Conservative Surgical Management of Late Carotid Patch Infection in a Patient with Subsequent Stenting for Restenosis

Carotid patch infection is a rare but dreaded complication after endarterectomy. About 160 cases can be found in literature, but presentation in a patient with post-endarterectomy stenting has not been reported. Most frequent clinical manifestations include the occurrence of a sinus, a pseudoaneurysm, or neck swelling, but in severe cases it may present anastomosis dehiscence with hematoma or hemorrhage. Usually, patch removal and reconstruction is recommended, but there is not a standard protocol for management. Conservative surgical management with patch preservation has only been reported in a minority of cases. We report a patient with a history of carotid endarterectomy and subsequent carotid stenting 21 months later because of >80% restenosis. He presented a sinus in the scar 81 months after the former intervention. The patient underwent surgery, and during the procedure, a detachment of a small segment of the Dacron patch from the surrounding tissue was found. The sinus tract was resected, and after verifying the integrity of the patch, it was irrigated with rifampicin and preserved in situ. S. epidermidis was isolated from tissue cultures. Twenty-four months later, the patient remains asymptomatic and duplex ultrasound shows no signs of infection. Conservative surgical approach can be a valid option for treatment and may be considered in selected patients with limited infection.

"Sleeve" Sinus of Valsalva Repair in Patients with Acute Type A Aortic Dissection

Purpose: The optimal surgical strategy of aortic root in acute type A aortic dissection (ATAAD) is controversial. The aim of this study was to evaluate the feasibility and safety of “Sleeve” Sinus of Valsalva repair for AAD limited to the non-coronary sinus or partial left and right coronary sinus without involvement coronary artery ostia. Methods: From September 2016 to March 2019, 20 patients with AAD involving non-coronary sinus or partial left and right coronary sinus Valsalva underwent “Sleeve” Sinus of Valsalva repair. A tailored Dacron patch was inserted into the dissected layers and two Dacron strips were placed inside and outside of the aorta, and the new five-layers root was sutured with 3/0 prolene continuous stitches. The artificial vessel was reversed about 1cm and anastomosed with the reconstructed root. Then, the reversed artificial vessel was pulled and anastomosed with the Dacron strip of the new proximal aorta. Results: There was no early death in hospital and one death occurred during the 30-day postoperative period. Re-thoracotomy due to bleeding was necessary in only one patient and no bleeding was related to the proximal anastomosis. The postoperative drainage was 390.5 ± 229.3 mL. During follow up, the echocardiography showed the normal sinus of Valsalva and aortic valvular function. Computed tomography angiography showed normal aortic root without endovascular leak or dissection around the sinus of Valsalva. All patients were free from reoperation. Conclusions: “Sleeve” Sinus of Valsalva repair with Dacron patch for aortic dissection limited to the non-coronary sinus or partial left and right coronary sinus without involvement coronary artery ostia was technically feasible and safe.

Postinfarction posterobasal ventricular septal defect closure with a triple-layer patch

We present the case of a 65-year-old patient who developed a large posterobasal ventricular septal defect resulting from an extensive acute myocardial infarction involving the inferior and basal septum and wall. We repaired the interventricular lesion by verticalizing the cardiac apex to perform a left posterobasal ventriculotomy. We removed a great part of the residual infarcted tissue, leaving the residual scar in place. Our technique first involved creating a double-layer patch comprising heterologous pericardium and a non-collagen-impregnated Sauvage Dacron patch, fixed with single pledgeted U-stitches from the right side of the anterior septum; then we applied a third layer of heterologous pericardium on the left side of the septum in order to have only a pericardial surface in contact with blood on both ventricular sides. A running suture was used to complete the procedure from the middle to the posterior rim of the ventricular septal defect.

Aorto-esophageal fistula: successful open surgical management of two cases

An aorto-esophageal fistula (AEF) is a rare yet life-threatening cause of upper gastrointestinal bleeding. We report our experience with open surgical management of two cases of AEF. Both cases presented with almost identical presentations: hematemesis and hemodynamic instability. The aorta in the first patient was normal; the defect was small and was repaired with a Dacron patch. The second patient had an aneurysmal aorta, which was replaced with a Dacron graft. Both cases were performed under partial bypass. The esophageal rent in both patients was debrided, primarily closed and buttressed with a vascularized intercostal pedicle. Nonavailability of endovascular personnel and equipment along with hemodynamic instability of the patient influenced our surgical strategy. Long-term follow-up of these patients is necessary to analyze the outcomes of our surgical repair.

Supravalvulaire Aortic Stenosis: Case Report

Introduction: Exceptional congenital heart disease (1 for 26000 birth) characterized by rétrécissement of aortic light. It can be isolated or part of William syndrome. The diagnosis is based on echocardiography. The intervention consists of an aortic root enlargement with Dacron patch. Surgery was indicated if gradient aortic left ventricle Superior of 50 mm hg. This clinical case is for us an opportunity to recall of this type of congenital aortic retrécissement. Methods: We reported the observation of patient 17-year-old without history presented since one-year dyspnea on exersion, palpitation and syncopes. Physical examination: murmur systolic in aortic home without other abnormalities. Chest X ray: CTI: 0.48., ECG: RSR with HVL. Echocardiography: supravalvulaire aortic stenosis; mean gradient AO-LV: 46 mm hg, LV -aortic; LV 48/26 mm + HLV, RV: 20 mm. Exploration per-opératoire: hipoplasie of the left coronary sinus, anomaly of implantation of antero -external pillar of mitral valve, aortic bicuspidie type 1, absence of coronary anomalies. It has benefit under cardio-pulmonary bypass an enlargement of the left coronary sinus according to DOTY technique with Dacron patch and conservation of aortic valve. Results: The immediate post-operative suites were favoured with gradient aortic –left ventricle drop to 20 mm hg. Conclusion: This is very rare congenital heart disease; echocardiography remains the key of diagnosis. It must be operated early. The prognostic is enhanced by the advances in surgical techniques. The treatment consists of surgery. Keywords: Supravalvulaire aortic stenosis; Surgery; Cardiopulmonary bypass

P1494 Incidental finding of aortic aneurysm formation following 34 years of coarctation repair by dacron patch aortoplasty

Introduction Aneurysms are found following all types of surgical repair of aortic coarctation, especially after Dacron patch aortoplasty. We describe the finding of an aortic aneurysm in an asymptomatic 52-year-old male, who was managed by Dacron patch aortoplasty for native coarctation of the aorta 34 years earlier. Case report A 52-year male, smoker, hypertensive on medication He had previous history of surgical repair of aortic coarctation at age of 18 years . Repair was by Dacron patch aortoplasty. Since then, his regular follow up was unremarkable. Recently, he was referred for cardiac evaluation as a part of pre-employment general check-up. He was asymptomatic with no history of shortness of breath or chest pain. Physical examination revealed that the pulse in the left arm was reduced in volume in comparison to the right one. The heart sounds were essentially normal but a pericardial murmur was audible, perhaps reflecting residual collateral flow. Blood pressure was 156/83 mmHg in right arm and 142/81 in the left arm. Transthoracic echocardiography revealed mild left ventricular hypertrophy with normal global and regional contractility and an ejection fraction of 58%. Supra sternal window images showed dilatation of the three aortic arch branches. The distal portion of aortic arch just distal to origin of left subclavian artery was narrowed with a peak systolic gradient across of 34 mmHg. A cystic structure (1.7 cm x 1.9 cm) was visualized attached to the narrowed segment of the aorta, suggestive of a saccular aneurysm, (figures A&B&C). Computed tomography aortogram showed a narrow-necked aneurysm arising from the posterolateral aspect of the distal aortic arch (anticipated site of the coarctation repair graft anastomosis). A small laminated thrombus was also noted within. Aneurysm measured approximately 2.2 x 3.3 cm in its craniocaudal and anteroposterior dimensions respectively, with no evidence of aortic luminal compromise. (figures D&E&F). Management Aneurysmectomy was performed subsequently. Interposition polyester grafts were used to reconstruct the aortic arch and proximal descending aorta and to connect this aortic segment to the subclavian artery via a lateral thoracotomy. The postoperative course thereafter was uneventful. Conclusion: This is a rare insidious complication of Dacron patch aortoplasty that occurred after more than 3 decades, which highlights the importance of diagnostic imaging in the follow up of these patients Abstract P1494 Figure.