Staged reconstruction for middle aortic syndrome

BACKGROUND/PURPOSE: Middle aortic syndrome is a rare condition that involves narrowing of the abdominal aorta and its visceral branches. The authors propose staged vascular repair to minimize renal ischemia and facilitate use of native arterial tissue for reconstruction. METHODS: Three adolescents (age 8(1/2), 12(1/2), 13(1/2)) presented with severe hypertension. Subsequent evaluation showed coarctation of the abdominal aorta extending above the celiac axis. All 3 patients had bilateral renal artery stenoses. There also were tight stenoses of the celiac or superior mesenteric arteries. In the first stage the right renal artery stenosis was relieved. In the youngest patient, this was accomplished by balloon angioplasty. However, in the other 2, right renal autotransplantation was performed to the right iliac vessels using end-to-side anastomoses of the renal artery and vein. Cold perfusion was used. The second stage was performed 2 to 5 months later via a thoracoabdominal approach in 2 patients. A Dacron tube graft was utilized from above the coarctation to the iliac bifurcation. The left renal arteries were detached and anastomosed end to side to the bypass graft. In 1 child there were actually 3 separate renal arteries that required reimplantation. In the youngest patient the aortic narrowing was relieved by a long Dacron patch aortoplasty and interposition of an internal iliac artery graft to the left renal artery. RESULTS: All 3 patients recovered well and returned to full activities. There was no measurable rise of BUN or serum creatinine postoperatively. Postoperative renal scans showed good renal perfusion bilaterally. Follow-up results 2 to 10 years later continue to show well functioning reconstructions. CONCLUSION: A staged approach is an effective reconstruction for children with middle aortic syndrome which minimizes risk to renal function.     

Successful Treatment of an Aorto-Ileal-Conduit Fistula with an Endovascular Stent Graft: Report of a Case

A 55-year-old man presented with a massive hemorrhage from the ileal conduit of the left ureter. He had previously undergone a total pelvic exenteration with ileal conduit construction of the ureters due to rectal carcinoma. A right ureteroarterial fistula developed, and he underwent an excision of the right common iliac artery with a femorofemoral bypass and a right cutaneous ureterostomy. Seven months later, a pseudoaneurysm developed at the aortic stump, followed by an aorto-ileal-conduit fistula. The patient was treated successfully with endovascular stent grafting and has since showed a good recovery no sign of graft infection or a recurrence of hematuria at the 10-month follow-up.     

Complete extra-anatomic bypass of the aortic root: treatment of recurrent mediastinal infection

A 45-year-old woman underwent complete extra-anatomic bypass of the aortic root for recurrent mediastinal infection. Operative repair consisted of removal of an aortic valve prosthesis and an ascending aortic graft. The aortic root and transverse aortic arch were closed primarily and a valved conduit was placed from the left ventricular apex to the descending aorta. Coronary flow was reestablished with saphenous vein grafts taken from the innominate and subclavian arteries to the coronary artery orifices. Infection did not recur, but the patient died 9 months following operation apparently of right coronary artery graft occlusion.     

A case report of translocation method for active infective aortic valve endocarditis with aortic root abscesses]

We experienced a case of 51-year-old woman who underwent emergency aortic valve replacement by translocation method for active infective aortic valve endocarditis with aortic root abscesses. Postoperative course was complicated as the following. Three days later, the perforation of noncoronary sinus of Valsalva into the right atrium was noted and she developed progressive heart failure due to the massive left-to-right shunt. The second operation was performed immediately for the patch closure of the perforation through the right atriotomy. Two months later, unstable angina appeared because of the stenosis of the vein graft to the left coronary artery, leading to the emergency third operation in which LITA was placed to the left anterior descending artery. In spite of these complications she recovered gradually and she was discharged 6 months after the first operation. She is now doing well in NYHA class 2. Translocation method is quite useful for such a case of the aortic valve endocarditis with periannular abscesses in whom conventional valve replacement is supposed to be impossible, but the long durability of this type of the repair is unknown. Careful follow-up of the patient is mandatory.     

Primary arteriovenous fistulas of the abdomen. Their occurrence secondary to aneurysmal disease of the aorta and iliac arteries

We present three cases of arteriovenous fistula secondary to aneurysmal disease. The first patient, a 75-year-old man, presented with abdominal pain, a large pulsatile mass, and renal failure. He underwent repair of his aortocaval fistula; his renal failure resolved and the remainder of his course was uneventful. The second patient, a 77-year-old man, presented with a several-day history of nausea, lower abdominal pain, and a pulsatile mass. He underwent repair of his aortocaval fistula but died on the 21st postoperative day of progressive pulmonary failure. The third patient, a 76-year-old man, presented with an episode of syncope and subsequent rapid development of left lower extremity edema. He was subsequently found to have a right iliac artery to left iliac vein fistula, which was repaired. He did well postoperatively with gradual resolution of his lower extremity edema.     

支架型人工血管临床应用的初步经验

目的探讨支架型人工血管治疗各类动脉瘤的临床效果。方法本组包括夹层动脉瘤 4 8例 ;腹主动脉瘤 13例 ;降主动脉、左锁骨下动脉、肾下和肾上腹主动脉假性动脉瘤分别为 4例、1例、2例和 1例 ;左、右髂动脉瘤各 1例。对夹层动脉瘤和假性动脉瘤均行破口封堵术 ,真性腹主动脉瘤行隔绝术。结果本组均获技术成功。围手术期死亡 2例。 5例夹层动脉瘤术后近侧有少量残余漏 ,但 4例半年后近侧渗漏消失 ,9例残存远侧破口少量返流。腹主动脉瘤 6例术后即时有轻度内漏 ,3个月后 5例内漏消失。结论支架型人工血管治疗夹层动脉瘤、假性动脉瘤和真性动脉瘤手术微创、安全 ,但其远期疗效需进一步观察。     

Combined double valve replacement and abdominal aortic aneurysm repair in a patient with infective endocarditis; report of a case

The choice of simultaneous or staged surgery in patients with valvular diseases and abdominal aortic aneurysms (AAA) remains controversial. We present a case of simultaneous surgery of double valve replacement and abdominal aorta replacement in a patient with infective endocarditis. A 74-year-old woman was admitted to our hospital because of general fatigue and appetite loss. Computed tomography (CT) scan showed a infrarenal AAA measuring 99 x 67 mm. Echocardiography showed severe regurgitation of mitral valve and aortic valve with vegetations. Electrocardiogram showed atrial fibrillation. She was diagnosed as heart failure due to infective endocarditis and treated with antibiotics, diuretics and catecholamine. However, heart failure did not improve; the patient underwent double valve replacement, pulmonary vein isolation and abdominal aorta replacement simultaneously. Postoperative course was uneventful.     

Successful management of mycotic abdominal arteriovenous fistula complicated with infective endocarditis--a case report

A 56-year-old man, who had been febrile for one month, suddenly had severe left foot pain. He also became dyspneic. Embolic occlusion of left femoral artery as well as severe acute aortic regurgitation due to Staphylococcus endocarditis was demonstrated by arteriography and echocardiography. The patient underwent emergency aortic valve replacement and above knee amputation of left foot at the same time. Postoperatively he continued to be hypotensive and, at 6th postoperative day, abdominal vascular bruit was first observed. Aortography revealed left common iliac aneurysm with an arterio-venous fistula. The aneurysm was excised and venous opening of the fistula was oversewn. Aortic end was reconstructed with bifurcated prosthetic graft. Antibiotic therapy was continued 6 weeks. His postoperative course was uneventful.     

Surgical treatment and their long-term results of the ascending aortic lesions involving coronary arteries

Seventeen patients underwent surgical treatment of the ascending aorta, aortic valve, and coronary artery as well. Diagnosis of 13 patients were annulo-aortic ectasia, 3 had dissecting aneurysm (type I: 2, type II: 1), and one had supra-valvular aortic stenosis. In annulo-aortic ectasia, Bentall's method was carried out in 11 cases, and Cabrol's operation was performed in 3, one of the latter group had received Bentall's procedure 4 years prior to the second operation. One patient died of acute myocardial infarction 3 days following operation, who had severe stenosis of the left anterior descending artery not detected by preoperative angiography. During long-term follow up, 2 patients died of cardiac failure. Three patients had dissection of the ascending aorta and coronary artery (right coronary artery: 2, left coronary artery: 1). The aorta was reconstructed, aortic valve was replaced, and coronary artery was revascularized with saphenous vein graft. They have been alive and well up to post operative 6 years. Right coronary ostioplasty as well as aortic valve replacement and extended aortoplasty were attempted in one patient with Williams' syndrome. This patient had been well until sudden death which occured 11 months after the operation.     

Suprarenal mycotic aortic aneurysm: surgical management and follow-up

A case is reported of a rare 7 cm saccular mycotic aneurysm that developed in the suprarenal abdominal aorta of a severely atherosclerotic 63-year-old man from presumed hematogenous inoculation of an atherosclerotic plaque. At operation a right axillobifemoral artery bypass graft was performed along with autotransplantation of the left kidney to the left common iliac vessels and the suprarenal aorta was ligated, excised, and widely debrided. The patient recovered and was in good health for 6 months when sudden occlusion of his axillofemoral graft required thrombectomy for limb salvage and to preserve renal function. Elective thoracoaortic to bilateral iliac artery bypass was successfully undertaken 8 months after the initial operation. However, the patient suffered a fatal myocardial infarction 2 weeks after operation. At autopsy a well-perfused nephrosclerotic kidney, healed aortic ligation, and no graft infections were found.     

Salvaging the dehisced lung transplant bronchial anastomosis with homograft aorta

This is a case of 50-year-old male who underwent left single lung transplantation for pulmonary fibrosis. He sustained a bronchial dehiscence with a pulmonary artery-bronchial fistula which was primarily repaired. One week later, there was complete bronchial dehiscence followed by a massive hemoptysis. At operation, following resection of necrotic donor bronchus there was a sizeable gap between donor and recipient bronchus, which was bridged with a cryopreserved aortic homograft. The homograft patch provided a satisfactory repair without malacia. The patient required retransplantation six months later for reasons unassociated with the repair. Homograft aorta proved useful material for salvaging the dehisced lung transplant bronchial anastomosis.     

A case of intimal dissection of the aorta during transfemoral angiography]

A 54-year-old man underwent right transfemoral angiography because of left renal hematuria. During angiography, dissection of abdominal aorta and thoracic aorta was encountered. It was initiated by intramural catheter passage at the bifurcation of the internal and external iliac artery. Transaxillary aortography about one month after the first angiography showed occlusion of the dissecting space in the thoracic aorta and existence of dissecting space in the abdominal aorta. Communicating orifices between the true space and the false space existed not only at the bifurcation of internal iliac artery and external iliac artery, but also at the abdominal aorta near the left renal artery. CT 1.5 months after the first angiography did not demonstrate more improvement. Surgery was performed. It was impossible to sew up and close the orifices of the space because of the fragility of the intima. Surrounding abdominal aorta and common iliac artery were wrapped near orifices with a dacron graft. A follow-up CT obtained 3 months postoperatively showed that the dissecting space in the abdominal aorta had disappeared. Wrapping was very useful to promote organization of the dissecting space.     

Type B aortic dissection with rupture of the left common iliac artery: a case report

Type B aortic dissection involves the appearance of a false lumen distal to the left subclavian artery and extending distally into the descending thoracic aorta and into the abdominal aorta. Complications of the dissection include rupture of the thoracic aorta, leg ischemia, visceral ischemia, and renal failure. A 37-year-old man presented with complaints of sudden onset of chest pain, left leg pain, and numbness. Examination revealed no femoral, popliteal, or distal pulses with decreased sensory and motor function on the left lower extremity. A CT scan revealed an aortic dissection at the proximal descending aorta extending into the iliac arteries with a left retroperitoneal hematoma at the iliac bifurcation. An MRI confirmed the dissection distal to the left subclavian artery into the iliac artery with a distal occlusion. Exploration revealed rupture of the left iliac artery dissection with arterial occlusion and a contained hematoma. The common iliac artery was ligated and an 8-mm Dacron bypass graft from the right common femoral artery to the left femoral artery was performed. Type B aortic dissection can present as rupture of the common iliac artery. Revascularization of the extremity with a femoral-femoral crossover graft is the recommended procedure in the absence of visceral ischemia. The surgeon should have a keen suspicion of this rare complication and its management.     

Repair of Truncus Arteriosus and Interrupted Aortic Arch

A total of seven patients with truncus arteriosus and interrupted aortic arch (IAA) comprises our surgical experience in this condition. All underwent primary complete repair via median sternotomy between June 1985 and December 1989. Median age at repair was 8 days and median weight, 3.2 kg. Anatomy of these seven patients was truncus arteriosus type "1 1/2" in five patients and type II in two patients, IAA type B in six patients and type A in one patient. Aortic arch was reconstructed by direct anastomosis of ascending aorta and descending aorta. Right ventricle to pulmonary artery continuity was established with a porcine valved conduit in four patients, aortic homograft in two, and aortic homograft monocusp patch in one. Three patients have required five reoperations (three in one patient). One reoperation was due to compression of the left main bronchus from the reconstructed aorta, one was due to obstruction of the aorta at the site of IAA repair, and one was due to compression of the left main bronchus, right pulmonary artery, and residual stenosis across the hypoplastic ascending aorta. There were no early or late deaths and all seven survivors are currently well with a mean follow-up of 29 months from initial repair.     

Arterial misplacement of a central venous catheter with a fatal cerebral embolism

A 26-year-old woman came to hospital with an acute abdomen and a history of abdominal pain for about 6 months. She showed signs of peritonitis and ileus and underwent a laparotomy after initial diagnostic procedures. There was massive terminal ileitis with perforation and localized peritonitis. Resection of the affected bowel was performed over 5 1/2 h without surgical or anesthetic complications. Postoperatively several attempts were made to insert a venous catheter via the internal jugular vein, first on the right and then on the left side. The catheter was finally placed and was used for infusions, although there were some signs that indicated a possible arterial position. Neurological disturbances followed the end of anesthesia; 2 h later the catheter was removed because of arterial malpositioning diagnosed by a blood gas analysis. The patient developed brainstem and cerebellar infarctions and died 2 days later. The main postmortem finding was massive swelling and paleness of the cerebellum and brainstem with macroscopically unaffected supporting arteries. The other main arteries of the head and neck were also unremarkable, except for two healing punctures of the left common carotid artery. Further examination revealed an embolism at the top of the basilar artery. The source was macroscopically obscure; stereomicroscopic examination of the heart showed small dark spots behind one fold of the aortic valve caused by parietal thrombosis of the damaged endothelium. The tip of the misplaced catheter had entered this region and caused the lethal embolism.     

Bartonella infective endocarditis of a prosthetic aortic valve with a subvalvular abscess

A patient with a prosthetic aortic valve, and culture negative endocarditis caused by Bartonella henselae presented with nonspecific constitutional symptoms, skin rash, and then later developed acute renal failure. The patient underwent redo sternotomy, aortic root, and ascending aorta replacement with a homograft, which resolved his symptoms and the renal failure.     

Arterio-venous fistula following a lumbar disc surgery

Vascular complications during posterior lumbar disc surgery are rare and its presentation with varicose veins is even rarer. A 23 year-old male patient presented with large varicose veins in right lower limb. He underwent a posterior lumbar spine discectomy surgery. He noticed mild swelling of the distal third right lower limb 3 months after index surgery and reported 6 months later when he developed varicose veins. Duplex Doppler confirmed varicose veins of the long saphenous vein and its tributaries with a patent deep venous system. A digital subtraction angiogram demonstrated a large right common iliac artery (CIA) false aneurysm with an arteriovenous fistula between right common iliac vessels. He had a right CIA covered stent insertion with good results. Varicose veins were later managed with sapheno-femoral junction ligation and a below knee long saphenous vein stripping. At six month follow-up the lower limb swelling had completely recovered and duplex ultrasound did not show any recurrence of varicose veins.     

Rupture of abdominal aortic aneurysm with tear of inferior vena cava in a patient with prior endograft

We report a case of contained rupture of abdominal aortic aneurysm and tear of the inferior vena cava (IVC) 15 months after placement of an aortic endograft (ANEURX graft, Medtronic, Sunnyvale, Calif). A 63-year-old man with significant coronary artery disease underwent endograft exclusion of abdominal aortic aneurysm with Aneurx graft. The patient was seen with a rupture of the aortic aneurysm, probably caused by poor proximal fixation of the graft associated with separation of the left iliac extension limb from the main body of the graft. Angulated right iliac limb of the stent graft penetrated into the Ivc just above the common iliac junction and caused sealed perforation. Successful repair with aortobiiliac graft reconstruction after removal of the endograft was accomplished. The IVC laceration was repaired. Possible mechanisms of failure of endograft are discussed.     

A Case Report of Successful Kidney Transplantation in a Patient With Autosomal Dominant Polycystic Kidney Disease Who Underwent Thoracic Endovascular Aortic Repair for Type B Aortic Dissection

BackgroundAutosomal dominant polycystic kidney disease (ADPKD) is associated with several cardiovascular disorders, including aortic dissection, which preferentially occurs at the thoracic or abdominal level. Because there are few case reports describing surgical repair for aortic dissection followed by renal transplantation in patients with ADPKD, kidney transplantation performed after repair for aortic dissection remains challenging.Case presentationA 34-year-old Japanese man with end-stage renal disease secondary to ADPKD underwent thoracic endovascular aortic repair for complicated acute type B aortic dissection 12 months earlier. A contrast computed tomography scan before transplantation revealed an aortic dissection involving the descending aorta proximal to the common iliac arteries and confirmed multiple large bilateral renal cysts. After simultaneous right native nephrectomy, the patient underwent preemptive living-donor kidney transplantation obtained from his mother. Intraoperatively, we noted that dissection of the external iliac vessels was difficult because of dense adhesions. Arterial clamping was performed immediately below the bifurcation of the internal iliac artery to prevent further aortic dissection of the external iliac artery. After end-to-end anastomosis to the internal iliac artery was completed and the vascular clamp was released, the kidney began to produce urine immediately.ConclusionThis case suggests that kidney transplantation in patients undergoing endovascular aortic repair for aortic dissection can be performed by adequately applying a vascular clamp proximal to the internal iliac artery during vascular anastomosis.     

Aortic valvular insufficiency and postductal aortic coarctation with small aorta syndrome: one-stage surgical management using extra anatomic bypass through median sternotomy

A 30-year-old man who had undergone repair for coarctation of the thoracic aorta at age 7 and mitral valve annuloplasty at age 9 was admitted for shortness of breath and claudication of both lower legs. The preoperative angiogram showed severe aortic regurgitation, moderate coarctation of the thoracic aorta beyond the left subclavian artery, a degree of hypoplasia of the infrarenal abdominal aorta, and total occlusion of both external iliac arteries. Aortic valve replacement, ascending-to-bilateral femoral arterial bypass, and end expanded polytetra fluoro ethylene (ePTFE) graft-to-descending aorta bypass was performed via a median sternotomy. Ascending-to-descending aortic bypass via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.