- Email: [email protected]
Novel Cannulation Strategy for Repair of an Ascending Aortic Pseudoaneurysm in a 2.8-kg Infant
Ann Thorac Surg 2015;100:1453–5
Novel Cannulation Strategy for Repair of an Ascending Aortic Pseudoaneurysm in a 2.8-kg Infant Rajesh Venkataraman, MCh, Periyasamy Thangavelu, MCh, Sivasubramanian Muthukumar, MCh, Ramkumar Jayavelan, MCh, Dheeraj Pyrra, MCh, Baskar Ranjith Karthekeyan, MD, Mahesh Vakamudi, MD, and Jebaraj Rathinasamy, MRCPCH Departments of Cardiothoracic Surgery, Anesthesiology, and Pediatric Cardiology, Sri Ramachandra University, Chennai, India
A
scending aortic pseudoaneurysm is rare in infants, with few cases reported in the literature [1–4]. There is an inherent risk of rupture of the pseudoaneurysm during redo sternotomy; therefore, peripheral cannulation is needed. Neck vessels are commonly used for peripheral cannulation in infants. We describe a 2.8-kg infant that developed mycotic pseudoaneurysm of the ascending aorta after repair of type 2 truncus arteriosus. We describe successful repair using an alternate cannulation strategy by direct retroperitoneal cannulation of descending aorta and inferior vena cava. A 2-month-old child (2.8 kg) was admitted with the diagnosis of type 2 truncus arteriosus. The child required ventilatory support because of pneumonic infiltrate and respiratory failure. After evaluation and stabilization, the child underwent truncus repair with a valved right ventricle to pulmonary artery conduit. After harvesting the pulmonary arteries from the truncus, the neoaorta was repaired primarily without the need for a patch. Postoperatively, the child needed ventilation for 3 days
VENKATARAMAN ET AL ENDOBRONCHIAL PNET
1453
and an intensive care unit stay of 6 days. The child was discharged on the tenth postoperative day. The predischarge echocardiogram showed good biventricular function, no neoaortic stenosis or regurgitation, and a wellfunctioning conduit. The child was readmitted after 1 week with respiratory distress secondary to aspiration and suspected right recurrent laryngeal nerve palsy. A chest radiograph showed mediastinal widening and a shadow in the right lung upper zone. Bedside echocardiography showed a large pseudoaneurysm of the ascending aorta just above the valve leaflets (Fig 1A). A contrast-enhanced chest computed tomogram (CT) with three-dimensional reconstruction confirmed the finding and delineated the extent of the pseudoaneurysm (Figs 1B, 1C). The pseudoaneurysm was stuck to the sternum, prohibiting safe sternal reentry, and peripheral cannulation was planned. The chest CT showed that the innominate artery was close to the pseudoaneurysm. After reviewing the CT, we believed that the carotid arteries were small for an adequate size cannula. In addition, because there was only a short segment of aorta between the pseudoaneurysm opening and the innominate artery origin, we believed that aortic cross clamping might not be possible. We ultimately decided against using the neck vessels for cannulation. A separate incision was made in the right iliac fossa with the aim to expose and cannulate the right common iliac artery (through a graft) and vein. The common iliac artery was also small (3 mm); therefore, the descending aorta and inferior vena cava were cannulated retroperitoneally using 8F DLP arterial and 12F Bio-Medicus venous cannula (Medtronic, Minneapolis, MN, USA), respectively, and cardiopulmonary bypass (CPB) was initiated (Fig 2). Deep hypothermia was established. The chest was opened during a period of low flow. Sternal opening led to entry into the pseudoaneurysm cavity. Head end was kept low to prevent air embolism. The opening in the ascending aorta was identified. The aorta between this opening and the origin of innominate artery could be dissected and clamped. Full-flow CPB was restarted. Cardioplegia was delivered through the coronary ostium. The pseudoaneurysm was thoroughly debrided and the aortic edges were freshened. Cultures were sent from the mediastinal contents and aortic wall. The posterior layer of the previous anastomosis was reinforced, and bovine pericardial patch repair was performed for the aortic defect. After de-airing, the cross clamp was released and gradual rewarming was performed. The child could be easily separated from CPB. The child made an uneventful recovery. Culture from the aortic wall grew Staphylococcus haemolyticus.
Comment Accepted for publication Nov 24, 2014. Address correspondence to Dr Venkataraman, Department of Cardiothoracic Surgery, Sri Ramachandra University, Porur, Chennai 600116; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ascending aortic pseudoaneurysm is rare in infants, with few cases reported in the literature [1–4]. Most aortic pseudoaneurysms occur in the descending aorta in relation to coarctation, following liver transplantation or 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.073
FEATURE ARTICLES
Pseudoaneurysm of the ascending aorta is rare in infants, with few cases reported in the literature. These aneurysms are usually mycotic, occurring after cardiac surgery, or caused by mediastinitis. They have high risk of spontaneous rupture. Surgery is usually complex because of the need for peripheral cannulation in small infants. We report an ascending aortic pseudoaneurysm in a less than 3-month-old infant that occurred within a month after repair of type 2 truncus arteriosus and was managed successfully with a modified cardiopulmonary bypass strategy. (Ann Thorac Surg 2015;100:1453–5) Ó 2015 by The Society of Thoracic Surgeons
CASE REPORT
1454
CASE REPORT VENKATARAMAN ET AL ENDOBRONCHIAL PNET
Ann Thorac Surg 2015;100:1453–5
FEATURE ARTICLES
Fig 1. (A) Two-dimensional echocardiogram showing the pseudoaneurysm (arrow), defect in the ascending aorta (dotted line) and the close proximity to aortic valve (9 mm). Contrast enhanced chest CT in (B) transverse and (C) threedimensional reconstruction showing the pseudoaneurysm (arrow) and its close relation to the sternum and innominate artery (IA).
umbilical artery catheterization [4–7]. All reported ascending aortic pseudoaneurysms in infants are mycotic pseudoaneurysms, occurring after cardiac surgery or mediastinal infection [1–3], and they have a high risk of rupture. Pseudoaneurysms tend to enlarge rapidly and are covered by adjacent tissues that are compressed by it. Mycotic pseudoaneurysms tend to develop because of
Fig 2. Right iliac fossa incision for retroperitoneal exposure of the descending aorta and inferior vena cava for cannulation.
bacteremia, direct spread as in mediastinitis, or infected indwelling catheters. Once bacterial contamination of a vulnerable region like a suture line occurs, bacterial enzymatic digestion or endarteritis leads to weakening of the suture line, predisposing to pseudoaneurysm formation. The management in this child was complicated by the early presentation (17 days) after surgery and the small size of the infant. The reason for this early presentation in addition to infection could be the thinning of aorta during mobilization. The options for cannulation in this child included cannulation of innominate artery, carotid artery, or the iliac arteries. Because of close proximity of the pseudoaneurysm to the innominate artery, we decided against dissecting this vessel for cannulation. Common carotid artery cannulation was another option that has been used by others [4, 5], but on contrast CT we believed that these were too small to allow adequately sized cannula for this infant. In addition, we needed a safe place for aortic clamp in the short segment of aorta between the pseudoaneurysm and the origin of innominate artery. Hence, we directly cannulated the inferior vena cava and the descending aorta retroperitoneally, with good venous drainage and flow. Retroperitoneal cannulation of descending aorta and inferior vena cava for peripheral cannulation before sternotomy has been reported in adults but not in infants. The peripheral cannulation strategy in small infants is usually the common carotid artery and the internal jugular vein. In retrospect, carotid
Ann Thorac Surg 2015;100:1455–8
artery cannulation could have been possible in our patient. When common carotid cannulation might not be possible, such as the presence of hematoma or infection, this cannulation strategy is a viable alternative for establishing CPB. The early presentation of ascending aortic pseudoaneurysm in a 2.8-kg infant and the modified cardiopulmonary bypass strategy used make this patient unique and may assist surgeons in treating similar patients. Once ascending aortic pseudoaneurysm is diagnosed, the procedure should be done as early as possible because of the risk of rupture. The importance of peripheral cannulation and institution of cardiopulmonary bypass before redo sternotomy cannot be overemphasized.
References
Endobronchial Primitive Neuroectodermal Tumor With Pneumothorax Ex Vacuo Wongyeong Han, MD, Dongmyung Huh, MD, PhD, Byoungho Kim, MD, PhD, Eunkyoung Kwak, MD, PhD, and Sunah Lee, MD Departments of Thoracic and Cardiovascular Surgery, Histopathology, and Oncology, Daegu Fatima Hospital, Daegu, Republic of Korea
We experienced a rare case of an endobronchial primitive neuroectodermal tumor of the left main bronchus. Initially we suspected pneumothorax caused by a collapsed left upper lobe and an air-entrapped lower lobe. After tube thoracostomy, the pneumothorax persisted without air leakage. A tumor was detected at the left main bronchus on computed tomography and bronchoscopy, and diagnosed pathologically as small cell lung cancer. Under the presumed diagnosis of limited-stage small cell lung cancer, we performed a left pneumonectomy. The tumor Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1455
was eventually identified pathologically as a primitive neuroectodermal tumor. Although adjuvant chemoradiotherapy was not performed, no recurrence was observed. (Ann Thorac Surg 2015;100:1455–8) Ó 2015 by The Society of Thoracic Surgeons
P
rimitive neuroectodermal tumors (PNET) are malignant tumors of small undifferentiated neuroectodermal cells thought to originate from neural crest cells [1]. Thoracic PNETs usually involve the extrapulmonary tissues of the chest wall and paravertebral structure, and rarely involve the primary pulmonary region [2]. Especially, endobronchial PNETs without lung involvement are very rare neoplasms of thoracic region. Herein, we present a case of endobronchial PNET of the left main bronchus with pneumothorax ex vacuo. A 29-year-old man presented with chest pain and progressive shortness of breath with coughing for 1 month. No constitutional symptoms such as body weight loss or fever were reported. Physical examination revealed decreased breathing sounds on the entire left thorax. Chest radiographic examination showed a left collapsed lung (Fig 1). The patient was diagnosed with left pneumothorax and tube thoracostomy using a 12-Fr tube was performed. However, follow-up chest radiograph showed incomplete lung expansion. We then performed a computed tomography scan, and an endobronchial tumor at the left upper lobe bronchus extending to the left main bronchus was observed. The tumor was thought to be causing atelectasis of the left upper lobe and volume expansion through air entrapment due to partial occlusion of the left lower lobe bronchus (Fig 2). Bronchoscopy showed complete obstruction of the mid-portion of the left main bronchial lumen that was caused by a polypoid mass covered with necrotic material. A low-grade malignant tumor, such as a carcinoid tumor, was suspected so a biopsy was performed. On bronchoscopic biopsy we recognized that the tumor was malignant, and small cell carcinoma, pulmonary blastoma, and malignant lymphoma were considered in the differential diagnosis. Small cell lung cancer was suspected on the basis of pathologic findings. The pulmonary function test was within the normal range. Positron emission tomography showed a hypermetabolic mass obstructing the left upper lobe; diffuse uptake of 2-[18F] fluoro-2-deoxy-d-glucose by the left lower lobe indicated inflammatory changes without metastatic evidence at lymph nodes or other internal organs. Under a preoperative diagnosis of limited-stage small cell lung cancer of the left upper to left main bronchus, Accepted for publication Nov 26, 2014. Address correspondence to Dr Huh, MD, Department of Thoracic and Cardiovascular Surgery, Daegu Fatima Hospital, 99 Ayangro, Dong-gu, Daegu City, Republic of Korea; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.073
FEATURE ARTICLES
1. Miyaji K, Nagata N, Matsui H, Yamamoto T. Mycotic pseudoaneurysm of the ascending aorta after mediastinitis in an infant. Eur J Cardiothorac Surg 2002;22:638–9. 2. Malec E, Mroczek T, G orecki W, Kordon Z. Successful surgical treatment of a mycotic pseudoaneurysm of the ascending aorta in an infant after hypoplastic left heart complex repair. Pediatr Cardiol 2003;24:89–91. 3. Barth H, Moosdorf R, Bauer J, Schranz D, Akint€ urk H. Mycotic pseudoaneurysm of the aorta in children. Pediatr Cardiol 2000;21:263–6. 4. Mainwaring RD, Lamberti JJ, Rohrer C, Winkler M. Neck cannulation for the repair of thoracic artery aneurysms in the infant. J Card Surg 1993;8:541–5. 5. Roy N, Azakiea A, Moon-Grady AJ, Blurton DJ. Mycotic aneurysm of the descending thoracic aorta in a 2-kg neonate. Ann Thorac Surg 2005;80:726–9. 6. Bergsland J, Kawaguchi A, Roland M, Pieroni DR, Subramanian S. Mycotic aortic aneurysms in children. Ann Thorac Surg 1984;37:314–8. 7. Mosca RS, Kulik TJ, Marshall K, Hernandez R, Fletcher SE. Mycotic pseudoaneurysm associated with aortic coarctation. J Cardiovasc Magn Reson 2000;2:209–12.
CASE REPORT HAN ET AL ENDOBRONCHIAL PNET
Novel Cannulation Strategy for Repair of an Ascending Aortic Pseudoaneurysm in a 2.8-kg Infant Rajesh Venkataraman, MCh, Periyasamy Thangavelu, MCh, Sivasubramanian Muthukumar, MCh, Ramkumar Jayavelan, MCh, Dheeraj Pyrra, MCh, Baskar Ranjith Karthekeyan, MD, Mahesh Vakamudi, MD, and Jebaraj Rathinasamy, MRCPCH Departments of Cardiothoracic Surgery, Anesthesiology, and Pediatric Cardiology, Sri Ramachandra University, Chennai, India
A
scending aortic pseudoaneurysm is rare in infants, with few cases reported in the literature [1–4]. There is an inherent risk of rupture of the pseudoaneurysm during redo sternotomy; therefore, peripheral cannulation is needed. Neck vessels are commonly used for peripheral cannulation in infants. We describe a 2.8-kg infant that developed mycotic pseudoaneurysm of the ascending aorta after repair of type 2 truncus arteriosus. We describe successful repair using an alternate cannulation strategy by direct retroperitoneal cannulation of descending aorta and inferior vena cava. A 2-month-old child (2.8 kg) was admitted with the diagnosis of type 2 truncus arteriosus. The child required ventilatory support because of pneumonic infiltrate and respiratory failure. After evaluation and stabilization, the child underwent truncus repair with a valved right ventricle to pulmonary artery conduit. After harvesting the pulmonary arteries from the truncus, the neoaorta was repaired primarily without the need for a patch. Postoperatively, the child needed ventilation for 3 days
VENKATARAMAN ET AL ENDOBRONCHIAL PNET
1453
and an intensive care unit stay of 6 days. The child was discharged on the tenth postoperative day. The predischarge echocardiogram showed good biventricular function, no neoaortic stenosis or regurgitation, and a wellfunctioning conduit. The child was readmitted after 1 week with respiratory distress secondary to aspiration and suspected right recurrent laryngeal nerve palsy. A chest radiograph showed mediastinal widening and a shadow in the right lung upper zone. Bedside echocardiography showed a large pseudoaneurysm of the ascending aorta just above the valve leaflets (Fig 1A). A contrast-enhanced chest computed tomogram (CT) with three-dimensional reconstruction confirmed the finding and delineated the extent of the pseudoaneurysm (Figs 1B, 1C). The pseudoaneurysm was stuck to the sternum, prohibiting safe sternal reentry, and peripheral cannulation was planned. The chest CT showed that the innominate artery was close to the pseudoaneurysm. After reviewing the CT, we believed that the carotid arteries were small for an adequate size cannula. In addition, because there was only a short segment of aorta between the pseudoaneurysm opening and the innominate artery origin, we believed that aortic cross clamping might not be possible. We ultimately decided against using the neck vessels for cannulation. A separate incision was made in the right iliac fossa with the aim to expose and cannulate the right common iliac artery (through a graft) and vein. The common iliac artery was also small (3 mm); therefore, the descending aorta and inferior vena cava were cannulated retroperitoneally using 8F DLP arterial and 12F Bio-Medicus venous cannula (Medtronic, Minneapolis, MN, USA), respectively, and cardiopulmonary bypass (CPB) was initiated (Fig 2). Deep hypothermia was established. The chest was opened during a period of low flow. Sternal opening led to entry into the pseudoaneurysm cavity. Head end was kept low to prevent air embolism. The opening in the ascending aorta was identified. The aorta between this opening and the origin of innominate artery could be dissected and clamped. Full-flow CPB was restarted. Cardioplegia was delivered through the coronary ostium. The pseudoaneurysm was thoroughly debrided and the aortic edges were freshened. Cultures were sent from the mediastinal contents and aortic wall. The posterior layer of the previous anastomosis was reinforced, and bovine pericardial patch repair was performed for the aortic defect. After de-airing, the cross clamp was released and gradual rewarming was performed. The child could be easily separated from CPB. The child made an uneventful recovery. Culture from the aortic wall grew Staphylococcus haemolyticus.
Comment Accepted for publication Nov 24, 2014. Address correspondence to Dr Venkataraman, Department of Cardiothoracic Surgery, Sri Ramachandra University, Porur, Chennai 600116; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ascending aortic pseudoaneurysm is rare in infants, with few cases reported in the literature [1–4]. Most aortic pseudoaneurysms occur in the descending aorta in relation to coarctation, following liver transplantation or 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.073
FEATURE ARTICLES
Pseudoaneurysm of the ascending aorta is rare in infants, with few cases reported in the literature. These aneurysms are usually mycotic, occurring after cardiac surgery, or caused by mediastinitis. They have high risk of spontaneous rupture. Surgery is usually complex because of the need for peripheral cannulation in small infants. We report an ascending aortic pseudoaneurysm in a less than 3-month-old infant that occurred within a month after repair of type 2 truncus arteriosus and was managed successfully with a modified cardiopulmonary bypass strategy. (Ann Thorac Surg 2015;100:1453–5) Ó 2015 by The Society of Thoracic Surgeons
CASE REPORT
1454
CASE REPORT VENKATARAMAN ET AL ENDOBRONCHIAL PNET
Ann Thorac Surg 2015;100:1453–5
FEATURE ARTICLES
Fig 1. (A) Two-dimensional echocardiogram showing the pseudoaneurysm (arrow), defect in the ascending aorta (dotted line) and the close proximity to aortic valve (9 mm). Contrast enhanced chest CT in (B) transverse and (C) threedimensional reconstruction showing the pseudoaneurysm (arrow) and its close relation to the sternum and innominate artery (IA).
umbilical artery catheterization [4–7]. All reported ascending aortic pseudoaneurysms in infants are mycotic pseudoaneurysms, occurring after cardiac surgery or mediastinal infection [1–3], and they have a high risk of rupture. Pseudoaneurysms tend to enlarge rapidly and are covered by adjacent tissues that are compressed by it. Mycotic pseudoaneurysms tend to develop because of
Fig 2. Right iliac fossa incision for retroperitoneal exposure of the descending aorta and inferior vena cava for cannulation.
bacteremia, direct spread as in mediastinitis, or infected indwelling catheters. Once bacterial contamination of a vulnerable region like a suture line occurs, bacterial enzymatic digestion or endarteritis leads to weakening of the suture line, predisposing to pseudoaneurysm formation. The management in this child was complicated by the early presentation (17 days) after surgery and the small size of the infant. The reason for this early presentation in addition to infection could be the thinning of aorta during mobilization. The options for cannulation in this child included cannulation of innominate artery, carotid artery, or the iliac arteries. Because of close proximity of the pseudoaneurysm to the innominate artery, we decided against dissecting this vessel for cannulation. Common carotid artery cannulation was another option that has been used by others [4, 5], but on contrast CT we believed that these were too small to allow adequately sized cannula for this infant. In addition, we needed a safe place for aortic clamp in the short segment of aorta between the pseudoaneurysm and the origin of innominate artery. Hence, we directly cannulated the inferior vena cava and the descending aorta retroperitoneally, with good venous drainage and flow. Retroperitoneal cannulation of descending aorta and inferior vena cava for peripheral cannulation before sternotomy has been reported in adults but not in infants. The peripheral cannulation strategy in small infants is usually the common carotid artery and the internal jugular vein. In retrospect, carotid
Ann Thorac Surg 2015;100:1455–8
artery cannulation could have been possible in our patient. When common carotid cannulation might not be possible, such as the presence of hematoma or infection, this cannulation strategy is a viable alternative for establishing CPB. The early presentation of ascending aortic pseudoaneurysm in a 2.8-kg infant and the modified cardiopulmonary bypass strategy used make this patient unique and may assist surgeons in treating similar patients. Once ascending aortic pseudoaneurysm is diagnosed, the procedure should be done as early as possible because of the risk of rupture. The importance of peripheral cannulation and institution of cardiopulmonary bypass before redo sternotomy cannot be overemphasized.
References
Endobronchial Primitive Neuroectodermal Tumor With Pneumothorax Ex Vacuo Wongyeong Han, MD, Dongmyung Huh, MD, PhD, Byoungho Kim, MD, PhD, Eunkyoung Kwak, MD, PhD, and Sunah Lee, MD Departments of Thoracic and Cardiovascular Surgery, Histopathology, and Oncology, Daegu Fatima Hospital, Daegu, Republic of Korea
We experienced a rare case of an endobronchial primitive neuroectodermal tumor of the left main bronchus. Initially we suspected pneumothorax caused by a collapsed left upper lobe and an air-entrapped lower lobe. After tube thoracostomy, the pneumothorax persisted without air leakage. A tumor was detected at the left main bronchus on computed tomography and bronchoscopy, and diagnosed pathologically as small cell lung cancer. Under the presumed diagnosis of limited-stage small cell lung cancer, we performed a left pneumonectomy. The tumor Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1455
was eventually identified pathologically as a primitive neuroectodermal tumor. Although adjuvant chemoradiotherapy was not performed, no recurrence was observed. (Ann Thorac Surg 2015;100:1455–8) Ó 2015 by The Society of Thoracic Surgeons
P
rimitive neuroectodermal tumors (PNET) are malignant tumors of small undifferentiated neuroectodermal cells thought to originate from neural crest cells [1]. Thoracic PNETs usually involve the extrapulmonary tissues of the chest wall and paravertebral structure, and rarely involve the primary pulmonary region [2]. Especially, endobronchial PNETs without lung involvement are very rare neoplasms of thoracic region. Herein, we present a case of endobronchial PNET of the left main bronchus with pneumothorax ex vacuo. A 29-year-old man presented with chest pain and progressive shortness of breath with coughing for 1 month. No constitutional symptoms such as body weight loss or fever were reported. Physical examination revealed decreased breathing sounds on the entire left thorax. Chest radiographic examination showed a left collapsed lung (Fig 1). The patient was diagnosed with left pneumothorax and tube thoracostomy using a 12-Fr tube was performed. However, follow-up chest radiograph showed incomplete lung expansion. We then performed a computed tomography scan, and an endobronchial tumor at the left upper lobe bronchus extending to the left main bronchus was observed. The tumor was thought to be causing atelectasis of the left upper lobe and volume expansion through air entrapment due to partial occlusion of the left lower lobe bronchus (Fig 2). Bronchoscopy showed complete obstruction of the mid-portion of the left main bronchial lumen that was caused by a polypoid mass covered with necrotic material. A low-grade malignant tumor, such as a carcinoid tumor, was suspected so a biopsy was performed. On bronchoscopic biopsy we recognized that the tumor was malignant, and small cell carcinoma, pulmonary blastoma, and malignant lymphoma were considered in the differential diagnosis. Small cell lung cancer was suspected on the basis of pathologic findings. The pulmonary function test was within the normal range. Positron emission tomography showed a hypermetabolic mass obstructing the left upper lobe; diffuse uptake of 2-[18F] fluoro-2-deoxy-d-glucose by the left lower lobe indicated inflammatory changes without metastatic evidence at lymph nodes or other internal organs. Under a preoperative diagnosis of limited-stage small cell lung cancer of the left upper to left main bronchus, Accepted for publication Nov 26, 2014. Address correspondence to Dr Huh, MD, Department of Thoracic and Cardiovascular Surgery, Daegu Fatima Hospital, 99 Ayangro, Dong-gu, Daegu City, Republic of Korea; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.073
FEATURE ARTICLES
1. Miyaji K, Nagata N, Matsui H, Yamamoto T. Mycotic pseudoaneurysm of the ascending aorta after mediastinitis in an infant. Eur J Cardiothorac Surg 2002;22:638–9. 2. Malec E, Mroczek T, G orecki W, Kordon Z. Successful surgical treatment of a mycotic pseudoaneurysm of the ascending aorta in an infant after hypoplastic left heart complex repair. Pediatr Cardiol 2003;24:89–91. 3. Barth H, Moosdorf R, Bauer J, Schranz D, Akint€ urk H. Mycotic pseudoaneurysm of the aorta in children. Pediatr Cardiol 2000;21:263–6. 4. Mainwaring RD, Lamberti JJ, Rohrer C, Winkler M. Neck cannulation for the repair of thoracic artery aneurysms in the infant. J Card Surg 1993;8:541–5. 5. Roy N, Azakiea A, Moon-Grady AJ, Blurton DJ. Mycotic aneurysm of the descending thoracic aorta in a 2-kg neonate. Ann Thorac Surg 2005;80:726–9. 6. Bergsland J, Kawaguchi A, Roland M, Pieroni DR, Subramanian S. Mycotic aortic aneurysms in children. Ann Thorac Surg 1984;37:314–8. 7. Mosca RS, Kulik TJ, Marshall K, Hernandez R, Fletcher SE. Mycotic pseudoaneurysm associated with aortic coarctation. J Cardiovasc Magn Reson 2000;2:209–12.
CASE REPORT HAN ET AL ENDOBRONCHIAL PNET