Trans-Iliac Aortic Valve Replacement: Feasibility, Safety, and Medium-Term Follow-up

Background: Transcatheter aortic valve replacement (TAVR) is nowadays generally accepted as the treatment of choice for high- to intermediate-risk patients with severe aortic stenosis not suitable for the standard surgical replacement. Many vascular accesses have been described for the valve delivery, comprising the common iliac artery as the arterial site of access. Methods: From September 2008 to June 2014, 440 patients underwent TAVR at our institution. We report a series of 12 patients that have undergone TAVR via a trans-iliac (TI) retroperitoneal surgical approach and also discuss its feasibility, security, and medium-term follow-up. Results: The 30-day survival rate was 92%. Only 1 local vascular access major complication occurred requiring an iliac-femoral bypass grafting with a vascular graft. Two patients experienced transient neurological ischemic attack. At 3-year follow-up, all the 11 patients were alive and well and the echocardiographic evaluation revealed good function of the prosthesis. Conclusions: The TI route seems to be feasible with a low profile of local complications. It may be a reasonable access alternative to the femoral artery and to the trans-apical approach. A broader, prospective study is advisable to gain general consensus on this approach.

Tricuspid Valve Incompetency Due to the Grenade Chip Embolization to the Heart

Migration of foreign bodies into the heart, although unusual, has been reported since 1834 when Davis published the first bullet embolus. Our case was a 29-year-old woman who suffered from a grenade explosion wound with a residual burst fragment inside her arm soft tissue. Two months later, she was admitted with progressive fatigue, palpitation, shortness of breath, and swelling in legs and neck. She was taking hormonal therapy for infertility as medical history. Ascultation detected holosystolic respiratory variable murmur maximal over the left lower sternal border. Severe tricuspid regurgitation and an obliterating mass on tricuspid valve (TV) with characteristic of central linear echogenicity were detected by transthoracic echocardiography. The diagnosis of “the embolized missile into heart with superimposed thrombosis” was determined. The patient underwent open heart surgery and the thrombotic rod shape chip that was embedded in anterior tricuspid leaflet was removed and then TV was repaired.

A Combined Radial and Pedal Access to Treat a Flush Chronic Total Occlusion of the Superficial Femoral Artery in a Critical Limb Ischemia Patient

We present a case of a flush chronic total occlusion of the superficial femoral artery treated successfully with a combined antegrade approach using radial access and a retrograde approach using a pedal access. Patient has total occlusion of the contralateral left external iliac and common femoral artery. Our case illustrates the feasibility of the combined pedal-radial approach in treating flush occlusions of the superficial femoral artery.

Serial PET-CT Scans Can Help Determine Duration of Antibiotic Therapy After Endovascular Mycotic Thoracic Aortic Aneurysm Repair

Mycotic aortic aneurysm is a rare vascular condition, with high-risk for fatal complications. In cases of bacterial infection, prolonged antibiotic therapy is administered. There is no consensus on duration of antibiotic therapy and close follow-up is recommended following surgical and endovascular interventions. We report a case of a patient, who was diagnosed with mycotic aneurysm and underwent successful endovascular repair. Extended postoperative antibiotic treatment was administered. The duration was determined by sequential Fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) scans over a period of 6 months.

The π-Circuit Technique in Coronary Surgery: Analysis of 1359 Consecutive Cases

Coronary artery bypass surgery still has its unique role in the treatment of coronary artery disease. It faces, however, the continuous challenge of becoming even less invasive and more effective as cases become more complex. We here present the results of 1359 cases treated with the π-circuit technique which consists of an off-pump total myocardial revascularization using composite arterial grafts. The results demonstrate that it is a safe technique providing low mortality, stroke, renal failure, wound infection, and other complication rates. We suggest the application of this technique, as well as of other similar techniques regarding similar principles, especially in high-risk patients.

A Surgical Case of Venous Aneurysm of the Cephalic Vein with Unique Clinicopathological Findings for Venous Dissection: A Possible New Entity

We presented an extremely rare case of a 38-year-old female’s venous aneurysm of left cephalic vein with unique histopathological features, displaying variably thinned medial wall with focal, markedly reduced or absent smooth muscle cells and elastic fibers, most likely leading to the venous dissection with an intimal tear and many medial blood-filled vascular channels. We propose that those venous dissection-like findings would be a new feature especially from the clinicopathological viewpoints and might be considered in the classification of venous aneurysm. Further prospective studies are needed to validate the presence and significance of venous dissecting aneurysm as a new histopathological entity, after collecting and investigating a larger number of venous aneurysm cases examined. This short report could interest the scientific community, taken together with potentially specific findings of new entity, venous dissecting aneurysm.

Kissing Stents for Superior Vena Cava Syndrome Due to Mediastinal Fibrosis

Purpose: To report the endovascular reconstruction of the superior vena cava (SVC), innominate and internal jugular veins following stenosis due to mediastinal fibrosis. Case Report: A 36-year-old female with mediastinal fibrosis was referred for symptomatic SVC syndrome (SVCS). A covered stent was inserted in the SVC with 2 kissing stents in the innominate and jugular veins via anterograde right femoral vein access with sandwich technique. She exhibited near-immediate relief of debilitating symptoms. Computed tomographic scan demonstrated patent vessels at 1 year. Conclusions: Extensive endovascular venous reconstruction is an effective treatment for SVCS due to mediastinal fibrosis.

Bilateral Internal Mammary Artery Bypass Grafting: Sternal Wound Infection in High-Risk Population. Should Sternal Infection Scare Us?

Background: Bilateral internal mammary arteries (BIMAs) remain underused in coronary artery bypass grafting (CABG), especially in elderly, diabetic, and obese patients. This study investigated incidence of sternal wound infection (SWI), sternal instability (SI), and reintervention for bleeding (RIB) in this high-risk population. Methods: A single-center retrospective observational study was performed in “Grand Hôpital de Charleroi, Gilly, Belgium.” A total of 319 patients undergoing CABG from December 2011 to December 2015 were included. Three main outcome measures (SWI, SI, and RIB) were investigated in obese vs nonobese, diabetic vs nondiabetic, and elderly vs younger patients. Results: In all, 14 SWI, 11 SI, and 6 RIB were discounted. Death rate was as follows: SWI: 2/14 vs 17/305 ( P = .178), SI: 2/11 vs 17/308 ( P = .081), and RIB: 2/6 vs 17/313 ( P = .004). In obese (n = 113) vs nonobese (n = 206) patients, there was no difference for SWI ( P = .263), SI ( P = .565), and RIB ( P = .332). In diabetic (n = 118) vs nondiabetic (n = 201) patients, there was no difference for SWI ( P = .642), SI ( P = .497), and RIB ( P = .298). In elderly (n = 62) vs younger (n = 257) patients, there was no difference for SWI ( P = .619), SI ( P = .915), and RIB ( P = .385). Conclusions: Obesity, age, and diabetes treated by insulin (or not) do not seem to be risk factors for developing SWI, SI, or RIB in patients receiving a CABG using BIMA. Nevertheless, mortality was higher in RIB group.

Postoperative Pericardial Adhesion Prevention Using Collagen Membrane in Pigs: A Pilot Study

Objective: The operating procedure of a resternotomy in open-heart surgery is a complicated procedure with potentially problematic outcomes partly due to potential adhesions in the pericardial cavity and retrosternal space. Use of a collagen membrane has shown encouraging results in adhesion prevention in several regions of the body. This study was designed to evaluate the effectiveness of the use of this collagen membrane in the prevention of pericardial adhesions. Materials and methods: A total of 12 pigs were divided randomly into 2 groups: an experimental group in which collagen membranes were used and a control group. After sternotomy and an anterior pericardiectomy, the epicardial surface was exposed to room air and irrigated with saline, and an epicardial abrasion was performed using a sponge. The pericardial defect was repaired using a collagen membrane in the experimental group or left uncovered in the control group. After 8 to 12 weeks, the pigs were killed, and a resternotomy was performed by a single-blinded surgeon enabling the evaluation of adhesions. The heart was then removed and sent for microscopic assessment conducted by a single-blinded pathologist. Results: The resternotomy operations performed using a collagen membrane demonstrated a nonstatistically significant trend of fewer macroscopic and microscopic adhesions in all regions ( P > .05), particularly in the retrosternal and defect regions. Conclusions: This study showed nonstatistically significant differences between the outcomes in the collagen membrane group and the control group in both macroscopic and microscopic adhesion prevention. Due to the many limitations in animal study design, further studies in human models will be needed before the true value of this procedure can be evaluated.

Driveline Infection in Ventricular Assist Devices and Its Implication in the Present Era of Destination Therapy

Advances in mechanical circulatory support devices provided the technology to develop long-term, implantable left ventricular assist devices as bridge to transplant, destination therapy, and in a lesser group of patients, as bridge to recovery. Despite the benefits from this innovative therapy, with their increased use, many complications have been encountered, one of the most common being infections. With the driveline acting as a portal to the exterior environment, an infection involving this structure is the most frequent one. Because patients with destination therapy are expected to receive circulatory support for a longer period of time, we will focus this review on the risk factors, prevention, and treatment options for driveline infections.