Jer-Shen Chen

Spiral Saphenous Vein Graft for Portal Vein Reconstruction in Pancreatic Cancer Surgery

The curative strategy for most pancreatic cancer is surgical resection. Extensive resection with lymph node dissection is the key to providing long-term survival. However, early diagnosis of pancreatic cancer is not always possible (ie, resectability is limited). One reason for such a nonresectable condition is vascular invasion or encasement. Portal vein involvement has been a contraindication for pancreatic cancer surgery for most general surgeons. Combining oncologic and vascular surgeons in the procedure has been a good solution. A multidisciplinary approach that includes general and vascular surgeons is appropriate in selected patients requiring vascular reconstruction at the time of pancreatectomy. The objective of this paper is to report a case in which spiral saphenous vein was used for portal vein reconstruction during pancreatic cancer resection.

Left Ventricle Apical Conduit to Bilateral Subclavian Artery in a Patient With Porcelain Aorta and Aortic Stenosis

Severe atherosclerosis or calcification of the ascending aorta is associated with increased morbidity and mortality rates in patients who underwent cardiac operations. Several techniques had been used to avoid the manipulation of the ascending aorta during cardiac surgery. We reported our extra-anatomic approach in a patient with coronary artery disease and severe aortic stenosis with porcelain aorta. A 76-year-old man with chronic obstructive pulmonary disease, aortic stenosis, and coronary artery disease was scheduled to have cardiac surgery. After a standard median sternotomy, we found that the ascending aorta was severely calcified. The surgical strategy was changed to the construction of the composite conduit from the left ventricle (LV) apex to bilateral subclavian artery and coronary artery bypass grafting with saphenous vein. The right axillary artery and right atrium were cannulated to set up the cardiopulmonary bypass. A composite graft with a 21-mm bioprosthetic valve (Hancock II, Medtronic Inc, Minneapolis, Minn) interposed into a 22–11–11 mm Y-shaped Hemashield graft (Meadox, Hemashield, Boston Scientific, Boston, Mass) was constructed. The proximal part of the composite graft was anastomosed directly to the LV apex. The distal portions of this composite graft were anastomosed end-to-side to the bilateral subclavian artery. Intraoperative transesophageal echocardiography demonstrated a wide opened connection and unlimited blood flow from the LV apex to the conduit (Figure 1). Flow in the bilateral proximal subclavian artery showed reversed flow, which highlighted the adequacy of new LV outflow tract. The postoperative plain chest film showed the unusual location of prosthetic valve (Figure 2). Magnetic resonance angiography showed the patency of this apical composite conduit (Figure 3). The patient had an uneventful recovery. In current practice, ascending aortic calcification or atherosclerosis could be identified by epiaortic ultrasound; however, preoperative noninvasive study such as high-resolution, noncontrast computed tomography could be used for this purpose.

Less Invasive Mitral Valve Surgery via Right Minithoracotomy

BACKGROUND/PURPOSE Current trends in cardiac surgical intervention are moving toward less invasiveness, with smaller wound or sternum-sparing, less pump time or off-pump, and beating rather than arrested heart. Data on the efficacy and safety of these newer less invasive techniques, as well as their cosmetic results, are limited. This study analyzed the results of a sternum-sparing mitral valve operation. METHODS Thirty patients with mitral valve diseases, including 20 who underwent mitral valve repair and 10 mitral valve replacement, were enrolled. Cardiopulmonary bypass was established via femoral cannulation, and blood cardioplegic arrest was induced by using a percutaneous, transthoracic cross-clamp. The main surgical wound was made over the lateral border of the right breast. Two additional small wounds were required for the transthoracic aortic clamp and the mitral retractor. RESULTS There was no operative mortality, and all patients had an uneventful recovery. Two patients underwent redo mitral surgery. Nine associated procedures were performed including tricuspid valve annuloplasty in six patients, tricuspid valve replacement in two patients and atrial septal defect repair in one patient. The length of the main wound was between 5.8 and 7.8 cm (mean, 7.1 cm). The mean cardiopulmonary bypass time and cross-clamp time were 91.1 and 43.7 minutes, respectively. Although the length of stay was not significantly reduced compared with traditional median sternotomy, all patients had satisfactory results with good cosmesis. CONCLUSION Sternum-sparing mitral valve surgery appears to be a safe and effective alternative to conventional mitral valve surgery; it is less invasive and provides superior cosmetic results for patients.

Recurrent Cervical Carcinoma Presenting as a Primary Aortoduodenal Fistula

Aortoduodenal fistula is a rare cause of gastrointestinal (GI) bleeding, and carries high morbidity and mortality even in modern practice. Cervical carcinoma is a major health threat among adult women, and its recurrence is not uncommon. We herein present a case of primary aortoduodenal fistula because of recurrent cervical carcinoma. Our case demonstrated that diagnosis of primary aortoenteric fistula requires a high index of suspicion and a combination of diagnostic modalities to establish the diagnosis. Prompt diagnosis and rapid treatment are critical in reducing mortality and morbidity. Although rare, metastatic carcinoma can lead to aortoenteric fistula.

The Provisional Extension To Induce Complete Attachment (PETTICOAT) technique to promote distal aortic remodelling in repair of acute DeBakey type I aortic dissection: preliminary results

OBJECTIVES To report our preliminary results of an aggressive technique, the Provisional Extension To Induce Complete Attachment (PETTICOAT), in repair of acute DeBakey type I aortic dissection. METHODS From April 2014 to November 2014, 18 patients with acute DeBakey type I aortic dissection were reviewed retrospectively. Nine patients underwent open repair combined with proximal stent grafting and distal bare stenting (PETTICOAT group). For comparison, another 9 patients underwent open repair combined with proximal stent grafting (NON-PETTICOAT group) were included. Open repair entailed ascending aorta plus total arch replacement under circulatory arrest, with variable aortic root work. Mortality and morbidity were recorded, and computed tomography was performed to evaluate the aortic remodelling at 6 months postoperatively. RESULTS Preoperative parameters were similar. In the PETTICOAT group, one early mortality was noted. One complication of cardiac tamponade and sternal wound infection led to reopen surgeries. In the NON-PETTICOAT group, one case of transient ischaemic attack took place. Compared with the NON-PETTICOAT group, a significant increase in diameter of true lumen (median, 0.6 vs 0.1 mm, P < 0.01) and a decrease in diameter of false lumen (FL; median, -0.9 vs 0.0 mm, P < 0.01) at the level of lowest renal artery were noted in the PETTICOAT group. Moreover, significant FL volume regression (median, -102.0 vs -42.2 mm(3), P = 0.03) was observed in the PETTICOAT group. More cases of total thrombosis or regression of FL down to the level of renal artery were also noted in the PETTICOAT group (5/8 vs 0/9, P < 0.01). Two patients of the NON-PETTICOAT group received endovascular distal aortic reintervention at 6 months. CONCLUSIONS The PETTICOAT technique in the management of acute DeBakey type I dissection is a feasible and promising method to promote distal aortic remodelling. However, outcomes are preliminary and further follow-up is required.

Cardioplegia Delivery by Transcutaneous Pigtail Catheter in Minimally Invasive Mitral Valve Operations

For cardioplegia delivery and removing air from the aorta in minimally invasive mitral valve operations, we would like to propose a cost-effective pigtail method. The 8F pigtail punctures the aorta, delivers cardioplegia, and stays in place for removing air from the aorta. We then slide its tip out of the aorta as an accessory drain. With more than 100 successes, we are using it in every case and would like to share it with peer surgeons.

Pseudoaneurysm of the ascending aorta

A 69-year old man underwent ascending aorta grafting and aortic valve replacement for an acute aortic dissection. Nine months later, he suffered from painful ecchymosis and swelling of the sternal wound (Fig. 1). Computed tomography revealed a huge pseudoaneurysm of the ascending aorta (Fig. 2). Reoperation was successfully performed to repair the anasto-motic suture line tears. Figure 1: Prominent ecchymosis and swelling were noted over the upper half of the sternotomy wound. This area was not pulsatile by palpation, but its size rapidly increased day-by-day. It was quite painful, even without touching. Figure 2: (A) A computed tomography revealed a huge ascending aortic pseudoaneurysm full of blood clots. Contrast extravasation could be easily identified over proximal anastomosis (arrowhead). (B) Although the sternum was stable without obvious malunion, trans-sternal extension of the pressurized blood clots in the pseudoaneurysm resulted in a rapidly expanding subcutaneous haematoma (arrow).

Delayed lung herniation after minimally invasive cardiac surgery.

A 29-year old man underwent mitral valvuloplasty for severe valve insufficiency via right minithoracotomy. Five years after the operation, a chest X-ray incidentally disclosed a subcutaneous air chamber, which was not found 1 year before (Fig. 1). Computed tomography showed right lung herniation via the fourth intercostal space (Fig. 2). Lung herniation is still possible many years after minimally invasive cardiac surgery.

Reverse-Loop Upper Arm Arteriovenous Graft for Chronic Hemodialysis

Options for an upper arm arteriovenous graft (AVG) commonly include the placement of a straight prosthetic graft connecting the brachial artery to the axillary vein. However, such configuration leads to underutilization of the upper arm veins, resulting in the loss of venous capital in the upper arm for future secondary fistula creation. In this retrospective analysis, we evaluated seven patients who had upper‐arm AVGs created in a reverse‐loop configuration. The prosthetic graft was created by connecting the brachial artery close to the cubital fossa and tunneled subcutaneously in a looped fashion distally thereby connecting the basilic or deep brachial vein just above the elbow. Endpoints were interventions, thrombosis, and loss of access at the last examination. The brachial vein was used in two patients and the basilic vein in the other five. The median duration of follow‐up with 100% patency of the AVGs was 10.0 (range, 3.0–25.0) months. Patients were able to achieve a target hemodialysis dose with a (Kurea × td)/Vurea value of 1.4 (range, 1.2–1.5). The median flow rates achieved were 205.0 (range, 203.3–236.7) and 266.7 (range, 203.3–276.7) ml/minute at the first and 3‐month dialysis sessions, respectively. The median dialysis venous pressures were 128.0 (range, 108.3–178.0) and 131.0 (range, 116.7–148.7) mmHg at the first and third month after operation, respectively. The median peak systolic velocity ratios of artery–graft and vein–graft junctions were 2.1 (range, 1.4–2.4) and 3.0 (range, 2.3–3.8) cm/second, respectively. In conclusion, this is a logical approach for patients who have exhausted their forearm vessels for AVG creation. In addition, it also provides a platform for future creation of a secondary fistula in the upper arm.

Total Laparoscopic Repair for Abdominal Aortic Aneurysm

Surgical resection and grafting have long been the standard treatment for abdominal aortic aneurysm and provide an excellent long-term outcome. However, there is tremendous impact on patients due to the surgical invasiveness. Endovascular aortic repair using stent graft was introduced in 1991. After refinement of the techniques and technology, endovascular aortic repair was approved by most health authorities and is associated with less periprocedural morbidities. In between these two extremes, some surgeons endeavored to create an alternative and perform less invasive surgeries. Hand-assisted laparoscopic aortic surgery and laparoscopic-assisted aortic surgery were introduced in 1996. In 2001, total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was first performed in Canada. Till now, only a few vascular units in North America and Europe perform these delicate techniques. We report our first case of total laparoscopic abdominal aortic aneurysm repair. Laparoscopic aortic surgery provides better visualization of the aneurysm neck, less bowel manipulation and avoidance of hypothermia. The minimal invasiveness could translate to better perioperative outcome. To our knowledge, this is also the first case report in Asia. The detailed techniques are described.