Minhaj S. Khaja

Fluoroscopic Targeting of Wallstents and Amplatzer Vascular Plugs in Sharp Recanalization of Chronic Venous Occlusions

Introduction/PurposeSharp recanalization of chronic venous occlusions is usually performed with targeting of wire-capture devices like loop snares or balloons. We describe sharp recanalization of chronic venous occlusions using self-expanding stents and vascular plugs.Material and MethodsWe retrospectively reviewed all sharp venous recanalization procedures performed over an 11-month period and found Wallstent and Amplatzer vascular plug (AVP) targeting was performed in 16 patients. Patient demographics, occlusion site, targeting device, technical success of the targeting, and overall procedural success were recorded.ResultsTechnical success was achieved in twelve (86%) Wallstent and two (67%) AVP deployments. Procedural success was achieved in 15 (94%). Three minor complications occurred.ConclusionWallstent and AVP targeting may be a useful technique when performing sharp recanalization for chronic venous occlusions. These devices expand the target space and present the same cross section viewed from any angle and can directly capture and extract the wire, features helpful in regions with crowded vascular anatomy.

Short-term outcomes of a simple and effective approach to aortic root and arch repair in acute type A aortic dissection

Objective: To evaluate short‐term outcomes following direct aortic root and arch repair in patients with acute type A aortic dissection (ATAAD) without technical adjuncts. Methods: Between 2012 and 2016, 94 consecutive patients with ATAAD underwent surgical repair, including aortic root repair (n = 45), root replacement (n = 39), or no root procedure (n = 10). Aortic root repair was achieved by running approximation of the dissected aortic wall circumferentially at the sinotubular junction and reinforcing the coronary ostia with 5‐0 Prolene. The aortic root and arch were anastomosed to the Dacron graft with 5‐0 Prolene without Teflon felt or biological glue. Results: Postoperative new‐onset myocardial infarction, stroke, renal failure, and complete heart block occurred in 0%, 4%, 13%, and 0% of patients, respectively, whereas 30‐day mortality was 4%. The incidences of permanent neurologic deficit and renal failure were 1% and 2%, respectively. Up to 5 years, the aortic root repair group was free from residual or recurrent aortic root dissection, major change in the aortic root diameter, and moderate to severe aortic regurgitation; the entire cohort was free of anastomotic pseudoaneurysm and reoperation for proximal aortic pathology or significant change in diameter of the aortic arch and descending thoracic aorta. Overall survival was 85% at 4 years and was significantly enhanced in the aortic root repair group compared with the Bentall group (n = 24) (93% vs 57%; P = .035). Conclusions: Direct aortic root and arch repair with approximation of the aortic wall without use of technical adjuncts is safe and effective for patients with ATAAD. If warranted, preservation of the native aortic valve should be considered for a potential survival benefit.

Transbiliary intravascular ultrasound-guided diagnostic biopsy of an inaccessible pancreatic head mass

Percutaneous image-guided biopsies of pancreatic malignancies may prove challenging and nondiagnostic due to a variety of anatomic considerations. For patients with complex post-surgical anatomy, such as a Roux-en-Y gastric bypass, diagnosis via endoscopic ultrasound with fine-needle aspiration may not be possible because of an inability to reach the proximal duodenum. This report describes the first diagnostic case of transbiliary intravascular ultrasound-guided biopsy of a pancreatic head mass in a patient with prior Roux-en-Y gastric bypass for which a diagnosis could not be achieved via percutaneous and endoscopic approaches. Transbiliary intravascular ultrasound-guided biopsy resulted in a diagnosis of pancreatic adenocarcinoma, allowing the initiation of chemotherapy.

Surgical Management of Necrotizing Mediastinitis With Large Aortic Pseudoaneurysm

We report a patient with necrotizing mediastinitis complicated by a giant retrosternal mycotic pseudoaneurysm and prosthetic valve endocarditis successfully managed with a redo sternotomy under hypothermic circulatory arrest. The approach then included extensive débridement of the mediastinum, replacement of the ascending aorta and aortic arch with selective antegrade cerebral perfusion, redo aortic valve replacement, and wound closure with omental flap and myocutaneous flap. After a 2-year survival, the patient suffered reinfection from hemodialysis. Our approach is also applicable to more common presentations of mediastinitis.

Staged hybrid approach for an acute-on-chronic aortic dissection with rupture in a Jehovah's Witness patient: Case report

From the Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich; and the Department of Radiology, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich. Disclosures: David Williams reports consulting fees from Boston Scientific and Gore and Associates. All other authors have nothing to disclose with regard to commercial support. Received for publication May 22, 2015; revisions received July 24, 2015; accepted for publication July 24, 2015; available ahead of print Aug 22, 2015. Address for reprints: Bo Yang, MD, PhD, Department of Cardiac Surgery, Cardiovascular Center, The University of Michigan, Ann Arbor, MI 48109 (E-mail: boya@med.umich.edu). J Thorac Cardiovasc Surg 2015;150:e63-5 0022-5223/

Endovascular Management of Acute Traumatic Aortic Injury

36.00 Copyright 2015 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.07.080 Acute-on-chronic dissection with rupture can be managed initially with stent grafting.

Endovascular retrieval of a CardioMEMS heart failure system

Acute traumatic injury of the thoracic aorta is a highly lethal condition, with many afflicted patients expiring before hospital arrival. While previously these conditions were managed with open surgery, endovascular repair has rapidly evolved and is now considered the standard of care for certain patterns of aortic injury at centers with appropriate expertise. The development of newer branched devices has allowed these techniques to be utilized further and further proximally into the aorta. Through minimally invasive techniques, many aortic injuries can now be treated percutaneously with shorter recovery time and less perioperative complications.

Management of retrograde intraoperative Type A aortic dissection from descending thoracic aortic injury.

As the creation and utilization of new implantable devices increases, so does the need for interventionalists to devise unique retrieval mechanisms. This report describes the first endovascular retrieval of a CardioMEMS heart failure monitoring device. A 20-mm gooseneck snare was utilized in conjunction with a 9-French sheath and Envoy catheter for retrieval. The patient suffered no immediate postprocedural complications but died 5 days after the procedure from multiorgan failure secondary to sepsis.

Total Endovascular Iliocaval Reconstruction Using Polytetrafluoroethylene Stent-Graft Placement for the Treatment of Inferior Vena Cava Resection

Intraoperative Type A aortic dissection during cardiothoracic surgery is extremely rare, but the consequences can be fatal. We report 2 case summaries of retrograde intraoperative Type A aortic dissection from descending thoracic aortic injury during ascending aortic cannulation and provide a discussion on management.

Pulmonary artery dissection complicating aortic dissection in a patient with bicuspid aortic valve and aortic coarctation

Resection of the inferior vena cava (IVC) is a rare surgical technique that is occasionally combined with nephrectomy in the setting of renal malignancy with intravascular tumor extension. While this may be fairly well tolerated in some patients due to extensive collateralization in the venous system, there is a clear potential for lower extremity venous insufficiency and deep vein thrombosis (DVT). This report describes a patient who underwent right nephrectomy and segmental IVC resection from the subhepatic space to the iliac confluence, which was complicated by profoundly symptomatic lower extremity DVT and gastrointestinal hemorrhage due to system-to-portal shunting. After performing sharp recanalization through the retroperitoneum, iliocaval reconstruction was accomplished utilizing covered stent-grafts, with complete resolution of symptoms.Level of Evidence Case Report, Level 5.