Interrupted aortic arch is a rare finding in the adult patient. This condition in combination with a descending thoracic aortic aneurysm is an even more exceptional occurrence. Surgical management includes open, endovascular, and hybrid options. We present the case of a 57-year-old man with interrupted aortic arch and concomitant descending thoracic aortic aneurysm, review characterization of this entity, and discuss management options with consideration to associated risks.

P ulmonary artery (PA) sarcoma is a rare tumor that often is mistaken for PA thrombus, 1,2 leading to underdiagnosis or delayed diagnosis. We describe a case in which PA sarcoma was found in a patient who presented with acute onset of dyspnea. The patient was misdiagnosed and was treated for pulmonary embolism. Case ReportA 77-year-old man was transferred from another hospital for treatment of a saddle PA embolus. The patient had reported acute onset of shortness of breath. Computed tomographic (CT) angiography of the chest had revealed a large filling defect within the main PA, which extended into both right and left PAs (Fig. 1). He had been treated with thrombolytic and anticoagulant agents without clinical improvement. After the patient's transfer to our hospital for further evaluation and treatment, the decision was made to proceed with PA embolectomy. Physical examination revealed a heart rate of 95 beats/min, temperature of 36.6 °C, blood pressure of 122/60 mmHg, and respiratory rate of 18 breaths/min. Intraoperative transesophageal echocardiography showed a mass arising from the right ventricular outflow tract (RVOT) and extending into the main PA (Fig. 2), a left ventricular ejection fraction of 0.60 to 0.65, severe tricuspid regurgitation, and a right ventricular systolic pressure of 98 mmHg.After initiating cardiopulmonary bypass, we incised the main PA and inspected the mass. The mass was fleshy and densely adherent to the leaflets of the pulmonary valve; it extended proximally into the RVOT and distally into both PAs. We then extended the arteriotomy into these areas. We divided the ascending aorta to provide better exposure of the right PA. En bloc resection of the mass and the pulmonary valve was achieved via a technique similar to that of PA endarterectomy. We replaced the valve with a bioprosthetic porcine valve and reconstructed the RVOT with a Dacron patch.After an uneventful postoperative course, the patient was discharged from the hospital on postoperative day 7. The histopathologic report showed a high-grade sarcoma with focal myogenic and chondrogenic differentiation (Fig. 3). Two months later, baseline CT angiography of the chest showed a residual mass adjacent to the left PA

P ulmonary tumor embolization from renal cell carcinoma (RCC) is associated with severe cardiopulmonary morbidity and high perioperative mortality rates. In one study, 1 the direct extension of RCC into the inferior vena cava (IVC) was observed in 22 of 295 patients (7%). Massive pulmonary embolism (PE) can occur during surgical treatment for RCC, especially when the tumor extends into the IVC.2-6 Advantages of using transesophageal echocardiography (TEE) during RCC excision include evaluating the cephalic extension of tumor into the IVC, monitoring the tumor during surgical mobilization, and evaluating cardiac function. 7,8We report a case in which continuous TEE monitoring prevented a patient's death from PE, when RCC extended into the IVC. Case ReportIn January 2012, a 71-year-old woman presented with severe right-sided abdominal pain. The patient's medical history included hypertension, chronic obstructive pulmonary disease, osteoarthritis, peptic ulcer disease, glaucoma, aortic insufficiency, mitral regurgitation, and hyperlipidemia. Her surgical history was notable for a C-section and treatment of a perforated peptic ulcer. Her medications included amlodipine, digoxin, hydrochlorothiazide, lisinopril, omeprazole, pravastatin, spironolactone, and zolpidem. She had no known drug allergies. Until recently, she had smoked one pack of cigarettes per day for approximately 15 years. Magnetic resonance images of the patient's abdomen revealed a 9.5 × 6-cm mass in the right kidney with a 2-to 3-cm extension into the infrahepatic portion of the IVC (Figs. 1 and 2). Contrast computed tomograms (CT) of the chest revealed substantial mediastinal lymphadenopathy and multiple small lung nodules. Results of a bone scan were negative. We decided to perform radical nephrectomy and resection of the intracaval mass. The urology team informed the patient that, at worst, surgery would be palliative rather than curative and might extend her life only for months.The patient's preoperative blood pressure (BP) was 120/65 mmHg, and her heart rate was 80 beats/min. She was given 2 mg of midazolam, and general anesthesia was induced. The patient was monitored by means of electrocardiography (ECG), pulse oximetry, a radial arterial line, a central venous pressure line, end-tidal carbon dioxide measurement, and a rectal temperature probe. An iE33 xMATRIX Echocardiography System probe (Koninklijke Philips N.V.; Best, The Netherlands) was placed. Initially,

No abstract

A 69-year-old woman presented with hematuria. Magnetic resonance imaging revealed a left renal mass extending into the retrohepatic inferior vena cava (IVC) (Figs. 1 and 2). Both magnetic resonance imaging of the brain and a bone scan were negative for distant metastases. Intraoperatively, the IVC was crossclamped below the level of the hepatic veins to prevent dissemination of the intracaval part of the tumor. Left radical nephrectomy and resection of the intracaval part of the tumor mass were successfully performed. The IVC was repaired primarily. The patient tolerated the procedure well and was discharged from the hospital on the 9th postoperative day. The histopathologic report showed papillary renal cell carcinoma, Fuhrman nuclear grade 3 ( Figs. 3 and 4).