Case Report: Acute arterial occlusion of the right lower extremity due to left atrial invasion from pulmonary metastases of thyroid cancer

Cardiac metastases of thyroid cancer are rare. The most common metastatic route is through lymphatic or hematogenous spread to the right side of the heart. Direct invasion of metastases from other adjacent organs to the left side of the heart is even rarer. In many cases, the disease progresses asymptomatically, and symptoms appear only when it is already fatal. A 68-year-old woman underwent total thyroidectomy and right-side lymph node dissection for papillary thyroid cancer and multiple lung metastases 7 years previously. The patient was referred to our hospital due to sudden pain in the right lower extremity and motor disturbance. Computed tomography revealed acute arterial occlusion of the right lower extremity due to tumor dispersal from a left atrial invasion caused by multiple pulmonary metastases of thyroid cancer, and only emergency thrombectomy was performed. Although blood flow was restored, the patient died of respiratory failure 2 months after the procedure. Radical resection is considered difficult in cases of direct invasion of metastases from other adjacent organs because multiple metastases have often already occurred. Therefore, in the terminal stage, it might be too invasive to resect a tumor only to prevent embolism recurrence. The treatment strategy should depend on the patient's prognosis and choice.

[Repeated Myocardial Infarction due to Intraluminal Thrombus in a Coronary Aneurysm Suspected to be Caused by Vasculitis in a Young Male:Report of a Case]

Coronary artery aneurysms are rare and are often associated with atherosclerosis in adults and Kawasaki disease in children. Thromboembolism and rupture of the aneurysm are common complications associated with this condition. We report a case of coronary aneurysm resection and coronary artery bypass grafting (CABG) in a 36-year-old man with a history of recurrent acute myocardial infarction. There was no coronary aneurysms in first acute myocardial infarction. Histopathological examination of the resected coronary artery aneurysm wall revealed features of vasculitis, although the patient showed no episodes and physical findings of vasculitis. Coronary vasculitis can cause vascular endothelial cell injury and therefore requires careful follow-up.

Spinal cord ischemia following open surgery of a ruptured isolated internal iliac artery aneurysm: A case report

INTRODUCTION

Isolated internal iliac artery (IIA) aneurysms (IIIAAs) rarely occur. However, they may enlarge asymptomatically and rupture, causing fatality. Even after successful surgery of ruptured IIIAAs, there might be a potential risk of postoperative spinal cord ischemia (SCI)-related paraplegia, which is extremely rare. However, this paraplegia significantly impacts patients' activities of daily living.

PATIENT CONCERNS

A 71-year-old man who had no remarkable medical history was referred to our hospital with sudden lower abdominal pain.

DIAGNOSIS

Computed tomography (CT) revealed right IIIAA with small volumes of contrast medium extravasation and hematoma. He presented with cyanosis in the bilateral lower limbs. Moreover, blood gas analysis showed lactic acidosis. Therefore, he was diagnosed with ruptured IIIAA complicated by peripheral circulatory failure.

INTERVENTIONS

Considering his pre-shock status, an emergency operation comprising ligation of the proximal neck and suture closure of the distal IIA orifice was successfully performed.

OUTCOMES

Immediately after surgery, motor and sensory dysfunction in the bilateral lower limbs occurred. Magnetic resonance imaging confirmed the presence of SCI. The patient could not stand independently and had neurogenic bladder and rectal disorder.

CONCLUSION

Postoperative SCI is a serious complication with no definitive predictors, preventive methods, or highly efficacious treatments. Therefore, vascular surgeons should preempt its occurrence and focus on preventing hemodynamic instability and maintain collateral extra-segmental arterial blood flow, especially in ruptured cases.

Surgical Treatment for a Super-Giant Right Coronary Artery Aneurysm Induced by Kawasaki Disease

A 32-year-old man diagnosed with Kawasaki disease at the age of three years presented with coronary artery aneurysm (CAA). The aneurysm increased in size, and the patient was referred to our hospital for surgery. Preoperative computed tomography scan showed a super-giant right CAA and giant left CAAs; surgery was performed. The super-giant right CAA was resected, and the ostium of the right coronary artery was closed; then, coronary artery bypass grafting was performed. The left CAAs were not treated surgically because the risk of rupture was low. Here, we describe the successful surgical treatment of a right super-giant CAA.

Hybrid operation for infectious thoracic and abdominal aortic aneurysms complicated with Bacillus Calmette-Guérin therapy for bladder cancer: A case report

RATIONAL

Bacillus Calmette-Guérin (BCG) intravesical instillation therapy is a widely used treatment for bladder cancer; however, an infectious aneurysm has been reported as a rare complication.

PATIENT CONCERNS

A 76-year-old man who underwent BCG intravesical instillation therapy for bladder cancer presented with prolonged dull back pain for 3 months.

DIAGNOSIS

Computed tomography (CT) revealed both thoracic and abdominal aortic aneurysms (AAAs). Follow-up CT at 4 weeks after the initial examination showed rapid enlargement of both aneurysms and typical findings of inflammation. Therefore, he was diagnosed with an impending rupture of infectious aneurysms.

INTERVENTIONS

Although open surgical resection of both aneurysms and vascular reconstruction were ideal, these operations were considered highly invasive for the patient. Therefore, a hybrid operation consisting of simultaneous endovascular repair of the thoracic aneurysm and open surgery of the abdominal lesion was performed.

OUTCOMES

BCG "Tokyo-172" strain was identified in the resected sample from the aneurysmal wall, and he continued to receive oral antituberculosis drugs for 6 months. No sign of recurrent infection was observed 1 year after the operation.

LESSONS

A hybrid operation might be justified as an alternative to the conventional open surgical procedure, especially for patients with infectious aneurysms caused by weak pathogenic bacteria such as, the BCG mycobacteria.

[Open Heart Surgery to Remove an Ablation Catheter Entrapped in the Left Ventricle;Report of a Case]

A 66-year-old man underwent catheter ablation for Wolff-Parkinson-White syndrome. When we advanced the ablation catheter clockwise in the left ventricle, it was entrapped and became unable to control. Thus, the patient underwent open heart surgery for catheter removal. During the surgery, the last few millimeters of the catheter were observed entrapped by multiple basal chordae of the posterior mitral valve. We released the catheter safely, and visual inspection of the left ventricle showed no abnormalities. His postoperative course was uneventful. Ablation catheter entrapment in the heart is a rare but severe complication that requires open heart surgery.

[Valve Re-replacement Combined with Patch Enlargement of the Aortic Annulus for Bioprosthetic Valve Deterioration;Report of a Case]

A 42-year-old woman had undergone aortic valve replacement with a 19 mm bioprosthetic valve for aortic stenosis due to a bicuspid valve 8 years before. She was admitted to our hospital for valve re-replacement owing to the prosthetic valve dysfunction. As the patient's valve annulus was markedly thickened owing to pannus formation, we were unable to pass a 19 mm valve sizer through the annulus even after removal of the prosthetic valve and the tissue surrounding the annulus. Valve re-replacement combined with patch enlargement of the aortic annulus was performed to obtain maximally effective orifice area. Her postoperative course was uneventful, and echocardiography revealed no perivalvular leak. In valve re-replacement, it is important to remove the prosthetic valve and the tissue surrounding the annulus to the greatest extent possible and consider patch enlargement of the aortic annulus to avoid patient-prosthesis mismatch in a patient with a small aortic annulus.

Exacerbation of severe constrictive pericarditis after prior inadequate pericardiectomy

Pericardiectomy is commonly used to treat constrictive pericarditis (CP); however, persistent calcification can complicate recovery. An 82-year-old man presented with CP following an inadequate pericardiectomy at another hospital two years earlier. He was referred to our hospital with a diagnosis of recurrent CP. Pre-operative computed tomography revealed that the pericardium was not calcified on the anterior of the heart, while the inferior, posterior and lateral surfaces exhibited calcification. Notably, calcification along the inferior portion of the heart formed a calcium envelope structure. Pericardiectomy via re-sternotomy without cardiopulmonary bypass was performed. While dissecting the calcium envelope, a paste-like substance was exuded. Cardiac function improved after pericardiectomy, although the postoperative recovery from heart failure was prolonged. Calcified pericardium should be removed to the extent possible to enhance the efficacy of pericardiectomy, which contributes to improved early surgical results and prevents CP recurrence.

Surgical treatment for saphenous vein graft aneurysm without redo sternotomy

BACKGROUND

Saphenous vein graft aneurysm (SVGA) is a rare complication after coronary artery bypass grafting; however, it may lead to fatal conditions. A redo sternotomy poses a high risk of injury to the patent graft.

CASE REPORT

A 59-year-old man with chest pain was diagnosed with a giant SVGA (67 mm) anastomosed to the right coronary artery (RCA) and compressing the right atrium. Considering the high risk of injury to a patent graft through the sternum, a surgical procedure was planned without redo sternotomy. Through an upper midline abdominal incision, redo bypass grafting was performed to the distal RCA using the right gastroepiploic artery, followed by resection of the aneurysm using the right anterior lateral thoracotomy approach. The postoperative course was uneventful.

CONCLUSION

In patients with an SVGA anastomosed to the right coronary system, our surgical strategy may be a useful alternative to redo sternotomy to avoid injury to the patent graft.

[Patch Closure of Posterior Type Ventricular Septal Perforation with Posterior Left Ventricular Aneurysm through Right Ventricular Incision]

We report a case of patch closure of posterior type ventricular septal perforation (VSP) with posterior left ventricular aneurysm (PLVAN) through right ventricular incision. A 70-year-old man was transferred to our hospital because of persistent epigastric pain. He was diagnosed with inferior acute myocardial infarction, and percutaneous coronary intervention was performed to the right coronary artery[ atrio-ventricular(AV)]. After 2 weeks, he developed congestive heart failure and was treated with inotropic support and intra-aortic balloon pumping. Echocardiography and computed tomography (CT)showed posterior type VSP between PLVAN and the right ventricle. The operation was performed via standard median sternotomy and under cardiopulmonary bypass. After right ventricle incision parallel to the left anterior descending artery, there was VSP (20×20 mm) behind the trabecular septmarginalis (TSM). We closed VSP with a 2-layer patch (40×40 mm) consisted of Dacron and bovine pericardial patches. Postoperative echocardiography showed no residual shunt, and postoperative CT showed no enlargement of PLVAN. He was discharged home on foot without right heart failure and has been well without major complications.

Surgery for Acute Type A Aortic Dissection in A Pregnant Woman At 28 Weeks' Gestation

A 27-year-old woman with sudden back pain was transported to our hospital. Abdominal ultrasonography revealed pregnancy of 28 weeks’ gestation. Computed tomography demonstrated a type A aortic dissection. Because of progressive fetal deterioration, an emergency cesarean section was forced to perform. The next day, simple hysterectomy followed by an aortic procedure was completed. Valve-sparing aortic replacement and total arch replacement were employed as central operations. The mother and baby are well 9 months postoperatively. Although the strategy for acute type A aortic dissection during pregnancy is controversial, collaborations among neonatologists, obstetricians, and cardiovascular surgeons can ensure mother and infant survival.

[Acute Pancreatitis after Thoracoabdominal Aortic Aneurysm Repair in Patient Having a History of Pancreaticoduodenectomy;Report of a Case]

A 76-year-old man who have a history of pancreaticoduodenectomy was admitted to our hospital for surgical treatment of pararenal abdominal aortic aneurysm. He underwent thoracoabdominal aortic aneurysm repair through the Stoney's thoracoabdominal incision under partial cardiopulmonary bypass. Postoperatively, laboratory examination showed elevated pancreatic amylase and computed tomography revealed acute pancreatitis. Pancreatitis was successfully treated by giving IV protease inhibition and the patient went well thereafter. In patients with a history of pancreaticoduodenectomy, gentle surgical maneuver around the residual pancreas and adequate perfusion of celiac artery during thoracoabdominal aortic aneurysm repair were considered mandatory.

[Surgical Experience of Mitral Valve Plasty in Patient with Persistent Left Superior Vena Cava;Report of a Case]

A 45-year-old man diagnosed with severe mitral regurgitation was admitted to our hospital for surgical treatment. Preoperative computed tomographic imaging revealed a persistent left superior vena cava. At operation, cardiopulmonary bypass was established with ascending aortic and bicaval cannulation. In addition to 2 venous cannulas, we directly cannulated to the left superior vena cava for sufficient venous drainage. Mitral valve plasty consisted of triangular resection of P2 segment was performed through the right side left atriotomy. Postoperative course was uneventful and echocardiography 3 months after the operation showed trivial mitral regurgitation. Precise preoperative evaluation concerning the persistent left superior vena cava should be mandatory for appropriate management of cardiopulmonary bypass.

Cardiac tamponade caused by acute coxsackievirus infection related pericarditis complicated by aortic stenosis in a hemodialysis patient: a case report

Background

Pericardial effusion is observed in the majority of viral pericarditis cases; however, viral pericarditis accompanied by a large effusion resulting in cardiac tamponade is rare.

Case presentation

Here, we report the case of a 75-year-old hemodialysis patient with acute viral pericarditis complicated by aortic stenosis. The patient was referred with a diagnosis of aortic stenosis and pericardial effusion. The pericardial effusion had increased during the preoperative examinations, and the inflammatory reaction had progressed. We decided to abort the surgical intervention and start oral administration of anti-inflammatory agents. We subsequently performed a pericardiocentesis. High antibody titers to coxsackievirus were noted in the pericardial effusion. Since no recurrence of the pericardial effusion was observed, the patient underwent an aortic valve replacement 2 months later. The pericardium completely adhered to the heart. Pathological examination of the pericardium showed fibrous pericarditis without active inflammation.

Conclusions

Here, we successfully treated a hemodialysis case with severe aortic stenosis complicated by cardiac tamponade and worsened by acute viral pericarditis. We waited for the pericarditis to resolve after administering anti-inflammatory agents and performed pericardial drainage before carrying out aortic valve replacement. The perioperative course of our case was unique and suggestive.

[Clinical Experience of Aortic Valve Replacement Using the New Stentless Bioprosthesis]

BACKGROUND

The SOLO SMART valve is a bovine pericardial stentless bioprosthesis which shows superior hemodynamic performance compared to the stented valves. It is designed for supraannular and subcoronary implantation. We report our surgical experience and results in patients undergoing aortic valve replacement(AVR) with this new bioprosthesis.

METHODS

Since June 2016, 19 patients with various types of aortic valve disease (mean age:72±7 years, 58% males) have undergone AVR with a SOLO SMART stentless bioprosthesis. Fourteen patients(74%)showed aortic stenosis( AS) and 9 patients(47%)had concomitant procedures;coronary bypass grafting (n=4), mitral valve surgery (n=3), total arch replacement (n=1), and pulmonary venous isolation( n=1). There was 1 patient with active infective valve endocarditis( IE) complicated with annular abscess and 1 patient was a redo AVR case. Surgical results of these patients were evaluated retrospectively. The hemodynamic performance was investigated with transthoracic echocardiography in pre and postoperative period.

RESULTS

There was no operative death and 1 hospital death (postoperative subdural hematoma;Heyde syndrome). One patient showed a mild trans-prosthetic valve leak. No patient required reoperation. Although postoperative transient thrombocytopenia was noted, it had cured at the time of discharge. At the last echocardiographic evaluation, the peak and mean gradients in the patients undergoing AVR for AS were 17±7 and 9±5 mmHg, respectively. No prosthesis-patient mismatch (PPM) occurred in any patient.

CONCLUSIONS

AVR using a SOLO SMART stentless bioprosthesis was performed with acceptable morbidity and mortality. The SOLO SMART stentless bioprosthesis showed excellent hemodynamic performance and early results. Because of favorable effective orifice area, the valve is attractive for patients at risk for PPM. Furthermore, it is expected to contribute to more complex AVR with concomitant mitral valve surgery, active IE or redo situation.

Proximal first: a beneficial strategy for no-touch saphenous vein graft

In the mid-1990s, a novel saphenous vein harvesting technique, in which the vein is harvested with its surrounding tissue without manual distention, was introduced. This no-touch technique provides an excellent long-term patency; however, graft twisting and kinking should be given attention. To fully bring out the benefit of the no-touch method while reducing the risk of twisting and kinking, we have modified the anastomosis strategy. Our simple modified strategy involved a proximal anastomosis prior to the distal anastomosis. This strategy was successfully used in 16 patients.

[Surgical Experience of Distal Aortic Arch Aneurysm Suspected to be Associated with Pre-existing Coarctation of the Aorta]

A 45 year-old-man who had undergone ventricular septal defect repair during childhood presented with hoarseness. He was diagnosed as having a distal aortic arch aneurysm by using computed tomography, and was referred to our hospital for surgical treatment. The operation was performed via a 4th intercostal thoracotomy in the right lateral position. The aortic aneurysm occupied the upper pleural cavity. The aortic arch was pressed up by the aortic aneurysm, so visual identification and clamping of the proximal aorta and the left subclavian artery were extremely difficult. Extracorporeal circulation was established via the right femoral artery and vein. Aneurysmal resection and graft replacement were performed using the open proximal method and retrograde cerebral circulation. The aneurysmal wall and proximal aorta were fragile and the proximal aorta was narrow, although the distal aorta was normal. The difference in diameters between the proximal and distal aorta suggested the presence of coarctation of the aorta.

[Surgical Results of Aortic Root Replacement;Technical Modification and Geometric Analysis of Aortic Root after Aortic Valve-sparing Procedure]

BACKGROUND

The Bentall procedure is a reliable treatment of various types of aortic root pathology. Furthermore, the aortic valve-sparing aortic root replacement also has been accepted as an ideal procedure especially in young patients. Recently, we have developed a simple valve-sparing operation focused on standardization and reproducibility.

METHODS

From 2011 to 2017, 44 consecutive patients underwent aortic root replacement( Bentall 17, David 27)in our institution. Surgical results of these patients were evaluated retrospectively. Geometric parameters of reconstructed aortic root were analyzed to evaluate aortic valve function.

RESULTS

There were 2 operative death( Bentall 2, David 0). Valve-sparing procedure was completed without conversion to valve replacement and no significant aortic insufficiency was noted soon after the operation. Patients underwent David operation were divided into 2 groups according to the annular diameter. There were 15 patients with large annulus and 12 with small annulus. The postoperative valve function was reproduced in both large and small annulus groups. From the results of geometric analysis of the aortic root, patients with large annulus and sino-tubular(ST) junction were anatomically more suitable and better treated with reimplantation technique. On the other hand, even in patients with small annulus, effective plication of ST junction and adequate suspension of commissure posts might be contribute to restore the valve competency with reimplantation technique. Two patients had aortic valve replacement 6 and 12 months after reimplantation, respectively.

CONCLUSIONS

The acceptable outcome was demonstrated in patients underwent aortic root replacement. Aortic valve was reproduced well with our simple modification of valve-sparing operation. Although our modified technique is considered to be safe, reproducible and technically less demanding, close observation would be mandatory in this particular circumstance.

[A Case of Gastric Cancer with Splenic Artery Aneurysm, Intraoperative ICG Fluorography Is Useful in Evaluating the Blood Flow of Stomach and Spleen]

An 81-year-oldwoman with advancedgastric cancer was referredto our hospital. Preoperative contrast-enhancedCT revealeda roundcalcification of the splenic hilum with 15mm in diameter as a splenic artery aneurysm. She underwent transcatheter arterial embolization(TAE)for the splenic artery aneurysm. Celiac artery angiography showedcollateral arterial network of the spleen from left gastric artery. Surgery for the gastric cancer was performed1 4 days after TAE. We cut the right gastric andbilateral epigastric arteries. After the left gastric artery clamping, we performedintraoperative indocyanine green(ICG)fluorography. ICG fluorography confirmedthat the bloodflow of the upper thirdof the stomach andspleen were maintained. We safely performed distal gastrectomy, and the postoperative course was uneventful.

Cardiovascular effects of methylflavonolamine hydrochloride (SIPI-549) in cross-circulated canine atrial and ventricular preparations

The cardiovascular effects of SIPI-549 [4'-methyl-7-(2-hydroxy-3-isopropylaminoproxy)-flavone hydrochloride] were investigated in isolated canine atrial and ventricular muscles perfused with heparinized arterial blood from a donor dog. When SIPI-549 was administered intravenously to the intact donor dog, a slight hypotension was induced in a dose range of 0.01 to 3 mumol/kg. At the same time, slight negative chronotropic and inotropic responses appeared in isolated and perfused atria, suggesting a cardiac depressant action. Direct administration of SIPI-549 into the cannulated sinus node artery of the isolated atrium produced negative inotropic and biphasic chronotropic responses in a dose related manner (0.01-1 mumol). SIPI-549 also induced a dose-dependent decrease in developed tension of the isolated left ventricle. The SIPI-549-induced negative chronotropic and inotropic effects were not modified by atropine in doses which blocked carbachol-induced negative chronotropic and inotropic effects. The SIPI-549-induced positive chronotropic effects were inhibited by propranolol but significantly potentiated by imipramine treatment, indicating that a large dose of SIPI-549 produces a release of catecholamine via a non-tyramine like action. Large doses of SIPI-549 did not significantly affect norepinephrine-induced positive chronotropic effects. These results indicate that SIPI-549 may have non-cholinergic cardiac depressant properties and no beta-adrenoceptor blocking activity. However, it appears to elicit a release of catecholamines in a non-tyramine-like manner at relatively large doses.

A Distant HII Region In The Galaxy

It has long been realized that 21 cm absorption studies can provide information about the distance of unidentified radio sources. When the radiation from a continuum source is absorbed by neutral hydrogen clouds in the foreground, an observation of the radial velocity range over which the absorption occurs indicates the position of the source in relation to the various hydrogen features along the line of sight. Whenever absorption effects can be seen, we can immediately tell whether the source concerned is galactic or extragalactic; if it is galactic, we can then place limits on its distance.