Vincenzo Lepore

Endograft therapy for diseases of the descending thoracic aorta: results in 43 high-risk patients.

Purpose: To report an initial experience with endovascular stent-graft implantation for diseases of the descending thoracic aorta in high-risk patients. Methods: Forty-three patients (28 men; mean age 67 years, range 17–82) with 16 descending thoracic aortic dissections, 14 aneurysms, 7 contained ruptures, 3 mycotic aneurysms, 2 posttraumatic pseudoaneurysms, and an aneurysm of an anomalous right subclavian artery were treated between June 1999 and July 2001. Twenty-three (53%) patients were treated emergently. Results: There were no conversions to open repair, but 3 (7%) patients died during the first 30 days (pneumonia, multiorgan failure, and acute bowel ischemia). Thirteen (30%) patients suffered 18 major complications (8 strokes, paraplegia in 3, respiratory insufficiency in 6, and 1 renal failure). Of 7 (16%) endoleaks detected in the early postoperative period, 3 required additional stents, while the other 4 were treated conservatively. Follow-up, which averaged 19 ± 6 months (median: 13; range 0–34), was 100% complete. Five (12%) patients died: 3 of aortic rupture at 34, 47, and 139 days, respectively, and 2 from heart failure at 3 and 15 months, respectively. No late migration or endoleaks have been detected in the remaining 35 patients; however, 1 (2%) patient showed progressive aortic dissection proximal to the stent-graft. In all other cases, the size of the aneurysm or the false lumen was unchanged or diminished. Conclusions: Treatment of descending thoracic aortic diseases with an endovascular approach has acceptable early mortality and morbidity in high-risk patients. In selected cases, stent-grafts may afford the best therapy.

Endovascular Treatment of Type B Thoracic Aortic Dissections

Abstract  Purpose: To evaluate the initial experience of endovascular repair of aortic dissections from a single center. Materials and Methods: From June 1999 to March 2002, endovascular stent grafting was performed in 20 high‐risk patients (16 to 80 years). Eighteen patients had a type B dissection (14 acute and 4 chronic). Two patients had chronic type A dissection. Preoperative work‐up included CT and MRI to evaluate the extent of the dissection, the relation to the left subclavian artery, the size of false and true lumen, and branch complications. Results: Stent‐graft deployment was technically successful in all cases. None was converted to open repair. Three patients died within 30 days, i.e., a 15% mortality rate. Four patients (20%) had a perioperative stroke. Paraplegia was observed in one case. No migration of the stent grafts or endoleaks was observed during the mean follow‐up period of 13 months. In all but two patient thrombosis of the false lumen was noted. Conclusions: Endovascular treatment of thoracic dissections is feasible. Early results are encouraging. While endovascular repair with stent‐grafts is progressing rapidly as a viable strategy for aortic dissections in selected patients careful investigations must continue to focus on its safety. Randomized controlled trials are urgently needed. (J Card Surg 2003;18:539‐544)

Post-infarction cardiac rupture: surgical treatment

OBJECTIVE Rupture of ventricular free wall (VFWR) may complicate acute myocardial infarction and accounts for high mortality. Surgical repair is the only therapeutic option. A review of our surgical experience is presented. METHODS Seventeen patients (11 men, mean age 68 years) underwent surgery for VFWR. Patch covering technique was used in 13 patients, infarctectomy with patch reconstruction in three patients, direct suture without patch in one patient. Coronary artery bypass grafting was performed in eleven patients. RESULTS Hospital mortality was 17.6% (three patients). Three patients died of cancer during the follow-up. The remaining 11 patients are in good condition after a mean follow-up of 45.8 months (range 7.5-84.2). CONCLUSIONS Postinfarction rupture of ventricular free wall treated surgically gives excellent long-term results. Our first choice for repair is the covering technique with a large pericardial patch anchored with biological glue and epicardial sutures.

Treatment of descending thoracic aneurysms by endovascular stent grafting.

Abstract  Purpose: Endovascular stent‐graft treatment for true aneurysms of the descending thoracic aorta is a valid and effective alternative to conventional surgery. A review of our experience with 21 consecutive patients is reported and technical considerations are discussed. Methods: Twenty‐one patients (mean age 73 years) with true aneurysms of the descending thoracic aorta (n = 14) or contained rupture (n = 7) were treated between October 1999 and July 2001. Seven patients (33%) underwent emergency endovascular procedure. Postoperatively, the patients were followed with CT scans at 1, 3, 6, and 12 months. Follow‐up, which averaged 17 months, was 100% complete. Thirty‐day results: No conversions to open repair were necessary. Two patients died (10%), one of acute intestinal ischemia and the other because of multiorgan failure. Four patients showed endoleaks immediately after stenting. Two patients required new endovascular stentgrafts, while the remaining two were treated conservatively. Besides endoleaks, eight major complications occurred in six patients (two stroke, two paraplegia, two respiratory insufficiency, and one renal failure). Mid‐term results: Three more patients died during the follow‐up period. One patient died of heart failure after a complicated postoperative course, 91 days after stenting. The second patient died because of aortic rupture, 139 days after stenting. The third patient died of heart failure, 15 months after the endovascular procedure. The remaining 16 patients are alive and have been regularly controlled by CT scans. No late migration or endoleaks have been detected. In all the survivors, the size of the aneurysm was unchanged or diminished. Conclusions: Treatment of descending thoracic aortic aneurysms by endovascular stentgraft devices has good early and mid‐term results. More accurate selection of patients may further reduce mortality and morbidity.

Autotransfusion of mediastinal blood in cardiac surgery

A series of 135 adults undergoing cardiac surgery was randomized to an autotransfusion group (n = 67) or a control group (n = 68). In the autotransfusion group mediastinal blood was collected and reinfused during the first 6 postoperative hours. Blood from the reservoir was taken for bacteriologic culture at the end of that time. The postoperative blood was comparable in the two groups. The average requirement of bank blood was 2.7 units in the autotransfusion group and 3.3 units in the controls (p less than 0.05). The average volume of autotransfusion blood was 336 ml. There were no clinical infections in the autotransfusion group, although 19% of the cultures were positive, and no apparent alteration of the coagulation mechanisms arose from infusion of autologous blood. No clinically significant intergroup differences were found in hematologic, renal or hepatic parameters, neurologic function or use of antibiotics.

Pneumothorax in pregnancy.

Since 1957, only 15 cases of isolated spontaneous pneumothorax in pregnancy have to our knowledge been reported in the English literature (1, 2, 3). The treatment of pneumothorax in pregnancy is more difficult than in non‐pregnant patients. A case is reported and therapy discussed.

Surgical Management of Tracheal Tumours

The annual incidence of primary tracheal tumours in Sweden is less than 1 per million population. Five cases of malignant tracheal neoplasm treated with segmental resection and primary reconstruction are described. Exploration and mobilization of the trachea were performed via right thoracotomy. Suprahyoid laryngeal release was also done in two cases, using a cervicomediastinal approach. The length of resected segment in these cases was 6 and 7 cm. High-frequency positive-pressure ventilation was used in four of the five cases and greatly facilitated the operation. Recovery was uneventful. Adenoid cystic carcinoma was too extensive for extirpation in one case, but 4 months after radiotherapy a 7 cm tracheal segment with residual tumour was removed; 3 years later the patient is well. There was no stenosis or other late complication and no local recurrence in the long-term survivors. No vocal paralysis occurred. The two patients with laryngeal release had remarkably little and transitory dysphagia. Technical problems are discussed and conclusions are presented.

Ectopic metaplastic ossification after sternotomy

Ectopic ossification is a rare complication after a major operation. We report a case of cutaneous infection and metaplastic ossification in an 80-year-old man who underwent coronary artery bypass grafting 4 years earlier. Computed tomographic scan demonstrated a partial pseudarthrosis of the corpus sterni. The infected part of the sternal scar was excised and sternal wires were removed. Eight months later, the wound has healed without complications and the cutaneous ossification is unaltered.

Endovascular Closure of Chronic Dissection Entries in the Aortic Arch Using the Amplatzer Vascular Plug II as a Sealing Button

Purpose: To present a new endovascular technique to avoid open surgical arch reconstruction in selected patients with aneurysmal dilatation due to small chronic dissection entries in the aortic arch. Technique: The true and the false lumen of the aortic arch are catheterized from the femoral arteries. An Amplatzer Vascular Plug II (AVP II) is advanced through the proximal entry from the false lumen side and deployed as a sealing button in the entry hole, with 1 disc in the true lumen and the remaining 2 discs in the false lumen. This technique was used in 4 patients with chronic dissection involving the aortic arch, three of whom had had previous surgery for acute type A aortic dissection. In 3 patients, the false lumen of the thoracic aorta was successfully obliterated, with thrombosis and aortic diameter reduction during follow-up. In 1 patient, false lumen flow persisted, and he was subsequently treated with a total arch reconstruction and frozen elephant trunk. Conclusion: Endovascular closure of small proximal dissection entries in the aortic arch with an AVP II used as a sealing button is feasible and may be an alternative to open surgical arch reconstruction in selected patients with chronic aortic dissection and secondary aneurysm expansion.

The 90° bent two-stage venous cannula

A 90 ° bent two-stage venous cannula for cardiopulmonary bypass is presented and discussed. Its main advantages, compared to similar straight ones, are that it is out of the way of the surgeon, by being placed under the right sternum and also that the venous return seems uninfluenced by displacement of the heart when operating on the posterior side of the heart. No major drawbacks for the cannula have been noticed so far. [Eur J Cardio-thorac Surg (1995) 9 : 526-527]