Endovascular aortic aneurysm repair with reversed chimney graft technique in a patient with crossed fused renal ectopia: a technical note.

Crossed fused renal ectopia is a very rare congenital ectopia and poses great challenges when performing abdominal aortic surgery because of the accompanying abnormal vessels and urinary tracts. A 79-year-old woman with an abdominal aortic aneurysm and L-shaped crossed fused renal ectopia was referred to our facility. One of the large ectopic renal arteries arose from the right common iliac artery. The aneurysm was treated with an endovascular aortic repair. The reversed chimney graft technique was applied to preserve the ectopic renal artery while elongating the distal landing zone on the right side. The patient experienced no complications such as renal dysfunction or recurrence of the abdominal aortic aneurysm during the 6-month follow-up period.

Popliteal Venous Aneurysm and Pulmonary Embolism Initially Presenting with Recurrent Pre-syncope: A Case Report.

INTRODUCTION: Popliteal venous aneurysm (PVA) can lead to recurrent pulmonary embolism (PE) and therefore necessitates prompt diagnosis and treatment. PVAs are often asymptomatic, and their most common symptoms are associated with thrombosis. The clinical presentation of PVAs varies from asymptomatic to PE induced cardiopulmonary arrest, but there are few reports of cases initially presenting with transient impairment of consciousness. REPORT: A 75 year old man was referred with recurrent episodes of pre-syncope. He had normal vital signs and oxygen saturations, and his electrocardiogram was normal. Detailed interview revealed that the patient had suffered from calf pain and swelling before visiting the clinic. Therefore, an evaluation for deep venous thrombosis and PE was conducted. Lower limb ultrasound revealed an enlarged popliteal vein, measuring 20 mm in diameter, with a spontaneous echo contrast. Enhanced computed tomography showed peripheral pulmonary artery embolism. The patient was diagnosed with PE secondary to PVA. An inferior vena cava filter was inserted, followed by tangential aneurysmectomy and lateral venorrhaphy; apixaban 10 mg/day was initiated on post-operative day 1. The filter was removed one week after the surgery, and the patient remained symptom free on completion of treatment and did not complain of any symptoms such as pre-syncope. DISCUSSION: This patient with PVA presented with the initial symptoms of repeated pre-syncopal episodes that were attributed to recurrent PE caused by thrombi from a PVA. Complete symptom resolution was obtained by inferior vena cava filter placement, PVA surgery, and post-operative anticoagulation. Transient consciousness disorders such as pre-syncope can be the initial symptoms of PVA and PE.

Endovascular Aortic Repair under Extracorporeal Cardiac Support in a Patient with an Abdominal Aortic Aneurysm Impending Rupture and Aortic Stenosis: A Case Report.

Aortic stenosis is a serious valvular disease that increases the risk of cardiac arrest and/or cardiogenic shock during noncardiac surgery. A 93-year-old woman with an abdominal aortic aneurysm impending rupture and aortic stenosis underwent endovascular abdominal aortic aneurysm repair. During surgery, the patient presented with ventricular tachycardia. Due to on-going cardiogenic shock, we did a direct cannulation into the right axillary artery for the immediate establishment of venoarterial extracorporeal membrane oxygenation. The endovascular treatment of the abdominal aortic aneurysm was completed according to the standard procedure. The patient recovered without any complications, including heart failure or neurological dysfunction.

Surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection.

OBJECTIVES: To evaluate the surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection. METHODS: Between 2008 and 2015, a total of 300 patients with acute Type A aortic dissection underwent emergency surgery, consisting of 271 hemiarch repairs and 29 total aortic arch replacements, using transapical cannulation and the adventitial inversion technique at a distal anastomosis. The mean follow-up periods were 31.7 ± 25.2 months. Overall, 18% (54/300) of the patients were octogenarians, and 21.7% (65/300) had cardiac tamponade; 25% (75/300) had preoperative malperfusion. RESULTS: The in-hospital and 30-day mortality rates were 8.3% (25/300) and 6.7% (20/300), respectively. The 30-day mortality rate was 2.7% (6/225) among patients without preoperative malperfusion and 18.7% (14/75) among patients with malperfusion (P < 0.0001), 7.4% (4/54) among octogenarians and 6.5% (16/246) among patients aged less than 80 years (P = 0.81), and 6.3% (17/271) among patients treated with hemiarch repair and 10.3% (3/29) among patients treated with total aortic arch replacement (P = 0.403). Preoperative malperfusion was an independent predictor of perioperative mortality in a multivariable analysis. During the follow-up period, distal reintervention was performed in 11% (33/300) of the patients. The rates of freedom from reintervention at 1, 3 and 5 years were 95.9%, 88.9% and 80.0%, respectively. The overall survival rates at 1, 3 and 5 years were 88.7%, 86.7% and 82.0%, respectively. The in-hospital mortality rate for elective reintervention was 3.0% (1/33). CONCLUSIONS: Aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection provides good early and mid-term results. The safety of elective distal reintervention can be guaranteed. To obtain better operative outcomes, effective treatment for cases with malperfusion is mandatory.

Sac angiography and glue embolization in emergency endovascular aneurysm repair for ruptured abdominal aortic aneurysm.

PURPOSE: The purpose of this study was to demonstrate a sac angiography technique and evaluate the feasibility of N-butyl cyanoacrylate (NBCA) embolization of the ruptured abdominal aortic aneurysm (AAA) sac in emergency endovascular aneurysm repair (EVAR) in hemodynamically unstable patients. METHODS: A retrospective case series of three patients in whom sac angiography was performed during emergency EVAR for ruptured AAA was reviewed. After stent graft deployment, angiography within the sac of aneurysm (sac angiography) was performed by manually injecting 10 ml of contrast material through a catheter to identify the presence and site of active bleeding. In two patients, sac angiography revealed active extravasation of the contrast material, and NBCA embolization with a coaxial catheter system was performed to achieve prompt sealing. RESULTS: Sac angiography was successful in all three patients. In the two patients who underwent NBCA embolization for aneurysm sac bleeding, follow-up computed tomography (CT) images demonstrated the accumulation of NBCA consistent with the bleeding site in preprocedural CT images. CONCLUSIONS: EVAR is associated with a potential risk of ongoing bleeding from type II or IV endoleaks into the disrupted aneurysm sac in patients with severe coagulopathy. Therefore, sac angiography and NBCA embolization during emergency EVAR may represent a possible technical improvement in the treatment of ruptured AAA in hemodynamically unstable patients.

Dynamic volumetric CT angiography for the detection and classification of endoleaks: application of cine imaging using a 320-row CT scanner with 16-cm detectors.

PURPOSE: To assess the feasibility and diagnostic performance of dynamic volumetric computed tomography (CT) angiography with large-area detectors in the detection and classification of endoleaks after endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: Low-dose dynamic volumetric CT angiography performed with the patient in Fowler position was used to scan the entire stent graft with a 16-cm-area detector during the first follow-up examination after EVAR. There were 39 consecutive patients (36 men and 3 women; mean age, 74 y ± 8.7) examined with approximately 14-20 intermittent scans (temporal resolution, 2 s; scan range, 160 mm). The effective radiation dose, image quality, interobserver and intraobserver agreement for endoleak detection, and time delay between peak enhancement of the aorta and endoleaks were evaluated. RESULTS: All examinations with the patient in Fowler position enabled the entire stent graft to be scanned and were rated as diagnostic. The mean effective radiation dose was 13.1 mSv. Endoleaks were detected in eight patients (type Ia, n = 1; type II, n = 6; type III, n = 1). Interobserver agreement (κ = 0.794) and intraobserver agreement (κ = 1.00) for detection of endoleaks were excellent. The mean time delay between peak enhancement of the aorta and the endoleaks was significantly less for type I/III endoleaks (2.0 s ± 0) compared with type II endoleaks (5.3 s ± 1.0; P < .001). CONCLUSIONS: Low-dose dynamic volumetric CT angiography performed with the patient in Fowler position is feasible after EVAR. Dynamic information, including cine imaging, the timing of peak enhancement, and the Hounsfield units index, is useful in detecting and classifying endoleaks.

The upside down Endurant iliac limb stent graft for treatment of a common iliac artery aneurysm.

Endovascular repair of the coverage from the common iliac artery to the external iliac artery after the internal iliac artery embolization has been proven to be a safe and effective treatment in isolated iliac artery aneurysms. But in cases in which the diameter of the proximal sealing zone is larger than that of the distal sealing zone, a reverse-tapered device is needed. We described the off-label use of the Endurant iliac limb stent graft in an upside down configuration to accommodate this diameter mismatch.

Mid-term results for the Maze procedure in patients with non-mitral valvular atrial fibrillation.

BACKGROUND: The Maze procedure in patients without mitral valve disease remains controversial, because of the increased invasiveness and operation time required to create additional incisions in the atria. The aim of this study was to assess prognosis following the Maze procedure in patients without mitral valve disease. METHODS AND RESULTS: One hundred and seven consecutive patients who underwent the Maze procedure between 2002 and 2008 was enrolled in this study. Patients were divided into two groups based on the presence or absence of mitral valve disease. Freedom from atrial fibrillation was compared by multivariate logistic regression analysis at discharge. The Kaplan-Meier method and Cox-proportional hazard analysis adjusted for other predictors were estimated to compare freedom from atrial fibrillation at follow-up. Follow-up was 98% complete and mean duration of follow-up was 457 days. Operation and aorta cross-clamp times were similar between groups. No differences were identified in freedom from atrial fibrillation at discharge (non-mitral valve surgery, 55% vs. mitral valve surgery, 66%) or follow-up (57% vs. 61%, respectively). In multivariate Cox proportional hazard modelling, the presence of mitral valve disease was not associated with a poor success rate of conversion. CONCLUSIONS: Results of the Maze procedure for atrial fibrillation without mitral valve disease were acceptable. The Maze procedure could be a beneficial option for these patients to avoid adverse events of atrial fibrillation.

Echocardiographic assessment of the effects of mitral valve repair on mitral valve geometry in rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: While mitral valve replacement is generally considered as the standard surgical treatment for rheumatic mitral stenosis (MS), mitral valve repair may be an alternative therapeutic option. Several techniques have been used to overcome the anatomic difficulties involved in the repair of a rheumatic mitral valve. In the present study, quantitative echocardiography was used to investigate the effects of mitral valve repair and the influence of surgical procedures on mitral valve geometry in patients with rheumatic MS. METHODS: Mitral valve repair was successfully performed in seven patients with MS, by the same surgeon. Ring annuloplasty and slicing of the anterior mitral leaflet (AML) were performed in all patients. Concomitant surgical techniques included commissurotomy, decalcification, chordal resection, and division of the papillary muscles. The preoperative and postoperative echocardiographic findings in these patients were compared. RESULTS: The thickness of both the AML and posterior mitral leaflet (PML) (p = 0.01 for both), the opening angles of the AML (p = 0.02) and PML (p = 0.01), and the closing angle of the PML, the extent of calcification in the AML, and the pressure half-time (PHT) (p = 0.03 for all three parameters) were all significantly improved after mitral valve repair. CONCLUSION: In the present study, the transmitral peak velocity and mean pressure gradient were not significantly changed after mitral valve repair, whereas the PHT showed a marked improvement. Hence, the PHT may represent a suitable marker for evaluating the efficacy of mitral valve repair for MS.

The role of EuroSCORE in patients undergoing off-pump coronary artery bypass.

INTRODUCTION: European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used to predict the postoperative mortality rate for patients undergoing open-heart surgery. The contributions of EuroSCORE in off-pump coronary artery bypass grafting (CABG) has not yet clearly elucidated. METHODS: Consecutive patients of isolated off-pump CABG performed from 2000 when we start performing 'routine' off-pump procedures were stratified using the additive EuroSCORE. Incidence of postoperative mortality, morbidity, and recovery were assessed, and compared to an historical cohort of on-pump procedures performed between 1991 until 1998 when CABG had been routinely performed under on-pump. RESULTS: There were 1318 patients in the off-pump and 1162 patients in the on-pump group. EuroSCORE of the off-pump group was significantly higher than that of the on-pump group. In both the on- and off-pump groups, mortality, total incidence of major complications, heart failure, and renal failure, and three parameters of recovery time were well correlated with EuroSCORE; however, the discriminatory power of the EuroSCORE model was always better in the on-pump group than in the off-pump group. Stroke was correlated with EuroSCORE only in the on-pump group. Pneumonia, mediastinitis postoperative myocardial infarction, or mediastinitis was not correlated with EuroSCORE in either group. In the off-pump group, postoperative major complication was reduced and postoperative recovery was shortened significantly, compared to those in the on-pump group. CONCLUSION: In off-pump CABG, EuroSCORE can, but not as good as in on-pump CABG, predict mortality, certain major postoperative complications, and postoperative recovery. This suggests off-pump technique appears to modify the risk stratification of the patients undergoing CABG.

The Use of Enclose(®)II Anastomosis Assist Device for the Proximal Coronary Branch Anastomosis to Vascular Graft.

We used the Enclose(®)II anastomosis assist device (Novare Surgical Systems, Inc., CA, USA), which was originally developed as an ancillary device for proximal anastomosis in off-pump coronary artery bypass grafting (OPCAB), to assist anastomosis for the vascular grafts without clamping those conduits in two cases. In these cases, it was difficult to clump vascular graft partially, because vascular graft was short. So we used Enclose(®)II anastomosis assist device for these cases. The advantage of this method is that the Enclose(®)II anastomosis assist device facilitates the anastomosis of arterial side branches to the artificial graft (1) by eliminating the use of partial clamp on the artificial conduits and (2) by providing a plane surface for easy handling for suture.

EuroSCORE predicts postoperative mortality, certain morbidities, and recovery time.

EuroSCORE (European System for Cardiac Operative Risk Evaluation) used for calculating the risk of the postoperative mortality rate for patients undergoing open-heart surgery may be able to predict postoperative complications as well. Consecutive cases of isolated on-pump coronary artery bypass grafting (CABG) (n=1552) performed between 1991 and 2006 at our hospital group were placed into a systematic database. Patients were stratified using additive EuroSCORE. Incidence of postoperative mortality, morbidity (bleeding, heart failure, mediastinitis, pneumonia, myocardial infarction, renal failure, and stroke), and recovery time (intubation time, ICU stay, and postoperative length of stay) was assessed in each EuroSCORE group. EuroSCORE was well correlated with mortality, total incidence of major complications, heart failure, renal failure, stroke, pneumonia and mediastinitis, and three parameters of recovery time. Postoperative myocardial infarction and incidence of bleeding were not correlated with EuroSCORE. EuroSCORE can predict not only mortality but also postoperative complications and recovery time.

Mycotic pulmonary artery aneurysm as a late complication of infective endocarditis after pacemaker implantation.

A 49-year-old-woman who had had a pacemaker implanted 15 years earlier became acutely ill with a continuous high fever and general fatigue. A pulmonary artery aneurysm had been rapidly developing and had arrived at the acute phase within 2 weeks. After removal of the pacemaker and with antibiotic therapy the aneurysm gradually decreased in size and has been without rupture for 3 years. Conservative treatment seemed to be sufficient for the management of a mycotic aneurysm in this case.

Long-term results for aortic valve replacement with small aortic annulus.

We determined whether aortic prosthesis size influences survival and hemodynamic function. Eighty-nine patients who underwent small aortic valve replacement were followed. The small internal orifice area index (IOAI) group was defined as having an internal orifice area/body surface area ratio of < or = 1.3 cm(2)/m(2) (n = 34). The control group was defined as having an IOAI >1.3 cm(2)/m(2) (n = 55). The actuarial survival rate at 10 years was 74.5% in the small IOAI group and 75% in the control group (NS). Freedom from valve-related impairment at 10 years was 87% in the small IOAI group and 85% in the control group (NS). Postoperative pressure gradients were higher in the small IOAI group (p < 0.05). Left ventricular mass index decreased in both groups (albeit nonsignificantly in the small group, but significantly decreased in the control group). The long-term results of aortic valve replacement for patients with small aortic annulus were satisfactory. However, the postoperative pressure gradient through the prosthesis and left ventricular hypertrophy remained at a high level in the small IOAI group.