Bronchogenic carcinoma associated with right aortic arch and postaortic left brachiocephalic vein--report of a case

61-year-old male was admitted to our hospital for surgical treatment of bronchogenic squamous cell carcinoma arising from left B8. The patient had right aortic arch with aberrant left subclavian artery and postaortic left brachiocephalic vein. Intraoperatively, left ligamentum arteriorsus forming vascular ring between the left subclavian artery and the pulmonary artery was found, however the ligamentum arteriorsus was not divided because no symptom of esophago-tracheal compression was observed. The left brachiocephalic vein was located between the ascending aorta and the arterial ligament. The lower lobe of the left lung was resected, and lymph nodes in the left side of the mediastinum were dissected easily because the aortic arch was positioned on the other side. Preoperative assessment of the type of branching and the course of arteries and veins is important for safe operation.     

Anomalous origin of the left coronary artery from the pulmonary artery in an adult: tubular reconstruction of the left main coronary artery under coronary perfusion

A 38-year-old female with anomalous origin of the left coronary artery (LCA) from pulmonary artery was surgically corrected by tubular reconstruction of the left main coronary artery (LMCA) using the pulmonary artery wall, and this repair was performed under beating heart. Thus, the pulmonary artery was divided above the orifice level and just above the pulmonary valve, and the commissure between nonfacing and left side sinuses was dissected away from the pulmonary artery wall to obtain lateral flaps. The pulmonary artery defect was reconstructed with a roll using an autologous pericardial patch, while the detached commissure was suspended on the pericardial patch. The long tube constructed using pulmonary artery tissue was anastomosed to the anterior aspect of the ascending aorta. These procedures were performed under beating heart simply by clamping the LMCA, since the preoperative myocardial contrast echocardiography confirmed the adequate coronary collateral flow from the right circulation. The postoperative course was uneventful, and a coronary artery angiogram demonstrated a widely patent LMCA. Our experience suggests that, in adult cases, this procedure could be performed without myocardial ischemia simply by clamping the LMCA because of well-developed coronary collateral arteries. The safety of this technique could be confirmed by myocardial contrast echocardiography.     

Coronary revascularization and abdominal aortic aneurysm repair in a patient with Beh?et's diseases

Beh?et's disease is a systemic disease characterized by oral aphta, genital ulcer, and ocular lesion. Arterial involvement is an uncommon complication of Beh?et's disease, and it most frequently affects the abdominal aorta followed by the femoral artery and the pulmonary artery. Coronary lesions in Beh?et's disease have been little reported in the literature. In this communication, we present a case with coronary artery stenosis and with subsequently developed supra-renal abdominal aortic aneurysm. The coronary lesions were revasculized with gastroepiploic artery, right internal mammary artery, and saphenous vein graft. Abdominal aortic repair was performed with partial cardiopulmonary stand by, because of the risk of coronary ischemia during the cross clamp including the celiac artery. To our knowledge, this is the first report of successful repair of combined lesions of the coronary and the abdominal aorta in a patient with Beh?et's disease.     

Different ancestor alleles: a reason for the bimodal fragment size distribution in the minisatellite D2S44 (YNH24)

The aim of this study was to evaluate whether MR could depict pulmonary arterial anatomy in more detail than routine angiography in patients with congenital interruption or acquired occlusion of the left pulmonary artery or pulmonary atresia. This study included 10 patients with tetralogy of Fallot (n=6) or pulmonary atresia with ventricular septal defect (n=3) or aorticopulmonary window (n=1) diagnosed by cardiac angiography and MR. Surgical confirmation was made in seven patients. Interruption of the proximal left pulmonary artery, diagnosed at the time of evaluation, was found in seven patients and acquired obstruction of the hilar pulmonary artery (PA) was found in two at cardiac angiography. In the remaining one patient with pulmonary atresia and an occluded palliative shunt, the central PA was not visualized at angiography. MR showed 3-6 mm-sized hilar PAs in five and a central PA in a patient with pulmonary atresia. In 4 of 6 (67%) surgically-proven patients with congenital or acquired left PA obstruction, the status of the PA distal to the obstruction was correctly diagnosed with MR. In conclusion, MR is an effective modality in depicting sizable PAs when routine angiography fails to visualize the PA anatomy.     

Laparoscopic colo-rectal surgery

Laparoscopic colorectal surgery was less invasive for patients although it was difficult to perform complete resection of colon combined with regional lymph node. The skillful manner of the laparoscopic surgery was required for the surgical team. The laparoscopic equipments, in order to perform curative dissection of mesenterium and intermediate lymph node, such as Ultrasonic-aspiration surgical unit (USU) or Harmonic scalpel laparoscopic coagulation shears (LCS), were useful for safer dissection of D2 regional lymph node. Meticulous manner of grasping forceps and special dissectors was made sufficient lymph node dissection. The reconstruction of extracorporeal anastomotic technique by hand or valtrac (biofragmentable anastomosis ring) were safer manner for anastomosis after resection of the right side colon. Reconstruction by double stapling technique of linear stapler and circular stapler was admired for anastomosis for left side colonic and rectal surgery. We had safely performed locar resection in 3, partial resection with Do dissection in 2, with D1 dissection in 14, with D2 dissection in 21 and right and left hemicolectomy in 1 each.     

Reconstruction of the aortic arch in invasive thymoma under retrograde cerebral perfusion

Extensive en-bloc resection of the aortic arch and anterior wall of the main pulmonary artery was performed in a 46-year-old man with invasive thymoma. The aortic arch was replaced with a Hemashield vascular graft under hypothermic circulatory arrest with retrograde cerebral perfusion. Patch plasty with Xenomedica was performed for the anterior wall of the main pulmonary artery under cardiopulmonary bypass. The patient was treated with postoperative radiotherapy and has remained asymptomatic for 15 months after the operation. An extensive operation is considered necessary to improve the prognosis of invasive thymoma.     

An experience of the modified Norwood's operation for hypoplastic left heart syndrome with aberrant origin of right subclavian artery and persistent left superior vena cava--the procedure without total circulatory arrest and cardiac arrest

We reported a successful case of the modified Norwood operation for a 21-day-old neonate with hypoplastic left heart syndrome (MS and AS) associated with an aberrant right subclavian artery and a persistent left superior vena cava. The modified Norwood operation was performed without total circulatory arrest and Cardiac arrest. A 4 mm Gore-Tex graft, which was anastomosed between the right carotid artery and the right pulmonary artery for systemic-pulmonary shunt, was used for cerebral perfusion during aortic arch reconstruction. Coronary perfusion was performed with a small cannula placed on the relatively large ascending aorta during anastomosis between the main pulmonary artery and the ascending aorta. Equine pericardial patch was used for aortic arch reconstruction and the ascending aorta was directly anastomosed to a part of the main PA. Postoperative course was uneventful and postoperative MRI revealed no stenosis of the aortic arch and the pulmonary artery.     

Surgical management of aortopulmonary window

BACKGROUND: Aortopulmonary window is a rare anomaly, and a variety of surgical techniques have been described for its closure. METHODS: We treated 6 infants with aortopulmonary window between 1993 and 1995. Three had associated type A interrupted aortic arch, and another had a muscular ventricular septal defect. The diagnosis was made by echocardiography, confirmed by cardiac catheterization in 4 infants. In 1 very sick neonate with interrupted arch, diagnosis of the window was considerably delayed. In 4 patients, we closed the window by using a flap of pulmonary artery, which was reconstructed without using a patch. In 2 neonates with interrupted arch we anastomosed the mobilized descending aorta directly to the aortic defect of the aortopulmonary window, closing the pulmonary artery with a pericardial patch. RESULTS: There were no hospital deaths, and all patients are in New York Heart Association functional class I at a mean follow-up of 30 months. Echocardiography shows no significant distortion of the great vessels. CONCLUSIONS: The techniques described achieve excellent results using only autologous tissues with the potential for normal growth.     

Imaging of electromagnetic resonances in a YBa2Cu3O7- delta bicrystal grain-boundary Josephson junction

The diagnosis of a discontinuous left pulmonary artery arising from a left ductus arteriosus was made by two-dimensional and Doppler echocardiography in an infant with recurrent pneumonia. The diagnosis was later confirmed at cardiac catheterization and surgery. The suprasternal notch views were especially useful for the identification of the left pulmonary artery. In this patient with a right aortic arch, the left pulmonary artery was supplied by a left ductus arteriosus that arose from the innominate artery. This case report describes the echocardiographic diagnosis of discontinuous left pulmonary artery as an isolated lesion, an unusual lesion that can easily be missed. It emphasizes the necessity of a careful and complete examination with particular emphasis on pulmonary artery continuity in patients suspected of having congenital heart disease or respiratory compromise as a result of a cardiovascular cause.     

Risk of progressive sensorineural hearing loss and Meniere''s disease after breast implantation

Subclavian artery aneurysms are rare. They occur predominantly on the right side. The most frequent cause of proximal subclavian artery aneurysm is atherosclerosis. An aneurysm of the left subclavian artery with normal origin is less common, and it is extremely rare when associated with an aortic coarctation. This report describes the first case of bilateral subclavian artery aneurysms associated with a pseudocoarctation of the aorta. Successful resection of the left subclavian artery aneurysms and the pseudocoarctation of the aorta was achieved using partial cardiopulmonary bypass.     

Surgical treatment of an aortic arch aneurysm: reports of 2 cases with lesion of the arch vessels

A 48-year old woman underwent surgery for an aortic arch aneurysm with stenosis or dilatation of three arch vessels caused by aortitis syndrome. Total arch replacement and reconstruction of three arch vessels were performed with hypothermic selective cerebral perfusion (SCP). To avoid atheroembolism and malperfusion to the brain, the rt. common carotid artery was perfused via the rt. subclavian artery through the dacron vascular graft and the lt. subclavian artery was cannulated and perfused distally to stenosis. A 65-year-old man who had an atherosclerotic aortic arch aneurysm with severe stenosis of the brachiocephalic artery underwent operation. In the operation, extracorporeal circulation was instituted with the arterial return through the lt. subclavian artery. Same as case 1, total arch replacement and reconstruction of three arch vessels were performed under hypthermic SCP. In this case, the left common carotid artery was transected and cannulated directly into the vessel, instead of cannulation through the aortic lumen because of atheromatous plaques in the orifice of the left common carotid artery. The patients recovered uneventfully and doing well now.     

Retrograde coronary artery flow in aortic valve disease

Retrograde coronary artery flow was observed angiographically in 43 patients with aortic stenosis and/or regurgitation. In the 24 patients with pure or predominant aortic stenosis, retrograde flow was seen in all 24 during end-systole. In the eight patients with pure aortic regurgitation, retrograde flow was seen mainly during end-diastole (6/8). Among the 11 patients with stenosis and regurgitation, retrograde flow was both end-systolic and enddiastolic. Dominant left coronary arteries were seen in 13 patients; 13 showed retrograde flow in the dominant arteries. Dominant right coronary arteries were seen in 25 patients: all 25 showed retrograde flow equally in the right and left coronary. Five of the 43 patients could not be evaluated for dominance because of coronary artery occlusions. The severity of retrograde flow did not correlate with usual clinical, hemodynamic or tension-stress parameters: angina, electrocardiographic abnormality, end-diastolic pressure or volume, end-systolic pressure or volume, ejection fraction, severity of aortic regurgitation, peak or mean valve gradient, aortic valve area, myocardial tension and stress calculations, or DPTI:SPTI. In summary, retrograde coronary artery flow was seen in all 43 patients with severe aortic valve disease. The time in the cardiac cycle when retrograde flow occurred was related to the type of valve disease. Retrograde flow was seen mainly in the coronary arteries supplying the left ventricle and may result from increased regional myocardial stresses.     

pH sensitive properties of Tc(V)-DMS: analytical and in vitro cellular studies

Coronary arteries anomalies may be part of complex congenital malformations of the heart or be an isolated defect. In our anatomic collection of congenital heart disease, an isolated anomalous origin of coronary arteries was observed in 27 of 1,200 specimens (2.2%): left coronary artery from pulmonary trunk in five, origin from the wrong aortic sinus in 12 (both right and left coronary artery from the right sinus in four and from the left sinus in seven, left coronary artery from the posterior sinus in one), left circumflex branch from right aortic sinus or from very proximal right coronary artery in three, high takeoff of right coronary artery in three, stenosis of the coronary ostia attributable to valvelike ridge in four. In 16 (59%) patients (12 males and 4 females, age ranging from 2 months to 53 years; median, 14), the final outcome was sudden death; it occurred in all cases of left coronary artery origin from right aortic sinus, in 43% of right coronary artery origin from left aortic sinus, and in 40% of the left coronary artery from the pulmonary trunk. Sudden death was precipitated by effort in eight (50%) and was the first manifestation of the disease in eight (50%); previous symptoms consisted of recurrent syncope in four, palpitations in three, and chest pain in one. Five patients who died suddenly during effort were athletes. In conclusion, (1) more than half of our postmortem cases with anomalous origin of coronary arteries died suddenly, (2) all but two patients with sudden death had anomalous coronary artery origin from the aorta itself, (3) the fatal event was frequently precipitated by effort, (4) palpitations, syncope, and ventricular arrhythmias were the only prodromic symptoms and signs. Recognition during life of these coronary anomalies, by the use of noninvasive procedures, is mandatory to prevent the risk of sudden death and to plan surgical correction if clinically indicated.     

Differential effect of unfractionated heparin and low molecular weight heparin on intravascular tissue factor pathway inhibitor: evidence for a difference in antithrombotic action

PURPOSE: Successful endovascular repair of an abdominal aortic aneurysm (AAA) requires the creation of a hemostatic seal between the endograft and the underlying aortic wall. A short infrarenal aortic neck may be responsible for incomplete aneurysm exclusion and procedural failure. Sixteen patients who had an endograft positioned completely below the lowest renal artery and 37 patients in whom a porous portion of an endograft attachment system was deliberately placed across the renal arteries were studied to identify if endograft positioning could impact on the occurrence of incomplete aneurysm exclusion. METHODS: Fifty-three patients underwent aortic grafting constructed from a Palmaz balloon expandable stent and an expandable polytetrafluoroethylene (ePTFE) graft implanted in an aorto-ilio-femoral, femoral-femoral configuration. Arteriography, duplex ultrasonography and spiral CT scans were performed in each patient before and after endografting to evaluate for technical success, the presence of endoleaks, and renal artery perfusion. RESULTS: There was no statistically significant difference in patient demography, AAA size, or aortic neck length or diameter between patients who had their endografts placed below or across the renal arteries. However, significantly more proximal aortic endoleaks occurred in those patients with infrarenal endografts (P < or = .05). Median serum creatinine level before and after endografting was not significantly different between the 2 patient subgroups, with the exception of 2 patients who had inadvertent coverage of a single renal orifice by the endograft. Median blood pressure and the requirement for antihypertensive therapy remained the same after transrenal aortic stent grafting. Significant renal artery compromise did not occur after appropriately positioned transrenal stents as shown by means of angiography, CT scanning, and duplex ultrasound scan. Mean follow-up time was 10.3 months (range, 3 to 18 months). Patients who had significant renal artery stenosis (> or =50%) before aortic endografting did not show progression of renal artery stenosis after trans-renal endografting. Two patients with transrenal aortic stent grafts had inadvertent coverage of 1 renal artery by the endograft because of device malpositioning, which resulted in nondialysis dependent renal insufficiency. In addition, evidence of segmental renal artery infarction (<20% of the kidney), which did not result in an apparent change in renal function, was shown by means of follow-up CT scans in 2 patients with transrenal endografts. CONCLUSION: Transrenal aortic endograft fixation using a balloon expandable device in patients with AAAs can result in a significant reduction in the risk of proximal endoleaks. Absolute attention to precise device positioning, coupled with the use of detailed imaging techniques, should reduce the risk of inadvertent renal artery occlusion from malpositioning. Long-term follow-up is essential to determine if there will be late sequelae of transrenal fixation of endografts, which could adversely effect renal perfusion.     

Intravascular ultrasound for monitoring percutaneous fenestration of a membrane from an aortic dissection

HISTORY AND CLINICAL FINDINGS: A 51-year-old man, having experienced sudden retrosternal pain was admitted to another hospital with suspected myocardial infarction. He also had dysaesthesia and later paresis of the left leg. There was no sign of acute infarction in the ECG. However, computed tomography revealed aortic dissection, type III (DeBakey). The left pedal pulses were diminished. The patient was transferred to our hospital for further diagnosis and treatment. At a blood pressure of 110/60 mm Hg the occlusion pressure of the leg artery was 55 mm Hg on the left and 95 mm Hg on the right. INVESTIGATIONS: Transoesophageal echocardiography detected no abnormality of the aortic valve and ascending aorta. But distal to the origin of the left subclavian artery it demonstrated a free floating membrane of an aortic dissection and computed tomography showed its extension to the aortic bifurcation. TREATMENT AND COURSE: At first, because of the incomplete ischaemia syndrome affecting the left leg, a percutaneous fenestration of the dissection membrane was performed. After conventional angiography intravascular ultrasound imaging was also undertaken; it revealed that the membrane was almost completely occluding the left iliac artery. Under ultrasound monitoring a puncture needle and two balloon catheters were introduced across the membrane and thus a window created in it. The clinical findings quickly disappeared and the patient was discharged without further operation. CONCLUSION: Monitoring with intravascular ultrasound imaging makes it possible to perform safely a percutaneous fenestration of the membrane of an aortic dissection and to obtain immediate evidence of its success.     

Coronary artery fistula with left atrial myxoma: report of a case

A 64-year-old male was referred for surgical treatment of left atrial myxoma. Preoperative coronary angiography revealed coronary artery fistula from the left anterior descending artery and the circumflex artery draining into the main pulmonary artery. Operative treatment was performed including resection of the myxoma, patch closure of the atrial septal defect, and closure of the fistula with pledgeted mattress sutures from within the main pulmonary artery on cardiopulmonary bypass. His postoperative course was uneventful, and disappearance of the left atrial myxoma and the coronary artery fistula was ascertained by echocardiography and coronary angiography.     

Video-assisted thoracic surgical resection with the neodymium:yttrium-aluminum-garnet laser

Since January 1991, we have performed 79 video-assisted neodymium: yttrium-aluminum-garnet laser resections for pulmonary nodular or interstitial disease. Pathologic examination demonstrated malignancy in 59 patients (32 primary and 27 metastatic), benign nodules in 11, interstitial processes in seven, and granulomatous disease in two. There were 39 men and 40 women with a mean age of 63.4 +/- 12.5 years. Thirty-nine patients underwent resection with the neodymium:yttrium-aluminum-garnet laser alone and 40 had lesions resected with a combination of laser and endoscopic stapling. Laser excision was performed for lesions deep in the substance of the lung or on its effaced surface; both are locations that make stapling alone difficult. Fifteen of 32 patients with a diagnosis of primary lung malignancy underwent open anatomic resections. Pulmonary reserves of the other 17 patients were inadequate for further resection. Operative time, duration of chest tube placement, length of hospital stay, and complication rate were compared with those for 72 patients undergoing video-assisted thoracic surgical resection of nodules with staplers alone. Although operative time for laser-assisted procedures was longer (p < 0.05), there were no differences in duration of chest tube placement or hospital stay compared with stapled resections. The complication rate for laser-treated cases was not higher than for stapled resections and consisted primarily of air leaks lasting 2 to 7 days. The neodymium:yttrium-aluminum-garnet laser is a safe and precise primary or adjunctive tool for video-assisted thoracic surgical pulmonary resection.     

High-grade coronary stenosis due to a bronchogenic cyst

A 32-year-old woman without preceding illness or significant cardiovascular risk factors was admitted to hospital because of a syncope after physical exertion. Transoesophageal echocardiography, performed to exclude aortic dissection, showed as an incidental finding a cystic space-occupying mass, 5 x 6 cm in diameter, dorsal to the aortic root and main pulmonary artery. Exercise ECG had S-T segment depressions of about 0.3 mV, associated with anginal symptoms, so that inadequate coronary artery flow on exertion was suspected. Subsequent coronary angiography demonstrated a funnel-shaped 80% stenosis at the origin of the main left coronary artery, while all other coronary arteries were normal and smooth-walled. A causal connection between the two findings was assumed and quickly undertaken surgical intervention revealed an intrapericardial bronchogenic cyst which, presumably as a result of its size and location, had pressed on the main stem of the left coronary artery and caused the stenosis of its ostium. The cyst was completely resected and angioplasty of the coronary artery ostium was performed to ensure its patency. 3 months postoperatively the patient underwent an exercise test of up to 125 Watt without signs of ischaemia. This case presents a previously unreported complication of a bronchogenic cyst.     

A patch technique for reconstruction of stenotic pulmonary bifurcation in a Rastelli-type operation after palliations for cyanotic congenital heart disease. A report of two cases

A Rastelli-type operation was successfully performed on two patients with cyanotic congenital heart disease with pulmonary artesia (PA) and severe stenosis or obstruction of the pulmonary bifurcation, following the improvement of a pulmonary artery index (PA index) after palliative systemic pulmonary shunts. It is a point that stenotic or obstructive pulmonary bifurcation was reconstructed by a patch technique. An extracardiac conduit was used a combination of a bicuspid valved pericardial roll and a prosthetic vessel graft. In a 5-year-old male with an extreme type of tetralogy of Fallot associated with PA and patent ductus arteriosus (PDA), the enlargement of stenotic pulmonary bifurcation was attempted using a brimshaped equine pericardial patch in order to get sufficient suture margin and be safely anastomosed with a conduit. In a 6-year-old female with complete transposition of the great arteries, PA, PDA and right aortic arch (RAA), an obstructive pulmonary bifurcation behind the RAA was enlarged using a brimshaped equine pericardial patch. The attachment of the conduit was shifted to the left pulmonary artery to avoid compression of an extracardiac conduit and pulmonary artery behind RAA. Reconstruction of the pulmonary bifurcation using an equine pericardial patch is useful to anastomose an extracardiac conduit and the stenotic or obstructive pulmonary bifurcation.     

Surgical treatment of coronary artery-pulmonary artery fistula

We experienced 4 cases of left coronary artery-pulmonary artery fistula. Two cases had small fistulas associated with atherosclerotic coronary lesions, and the other 2 had large fistulas with aneurysmal enlargement. In the former 2 cases, ligation of the fistulas and closure of the opening of fistula into the pulmonary artery through pulmonary arteriotomy were performed together with coronary artery bypass grafting and left ventricular aneurysmectomy. In one of the latter 2 cases, the fistula arising from the anterior descending branch was ligated and the opening of fistula draining into the pulmonary artery was closed through pulmonary arteriotomy. In another case, both openings of the fistula into the anterior descending branch and the pulmonary artery were closed from inside through incision of the dilated fistula. In all 4 cases, operations were performed using cardiopulmonary bypass and retrograde coronary perfusion, which could afford good heart protection even in cases with coronary lesions and coronary steal phenomenon. All cases went an uneventful postoperative course. Postoperative angiograms showed disappearance of the fistulas in 3 cases. In one case, however, residual fistula was found because a fine fistula might be overlooked. In such a case with complicated fistulas with aneurysmal enlargement, fistulas should be examined carefully through incision of the enlarged anomalous vessels. In this paper, diagnosis, operative indication and treatment for coronary artery-pulmonary artery fistula were discussed.