Patrick Casey

Thrombosed giant coronary artery aneurysm presenting as an intracardiac mass

Giant coronary artery aneurysms are rare in adults and are usually found in association with Kawasakis disease arising in childhood. We report a case of a thrombosed giant right coronary artery aneurysm presenting as an intracardiac mass detected after inferior wall myocardial infarction. Histologic analysis indicated that fibromuscular dysplasia was the underlying cause of the aneurysm.

The effects of systemic hypothermia on a murine model of thoracic aortic ischemia reperfusion

INTRODUCTION Hypothermia is widely used to mediate ischemia-reperfusion injury associated with repair of the thoracoabdominal aorta. Experiments were designed in a murine model of thoracic aortic ischemia-reperfusion (TAR) to evaluate the effect of moderate systemic hypothermia on neurologic function, spinal cord morphology, and indices of inflammation in critical organs. METHODS C57BL/6 mice were subjected to TAR under hypothermic (34 degrees C) or normothermic (38 degrees C) conditions, followed by 24 or 48 hours of normothermic reperfusion. Neurologic functions were assessed during reperfusion. Spinal cords were examined at 24 and 48 hours after reperfusion, and the degree of injury qualified by counting the number of viable motor neurons within the anterior horns. Keratinocyte chemokine, interleukin-6, and myeloperoxidase levels were measured from lung, liver, and kidney at 24 and 48 hours. RESULTS Normothermic TAR resulted in a dense neurologic deficit in all mice throughout the reperfusion period. Mice subjected to TAR under hypothermic conditions had transient, mild neurologic deficit during the initial periods of reperfusion. Between 24 and 48 hours, delayed paralysis developed in half of these mice, whereas the other half remained neurologically intact. Spinal cord histology showed a graded degree of injury that correlated with neurologic function. There was no correlation between markers of inflammation in various organs and neurologic outcomes following TAR. CONCLUSION Systemic moderate hypothermia was protective against immediate paralysis after TAR in all cases and was associated with delayed paralysis in 50% of mice. This study suggests that delayed-onset paralysis may be the result of a local insult, rather than a systemic inflammatory event, precipitating spinal cord injury.

Open vs endovascular repair of blunt traumatic thoracic aortic injuries

A 42-year-old female is involved in a motor vehicle accident and presents with a number of injuries. She is hemodynamically stable and is found to have multiple rib fractures, a hemopneumothorax, and several uncomplicated long bone fractures. A CT scan of her chest reveals a traumatic injury to her proximal descending thoracic aorta with evidence of pseudoaneurysm formation and surrounding hematoma (Fig 1). The following debate attempts to resolve whether open repair remains the gold standard for the treatment of blunt thoracic aortic injuries.

PJ34, a poly-ADP-ribose polymerase inhibitor, modulates visceral mitochondrial activity and CD14 expression following thoracic aortic ischemia-reperfusion

BACKGROUND Visceral ischemia-reperfusion injury (VI) contributes to adverse outcomes following the repair of thoracoabdominal aneurysms. Experiments were designed to determine whether a poly-adenosine diphosphate-ribose polymerase (PARP) inhibitor modulates indexes of metabolic function (mitochondrial activity), inflammatory cell activation, and tissue inflammation (lipopolysaccharide receptor CD14 messenger ribonucleic acid) following VI. METHODS 129S1/SvImj mice were subjected to thoracic aortic occlusion followed by 48 hours of reperfusion. Normal saline was administered to 25 untreated control mice and PJ34 to 21 mice before and immediately after thoracic aortic ischemia-reperfusion. Sham mice (n = 13) underwent median sternotomy alone. At 48 hours, all animals were euthanized and tissues harvested for quantitative analysis. RESULTS PJ34 improved intestinal (P < .05) but not hepatic mitochondrial activity following reperfusion. CD14 messenger ribonucleic acid levels in liver (P < .004), kidney (P < .003), and spinal cord (P < .03) tissue were less in PJ34-treated mice. CONCLUSIONS PJ34 preserved the metabolic function of intestinal but not hepatic tissue during reperfusion. PJ34 uniformly decreased the expression of an important marker of inflammatory cell activation and tissue inflammation in visceral tissue following VI. PARP inhibitors may serve as a therapeutic modality to abrogate the stress response to VI.

Endovascular Exclusion of a Splenic Artery Aneurysm Using a Pipeline Embolization Device

The Pipeline Embolization Device (ev3 Endovascular Inc, Plymouth, Minnesota) is a new endovascular device designed to exclude suitable intracranial aneurysms. A 56-year-old woman presented with a symptomatic 4.1-cm splenic artery aneurysm (SAA) that was successfully managed with a two-staged treatment plan involving selective segmental splenic artery embolization and subsequent deployment of a Pipeline Embolization Device across the aneurysm neck to exclude the aneurysm and maintain splenic perfusion.

Surgically Positioned Paravertebral Catheters and Postoperative Analgesia After Open Abdominal Aortic Aneurysm Repair

Results: The Ottawa Hospital experienced a 61% decline in the number of OARs performed between 2005 and 2016. Age of participants was significantly increased in the 2014 to 2017 group (P 1⁄4 .0141), whereas the number of women was significantly decreased (P 1⁄4 .05). Total operating room time and anesthesia time were longer in the 2014 to 2017 group, whereas surgical times remained consistent. Suprarenal clamp time and blood loss during the procedure were decreased in the 2014 to 2017 group. Intensive care unit and overall hospital stay were not significantly different between groups; however, there were large standard deviations observed for the 2014 to 2017 group. As well, 18.4% of patients in the 2014 to 2017 group experienced postsurgical complications of Clavien-Dindo grade IIIa or higher compared with 11.3% of patients in the historical control group. Mortality was increased in the 2014 to 2017 group, although this was not significant. Conclusions: The reduced rate of OAR performance at The Ottawa Hospital reflects the global trend toward endovascular repair. Anesthesia and operating room time increased during the time examined, reflecting a possible loss of expertise in the study period. Complications also increased during this time for anatomically similar patients. Taken together, these findings may reflect a decreased institutional familiarity with open aneurysm repairs and postsurgical care.

Intraoperative insertion of paravertebral catheter for postoperative analgesia in retroperitoneal aortic aneurysm repair

ABSTRACT Paravertebral catheters are a well‐established analgesic modality in thoracic surgery but have not been described in abdominal aortic surgery. We describe a simple, safe, and effective technique of paravertebral catheter insertion by the operative surgeon after a retroperitoneal abdominal aortic aneurysm repair. Once the aneurysm repair is complete, an extrapleural plane between the parietal pleura and the twelfth rib is created through blunt dissection. A catheter is advanced into the space percutaneously under direct vision, and a continuous infusion of local anesthetic is administered. Paravertebral catheters typically remain in place for 3 to 5 days and provide excellent postoperative non‐narcotic analgesia.

Salvage of bilateral renal artery occlusion after endovascular aneurysm repair with open splenorenal bypass

We report renal salvage maneuvers after accidental bilateral renal artery coverage during endovascular aneurysm repair of an infrarenal abdominal aortic aneurysm. A 79-year-old man with an infrarenal abdominal aortic aneurysm was treated with endovascular aneurysm repair. Completion angiography demonstrated coverage of the renal arteries. Several revascularization techniques were attempted, including endograft repositioning and endovascular stenting through the femoral and brachial approach. The patient eventually underwent open splenorenal bypass with a Y Gore-Tex graft (W. L. Gore & Associates, Flagstaff, Ariz). After 3 months, computed tomography showed no evidence of endoleak and patent renal arteries. Renal function was well maintained, and the patient did not require dialysis.