Retroperitoneal approach for suprarenal abdominal aortic aneurysm in Marfan syndrome

Suprarenal abdominal aortic aneurysms pose a surgical challenge, as it is difficult to reanastomose the renal arteries and to place a cross-clamp to the aortic segment involving the visceral arteries through the diaphragmatic crux. The retroperitoneal approach with a limited thoracoabdominal incision through the ninth intercostal space offers some advantages over the midline transperitoneal approach which we explain by presenting its use in a patient with Marfan syndrome and a true abdominal aortic aneurysm. This technique should be in the armamentarium of aortic surgeons as they have to face with ever-increasingly difficult cases in the endovascular era

İnfarktüs sonrası gelişen ventriküler septal rüptür tamiri sonuçlarımız: Morbidite ve mortalite üzerine etkili değişkenlerin değerlendirilmesi

Postinfarction ventricular septal defect (VSR) developing in 1-2% of patients is a serious complication with high mortality rates. in this study, VSRs repaired surgically were evaluated retrospectively with clinical and echocardiographic findings to analyse variables affecting mortality and morbidity as well as surgical technique. the preoperative, perioperative, and postoperative early and mid-term follow-up data of 21 patients with VSR who underwent surgical repair from 1996 through 2001, were evaluated. Preoperative coronary angiography, cardiac catheterization were performed in all patients. Preoperative and postoperative control echocardiography were also performed in all patients but two patients who died perioperatively. Follow-up data after the discharge of these patients were obtained via monthly periodical examinations in the first 6 months, and thereafter via telephone interviews. the mean follow-up time of surviving 13 patients was 27.62±22.60 (2-67) months. Overall mortality and early mortality rates were 42.9% and 38.1%, respectively. Postoperative complications were observed in 13 (68.4%) patients. the most frequently encountered complication was congestive heart failure developed in 8 patients. Advanced age and cardiogenic shock were significant risk factors for postoperative renal failure and congestive heart failure. Overall morbidity was significantly high in patients with preoperative QP/QS>2. Advanced age, anterior MI, ejection fraction (LVEF);lt;40%, anterior VSR, and single-patch repair technique used to repair anterior VSR were found to be the determinants of mortality. Despite the improved surgical techniques, postinfarction ventricular septal defect with extensive myocardial damage still continues to be a very difficult surgical challenge with high mortality rates.Akut miyokard infarktüsü sonrası ventriküler septal rüptür (VSR) %1-2 hastada oluşan çok yüksek mortalite ile seyreden bir komplikasyondur. Çalışmamızda cerrahi tedavi uygulanan postinfarktüs VSR'ler cerrahi teknik ve mortalite ile morbiditeye etkili risk faktörleri açısından klinik ve ekokardiyografik bulguları ile retrospektif olarak değerlendirilmiştir. Merkezimizde 1996-2001 arasında akut postinfarktüs VSR saptanan 21 olguya cerrahi tedavi uygulanmıştır. Bütün olgulara preoperatif koroner anjiografi, sol ventrikülografi ve perioperatif olarak kaybedilen iki olgu haricindeki bütün olgulara preoperatif ve postoperatif ekokardiyografi yapılmıştır. Olgular postoperatif ilk 6 ayda poliklinik kontrolleri, sonrasında telefon görüşmeleri ile izlenmişlerdir. Postoperatif kontrolleri yapılan toplam 13 olgunun ortalama izlem süresi 27.6±22.6 (2-67) aydır. Toplam mortalite 9 (%42.9) olgu olup, 8 (%38.1) olgu erken dönem hastane mortalitesidir. Postoperatif dönemde yaşayan 19 olgudan 13'ünde (%68.4) 30 komplikasyon gelişmiştir. En sık karşılaşılan 8 (%42.1) olguda gelişen KKY'dir. İleri yaş ve kardiyojenik şok ile postoperatif renal yetersizlik ve KKY ilişkisi anlamlı bulunmuştur. Preoperatif şantı fazla (>2) olan olgularda genel morbidite anlamlı derecede yüksek bulunmuştur. İleri yaş, ön yüz lokalizasyonlu MI, LVEF (%40), anterior VSR ve yine anterior VSR lerde uygulanan tek-yama tamir tekniği ile postoperatif mortalite ilişkisi anlamlı bulunmuştur. Yaygın bir miyokard enfartüsü sonucu meydana gelen ve geniş miyokard hasarının da birlikte olduğu akut VSR halen günümüzde en ileri cerrahi tekniklerin kullanılmasına rağmen mortalitesi yüksek bir patolojidir

Tip I akut aort disseksiyonunda malperfüzyon

Background: Malperfusion, which is an important complication of acute type 1 aortic dissection, appears with myocardial, cerebral, visceral and extremity ischemia. In this study, emergency operation, distributions of malperfusion and mortality rate were studied retrospectively in the patients who have type I aortic dissection with signs of malperfusion. Methods: Twenty-seven patients (23 male and 4 female), who have totally 36 malperfusions, within 83 urgently operated patients for acute type 1 aortic dissection, were studied retrospectively. All of the patients were operated under deep hypothermic circulatory arrest. Ascending aortic with/without arcus graft replacement was performed in 9 patients, ascending aortic graft replacement and aortic valve resuspention was performed in 14 patients, and ascending aorta with/without arcus and aortic valve replacement with a composite graft/and mechanical aortic valve was performed in 3 patients. Results: Thirty-six malperfusions were diagnosed in 27 patients. Number of malperfusion of the extremities was 19, number of malperfusion of the myocardium was 6, number of malperfusion of the cerebrum was 7, and number of malperfusion of the visceral organs was 4. Mortality rate of the patients, who were urgently operated for acute type I aortic dissection, was 26%. Mortality rate of the patients, who did not have any sign of malperfusion appeared, as 19% whereas it was 40.7% for the patients, who had malperfusion signs. Sixteen patients survived (59.3%). Conclusion: We are in the opinion that primary treatment of acute type 1 aortic dissection is ascending aortic replacement and closure of the false lumen, and peripheral vascular surgical intervention should rarely be applied.Amaç: Tip l akut aort disseksiyonun önemli bir komplikasyonu olan malperfüzyon karşımıza miyokardiyal, serebral, visserai ve ekstremite iskemisi şeklinde çıkar. Bu çalışmada kliniğimizde malperfüzyon bulguları olan tip l aort disseksiyonlu olgulara yapılan acil cerrahi müdahale, malperfüzyonun dağılımı ve mortalite oranının retrospektif olarak değerlendirilmesi amaçlanmıştır. Materyal ve Metod: Kliniğimizde acil olarak ameliyat edilen 83 akut tip I aort disseksiyonu olgusu içinde 23'ü erkek, 4'ü kadın olan 27 hastada tespit edilen 36 malperfüzyon retrospektif olarak değerlendirildi. Bütün hastalar derin hipotermik sirkulatuvar arrest altında ameliyat edildi. Cerrahi işlem olarak 9 hastada asandan aort ± arkus greft replasmam, 14 hastada asandan aort greft replasmanı ve aort kapak resuspansiyonu, 3 hastada kompozit kapaklı greft ile aort kapak, asandan aort ± arkus replasmanı yapıldı. Bulgular: Bu hastalarda toplam 36 malperfüzyon saptandı. Ekstremite malperfüzyonu sayısı 19, miyokard 6, serebral 7 ve visserai 4 olarak tespit edildi. Tip l akut aort disseksiyonu nedeni ile acil olarak ameliyat edilen hastalarda toplam mortalité oranı %26 olarak bulundu. Malperfüzyon bulunmayan hastalarda mortalité oranı %19 olarak tespit edildi. Malperfüzyonlu hastalarda global mortalité %40.7 iken, 16 olgu (%59.3) takip altındadır. Sonuç: Tip I akut aort disseksiyonunda asandan aort replasmanı ve yalancı tümeni kapatmanın öncelikli tedavi şekli olduğu ve periferik vasküler cerrahi girişimlerin nadir başvurulması gereken cerrahi yöntemler olduğu kanısındayız