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Introduction: Injury of the innominate artery (IA) is associated with high mortality and morbidity, such as a major neurologic event. The aim of this case report was to describe an example of prioritization in polytrauma management by applying endovascular intervention in a difficult case with impending uncal herniation, extensive cerebral infarction, and large pseudoaneurysm from concomitant innominate and right subclavian artery injuries. Case Report: A 34-year-old woman sustained a gunshot wound to her upper chest that lodged in the anterior triangle of her neck and presented with tension pneumothorax and cardiac arrest, which was successfully resuscitated. Subsequently she developed drowsiness and left hemiparesis, and computerized tomography demonstrated a large right cerebral hemisphere and left cerebellar region infarction with impending uncal herniation and pseudoaneurysms from the IA and proximal right subclavian artery. After emergency craniectomy to avert herniation, endovascular treatment was performed to facilitate vessel repair due to anatomical difficulty and the patient's unstable condition. She was discharged home 3 weeks after operation, and 2 months postoperatively, she was neurologically intact with no evidence of endoleakage or pseudoaneurysm. Conclusion: In such a complex polytrauma case, correct prioritization of interventions is crucial to obtaining the best outcomes, and the Endovascular Resuscitation and Trauma Management protocol can be applied as an alternative treatment protocol with good results. [ABSTRACT FROM AUTHOR]

Background: Post-transcatheter aortic valve replacement (TAVR) thrombocytopenia has been reported to be a predictor of higher mortality and worse clinical outcomes in published studies mostly from Western countries; however, data from Asian countries are generally limited, while data from Thai population are lacking. Objective: To evaluate the incidence and outcomes of Thai patients who developed thrombocytopenia after TAVR. Materials and Methods: The present research was a retrospective observational study. The authors collected data from patients underwent TAVR at Siriraj Hospital between 2009 and 2019. The patients were stratified into four groups according to nadir platelet count, no thrombocytopenia with platelet of 150,000/uL or more, mild with platelet of 100,000 to 149,999/uL, moderate at 50,000 to 99,999/uL and severe at less than 50,000/uL. In addition, the patients with moderate to severe thrombocytopenia were stratified into two groups according to the percentage decline in platelet count (DPC) post procedure as DPC of less than 50% or DPC of 50% or more from the baseline platelet count. Results: Eighty-three patients were reviewed. One patient who died intraoperatively was excluded. Thrombocytopenia occurred in 62 patients (75.6%), in which 36.6% (n=30) of the cases were classed as moderate, and 8.5% (n=7) as severe thrombocytopenia. The platelet count returned to baseline before discharge or during the follow-up period in 83.8% (n=52) of patients. The incidence of in-hospital mortality was significantly higher in patients with severe thrombocytopenia than those with mild thrombocytopenia at 28.6% versus 4% (p=0.011). The duration of admission, length of stay in the CCU, incidence of life-threatening bleeding, clopidogrel discontinuation, platelet transfusion, rate of infection, shock, and acute kidney injury were also significantly higher in patients with moderate to severe thrombocytopenia. Conclusion: Acquired thrombocytopenia after TAVR is a common phenomenon in Thai patients (75%) but usually transient with a nadir platelet count greater than 50,000/uL. Most patients had spontaneous platelet recovery. The presence of severe thrombocytopenia with a nadir platelet count of less than 50,000 is a red flag sign for concomitant infection. The severity of thrombocytopenia is significantly associated with higher mortality and post-procedural adverse events. [ABSTRACT FROM AUTHOR]

Objective: To compare 30 days mortality and clinical outcomes between transapical transcatheter aortic valve replacement (TA-TAVR) and transfemoral transcatheter aortic valve replacement (TF-TAVR) in Thai patients who underwent transcatheter aortic valve replacement (TAVR). Materials and Methods: The observational study included 83 consecutive patients that attended the authors' center for TAVR between January 2009 and December 2019. The patients' baseline demographic data and surgical risks were recorded. The clinical outcomes at 30 days and one year were prespecified targets. Results: Eighty-three patients underwent TAVR at the authors' center between 2009 and 2019, with 77% of them considered inoperable or at high surgical risk by the authors' heart team. Of the 83 patients, 40 had a porcelain aorta (48.2%). The median Society of Thoracic Surgeons (STS) score and logistic EuroSCORE were 5.7 (4.6, 8.3) and 21.7 (15.2, 31.2), respectively. Twenty-two patients had a transapical approach (26.5%). The cardiovascular (CV) mortality rate was 2.4% at 30 days. The all-cause mortality 30-day rate and 1-year rate were 3.6% and 12.0%, respectively. Comparing between TA-TAVR and TF-TAVR, TA-TAVR had a significantly lower incidence of new permanent pacemaker placement after TAVR (p=0.032), but a longer length of hospital stay (p=0.087). There was a trend for a higher incidence of new onset atrial fibrillation in TA-TAVR. The all-cause mortality 30-day rate and 1-year rate were similar between TA-TAVR and TF-TAVR. Conclusion: In Thai symptomatic severe aortic stenosis patients, of whom most patients were considered inoperable or at high surgical risk, both TA-TAVR and TF-TAVR showed acceptable short- and long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Vascular ring is a rare congenital vascular disease. The result of vascular ring surgery in Thailand remains unknown as it lacks serial data. The purpose of the present study was to evaluate the result of vascular ring surgery at Siriraj Hospital and demonstrate the usefulness of the computed tomograph angiographic scanning (CTA) for preoperative anatomical diagnosis of the vascular ring for planning the surgical correction., Material and Method: We reviewed our experiences for all patients that underwent vascular rings surgery at our institute between 1979 and 2009, about preoperative diagnostic imaging, operative technique, and clinical outcome., Results: Twelve medical records of patients that underwent vascular rings surgery were reviewed. The age at time of operation ranged from one month to two years (median 3 months). The surgical approaches were eight median sternotomies, three left thoracotomies, and one right thoracotomy. There were two cases ofpostoperative complication (residual tracheal and left pulmonary artery stenosis and surgical bleeding). There was one hospital mortality (pneumonia and sepsis)., Conclusion: Surgical correction of vascular ring is effective and safe. CTA can give the precise anatomic diagnosis of the vascular rings, lead to good surgical planning, proper surgical approach, and good outcome.

Background: The thoracic endovascular aortic repair (TEVAR) has become popular due to its favorable immediate outcome. However, the outcome in longer duration is still questionable. The aim of the present study was to analyze the incidence and risk factors associated with 90 days mortality after TEVAR., Material and Method: After the Siriraj Institutional Review Board, Thailand approved and waived the needfor the informed consent, the database that included 160 consecutive patients having TEVAR procedures between December 2006 and December 2010 was examined Patients' characteristics, including operative procedures and anesthesia techniques were studied. The mortality and complications were extracted and analyzed. Major adverse events and the others factors were analyzed to determine the risk factors. Other complications such as bleeding, endoleak, infection, and reintervention were examined and analyzed., Results: One hundred sixty patients underwent TEVAR. They included 118 male (74%) and 42 female (26%) with mean age of 65. Perioperative mortality (within 24 hours postoperatively) was 1 (0.6%), 30 days mortality was 7 (4.4%) and the overall 90 days mortality was 10 (6.25%). Causes of death included sepsis [4 patients (2.5%)], multi-organ failure [3 patients (1.9%)], ischemic heart disease [1 patient (0.6%)], uncontrolled bleeding [1 patient (0.6%)], and graft ruptured [1 patient (0.6%)]. The risk factor related to mortality was postoperative neurological morbidity (OR 6.77, 95% CI = 1.08-42.36, p = 0.4). General anesthesia with endotracheal tube was used in the majority of the patients (92.5%), with no statistical significance in anesthesia-related mortality. Major adverse events including pneumonia 11.9%, cardiac arrhythmia 11.3%, graft infection 7.5%, neurological complication 7.0% (ischemic stroke 9 andparaplegia 1), renal failure 3.8%, and myocardial ischemia 0.6%., Conclusion: The incidence of 90 days mortality after TEVAR was 6.25% (10 from 160). The risk factor associated with mortality was the development of neurologic complication postoperatively.

Objective: To access the performance of the EuroSCORE when applied to CABG patients at Siriraj hospital., Material and Method: One thousand five hundred forty nine patients diagnosed with coronary artery disease (CAD) who underwent isolated CABG between January 2007 and December 2009 was prospectively studied., Results: The patients included 1,102 men and 447 women and had a mean age of 67 years old. The mean additive score in expired and survived groups were 9.65 +/- 5.14 and 3.87 +/- 3.06. In logistic, score were 25.43 +/- 26.31 and 4.88 +/- 7.88 respectively (p < 0.001). The best cut-off value of EuroSCORE for prediction of a death rate was 6 for additive score and 10 for logistic score. Area under the curve was 0.831 for the additive score and 0.823 for the logistic score. The observed overall mortality rate was 2.0% while the predict mortality was 5.27%. The difference between observed and predicted deaths was significant with additive score and logistic score (p < 0.001)., Conclusion: Our results suggest that EuroSCORE is not valid for CABG in Thai patient due to over prediction.

Aortic valve replacement (AVR) is the standard treatment for patients with symptomatic severe aortic stenosis (AS). However many patients are not offered surgery due to high surgical risk for open AVR. Transcatheter aortic valve implantation has been an alternative to open heart surgery in patients with symptomatic severe aortic stenosis (AS) who are not suitable for open surgery. The first transcatheter aortic valve implantation in Thailand via the transapical route is described. An 87-year-old woman with symptomatic severe AS, calcified aorta and peripheral arterial disease, who was at high surgical risk, was successfully treated, and had good functional and haemodynamic results at six-months follow-up.

Objective: Analyze the incidence and findings of endoleak after thoracic endovascular aortic repair by using CT angiography, Material and Method: Between August 2006 and December 2008, 68 patients diagnosed with thoracic aortic aneurysm underwent thoracic endovascular aortic repair and were included in the present study. The patients were 47 men and 21 women, with a mean age of 69 +/- 9.4 years old. Thoraco-abdominal CT angiographic images (64-slice MDCT) after operation of 68 patients were retrospectively reviewed to evaluate incidence of endoleak and classify findings of endoleak., Results: Endoleaks were detected in 26 patients (38.2%). There were type I endoleaks in three cases (11.5%), type II endoleaks in 22 cases (84.6%), and type III endoleaks in one case (3.9%). Type II endoleaks were detected as peritubular collection, mostly located at periphery of the aneurysm. Eleven cases (50%) of type II endoleaks were supplied by left subclavian artery. Twenty patients who had completed 1, 3, and 6 months follow-up CT angiography were selected for further evaluation of changing in size of aneurysm. The measurement of the thoracic aneurysm showed no decreasing of the maximum length of diameter and volume of the aneurysmal sac in endoleak group., Conclusion: Follow-up CT angiography is useful for detection and characterization of endoleak after endovascular aortic repair of thoracic aneurysm. Most of type II endoleaks show peritubular (collection) shape and locate at the periphery. Patients with endoleak after thoracic endovascular aortic repair tend to continue to have sac expansion.