Aortic Dissections Complicating Open Cardiac Surgery: Report of Three Cases

Between June 1991 and February 1999, three patients suffered ascending aortic dissection as a complication of cardiopulmonary bypass operations with aortic cannulation at our hospital. The dissection occurred during the operation in two of the three patients and several months after the operation in one. Among a total of 2 207 cardiac operations performed during this period, the incidence of perioperative ascending aortic dissection was 0.14%. In addition to visual inspection and palpation, either epicardial or transesophageal echocardiography proved extremely useful for establishing an intraoperative diagnosis of ascending aortic dissection as a complication of open cardiac operation. One of the three patients underwent closed plication but subsequently died of vital organ ischemia. In this case, failure of reapproximation of the injured intima by closed plication might have led to extension of the dissection. Despite prolonged cardiopulmonary bypass and myocardial ischemic time, graft replacement of the ascending aorta was successfully carried out in the other two patients. Thus, we believe that graft replacement of the ascending aorta should be performed for patients with extensive aortic dissection complicating an open cardiac operation. Received: August 12, 1999 / Accepted: May 30, 2000     

Mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer: report of a case

We report a case of mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer (PAU). An 81-year-old woman was admitted to a local hospital with fever and abdominal pain, and when her symptoms were not improved by antibiotics, she was referred to our department. Computed tomography (CT) and angiography showed a saccular aneurysm below the renal arteries, and an emergency laparotomy was performed because we suspected a mycotic abdominal aortic pseudoaneurysm. An abscess was found on the proximal side of the jejunum, caused by an aneurysm penetrating the serosa. We diagnosed a mycotic pseudoaneurysm after finding the anterior wall of the aorta penetrated by intense calcification. The pseudoaneurysm was resected with the abscess and the area was covered with a pedicled omental flap to prevent infection. An axillofemoral bypass was also done. The patient recovered well.     

Mycotic abdominal aortic aneurysm associated with myelodysplastic syndrome (MDS): Report of a case

(Received for publication on Aug. 6, 1996; accepted on May 12, 1997)     

Transcatheter Management of Hepatic Artery Pseudoaneurysm Following Pancreaticoduodenectomy: a Report of three Cases

Pseudoaneurysm formation is a rare, but potentially life threatening delayed complication of major pancreatic surgery. Redo surgery several weeks after pancreaticoduodenectomy can be hazardous, especially in debilitated patients. Percutaneous, transcatheter exclusion of the pseudoaneurysm by means of embolic coils can be an efficient, safe and minimally invasive alternative to open surgery with good mid-and long-term results. We present our experience in Three patients undergoing transcatheter embolization of hepatic artery pseudoaneurysms detected several weeks after Whipple’s operation.     

Successful Management of a Ruptured Mycotic Pseudoaneurysm Following Pancreas Transplantation Using Bovine Pericardial Patch: A Case Report

Arterial mycotic pseudoaneurysms are a rare complication of pancreas transplantation. Rupture results in catastrophic hemorrhage with a high risk of mortality. Definitive management is complicated by an extensive arterial defect within a contaminated surgical field. Synthetic vascular grafts often fail due to subsequent graft infection whereas primary repair often results in arterial stenosis. Arterial ligation may be required to prevent exsanguination. A 41-year-old man, type 1 diabetic with associated renal failure, underwent successful simultaneous pancreas and kidney transplantation. He presented, 9 months following transplantation, with life-threatening rectal bleeding secondary to a ruptured mycotic pseudoaneurysm. This was successfully managed with a bovine pericardial patch (BPP) repair of the arterial defect and enteric diversion following graft pancreatectomy. He remains well with no vascular insufficiency 18 months following the procedure. A ruptured mycotic pseudoaneurysm following transplantation carries a significant risk of mortality and represents a surgical challenge as conventional techniques using synthetic materials often fail due to the contaminated field. A BPP offers good handling characteristics, excellent hemostatic properties and a favorable profile of infection risk in comparison with synthetic grafts. This case highlights its use as a treatment for a post-transplantation ruptured mycotic pseudoaneurysm.     

Hepatic Artery Pseudoaneurysm: A Report of Seven Cases and a Review of the Literature

Purpose To analyze seven cases of hepatic artery pseudoaneurysm (HAP) encountered at our hospital and review the relevant literature.Methods We searched the computerized medical record database from January 1, 1996, to September 1, 2003, to identify all cases of HAP, which we then reviewed in detail, examining etiology, findings, laboratory data, therapeutic intervention, complications, and outcome. We then compared these findings with those reported in the literature.Results There were five cases of HAP among 18 015 trauma and surgical admissions to the University of California Irvine Medical Center, representing an incidence of 0.03%. There were an additional two cases of HAP among 200 orthotopic liver transplants (OLT). The five HAPs not associated with OLT were preceded by blunt abdominal trauma, liver biopsy, pancreatic pseudocyst, and polyarteritis nodosa, in one patient each, and there was no apparent cause in one patient. Two patients were treated by ligation, and the patients with post-OLT HAP underwent resection and replacement with saphenous bypass grafts. Successful embolization was performed in the other three patients.Conclusion Hepatic artery pseudoaneurysm is a rare but dangerous complication of both acute surgical and chronic injury to the hepatic artery. However, early diagnosis and intervention can result in an excellent long-term outcome.     

Anterior Tibial Artery Pseudoaneurysm in a Patient with Hemophilia: A Complication of Ankle Arthroscopy

Arterial pseudoaneurysm formation as a complication of ankle arthroscopy is extremely rare. We present a case of anterior tibial artery pseudoaneurysm identified 10 days after ankle arthroscopy in a patient with hemophilia. The diagnosis was confirmed with a duplex ultrasound scan. The patient was referred to the vascular surgeon and underwent evacuation of the hematoma, resection of the damaged segment of the artery, and reconstruction with a reversed long saphenous vein interposition graft. The patient had an uneventful recovery after the second surgery. The prevention of this complication in patients with hemophilia is discussed, as well as diagnosis and management. Preventative measures include careful dissection while making the portals, preoperative mapping of the artery with a duplex or a handheld Doppler in patients with coagulopathy, and performance of open rather than arthroscopic surgery to excise large osteophytes.     

Aortic root physiology late after a "perfect" ross operation: magnetic resonance imaging study of three operative techniques

In order to define physiological properties of the autograft root, magnetic resonance imaging (MRI) findings relative to three different operative techniques were compared with those of control subjects. Twenty-three patients, 18/5 M/F, aged 32 ± 9 years, underwent MRI assessment of the aortic root. Patients with normally functioning autograft valve and at least 4 years of follow-up (average 5.6 ± 1.9, range 4-10 years) were selected for each technique: six subcoronary (Group 1), nine inclusion (Group 2), and eight freestanding root (Group 3). Results were compared among patient groups and with seven control subjects, 6/1 M/F, aged 30 ± 2 years (P = ns). Morphological and functional properties were defined using transverse and paracoronal views, during systole and diastole. Mean aortic size in each group was greater than control, except for the LV-aortic junction and the sinus of Valsalva in Group 1 (26 ± 5 vs. 23 ± 3 mm, P = 0.2 and 33 ± 6 vs. 30 ± 5 mm, P = 0.3). Aortic valve plane rotation (P = 0.02) and root dilatation (P = 0.02) were more common in Group 3. Altered valve opening dynamics and asymmetrical aortic flow profile were also more common in Group 2 (P = 0.03) and Group 3 (P = 0.04). Distensibility was significantly reduced at sinus level in Group 2 and 3 compared with control (4.1 ± 3.5% and 3.6 ± 4.4% vs. 9.0 ± 4.7%, P = 0.03). Asymmetrical aortic flow profile was more common in patients with aortic dilatation (P = 0.05) and with severely reduced (<4%) root elasticity (P = 0.06). Among the three techniques, only subcoronary grafting allows preservation of physiological autograft valve dynamics, aortic flow and distensibility, at all root levels, late after operation. These findings may have relevant implications in the selection of the ideal Ross technique.     

Glasgow Aneurysm Score in Patients Undergoing Elective Open Repair of Abdominal Aortic Aneurysm: A Finnvasc Study

OBJECTIVE: To use Finnvasc to determine whether the Glasgow Aneurysm Score predicts postoperative outcome after open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective study. MATERIAL AND METHODS: The operative risk of 1911 patients undergoing open repair of AAA was retrospectively graded according to the Glasgow Aneurysm Score. RESULTS: At 30 days 100 (5%) patients had died and 21% had developed severe postoperative complications. Receiver operating characteristics (ROCs) curve analysis showed that the Glasgow Aneurysm Score was predictive of postoperative mortality (area under the curve (AUC): 0.668, p<0.0001), severe complications (AUC: 0.654, p<0.0001), cardiac complications (AUC: 0.689, p<0.0001) and intensive care unit stay >5 days (AUC: 0.634, p<0.0001). Patients scoring >76 had significantly higher mortality (9% vs. 3%, p<0.0001), severe (31% vs. 15%, p<0.0001) and cardiac complications (12% vs. 4%, p<0.0001) and intensive care unit stay >5 days (12% vs. 6%, p<0.0001). CONCLUSIONS: The Glasgow Aneurysm Score is a rather good predictor of immediate postoperative mortality and morbidity after elective open repair of AAA.     

Stanford B型主动脉夹层腔内修复后转为Stanford A型10例分析

目的：探讨Stanford B型主动脉夹层腔内修复后转为Stanford A型的原因、处理和预防。方法：2000年8月至2006年10月完成430例Stanford B型主动脉夹层腔内修复。其中10例术后转变为Stanford A型,男7例,女3例,平均年龄(43±11)岁；合并高血压者7例,另3例为马方综合征(Marfan syndrome)。回顾分析发生的原因、治疗经过和结果。结果：支架型人工血管(简称支架)近端均锚定于主动脉弓部。A型夹层发生时间为：术中支架释放后2例,术后2 h 1例,1周2例,1个月3例,6个月1例,29个月1例。新发破口位置：7例位于支架近端的主动脉弓部,1例在支架近端裸支架头端与无名动脉开口接触部位,1例位于裸支架覆盖区域内,1例猝死未能行影像学检查。保守治疗3例,胸主动脉人工血管置换7例。死亡3例,另7例随访3～42个月,CT血管造影显示胸腔段假腔完全血栓形成。结论：动脉壁薄弱是Stanford B型主动脉夹层腔内修复后转为Stanford A型的重要因素和基础,支架和腔内操作是致损伤的潜在因素。中转胸主动脉人工血管置换是有效处理方法。注重病例选择和规范腔内操作有助于降低发生风险。     

The Replacement of the Ascending Aorta and Aortic Valve with a New Design Composite Graft: A Six-Year Experience

The problems encountered in coronary artery reattachment when the ascending aorta and aortic valve are replaced with a composite graft induced Gallucci and one of the authors to develop a new aortovalvular prosthesis in clinical practice. The unique transverse ovoidal shape of this graft is intended to conform to the natural aortic root and facilitate the coronary anastomoses and minimize bleeding. We present our 6-year experience with 56 patients operated upon with this prosthesis. In all patients we were able to connect the coronary arteries directly to the graft without complications including hemorrhage or distortion of the coronary ostia. The survivors were evaluated with chest X ray, two-dimensional echocardiography, and conventional or digital subtraction angiography to detect the presence of pseudoaneurysms at the site of the coronary anastomosis, reported by others that have used the composite graft technique. The notable absence of this complication in our patients at a mean follow-up of 41 months (range 3-71) documents that this ovoidal composite graft is a reliable tool in the treatment of aortic root pathology.     

注射毒品所致的股动脉假性动脉瘤的治疗：附45例报告

目的：探讨注射毒品所致的股动脉假性动脉瘤的外科治疗方法及效果。方法：对45例注射毒品所致的股动脉假性动脉瘤患者临床资料进行回顾性分析。其中27例进行血管重建,包括20例直接采用ePTFE人工血管移植,4例自体大隐静脉移植,3例覆膜支架腔内隔绝;18例直接采用单纯股动脉三头结扎。分析患者的近期治疗效果及随访资料。结果：所有患者均保肢成功。血管结扎术后3例分别于6个月、2年、3年出现间歇性跛行3例,2例分别于术后1年和2年出现肌肉萎缩乏力;血管重建术后近期2例出现人造血管感染和术后再出血4例。结论：患者一般情况允许时,应尽可能行假性动脉瘤切除+人工血管解剖旁路移植,但需预防近期术后再出血及感染发生;若患者一般情况差,不耐受大手术,或局部感染严重,单纯股动脉三头结扎是可行的方法,但需预防远期肌肉萎缩等并发症;覆膜支架腔内隔绝适合无明显感染且动脉瘤未破裂的患者。

     

A Unique Method of Closure for an Aortocaval Fistula in Association with a Ruptured Abdominal Aortic Aneurysm: Report of a Case

(Received for publication on June 30, 1997; accepted on Jan. 6, 1998)     

Aortic dissection in patients with autosomal dominant polycystic kidney disease: A series of two cases and a review of the Literature

Aortic dissection (AD) is the most common life‐threatening disease involving the aorta. It is rarely associated with systemic disorders such as Autosomal Dominant Polycystic Kidney Disease (ADPKD), a genetic syndrome characterized by cystic degeneration of kidneys, possible presence of cysts in other organs and extra‐renal manifestations, including cardiovascular disorders. We performed a systematic literature search focused on the occurrence of AD associated with ADPKD (25 cases identified), and reported two cases from our experience. We selected data on sex, age, family history of ADPKD and/or AD, habitus, hypertension, renal function, presence of hepatic/pancreatic/splenic cysts, clinical presentation of AD, AD type according to the Stanford classification, treatment and outcome. Furthermore we compared this dataset with the data of the overall population with AD from the International Registry of Acute Aortic Dissection (IRAD). Stanford A type AD was documented in 62% of patients. As expected, the initial manifestation of AD was most commonly chest and back pain (80%). The mean age of AD occurrence appears significantly reduced in ADPKD patients compared to the general population with AD (49 ± 12 vs 62 ± 14, P < 0.001). Of note, our analysis shows a remarkably higher frequency of hypertension (90%) compared to the overall AD population (75%), although not significantly (P = 0.133). AD should be always ruled out in ADPKD subjects with chest and back pain symptoms, despite them being young and at lower risk. A careful preventive monitoring as well as an optimal blood pressure control may reduce the risk of AD and improve the outcome of these patients.     

Dislodgement of a renal stent causing renal infarct during endovascular abdominal aortic aneurysm repair with chimney graft for juxtarenal aortic aneurysm: A rare complication

Chimney grafts (CG) have been used in the repair of juxtarenal aortic aneurysm (JAA) as a pure endovascular approach, which involve the concurrent deployment of an aortic endograft with covered stents in the renal arteries. In the present study, we report a rare but significant complication of chimney grafting in a case of JAA with iliac artery ectasia. During the placement of CG, one of the covered stents was dislodged in a distal branch of the right renal artery, resulting in segmental infarct of the right kidney.