Apurb Sharma

Complex Cervical Aortic Arch With Hypoplasia: A Simple Solution to a Complex Problem

We report a rare case of a 6-year-old boy with a complex right-sided cervical aortic arch, with retroesophageal hypoplastic transverse arch, left subclavian artery arising from the Kommerell diverticulum of the descending aorta, and a vascular ring formed by the ductus ligament. An extraanatomic ascending-to-descending aorta bypass was done through a median sternotomy along with division of the ductus ligament, without any complications and good results.

Primary surgical repair of coarctation of the aorta in adolescents and adults: intermediate results and consequences of hypertension†

OBJECTIVES Coarctation of the aorta is known to present with hypertension in older patients; we reviewed our experience and assessed the outcome of hypertension following surgical correction. METHODS From April 2004 to date, 43 patients above the age of 12 underwent coarctation of the aorta repair. The mean age was 20.4 + 9.7 years (maximum 56 years); 21 (48.8%) were older than 18 years and 28 (65.1%) were men. Thirty (69.8%) patients had hypertension. Fourteen (32.6%) had a bicuspid aortic valve; 11 (25.6%) had patent ductus arteriosus; 6 (14%) had myxomatous mitral valve; 4 (9.3%) had ascending aortic aneurysms; and 2 (4.7%) had descending aneurysms. RESULTS Surgical correction included resection and interposition of a tube graft in 31 (72.1%), an end-to-end anastomosis in 6 (14%) and patch aortoplasty in 3 (7%). Three (7%) patients required an extra-anatomical bypass: 1 had a long segment coarctation of the aorta, and 2 had a Bentall procedure with an ascending-to-descending aortic bypass. Staged procedures were done for concomitant disease in 4 (9.3%). There was 1 death: a 56-year-old woman died of refractory ventricular fibrillation during surgery. Thirty (69.8%) patients were discharged with antihypertensive medication. At a follow-up of 2.8 ± 2.2 years (maximum 9.2 years), the number of hypertensive patients decreased (17/36; 47.2%) (P = 0.042). Univariable predictors for persistence of hypertension revealed the use of an interpositional tube graft for repair (odds ratio 13.855, confidence interval 0.000-0.001; P = 0.001) as an indicator, whereas there were no independent predictors for persistence of hypertension. CONCLUSIONS Surgical intervention is warranted irrespective of age and helps correct and control hypertension better; however, significant numbers of patients still require antihypertensive medication and regular monitoring. Intervention using an interposition tube graft may affect the prevalence of hypertension.

eFAST for the diagnosis of a perioperative complication during percutaneous nephrolithotomy

A 29-year-old patient with normal preanesthetic evaluation was planned for percutaneous nephrolithotomy (PCNL) for right nephrolithiasis with right pyelolithiasis. Surgery was performed under general anesthesia with endotracheal intubation with muscle relaxation. At the conclusion of surgery, when the patient was turned over to supine position, tense abdomen was noted. Immediately extended focused assessment with sonography in trauma (eFAST) was done in which both right and left quadrants of abdomen including pericardial and suprapubic region, right and left thoracic, and both lung basis were examined. Fluid collection was seen in Morison’s pouch which was drained by the urologist under real-time ultrasonography guidance by anesthesiologist. Distension of abdomen subsequently subsided and patient had normal vitals. Trachea was extubated and patient shifted to post-operative ward. eFAST and FAST scans are routine procedures in the rapid assessment of trauma victims in emergency settings. The fluid extravasation during a routine PCNL procedure may lead to abdominal compartment syndrome. This case demonstrated that use of eFAST rapidly detected abdominal collection and ruled out life-threatening conditions such as hemothorax and pneumothorax and prevented abdominal compartment syndrome. Our case is only an example that potentially lethal conditions like these may be encountered in the perioperative setting and the knowledge of eFAST scan may be of great help.