Two patients with ascending aortic aneurysms due to cystic medical necrosis are described. One of them was phenotypically normal while the other had features of Marfan's syndrome. Both were disabled by dyspnoea and angina which required corrective surgery.
This is a case report of a pseudoaneurysm due to Salmonella aortitis in a 52 year old man. The condition is rare and represents one of the few cases reported in Malaysia. The diagnosis was made preoperatively by ultrasonography and computed tomography. This was confirmed at surgery where there was a 3 cm defect at the posterior wall of the aorta at L2/3 level. The aneurysmal sac extended to the retrocrural space at the 12th vertebra level cranially on the right side to the lower border of the 3rd lumbar vertebra caudally. It had a smooth fibrous wall and contained a mixture of organised haematoma and pus. At operation the aneurysm was excised, the affected region was carefully debrided and the aorta grafted with an in-situ in-lay graft. Antibiotic therapy was instituted until clinical response was evident, leukocytosis was reduced and blood culture was negative. However 4 months after surgery, the patient returned in irreversible shock and succumbed to disseminated intravascular coagulation secondary to massive upper gastrointestinal haemorrhage from an aortoduodenal fistula.
Aneurysms of the sinus of Valsalva are uncommon disorders and are usually congenital in origin. When these aneurysms rupture into an intracardiac chamber, they may be silent initially but later give rise to progressive heart failure due to left or right shunting and aortic regurgitation. The mortality and morbidity in untreated cases is high. We report 13 patients with ruptured aneurysms of the sinus of Valsalva who underwent surgical repair. There were seven males and six females with a mean age of 24.5 years. Three patients were asymptomatic and five were in congestive cardiac failure. The majority of patients (61.5%) had insidious onset of symptoms, only 2 cases presenting acutely. The connection was between the right aortic sinus and the right ventricle in 11 cases and the non coronary sinus and the right ventricle in 2 cases. Associated cardiac anomalies included a ventricular septal defect (8 patients) and aortic regurgitation (6 patients). There was 1 post operative death and 1 patient required re-operation three months later for a recurrence of the fistula. All 6 patients with aortic regurgitation required aortic valve replacement. All patients remained well and asymptomatic during follow up ranging from 2 to 19 years.
Cardiac complications comprise as much as 50% of perioperative vascular surgical morbidity and mortality. Using the Goldman multifactorial index for evaluating cardiac risk pre-operatively, 53 consecutive patients who underwent abdominal aortic aneurysm surgery were prospectively studied. Forty patients (75.5%) were also evaluated with echocardiography for assessment of left ventricular function. There were 14 (23.7%) peri-operative events, of which nine (17.0%) were acute myocardial infarctions--two of whom died (3.8%). The minor complications included three with hypovolaemic renal failure, and one each with acute respiratory failure and cerebrovascular accident. Patients with Goldman cardiac risk index (CRI) classes III and IV were associated with significantly higher risks of peri-operative complications (p less than 0.001), i.e. 77.8% and 66.7% respectively, compared with class II (22.7%) and class I (nil). Echocardiographic left ventricular shortening fraction (LVFS) of less than 28% helped identify high risk groups in all classes, although its positive predictive value was low (42.3%). Combining LVFS less than 28% with Goldman CRI categories II to IV improved the sensitivity to 91.7% and the positive predictive value to 61.1%. Careful pre-operative assessment using the simple Goldman index and echocardiography is helpful in identifying higher risk patients who would benefit from pre-operative stabilisation and more rigorous perioperative hemodynamic monitoring preferably including intensive care (ICU) management, so as to reduce cardiac complications.
This is a case report of single-stage total thoracic aortic repair by the frozen elephant trunk technique for a 75-yearold female with a complex aortic pathology of mega-aorta extending from the ascending aorta to the descending aorta. We used a Thora flex™ Hybrid device, a frozen elephant trunk device with four branched grafts and the distal stent graft. The distal stent graft was inserted into the downstream descending aorta via an aortic arch and positioned 15 cm beyond the left subclavian artery after total arch replacement had been performed using a four-branch graft. The postoperative course was unremarkable with no complications. A post procedural computed tomography scan demonstrated complete exclusion of the descending thoracic aneurysm without endoleak. Therefore, fixing the whole mega-aorta in a single stage using the frozen elephant trunk was effective and safe.
Acute type A aortic dissection remains one of the most challenging conditions in aortic surgery. Despite the advancements in the field, the mortality rate still remains high. Though there is a general consensus that the ascending aorta should be replaced, the distal extension of the surgery still remains a controversy. Few surgeons argue for a conservative approach to reduce operative and postoperative morbidity while others considering the problems associated with "downstream problems" support an aggressive approach including a frozen elephant trunk. The cohort in the Indian subcontinent and APAC is far different from the western world. Many factors determine the decision for surgery apart from the pathology of the disease. Economy, availability of the suitable prosthesis, the experience of the surgeon, ease of access to the medical facility all contribute to the decision making to treat acute type A dissection.
Bacterial arteritis is relatively uncommon and management of this condition, which carries high morbidity and mortality, is difficult and time-consuming. Common organisms implicated include Salmonella and Staphylococcus. Arteritis as a result of infection by Burkholderia pseudomallei (formerly Pseudomonas pseudomallei) has been rarely reported in the English literature. This organism, which is endemic in our part of the world, is well known to cause a wide spectrum of septic conditions. A review of cases managed at Hospital Kuala Lumpur revealed that bacterial arteritis due to melioidosis is not such a rare entity. We share our experience in the management of this condition using three cases as examples.
Though peripheral arterial disease is not as common as in the Western countries, abdominal aorit aneurysm (AAA) is the most frequent arterial problem in Malaysia. A prospective study was made of 100 consecutive patients who presented with AAA to the author between January 1986 to September 1988 (31 months' period). There were 88 males and 12 females. The age range was 47-90 years, mean = 68.7. All the major ethnic rates were equally affected. The sizes of the AAA were documented by ultrasonography and the diameters ranged from 3-10 centimetres, mean = 5.8. Aneurysmectomy was performed on 58 patients, 17 of which were emergencies for ruptured AAA. The operative mortality for elective surgery was 2 percent, but that for emergency surgery was 47 percent. Ten patients refused surgery and 28 were not offered an operation. The true incidence of AAA is likely to be much higher than the number of patients referred for treatment. Many cases are not diagnosed or referred for treatment. Many cases of ruptured AAA died at home or in peripheral hospitals without a diagnosis being made. It is estimated that an AAA is present in 17,000 persons in Peninsular Malaysia. The risk of elective surgery is significantly lower than that of emergency. The overall mortality for ruptured AAA is even higher at about 99 percent. Furthermore, AAA is a benign disease and after surgery the patients return to their normal life expectancy. It is recommended that patients with AAA of five centimetres or more should be advised surgery if premature death is to be avoided.
Delayed ascending aortic dissection following coronary artery bypass surgery is a rare but lethal complication. We present the case of a 54-year-old man with a delayed acute Stanford A aortic dissection following an off-pump coronary artery bypass surgery in preexisting chronic type B disease. Such a case of an iatrogenic acute aortic dissection poses a significant challenge and dilemma in choosing the best technique for coronary revascularization in this group of patients. The pathophysiology and technical options are discussed.