Ronald A. Kahn

Intraoperative rupture of an abdominal aortic aneurysm during an endovascular stent-graft procedure

PurposeTo highlight the risk of intraoperative rupture as a complication of endovascular aortic repair.Clinical featuresAn 81-yr-old man was admitted for endovascular aortic repair of a 6 cm infrarenal abdominal aortic aneurysm. After establishment of a conduction blockade using a combined spinal-epidural technique, a balloon-activated endovascular stent-graft was advanced to the proximal aneurysmal neck. Approximately four minutes after the stent-graft was deployed, the mean arterial pressure decreased to 30 mmHg and the heart rate increased to 135 bpm. While fluid and vasoactive medications were administered and the airway was secured, repeat aortography confirmed contrast extravasation into the retroperitoneal space at the junction of the proximal aortic neck and the aneurysm sac. The angioplasty deployment balloon was repositioned and inflated proximal to the presumed site of aortic rupture, thus providing aortic control until an open repair of the aorta was undertaken.ConclusionAlthough endovascular stent-graft placement may be a less invasive method than conventional open aortic reconstruction, it must be recognized that the potential for devastating consequences such as aortic rupture is present.RésuméObjectifSouligner le risque de rupture peropératoire comme complication d’une réparation aortique endovasculaire.Éléments cliniquesUn homme de 81 ans a été admis pour la réparation aortique endovasculaire d’un anévrisme infrarénal de l’aorte abdominale. Après avoir établi un bloc de conduction selon une technique rachidienne et péridurale combinée, un greffon-tuteur endovasculaire, activé par un ballonnet, a été introduit jusqu’au collet proximal de l’anévrisme. Environ quatre minutes après le déploiement du greffon-tuteur, la tension artérielle moyenne a chuté à 30 mmHg et la fréquence cardiaque a augmenté à 135 bpm. Pendant l’administration de liquide et de médicaments vasoactifs et les manoeuvres visant à assurer la liberté des voies aériennes, l’aortographie répétée a confirmé une extravasation de contraste dans l’espace rétropéritonéal à la jonction du collet aortique proximal et du sac anévrismal. Le ballonnet a été replacé et gonflé près du site présumé de la rupture aortique, permettant ainsi de préserver l’aorte jusqu’à ce qu’une réparation chirurgicale soit réalisée.ConclusionBien que la mise en place d’un greffon-tuteur endovasculaire soit moins effractif que la reconstruction aortique chirurgicale habituelle, il faut reconnaître la présence potentielle de graves conséquences, comme une rupture aortique.

Intraoperative Imaging and Off-Pump Ligation of Coronary Artery Fistula

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Noncardiac entrapment of a pulmonary artery catheter during heart transplantation: inadvertent cannulation and perforation of the internal thoracic vein ☆ ☆☆

Placement of a central venous catheter into an internal thoracic vein occurs in approximately 2% of all catheterizations. A case in which a pulmonary artery catheter was trapped within the internal thoracic vein during orthotopic heart transplantation is presented.