Coiling (or looping) of the artery is a rare morphologic entity, most frequently described in the internal carotid artery. In other arteries, coiling is rarely reported because it remains asymptomatic and without clinical relevance unless inadvertently injured, as for diagnostic or monitoring purposes. We present a case of an unusually difficult thrombectomy of the brachial artery after occlusion following withdrawal of the arterial cannula placed for monitoring during cardiac surgery owing to coiling of the distal part of the artery, which produced the "spring-squeeze phenomenon" during balloon catheter thrombectomy.

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I n the presence of neurologic symptoms, surgical treatment of acute aortic dissection requires special attention. Whether repair of the ascending aorta needs to be supplemented by reconstruction of the arch vessels is still uncertain. There are few published papers 1,2 concerning the successful concomitant repair of arch vessels. Here we report the successful repair of a brachiocephalic artery, followed by reconstruction of the ascending aorta with the patient in profound hypothermia. Case ReportIn November 2012, a 40-year-old man was admitted to a regional hospital after the sudden onset of severe chest pain. An emergency-unit physician established a preliminary diagnosis of type A acute aortic dissection. Soon thereafter, the patient was transferred to our institution. At the time of admission, he was drowsy and reported right-hand numbness. No pulses were present in the right upper extremity, and the right carotid pulse was diminished. A bedside transthoracic echocardiogram confirmed the presence of an intimal flap in the ascending aorta. There were no signs of cardiac tamponade, and the patient was hemodynamically stable. We proceeded with an emergent 64-slice multidetector computed tomographic (MDCT) scan (Fig. 1), which showed type A acute aortic dissection with 3 intimal tears. One tear was at the left main coronary ostium, and the 2 others were at the level of the aortic arch-the second between the brachiocephalic and left carotid arteries, and the third below the left subclavian artery. The right subclavian artery was proximally occluded, and the flow in the right common carotid artery was diminished by false-lumen compression. The coronary arteries were free of disease.Our surgical plan was to reconstruct the brachiocephalic artery while the patient was cooling down in preparation for deep hypothermic circulatory arrest (DHCA). We established extracorporeal circulation via transventricular (apical) arterial and standard venous cannulation. We exposed the brachiocephalic artery in a usual manner (by means of a separate incision on the right side of the neck), and, as the patient's core temperature decreased to 22 °C, we constructed end-to-end anastomoses between branches of a bifurcated Y graft (12 × 6 mm) and the carotid and subclavian arteries. We then conducted the remnant of the Y graft into the anterior mediastinum, separately cannulated the arterial branches with intraluminal cannulas, and began antegrade cerebral perfusion (ACP) at a flow rate of 350 mL/min.During DHCA (54 min at 18 °C), a separate 30-mm Dacron graft was used for hemiarch reconstruction (the distal anastomosis having been secured by suturing the Case Reports

Transapical cannulation is very simple and safe method for quick establishment of extracorporeal circulation. It always gives patient sufficient antegrade, physiological flow on heart-lung machine. This is the way to minimize possibility of malperfusion syndrome and to significantly diminish risk of neurological complication. By using this method all negative effects of other cannulation sites will be avoided.

Avoiding allogeneic blood transfusion during cardiac surgery and during the post-operative period is of great importance. Acute normovolemic hemodilution (ANH) is one of the options for blood salvage. We have prospectively analyzed 310 consecutive patients (pts) after different open heart procedures, operated on during April—May, 2000. ANH was possible in 226 pts (73%) with hemoglobin level over 125 g/l and hematocrit over 36%. Of those, one unit of blood was withdrawn in 128 pts (70%), while two to five units of blood were taken in 68 pts (30%). Total number of autologous blood units taken was 296, for the average of 1.31 units/pt. Predictors of increased intra- and post-operative blood loss were hematocrit (Hct) <39% (76% vs. 24%, p<0.001), age over 65 ( p=0.028), female sex ( p=0.006), CPB duration over 90 min (63% vs. 37%; p<0.001) and preoperative left ventricular ejection fraction (LVEF) <35% (63% vs. 37%; p<0.001). All pts with the above-mentioned characteristics were in need for allogeneic blood transfusion. During their hospital stay, 142 pts did not get allogeneic blood (142/310, 46%), and all were in the ANH group (142/226, 62%).