Left thoracotomy approach for left ventricular pseudoaneurysm due to myocardial infarction after mitral valve replacement for papillary muscle rupture

A 59-year-old man with acute mitral regurgitation due to papillary muscle rupture after myocardial infarction was admitted to our hospital. He underwent emergent mitral valve replacement with a mechanical valve by median sternotomy. Although postoperative echocardiography showed no sign of a ventricular aneurysm, echocardiography performed 5 weeks after the surgery showed enlarging left ventricular pseudoaneurysm of the inferior to the posterior cardiac wall. He underwent dacron patch closure of the orifice by fifth intercostal left thoracotomy. The postoperative course was uneventful and he was discharged on postoperative day 10. The patient was successfully treated for two life-threatening complications occurring subsequently after myocardial infarction.     

Extensive traumatic pneumomediastinum. without injuries of organs in the thorax: report of a case

A 57-year-old man was accidentally hit by concrete blocks weighing 3 tons on his right side, and was admitted to a hospital. The radiologic findings taken immediately after trauma demonstrated pneumo-mediastinum, subcutaneous emphysema with multiple rib fractures and right clavicle fracture. At computed tomography (CT) scan 16 hours after trauma, pneumomediastinum and subcutaneous emphysema turned out to be worsened with an increased bilateral pleural effusion. An emergency thoracotomy revealed no abnormalities of trachea or esophagus, and neither bronchoscopy or esophagogastroscopy, showed injuries anywhere inside. The chest cavities and mediastinum were washed well with 3 liters of saline solution. The patient had a good course after surgery without any complications, and was discharged at the 18th hospital day. Mediastinal drainage by an emergency operation should always be a choice to a patient having a progressively worsening pneumomediastinum which might cause tachycardia, low blood pressure, and severe dyspnea due to compression of blood vessels and trachea.     

Renal artery pseudoaneurysm secondary to blunt trauma treated with microcoil embolization

Background

Renal artery pseudoaneurysms are rarely described sequelae of blunt abdominal trauma. Interventional radiological advances have allowed such lesions to be managed nonoperatively.

Methods

The authors review the presentation, diagnostic evaluation, and hospital course of an 11-year-old girl who developed a right renal artery pseudoaneurysm 14 days after blunt abdominal trauma.

Results

An 11-year-old girl fell off a horse onto her right flank. She sustained multiple right hepatic lobe lacerations and a complex fracture of the upper pole of the right kidney. Her initial hospital course was uncomplicated, and she was discharged after an uneventful 6-day course. The child did well for 2 weeks, until she developed right back pain and gross hematuria. A computed tomography scan revealed a right renal artery pseudoaneurysm. Angiography confirmed the presence of a pseudoaneurysm, which was fed by a single segmental branch originating from the renal artery. The artery was successfully occluded with a single platinum microcoil, which was demonstrated by the absence of contrast flow into the pseudoaneurysm. The patient recovered and was discharged shortly after the procedure. She initially had intermittent pain and hematuria, which resolved. Follow-up computed tomography scans have shown resolution of both the renal and hepatic lesions.

Conclusions

Renal artery pseudoaneurysms that arise after blunt abdominal trauma in the pediatric population may be safely and effectively managed with arterial embolization, thereby avoiding extensive surgical interventions.     

Pseudoaneurysm rupture causing hemoperitoneum following rectal impalement injury: A case report

IntroductionAlthough vascular anatomy of the rectum is complex, pseudoaneurysm followed by massive hemoperitoneum after rectal impalement injury is extremely rare.Case presentationA 43-year-old man presented with abdominal distension. One day earlier, he had undergone sigmoid loop colostomy for rectal implement injury at a local hospital. After the operation, he had become hemodynamically unstable. Digital rectal examination showed a penny-sized anterior rectal wall defect 6 cm from the anal verge. Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with bleeding in the pelvic cavity and an adjacent pseudoaneurysm in the rectum. A large amount of blood and massive hematoma were evacuated by surgery. The Hartmann procedure was performed, but the pseudoaneurysm was not resected. On the 11th postoperative day, hemoglobin decreased (11.6 g/dL–7.9 g/dL), and CT revealed a recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity, with a residual pseudoaneurysm. Angiography failed to localize the pseudoaneurysm. Consequently, prophylactic embolization at the anterior branch of both the internal iliac arteries was performed. The subsequent hospitalization course was uneventful.DiscussionRectal impalement injury may result in pseudoaneurysm of the rectal arteries. However, pseudoaneurysm rupture of the mid rectal artery, followed by massive hemoperitoneum, has not been reported in the English literature. From our experience, preoperative diagnosis of a pseudoaneurysm is crucial for definite surgical management. When surgical resection is indicated, it should include the underlying pseudoaneurysm.ConclusionAlthough pseudoaneurysm rupture causing hemoperitoneum after a rectal impalement injury is extremely rare, meticulous preoperative evaluation is necessary for correct management.     

A case of congenital hydronephrosis suffering from rupture of the renal pelvis due to trauma

A 19-year-old male patient was admitted with the chief complaint of left abdominal pain. After receiving a mild punch in the abdomen during boxing exercises, he had severe abdominal pain and was brought to an emergency room. Since abdominal CT scanning revealed the retention of massive fluid in the retroperitoneum, hydronephrotic rupture due to the trauma was diagnosed and nephrectomy was performed. The removed kidney was filled as a result of urinary retention, and congenital hydronephrosis accompanied by the ureteropelvic junction obstruction was macroscopically and pathohistologically diagnosed. Postoperative course was favorable and the patient was discharged on the 10th hospital day.     

Successful Surgical Treatment of an Infrarenal Abdominal Pseudoaneurysm Caused by Tuberculosis: Report of a Case

A 76-year-old man was admitted to our hospital for investigation of an apparent abdominal aortic aneurysm detected during treatment for epididymitis. A chest X-ray showed miliary shadows in the bilateral lung fields strongly suggestive of tuberculosis. The diameter of the aneurysm increased, and examinations showed impending rupture of a pseudoaneurysm. However, a definitive disease pathogenesis was not obtained before surgery. We performed a subemergency operation, which revealed an infrarenal abdominal pseudoaneurysm caused by tuberculosis. The pseudoaneurysm appeared to have resulted from direct extension of tuberculous lymphadenitis to the aortic wall, which ruptured. We review 24 other cases of tuberculous aortic aneurysms surgically treated in Japan before 2004.     

Fistula between cystic artery pseudoaneurysm and cystic bile duct cause of acute anemia one year after laparoscopic cholecystectomy

We present a case of hemorrhage from a cystic artery pseudoaneurysm one year after laparoscopic cholecystectomy. A 78-year-old male with a history of recurrent melena, hematemesis, and right upper abdominal pain was admitted to our emergency department. His blood pressure was 60/30 mm Hg with a pulse rate of 100 beats per minute. Hemoglobin was 7.6 g/dL and white blood cell count 19500/mm(3). Computed tomography scan of the abdomen and selective digital subtraction arteriography showed a pseudoaneurysm in the region of the former bed of the gallbladder. During gastroscopy, a pulsatile bleeding out of the papilla of Vater was found. Surgery by the open approach confirmed the presence of a cystic artery pseudoaneurysm and showed an additional fistula between the pseudoaneurysm and the cystic bile duct. Resection of the pseudoaneurysm and revision of the common bile duct with implantation of a T-tube was performed. The patient recovered well and was discharged from our hospital three weeks after surgery.     

Isolated extrahepatic bile duct rupture: a rare consequence of blunt abdominal trauma. Case report and review of the literature

ABSTRACT: A 16-year-old girl suffered blunt abdominal trauma. Clinically, a severe motor impairment with paraesthesia of the legs was found. Posterior osteosynthesis in T10-L1 with laminectomy in T10-T12 and posterolateral arthrodesis in T11-T12 was performed because of a dorsal traumatic vertebral fracture. On hospital day 7, because of an acute abdomen, surgical laparoscopic exploration showed sterile bloody fluid without any evident hemorrhagic injury. On hospital day 11, the patient was reoperated on by the laparoscopic approach for increasing abdominal pain and fever: a peritoneal biliary fluid was aspirated. After conversion to open surgery, cholecystectomy was performed. Intraoperative cholangiography was considered as normal. On arrival at our institution 13 days after injury, the patient was operated on for a biliary peritonitis. Intraoperatively, a trans-cystic cholangiography showed a biliary leakage of the common bile duct; a T-tube was placed into the common bile duct; a subhepatic drainage was placed too. On postoperative day 30, a Ttube cholangiography showed a normal biliary tree, without any leakage, and the T-tube was subsequently removed. The patient had a complete recovery.     

Primary Abscess of the Omentum: Report of a Case

We report a case of a primary abscess of the omentum without any obvious etiology. A 62-year-old man was referred to our clinic with lower abdominal pain, and computed tomography showed an intra-abdominal abscess in the left pelvic area. Laparotomy revealed that the abscess adhered to the urinary bladder and abdominal wall, but no perforation of the alimentary tract was identified and there was no foreign body in the abscess cavity. A culture of the abscess fluid grew Clostridium perfringens. The patient was discharged on the 16th hospital day after an uneventful postoperative course without any complications.     

Pseudoaneurysm of the brachiocephalic artery

Pseudoaneurym of the brachiocephalic artery is uncommon. A 62-year-old male patient with a mediastinal tumor underwent tumor resection at the Department of Thoracic Surgery in our hospital. Urgent transverse aorta-right common carotid artery bypass with an 8-mm prosthetic graft was performed intraoperatively, due to uncontrolled bleeding from the brachiocephalic artery where severe adhesion between the anterolateral aspect of the brachiocephalic artery and the tumor was encountered. After surgical removal of the tumor, frozen-section analysis revealed no malignant cells in the tumor, which instead comprised hematoma with organized changes and no evidence of malignancy. Based on pathological results, the resected tumor was diagnosed as a pseudoaneurysm of the brachiocephalic artery. Postoperative course was uneventful. Cause of the pseudoaneurysm was considered iatrogenic, as the aneurysmal wall displayed no atherosclerotic degeneration, and although no history of blunt trauma to the chest or central venous puncture was present, the patient had undergone cerebral artery angiography via the right brachial artery following right thalamic hemorrhage 2 years earlier.     

The diagnosis of delayed expanding traumatic pseudoaneurysm of thoracic aorta caused by self-inflicted penetrating injury with crossbow bolt: A case report

Introduction and importancePenetrating chest trauma caused by a crossbow bolt is very rare. Herein, we report a successfully treated patient who attempted suicide by directing a crossbow to the chest cavity and developed an expanding pseudoaneurysm of the thoracic aorta during eight-day follow up.Case presentationA 51-year-old male was admitted to the emergency department after firing a crossbow bolt twice into his left chest. At admission, the patient was hemodynamically stable and maintaining oxygenation. The bolt had already been removed from the body. Contrast-enhanced computed tomography (CT) revealed a cavity pseudoaneurysm 2.5 mm in size in the aortic arch. Three-dimensional reconstruction of the CT demonstrated wound tracts showing probable damage by the bolt. The patient was admitted to the emergency department for careful observation and transferred to the psychiatric ward on day two. Follow-up contrast-enhanced CT on day eight demonstrated rapid expansion of the pseudoaneurysm from 2.5 mm to 4.0 mm in size. We performed thoracic endovascular aortic repair (TEVAR) on day 13. The patient was uneventfully discharged on the 20th hospital day.Clinical discussionEmergency physicians should be aware that damage to the surrounding tissue may be accompanied by delayed expansion of an aortic pseudoaneurysm, even if the bolts do not cause direct aortic wall injury.ConclusionThis case suggests that understanding the injury mechanism, confirming the tract of the bolts, and carefully exploring traumatic pseudoaneurysm can lead to a less invasive operation due to early detection.     

Transarterial endovascular coil embolization in managing intractable bleeding from fibular artery: A case report

IntroductionPseudoaneurysms of the fibular artery are rare. Recently, endovascular techniques have been preferred over open surgery.Case presentationA 50-year-old male patient complained of recurrent bleeding from surgical wounds that had been present for one month. The patient sustained an open cruris fracture. No source of active bleeding was found at the time of exploration. The patient has then performed angiography with coiling and showed a pseudoaneurysm originating from the left fibular artery branch. Surgical debridement and external fixation were performed one day after the angiography and embolization procedure. The patient was discharged on the third day, and there has been no recurrent bleeding ever since.Case discussionA pseudoaneurysm can be thought of as one of the intractable bleeding causes. Recently, the endovascular technique has been commonly used as an alternative treatment if we did not find the source of bleeding in exploration. Many kinds of the literature showed the success of using non-surgical management, especially the coil embolization as the patient received.ConclusionIn the management of pseudoaneurysm following trauma which cannot be found in open surgery, an endovascular technique like coil embolization can be the alternative method.     

Endovascular treatment of anterior tibial artery pseudoaneurysm following locking compression plating of the tibia

Less invasive surgery and interventional radiology are relatively new techniques. This case report describes a patient with a distal tibial fracture that was stabilized using minimally invasive osteosynthesis consisting of a precontoured metaphyseal Locking Compression Plate (LCP). Postoperative radiographs showed good alignment of the bone, and the initial postoperative course was uneventful. At the sixth-week follow-up visit after surgery, the patient presented with a pulsating and tender mass on the lower leg that was palpable subcutaneously. Arteriography showed a pseudoaneurysm of the anterior tibial artery. At the same procedure an endovascular stent was placed, thereby excluding the pseudoaneurysm from the main circulation while keeping the vessel lumen patent. At the time of the last visit, 6 months after the operation, the patient was fully weightbearing with normal function of the ankle but with a nonhealing fracture on the x-ray. The dorsalis pedis pulse was equally strong as on the right side. Endovascular treatment with a covered stent proved to be an effective treatment for the described posttraumatic pseudoaneurysm of the anterior tibial artery. This case illustrates a risk of less invasive fracture surgery and at the same time underlines the value of a multidisciplinary approach to complications in trauma surgery.     

Diaphragmatic hernia caused by heterotopic endometriosis in Chilaiditi syndrome: report of a case

A 50-year-old Japanese female was admitted to our hospital because of ileus due to Chilaiditi syndrome. Her symptoms did not improve with conservative therapy, so chest and abdominal computed tomography (CT) was performed on the fifth day after hospital admission. A diagnosis of incarceration of a right diaphragmatic hernia was established in the coronal view of CT, and emergency surgery was performed. A dilated loop of small intestine was seen in the right thoracic cavity, which was strangulated by the 2-cm defect in the diaphragm. Primary closure of the diaphragm was performed. Approximately 80 cm of the terminal ileum showed obvious ischemic changes, and it was cut and reconstructed. Postoperatively, the patient made an uneventful recovery and was discharged on the 15th postoperative day. A histological examination of the specimen of the diaphragm around the hernia orifice showed the presence of a small cystiform glandular system with hemorrhage and congestion. These findings indicated that heterotopic endometriosis was present in the diaphragm. This report describes the first known case of right diaphragmatic hernia secondary to heterotopic endometriosis in a patient with Chilaiditi syndrome. The clinical course and management of affected patients and a literature review of these three unusual conditions are discussed.     

Non-operative management of a hepatic pseudoaneurysm and a biloma complicating a blunt abdominal trauma

Hepatic artery pseudoaneurysm and bilioma are rare complications of blunt abdominal trauma in children. We report a case in an 11-year-old patient after a hepatic and splenic blunt trauma following a car accident. The initial evolution was simple with haemodynamic stability. On Day 12, a pseudoaneurysm was discovered on an abdominal magnetic resonance imaging whereas the patient presented a major pain syndrome and an icteric cholestase. Embolisation was realised a few hours later in emergency because of a haemorrhagic shock. On Day 26, an endoscopic retrograde cholangiopancreatography highlighted two bilary leaks: one extrahepatic, the other intrahepatic. The first one was treated with a stent and the second one needed three drains: two peritoneal and one in the biloma. The characteristic of this case relies on the association of two complications. It underlines the need of multidiscipline and non-operative management of pediatric blunt hepatic trauma.     

Large Perigraft Seroma After Aortoiliac Bypass with an Expanded Polytetrafluoroethylene Graft: Report of a Case

A 63-year-old man who had undergone aortoiliac bypass with an expanded polytetrafluoroethylene (PTFE) graft was referred to our hospital for investigation and treatment of a possible pseudoaneurysm of the abdominal aorta. A tender, pulsatile, and bulging mass, about the size of an adult fist, was palpated around the navel. Enhanced computed tomography (CT) showed a large low-density area around the abdominal aorta and PTFE graft, and aortography showed a patent graft with no anastomotic leakage. Operative inspection revealed that the pulsatile mass was a large perigraft seroma, and we replaced the PTFE graft with a new woven Dacron graft. The patient has been well with no sign of recurrence for 1 year, although close long-term follow-up is mandatory.     

Complete Cure of Malignant Lymphoma of the Stomach with a Huge Adrenal Lesion Achieved by Preoperative Chemotherapy and Surgery: Report of a Case

We report herein the case of a 53-year-old woman with malignant lymphoma of the stomach who was successfully treated by preoperative chemotherapy and surgery. The patient consulted our hospital with the chief complaint of upper abdominal pain. Endoscopy demonstrated a protruding lesion at the antral posterior wall of the stomach, and a post-biopsy pathological diagnosis of diffuse large cell type B-cell lymphoma was established. Moreover, abdominal ultrasonography, computed tomography, and magnetic resonance imaging demonstrated a tumor measuring approximately 10 cm in diameter in the left adrenal gland. A total of three courses of chemotherapy using the CHOP regimen were given preoperatively. The CHOP regimen consisted of 100 mg of prednisolone administered for 8 days together with 1.9 mg of vincristine, 1 000 mg of cyclophosphamide, and 60 mg of epirubicin administered intravenously on the first day. This resulted in tumor shrinkage, and a distal gastrectomy, lymph node dissection, and left adrenalectomy were subsequently performed. Since the pathological findings of the resected tissue specimen demonstrated complete elimination of the malignant lymphoma, this combination of procedures was defined as having resulted in a complete response. The postoperative course of this patient was uneventful. She is still alive without any sign of tumor recurrence 6 years after her operation, and is being followed up at the outpatient clinic. Received: September 27, 1999 / Accepted: September 26, 2000     

Pseudoaneurysm of the thoracoabdominal aorta caused by a severe migration of an anterior spinal device

Background ContextCase report.PurposeTo describe the case of pseudoaneurysm of the thoracoabdominal aorta caused by the severe migration of an anterior spinal device 5 years after surgery.Study Design/SettingCase report.MethodsA 70-year-old woman was referred to us because of migrated anterior spinal devices and a pseudoaneurysm of the thoracoabdominal aorta. This patient had undergone anterior corpectomy and spinal fusion from Th12 to L2 because of delayed palsy after a burst fracture using a smooth rod Kaneda device (SRK) with bioactive ceramic (apatite-wollastonite containing glass ceramic) at a local hospital. She had persistent low back pain after the surgery.ResultsFive years after the initial surgery, the patient was referred to us because of increasing of her low back pain and the migrated SRK devices shown on plain X-ray films. An enhanced computed tomography scan taken in our hospital clearly showed a pseudoaneurysm of the thoracoabdominal aorta surrounding the SRK devices. The pseudoaneurysm was resected, the aortic defect was repaired with an artificial patch, and the migrated SRK devices were removed.ConclusionsThe pseudoaneurysm of the aorta can occur secondary to a migrated anterior spinal fixation device and can be successfully treated by revision anterior surgery with vascular repair and implant removal.     

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.     

Pseudoaneurysm of the abdominal aorta due to a needle-like osteophyte on the first lumbar vertebra

A 46-year-old woman was admitted with acute abdominal pain radiating to the back. Computed tomography examinations showed a needle-thin perforation of the aorta, opposite the origin of the superior mesenteric artery, with a pseudoaneurysm. A needle-sharp spinal osteophyte was located exactly opposite the perforation. There was no sign of infection, and the perforation seemed to have been caused by the osteophyte. This aortic perforation occurred without any major trauma, but repeated minor occupational trauma to her abdomen may have played an etiologic role. The pseudoaneurysm and adjacent aorta were exposed through a thoracolaparotomy. The aortic wall was normal, with good tensile strength; therefore, the perforation in the aortic wall was sutured with a double vascular suture, and the osteophyte was resected. To our knowledge, aortic perforation due to a vertebral osteophyte in the absence of major trauma has not previously been described.