectodermal Tumor: a Diagnostic Dilemma

Malignant gastrointestinal neuroectodermal tumor (GNET), a rare soft tissue sarcoma, is a recently described distinct clinicopathological entity. With only a few cases reported in literature till date, there is limited knowledge about the behavior as well as diagnosis of this tumor. GNET mimics several other tumors and hence presents as a diagnostic challenge to clinicians and pathologists alike. We report a case of gastrointestinal neuroectodermal tumors with liver metastasis.