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OBJECTIVES: Zone 2 anastomosis with total cervical branch reconstruction for acute type A aortic dissection and aortic arch aneurysms became possible after stent-graft introduction. This may be an easier procedure and reduce the risk of recurrent laryngeal nerve palsy. Therefore, this study aimed to compare the outcomes between Zone 2 and Zone 3 distal anastomoses. METHODS: After evaluating the patient data in our institute between April 2016 and April 2022, the patients in whom distal anastomosis was performed at Zone 2 with a stent-graft were defined as the Zone 2 group (n = 70). The patients in whom distal anastomosis was performed at Zone 3 were defined as the Zone 3 group (n = 24). RESULTS: The incidence of new-onset recurrent nerve palsy was one patient (1.4%) in the Zone 2 group and six patients (25.0%) in the Zone 3 group (p < 0.001). The lower body perfusion arrest time was 44.3 ± 9.1 min in the Zone 2 group and 52.9 ± 12.8 min in the Zone 3 group (p = 0.005). There were no significant differences in in-hospital mortality and morbidities. Multivariable analysis showed that only age was an independent predictor of overall mortality. CONCLUSIONS: Performing distal anastomosis at Zone 2 with a frozen elephant trunk or stent-graft reduced the lower body perfusion arrest time and possibly prevented recurrent nerve palsy.
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OBJECTIVE: The predissection aortic diameter is the best reference for determining the size of the frozen elephant trunk in aortic dissection. We aimed to develop a new prediction method to estimate the predissection diameter of proximal descending aorta. Furthermore, we evaluated the accuracy of the estimated predissection proximal descending aortic diameters calculated using 3 prediction methods. METHODS: A total of 39 patients with acute type A aortic dissection who underwent predissection computed tomography were included in derivation sets. We measured the aortic dimensions at 3 levels of the proximal descending aorta: 5, 10, and 15 cm from zone 2. We developed a new prediction method-postdissection aortic diameter divided by 1.13 (AoDNew factor)-and estimated the predissection aortic diameter using the new and previously proposed methods by Rylski (AoDRylski) and Yamauchi (EquationYamauchi). Furthermore, we validated the new prediction method using a validation dataset with 24 patients. RESULTS: The rate of bias ≤2 mm was significantly greater with EquationYamauchi and AoDNew factor than with AoDRylski in the derivation group at each level of the proximal descending aorta (P < .001). In the validation group, the rate of bias ≤2 mm was significantly greater with EquationYamauchi and AoDNew factor than with AoDRylski at 10 cm and 15 cm from zone 2 (10 cm: P = .014, 15 cm: P < .001). CONCLUSIONS: These results suggest that the new prediction method can be used as a simple and accurate estimation method for the predissection aortic diameter at the proximal descending aorta.
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A 78-year-old man presented with severe stage 3 (Fontaine IV, Rutherford 5, W1 I3 FI0) right limb ischemia. Although his artery was completely occluded from below the right external iliac to the popliteal artery, collateral circulation from the right lateral femoral circumflex artery was well developed and supplied the lower extremity arteries. We selected an uncommon crossover bypass strategy with the left common femoral artery to the right lateral femoral circumflex artery to improve lower extremity perfusion via indirect revascularization. Bypass using the lateral femoral circumflex artery as an outflow is an option for patients with major lower extremity artery occlusions.
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Negative impact of prosthesis-patient mismatch on long-term survival after valve replacement has been reported. However, the effect of prosthesis-patient mismatch after bioprosthetic mitral valve replacement has not yet been well examined. The purpose of this study was to investigate the effect of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation. A total of 181 patients underwent bioprosthetic mitral valve replacement between April 2008 and December 2016. After excluding patients with mitral stenosis and those with incomplete data, 128 patients were included in the study. Postoperative transthoracic echocardiography was performed before discharge for all patients and the effective orifice area of bioprosthetic mitral valve was calculated using the formula: 220/pressure half-time, and the effective orifice area index was calculated by the formula: effective orifice area/body surface area. Prosthesis-patient mismatch was defined as a postoperative effective orifice area index ≤ 1.2 cm2/m2. The characteristics and outcomes were compared between the groups. There were 34 patients (26.6%) with prosthesis-patient mismatch and 94 patients (73.4%) without prosthesis-patient mismatch. There were no significant differences in the in-hospital mortality and morbidities. Multivariable analysis showed that prosthesis-patient mismatch was an independent predictor of late mortality (hazard ratio 3.38; 95% confidence interval 1.69-6.75; p = 0.001) and death from heart failure (hazard ratio 31.03, 95% confidence interval 4.49-214.40, p < 0.001). Prosthesis-patient mismatch at discharge after mitral valve replacement for mitral regurgitation was associated with long-term mortality and death from heart failure.
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Insuficiencia Cardíaca , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral , Válvula Aórtica/cirugía , Insuficiencia Cardíaca/cirugía , Prótesis Valvulares Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Diseño de Prótesis , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
PURPOSE: We describe a pull-through pull-back technique to revascularize the left common carotid artery (LCCA) that was unintentionally covered during thoracic endovascular aortic repair (TEVAR). CASE REPORT: A 69-year-old man presented with back pain secondary to acute type B aortic dissection with an intimal tear in the proximal descending aorta. Serial computed tomography (CT) revealed an enlarged descending aorta and proximal progression of the aortic dissection. He underwent left carotid-subclavian artery bypass and TEVAR, 10 days after admission. The Valiant Navion stent graft without a bare stent was deployed proximally; however, the LCCA was unintentionally covered by the stent graft during this procedure. A pull-through form was created between the left axillary and femoral arteries using a 0.035-inch guide wire. The pull-through guide wire was gently pulled, and the greater curvature of the proximal end of the stent graft was displaced distally. Angiography confirmed restoration of antegrade blood flow into the LCCA. The patient's postoperative course was uneventful. Follow-up CT performed 6 months postoperatively confirmed preserved blood flow into the LCCA without endoleak nor stent migration. CONCLUSION: The pull-through pull-back technique is a feasible troubleshooting strategy for accidental coverage of supra-aortic vessels during TEVAR.
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Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Anciano , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Arteria Carótida Común/diagnóstico por imagen , Arteria Carótida Común/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Humanos , Masculino , Diseño de Prótesis , Stents , Resultado del TratamientoRESUMEN
Thoracic endovascular aortic repair is widely used for type B aortic dissection. However, there is no favorable stent-graft for type A aortic dissection. A significant limitation for device development is the lack of an experimental model for type A aortic dissection. We developed a novel three-dimensional biomodel of type A aortic dissection for endovascular interventions. Based on Digital Imaging and Communication in Medicine data from the computed tomography image of a patient with a type A aortic dissection, a three-dimensional biomodel with a true lumen, a false lumen, and an entry tear located at the ascending aorta was created using laser stereolithography and subsequent vacuum casting. The biomodel was connected to a pulsatile mock circuit. We conducted four tests: an endurance test for clinical hemodynamics, wire insertion into the biomodel, rapid pacing, and simulation of stent-graft placement. The biomodel successfully simulated clinical hemodynamics; the target blood pressure and cardiac output were achieved. The guidewire crossed both true and false lumens via the entry tear. The pressure and flow dropped upon rapid pacing and recovered after it was stopped. This simulation biomodel detected decreased false luminal flow by stent-graft placement and detected residual leak. The three-dimensional biomodel of type A aortic dissection with a pulsatile mock circuit achieved target clinical hemodynamics, demonstrated feasibility for future use during the simulated endovascular procedure, and evaluated changes in the hemodynamics.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Humanos , Stents , Resultado del TratamientoRESUMEN
An 85-year-old man with appetite loss, lightheadedness, and leg edema was referred to our institution. Computed tomography and transthoracic echocardiography revealed a left ventricular pseudoaneurysm with a maximal diameter of 80 mm and severe mitral regurgitation. Coronary angiography showed 90% stenosis and total occlusion of the left circumflex artery at segments 11 and 12, respectively. He was diagnosed with postinfarction left ventricular pseudoaneurysm and underwent patch repair using two bovine pericardium patches and biological glue, mitral valve replacement, and coronary artery bypass grafting. His postoperative course was uneventful.
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Aneurisma Falso/cirugía , Procedimientos Quirúrgicos Cardíacos , Aneurisma Cardíaco/cirugía , Infarto del Miocardio/complicaciones , Pericardio/trasplante , Proteínas/uso terapéutico , Adhesivos Tisulares/uso terapéutico , Anciano de 80 o más Años , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Animales , Bovinos , Aneurisma Cardíaco/diagnóstico por imagen , Aneurisma Cardíaco/etiología , Xenoinjertos , Humanos , Masculino , Infarto del Miocardio/diagnóstico por imagen , Resultado del TratamientoRESUMEN
A 38-year-old man underwent thoracic endovascular aortic repair for impending rupture of acute type B aortic dissection. Computed tomography revealed abscess formation around the proximal descending aorta 4 weeks after endovascular treatment. He underwent one-stage total arch and descending aorta replacement and omental wrapping via left thoracotomy. At the 6-month follow-up, his postoperative course was uneventful.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Adulto , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Humanos , Masculino , Reimplantación , Toracotomía , Resultado del TratamientoRESUMEN
A 77-year-old woman who presented with chest pain was diagnosed with acute anterior myocardial infarction. Echocardiography revealed pericardial effusion, and she underwent sutureless repair for postinfarction left ventricular free wall rupture. Echocardiography performed 2 days postoperatively revealed ventricular septal rupture and left ventricular acute dilatation. Hemodynamic instability with ventricular tachycardia and rapid decline of kidney function developed. Four days after the primary surgery, we performed successful sandwich repair for ventricular septal rupture and the dilatation. Her postoperative course was uneventful, and postoperative evaluation did not show a residual shunt or left ventricular dilatation.
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Rotura Cardíaca , Rotura Septal Ventricular , Anciano , Dolor en el Pecho , Ecocardiografía , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/cirugía , Humanos , Rotura Septal Ventricular/diagnóstico por imagen , Rotura Septal Ventricular/etiología , Rotura Septal Ventricular/cirugíaRESUMEN
OBJECTIVES: We investigated the outcomes of a fenestrated frozen elephant trunk (FET) technique performed without reconstruction of one or more supra-aortic vessels for aortic repair in patients with acute type A aortic dissection. METHODS: We investigated 22 patients who underwent the fenestrated FET technique for acute type A aortic dissection at our hospital between December 2017 and April 2020. The most common symptom was chest pain and/or back pain. Nine patients presented with malperfusion and 1 with cardiac arrest, preoperatively. A FET was deployed under hypothermic circulatory arrest and manually fenestrated under direct vision. Single fenestration was made in the FET in 15 patients, 2 fenestrations in 5 patients and a total fenestrated technique in 2 patients. Concomitant procedures were performed in 5 patients. RESULTS: The cardiopulmonary bypass, aortic cross-clamp and hypothermic circulatory arrest times were 181 ± 49, 106 ± 43 and 37 ± 7 min, respectively. In-hospital mortality, stroke, or recurrent nerve injury did not occur in any patient. One patient developed paraparesis, which completely recovered at discharge. During the follow-up period (mean 18 ± 7 months), 1 patient died of heart failure. Fenestration site occlusion did not occur. Follow-up computed tomography (mean 12 ± 6 months postoperatively) revealed that the maximal aortic diameter remained unchanged at the levels of the distal end of the FET, the 10th thoracic vertebra and the coeliac artery; however, the aortic diameter was significantly reduced at the level of the pulmonary artery bifurcation. CONCLUSIONS: The fenestrated FET technique is a simple, safe and effective procedure for selected patients with acute type A aortic dissection.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Humanos , Estudios Retrospectivos , Stents , Resultado del TratamientoRESUMEN
Marfan syndrome (MFS) is a connective tissue disorder caused by mutations in the FBN1 gene that produces wide disease phenotypic variability. The lack of ample genotype-phenotype correlation hinders translational study development aimed at improving disease prognosis. In response to this need, an induced pluripotent stem cell (iPSC) disease model has been used to test patient-specific cells by a proteomic approach. This model has the potential to risk stratify patients to make clinical decisions, including timing for surgical treatment. The regional propensity for aneurysm formation in MFS may be related to distinct smooth muscle cell (SMC) embryologic lineages. Thus, peripheral blood mononuclear cell (PBMC)-derived induced pluripotent stem cells (iPSC) were differentiated into lateral mesoderm (LM, aortic root) and neural crest (NC, ascending aorta/transverse arch) SMC lineages to model MFS aortic pathology. Isobaric Tags for Relative and Absolute Quantitation (iTRAQ) proteomic analysis by tandem mass spectrometry was applied to profile LM and NC iPSC SMCs from four MFS patients and two healthy controls. Analysis revealed 45 proteins with lineage-dependent expression in MFS patients, many of which were specific to diseased samples. Single protein-level data from both iPSC SMCs and primary MFS aortic root aneurysm tissue confirmed elevated integrin αV and reduced MRC2 in clinical disease specimens, validating the iPSC iTRAQ findings. Functionally, iPSC SMCs exhibited defective adhesion to a variety of extracellular matrix proteins, especially laminin-1 and fibronectin, suggesting altered cytoskeleton dynamics. This study defines the aortic embryologic origin-specific proteome in a validated iPSC SMC model to identify novel protein markers associated with MFS aneurysm phenotype. Translating iPSC findings into clinical aortic aneurysm tissue samples highlights the potential for iPSC-based methods to model MFS disease for mechanistic studies and therapeutic discovery in vitro.
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Aorta/metabolismo , Aneurisma de la Aorta Torácica/genética , Células Madre Pluripotentes Inducidas/metabolismo , Síndrome de Marfan/genética , Cresta Neural/metabolismo , Proteómica/métodos , Aorta/patología , Aneurisma de la Aorta Torácica/metabolismo , Aneurisma de la Aorta Torácica/patología , Estudios de Casos y Controles , Adhesión Celular , Diferenciación Celular , Linaje de la Célula/genética , Femenino , Fibrilina-1/genética , Fibrilina-1/metabolismo , Fibronectinas/genética , Fibronectinas/metabolismo , Perfilación de la Expresión Génica , Regulación de la Expresión Génica , Humanos , Células Madre Pluripotentes Inducidas/patología , Integrinas/genética , Integrinas/metabolismo , Laminina/genética , Laminina/metabolismo , Leucocitos Mononucleares/metabolismo , Leucocitos Mononucleares/patología , Lectinas de Unión a Manosa/genética , Lectinas de Unión a Manosa/metabolismo , Síndrome de Marfan/metabolismo , Síndrome de Marfan/patología , Glicoproteínas de Membrana/genética , Glicoproteínas de Membrana/metabolismo , Mesodermo/metabolismo , Mesodermo/patología , Cresta Neural/patología , Cultivo Primario de Células , Receptores de Superficie Celular/genética , Receptores de Superficie Celular/metabolismo , Adulto JovenRESUMEN
BACKGROUND: Decision-making regarding the operability of thoracic aortic disease in nonagenarian patients remains controversial because outcomes of open surgical repair of the thoracic aorta are unclear. We investigated the surgical and nonsurgical outcomes of acute thoracic aortic syndrome treatment in nonagenarians. METHODS: After evaluating data in our institute from April 2016 to March 2020, we included 10 nonagenarians who needed surgical intervention on the thoracic aorta via a median sternotomy for acute thoracic aortic syndrome. The mean age of the cohort was 91.9 ± 2.1 years. Five patients underwent open surgical repair of the thoracic aorta (surgical group), and 5 refused surgery (nonsurgical group). All patients in the surgical group performed activities of daily living independently, with a mean clinical frailty scale of 3.2 ± 0.4. The surgical group included 4 patients with type A aortic dissection and one with a ruptured thoracic aortic aneurysm. Hemiarch replacement was performed in 3 patients and total arch replacement in 2. The mean follow-up period was 17.8 ± 5.1 months. RESULTS: Hospital mortality rates were 0% in the surgical and 80% in the nonsurgical group. The mean length of hospitalization was 28.4 ± 6.7 days in the surgical group. The 1-year survival rates were 100% in the surgical group and 20% in the nonsurgical group. CONCLUSION: Open surgical repair for acute thoracic aortic syndrome via median sternotomy is a reasonable treatment option even in nonagenarians. Involvement of family members is important for decision-making to devise the optimal treatment strategy (surgical vs. medical).
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Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Esternotomía , Factores de Edad , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Toma de Decisiones Clínicas , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Selección de Paciente , Complicaciones Cognitivas Postoperatorias/mortalidad , Medición de Riesgo , Factores de Riesgo , Esternotomía/efectos adversos , Esternotomía/mortalidad , Síndrome , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Limited data is available on the use of a polyester graft limb with a helical stent configuration deployed in the external iliac artery (EIA) during endovascular aneurysm repair (EVAR), so we prospectively analyzed the efficacy of the Zenith Spiral-Z limb deployed in the EIA.MethodsâandâResults:Patients undergoing EVAR using a Zenith stent-graft and Spiral-Z limb deployed in the EIA were prospectively registered in 24 Japanese institutions from June 2017 to November 2017. In total, 65 patients (74 limbs) (mean age: 77.1±8.0 years, 87.7% men, mean abdominal aortic aneurysm (AAA) diameter: 51.9±7.2 mm, mean iliac artery aneurysm (IAA) diameter: 38.3±10.0 mm) were registered and followed up. The most common reason for deployment in the EIA was a common IAA (43 limbs, 58.1%), and 8 limbs (10.8%) had a bare nitinol stent placed at the Spiral-Z limb. A total of 61 patients (70 limbs) completed a 24-month follow-up. There were 2 Spiral-Z limb stenoses and 1 occlusion, leading to a primary patency of 95.5% and a secondary patency of 100%, at 24 months. Buttock claudication occurred in 24.3% of the limbs treated at 1 month but decreased to 4.3% at 24 months. CONCLUSIONS: Our multicenter prospective study showed that Spiral-Z limb deployed in the EIA was associated with satisfactory results and seems to be a durable option, even in the era of iliac branch devices.
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Aneurisma de la Aorta Abdominal/cirugía , Estenosis de la Válvula Aórtica/etiología , Implantación de Prótesis Vascular/métodos , Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/métodos , Oclusión de Injerto Vascular/etiología , Arteria Ilíaca/cirugía , Diseño de Prótesis , Stents/efectos adversos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/epidemiología , Estenosis de la Válvula Aórtica/epidemiología , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/epidemiología , Humanos , Arteria Ilíaca/patología , Japón/epidemiología , Masculino , Estudios Prospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Figure 4. OBJECTIVES: We investigated the clinical and haemodynamic outcomes in elderly patients undergoing composite aortic root replacement. METHODS: Between 2005 and 2017, 135 patients underwent aortic root surgery at our hospital. Of these 135 patients, 47 patients aged ≥65 years were included in this study. Pathologies included aneurysms in 31, chronic aortic dissection in 6, acute aortic dissection in 4 and other causes in 6 patients. A bioprosthesis was used in 27 and a mechanical valve in 20 patients. The mean age was 71.0 ± 4.3 years. The mean follow-up period was 61 ± 35 months. Follow-up echocardiographic data (average 48 months after surgery) were collected in 35 patients (74%). RESULTS: The in-hospital mortality rate was 2.1% (1 patient). Seven late deaths occurred during follow-up. The 1-, 5- and 8-year overall survival was 93.6%, 82.9% and 82.9%, respectively. Infective endocarditis, Marfan syndrome and diabetes were independent predictors of poorer survival. During the follow-up, thromboembolism occurred in 1 patient, major bleeding events in 5 patients, or proximal reoperation for prosthetic valve endocarditis in 1 patient. The type of valve, mechanical or biological valve, did not affect late mortality and morbidity. Follow-up echocardiography revealed significantly improved left ventricular ejection fraction compared with that at discharge. CONCLUSIONS: Composite aortic root replacement provided satisfactory midterm outcomes in patients aged ≥65 years. Further studies with a longer follow-up are warranted to evaluate late valve-related events.
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Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Bioprótesis , Prótesis Vascular , Complicaciones Posoperatorias/epidemiología , Factores de Edad , Anciano , Disección Aórtica/mortalidad , Aneurisma de la Aorta/mortalidad , Femenino , Hemodinámica , Mortalidad Hospitalaria , Humanos , Masculino , Reoperación , Volumen Sistólico , Función Ventricular IzquierdaRESUMEN
BACKGROUND: An aortic pseudoaneurysm after cardiovascular surgery can be fatal. METHODS/RESULTS: Here, we describe the staged successful treatments of three pseudoaneurysms in a 77-year-old female patient who underwent total arch replacement and coronary artery bypass grafting 5 years ago. Computed tomography revealed three pseudoaneurysms: in the distal anastomosis of the total arch replacement, in the anastomosis of the left common carotid artery, and in the proximal anastomosis of the saphenous vein graft. Endovascular treatment and surgical repair were performed to treat these three pseudoaneurysms. DISCUSSION: An aortic pseudoaneurysm is a rare complication after cardiac or aortic surgery. Here, we present a case of combined endovascular and surgical repairs of three pseudoaneurysms in one patient.