The patient was a 59-year-old man who had undergone aortic valve replacement with a mechanical valve for aortic stenosis eight years ago. Six months ago, he developed complete atrioventricular block and underwent pacemaker implantation. One day before admission, he presented to a local clinic with complaints of dyspnea and chest pain. Suspecting acute myocardial infarction, he was referred to our hospital for further evaluation and was subsequently admitted. On admission, he exhibited fever and elevated inflammatory markers. Transthoracic echocardiography and computed tomography revealed vegetations on the prosthetic valve and an annular abscess with aneurysmal dilatation of the sinus of Valsalva. Based on these findings, prosthetic valve endocarditis was diagnosed, and semi-urgent surgery was performed. Intraoperatively, numerous vegetations were found attached to the prosthetic valve annulus, and the annular abscess had extensively invaded the myocardium circumferentially. Aneurysmal dilatation of the sinus of Valsalva was observed, especially around the left and right commissures. After debridement of the abscess cavity, it was determined that Bentall procedure was not feasible due to extensive annular destruction and fragility of the surrounding myocardial tissue. Therefore, we opted for a root reconstruction using the “graft insertion technique” as described by Nakamura et al. A 5-cm length of tube graft was inverted and inserted from the aortic root into the left ventricular outflow tract (LVOT). Nine mattress sutures using 3-0 polypropylene with pledgets were placed from inside the graft through the LVOT, with external reinforcement using a Teflon felt strip, followed by continuous suturing for added security. The intraventricular portion of the graft was pulled out through the LVOT and trimmed. A preconstructed composite graft was then anastomosed to the trimmed end. The right coronary artery was reimplanted using the button technique. The left coronary artery was injured during dissection of adhesion and could not be reimplanted; therefore, a bypass from the great saphenous vein to the left anterior descending artery was performed. Despite the loss of healthy annular tissue due to complete debridement of the infected valve and myocardial abscess, the reconstruction of the aortic root was successful without the need for additional hemostatic sutures. The “graft insertion technique，” though not yet widely established, offers a valuable approach for reconstructing severely damaged and fragile aortic roots in the setting of prosthetic valve endocarditis. It allows for safe and reliable surgical repair even in challenging anatomical conditions.

Peripheral arterial disease (PAD) is a common complication of Diabetes Mellitus (DM) and often culminates in amputation of the affected foot. Pseudomonas aeruginosa infections associated with PAD are difficult to treat due to their multi-drug resistance. Herein we report a 38 year old male who reported with DM, chronic kidney disease (CKD) and rest pain of the right second toe in October 2011. He underwent percutaneous transluminal angioplasty (PTA) which was unsuccessful. The gangrene of the toes worsened and amputation of the right second toe was done. Bacteriological examination showed presence of P. aeruginosa which during the course of antibiotic therapy became multi-drug resistant. Gangrene and abscess of the foot worsened and amputation of the right third toe was performed. Then autologous peripheral blood mononuclear cell (PBMNC) therapy was performed but as infection control could not still be achieved, the fourth toe was amputated. A protocol of foot bath using carbonic water, local usage of antibiotics (Polymyxin-B), and basic fibroblast growth factor (b-FGF) spray was then employed after which the infection could be controlled and improvement in vascularity of the right foot could be observed in angiography. This combined approach after proper validation could be considered for similar cases.
Abscess ; Amputation ; Angiography ; Angioplasty ; Anti-Bacterial Agents ; Baths ; Carbon ; Cell- and Tissue-Based Therapy ; Diabetes Mellitus ; Drug Resistance, Multiple ; Fibroblast Growth Factor 2 ; Fibroblast Growth Factors* ; Foot ; Gangrene* ; Humans ; Infection Control* ; Kidney Failure, Chronic* ; Limb Salvage* ; Male ; Peripheral Arterial Disease ; Pseudomonas aeruginosa ; Renal Insufficiency, Chronic ; Toes* ; Water

We report an extremely rare case of early disruption of a woven Dacron graft by the mechanical force of the lumbar vertebral body after a thoracoabdominal aortic aneurysm repair. A 75-year-old man with thoracoabdominal aortic aneurysm of Crawford type III underwent replacement of the thoracoabdominal aorta using a Gelweave thoracoabdominal graft (Vascutek) and a Gelweave bifurcate graft (Vascutek). His postoperative course was uneventful and discharged on postoperative day 20. On the 22nd postoperative day, he was re-hospitalized with low back pain. Computed tomography scanning showed a massive hematoma around the region of the graft-to-graft anastomosis. He underwent an emergency operation. At laparotomy, the Gelweave thoracoabdominal graft had a 2-mm hole which had been caused by the mechanical force of lumbar vertebral body, which was not related to the anastomosis. The graft was repaired with a 4-0 polypropylene buttress suture and a new prosthesis graft was used to wrap around the disrupted graft.