Journal of Interventional and General Cardiology

Critical lower limb ischemia is a clinical condition that is life threatening with impending loss of limb viability, and must be treated urgently to avoid major amputation. Revascularization is the most effective treatment method and can be carried out by surgical or endovascular techniques. For patients with chronic total occlusion of the Superficial Femoral Artery (SFA), amputation could be limited to below the knee using revascularization and below knee amputation. Combining these two approaches into a “hybrid technique” makes it possible to treat patients who were initially billed for above knee amputation. We report on a case of lower limb critical ischemia with chronic total occlusion of the left SFA treated using a combination of endovascular techniques and below knee amputation, in an application of the hybrid technique.

Introduction: Undiagnosed aortic coarctation discovered in the adults represents surgical challenge due to more extensive pathological changes and collateralized circulation. Although a considerable number of cases can be relived through catheter intervention, still some cases are not suitable for this approach. Five to 30% of patients with previous coarctation repair have re-coarctation and require re-intervention and some cases are associated with concomitant cardiac pathology. Ascending to descending aortic bypass graft via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for these groups of patients.
Patients and methods: We reviewed the data of 7 patients that underwent extra-anatomic ascending to descending aortic bypass grafting through median sternotomy between February 2011 to December 2014. Concomitant procedures performed in 5 patients included the following; ventricular septal defect closure (VSD), coronary artery bypass grafting (CABG), mitral valve replacement (MVR), aortic valve replacement (AVR), and resection of a subaortic membrane. They were 5 males and 2 females with mean age 37 years ranging from 18 to 45 years old.
Results: All patients survived the operation and were alive with patent CoA bypass graft at a mean follow up of 21.6 ± 10.0 months. No graft-related complications occurred. Systolic blood pressure decreased after surgery by an average of 46 mmHg.
Conclusion: Ascending to descending aortic bypass through a median sternotomy and posterior pericardiotomy is safe technique when patients present in adulthood with re-coarctation and concomitant cardiac lesions.

A 45 year-old man was admitted to emergency service with new onset chest pain for 30 minutes. Electrocardiogram (ECG) showed ST-segment elevation in D1, AVL and V1-V6 leads and coronary angiography (CAG) detected proximal total occlusion of left anterior descending artery (LAD). Primer percutaneous intervention (PCI) was performed. Following intervention, ECG was normalized. Twenty minutes after PCI chest pain re-emerged and ECG showed ST-segment elevation in the D2, D3 and AVF leads. The patient was immediately transferred to catheterization laboratory and CAG showed acute LAD stent thrombosis. The culprit was successfully treated and the patient was discharged after three days with no complaint.

Initiation of extracorporeal membrane oxygenation may increase left ventricular volume, pressure and wall stress. Left atrial decompression may reduce ventricular wall stress and filling pressures, thus improving coronary perfusion. This may contribute to ventricular functional recovery.

The pediatric experience consists mainly of postoperative congenital heart disease patients. Scarce reports exist about neonates on extracorporeal membrane oxygenation due to other acute cardiac causes. We present a neonate with fulminant myocarditis with severe pulmonary edema upon extracorporeal membrane oxygenation initiation, which improved almost instantly after atrial decompression.