Huge, Infected Pancreatic Necrosis After Total Arch Replacement in a Patient With Immunoglobulin G4-Related Syndrome.

A 77-year-old male patient with immunoglobulin (Ig)G4-related disease was diagnosed with a 60-mm aortic arch aneurysm and atherosclerosis of the aorta advanced throughout the body. Aortic arch replacement surgery was performed with circulatory arrest at 28°C. One week later, the patient developed acute pancreatitis, followed by encapsulated necrosis in the chronic phase. After debridement surgery, the patient's condition improved.

Identification of a Dissection Site in the Internal Thoracic Artery Using Fluorescence Imaging: A Case Report.

A 66-year-old man with a history of type 2 diabetes mellitus who was undergoing hemodialysis presented with angina. Coronary angiography revealed triple-vessel coronary artery disease. He underwent multiple percutaneous coronary interventions due to recurrent restenosis and was referred for coronary artery bypass grafting (CABG). The left internal thoracic artery and bilateral saphenous veins were harvested under general anesthesia. Four CABGs were performed: left internal thoracic artery to the left anterior descending artery; saphenous vein graft to the obtuse marginal branch of the circumflex artery; and saphenous vein graft to two sites in the right coronary artery. Intraoperative assessment with transit-time flow measurements showed no abnormalities, and the surgery was completed. On postoperative day seven, coronary and graft angiography revealed dissection of the left internal thoracic artery at its midportion with restricted flow. On postoperative day eight, a surgical intervention was performed to excise the dissected segment of the left internal thoracic artery. The dissection site was identified by fluorescence imaging. The dissected segment was excised, and the artery was re-anastomosed. The postoperative course was uneventful, and graft angiography performed on postoperative day 22 confirmed good blood flow. Fluorescence imaging was valuable in identifying the dissection site in the left internal thoracic artery.

Mid-term outcomes of physician-modified endograft therapy for complex aortic aneurysms.

OBJECTIVES: Our goal was to evaluate early and mid-term outcomes of physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms from 10 Japanese aortic centres. METHODS: From January 2012 to March 2022, a total of 121 consecutive adult patients who underwent physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms were enrolled. We analysed early and mid-term postoperative outcomes, including postoperative complications and mortality. RESULTS: The pararenal and thoraco-abdominal aortic aneurysm groups included 62 (51.2%) and 59 (48.8%) patients, respectively. The overall in-hospital mortality rate was 5.8% (n = 7), with mortality rates of 3.2% (n = 2) and 8.5% (n = 5) in pararenal and thoraco-abdominal aortic aneurysm groups, respectively (P = 0.225). Type IIIc endoleaks occurred postoperatively in 18 patients (14.9%), with a significantly higher incidence (P = 0.033) in the thoraco-abdominal aortic aneurysm group (22.0%, n = 13) than in the other group (8.1%, n = 5). Major adverse events occurred in 7 (11.3%) and 14 (23.7%) patients in pararenal and thoraco-abdominal aortic aneurysm groups (P = 0.074), respectively. The mean follow-up period was 24.2 months. At the 3-year mark, both groups differed significantly in freedom from all-cause mortality (83.3% and 54.1%, P = 0.004), target aneurysm-related mortality (96.8% and 82.7%, P = 0.013) and any reintervention (89.3% and 65.6%, P = 0.002). Univariate and multivariate regression analyses demonstrated that ruptures, thoraco-abdominal aortic aneurysms and postoperative type IIIc endoleaks were associated with an increased risk of all-cause mortality. CONCLUSIONS: The mid-term outcomes of physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms were clinically acceptable and comparable with those in other recently published studies. Notably, pararenal and thoraco-abdominal aortic aneurysms represent distinct pathological entities with different postoperative outcomes.

Mitral valve repair for infective endocarditis after esophageal reconstruction: a case report.

BACKGROUND: In patients with retrosternal neo-esophageal conduit after right thoracotomy, the approach to cardiac surgery could be challenging. Particularly, in patients with infective endocarditis, there is a risk of injury to the conduit through standard median sternotomy. Moreover, right lung adhesions could be predicted. Herein, we present a case of successful mitral valve repair in a patient with infective endocarditis through a redo right thoracotomy after esophageal reconstruction. CASE PRESENTATION: A 66-year-old male patient was diagnosed with infective endocarditis and a large anterior mitral leaflet vegetation after a previous esophageal reconstruction via right thoracotomy for esophageal cancer. Due to the retrosternal esophageal reconstruction, we performed a mitral valve repair through a redo right thoracotomy. After resecting the vegetation, the defect was closed with a fresh autologous pericardial patch. Mitral valve annuloplasty was performed. Postoperatively, antibiotics controlled the infection. The patient was discharged on postoperative day 30. CONCLUSIONS: Successful mitral valve repair was performed for infective endocarditis through a redo right thoracotomy after esophageal reconstruction.

Physician-modified inner-branched endovascular repair with re-intervention.

OBJECTIVES: Treatment of thoracoabdominal aortic aneurysms in high surgical risk patients can be challenging. Reports of physician-modified inner-branched endovascular repair (PMiBEVAR) are increasing. Despite low morbidity and mortality rates, re-interventions for endoleaks with these grafts are serious. There are no reports of additional treatment for PMiBEVAR failure. METHODS/RESULTS: A 75-year-old man presented to our hospital with a Crawford's type IV thoracoabdominal aortic aneurysm. A PMiBEVAR was performed. Postoperative computed tomographic angiography revealed an endoleak from the inner branch of the right renal artery. A re-intervention was performed with coil embolization of the endoleak. Imaging after re-intervention showed successful obliteration of the endoleak. CONCLUSIONS: We thereby report a successful case of re-intervention for PMiBEVAR failure.

Initial two-day blood pressure management after endovascular aneurysm repair improves midterm outcomes by reducing the incidence of early type II endoleak.

OBJECTIVE: The aim of this study was to evaluate midterm outcomes of our novel strategy of postoperative initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the prevention of subsequent type II endoleak (T2EL) in a single-center series. METHODS: Between 2008 and 2014, 137 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from 2013, the mean blood pressure was maintained between 75 and 90 mmHg for the initial 24 hours after EVAR followed by systolic pressure controlled below 120 mmHg during the next 24 hours in the treatment group (n = 76). The incidence of T2EL detected at 7 days, reintervention, and AAA sac diameter up to 5 years after EVAR were compared with those of the control group comprising of 60 consecutive patients who underwent standard EVAR without BPM prior to 2013. RESULTS: Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL at 7 days (19.7% vs 40.0%; P = .009), a mean decrease of AAA sac diameter at 1-year (-5.1 ± 4.9 vs -2.2 ± 6.7 mm; P = .013) and 2-year (-5.4 ± 7.7 vs -1.7 ± 10.8 mm; P = .045). In addition, there was a significant decrease in the incidence of T2EL detected at 7 days with the use of the Gore Excluder with 22.7% in the treatment group vs 80.0% in the control group (P < .001), which resulted in a significant decrease in the aneurysm sac diameter up to 4 years after EVAR. Survival rate without AAA sac enlargement at 5 years after EVAR (83.0% vs 70.0%; P = .021) in the treatment group was significantly higher than that of the control group, whereas no significant differences were observed in the freedom rates of reintervention, T2EL-related reintervention, and all-cause mortality between the groups. CONCLUSIONS: Postoperative initial 2-day BPM had a preventive effect on AAA sac enlargement until midterm periods, by reducing the incidence of T2EL at 7 days after EVAR. The usage of Gore Excluder under BPM was especially associated with sustained positive effects until the midterm follow-up.

Mitral Valve Infective Endocarditis Associated With Prednisolone-Induced Immunosuppression: A Case Report.

A 74-year-old man with pemphigoid, for which he was on a daily regimen of 14 mg of prednisolone and immunosuppressive drugs, was admitted to the orthopedic surgery department with a fever of 38 °C. An MRI scan of his head revealed multiple bilateral cerebral infarcts, and echocardiography showed a 30-mm structure attached to the anterior apex of the mitral valve. The patient was diagnosed with infective endocarditis and administered antibiotic therapy. Five days after the diagnosis, the patient underwent mitral valve surgery, during which the mitral valve was observed to be severely deteriorated and hence replaced with a bioprosthetic valve. Blood flow disturbance was observed in the right lower extremity, and a thrombectomy was performed. A dispersed vegetation around the heart was observed and removed. After the surgery, the patient progressed without mediastinitis and had a good postoperative course. He was discharged from the hospital on the 56th postoperative day after continued antibiotic therapy.

Pathological Characteristics of the Vascular Septum in Chronic Aortic Dissection: A Case Report.

A 46-year-old male developed a Stanford type B aortic dissection. At age 48, he underwent left open thoracic descending aorta replacement because of the enlargement of the descending thoracic aorta. At 51 years old, he underwent abdominal aorta replacement because of ischemia in the right lower extremity and the enlargement of an abdominal aortic aneurysm. The septum between the true and false lumens was submitted to histopathological examination, which revealed bilateral intimal tissue with the tunica media lying in between.

Multivariate analysis of the factors affecting medical students' decision to join the cardiovascular surgery department.

OBJECTIVE: The purpose of this study was to statistically analyze the factors that influence cardiovascular surgery recruitment. METHODS: Fifth- and sixth-year medical students and first-year residents who participated in cardiovascular surgery-related events at our university over a 10-year period from April 2013 to August 2022 were included. The primary endpoint was admission to the department of cardiovascular surgery. Gender, participation in sixth-year elective clinical training, participation in national academic conferences, participation in cardiovascular surgery summer school, and the cost of participation in these events (airfares and lodging) were included as analytic factors. RESULTS: Fifty-three participants attended cardiovascular surgery events during the study period. The sample included 48 males (84%) and 9 females (16%), and 3 fifth-year medical students (5%), 45 sixth-year students (79%), and 9 students in their first year of clinical training (16%). Eighteen (32%) of the participants eventually joined the department. Gender, participation in national academic conferences, cardiovascular surgery summer school, and cost of participation were not significantly related to the decision to join the department, but participation in elective clinical training was significantly positively related to the decision to join the department for sixth-year students (p < 0.01). CONCLUSIONS: We statistically analyzed the factors involved in the recruitment of students and initial clinical residents to the department of cardiovascular surgery. The results showed that participation in elective clinical training was significantly positively associated with the decision to join the department, suggesting that efforts to encourage participation in elective clinical training are important.

Platelet Function Testing Using Sonoclot and TEG6s as a Platelet Transfusion Prediction Tool in Open Heart Surgery.

Introduction The point-of-care test (POCT) is useful for blood coagulation management during cardiovascular surgery. Although thromboelastography (TEG6s) has been reported to have targeted benefits for blood transfusion in cardiac surgery, Sonoclot analysis has not yet been fully validated. In this study, we evaluated the accuracy of Sonoclot, especially platelet function (PF) as a platelet concentrate (PC) transfusion parameter, compared to TEG6s in cardiovascular surgery. Methods This single-center, prospective, randomised trial was conducted at a university hospital. Forty-two adult patients who underwent elective cardiac surgery requiring cardiopulmonary bypass were included in this study between 2017 and 2021. The participants were randomly assigned to the Sonoclot (S) or Sonoclot and TEG6s (ST) groups. The amount of intraoperative PC was determined according to the POCT parameter values at the time of protamine administration. In addition, we investigated the correlation between PF parameters of POCT and platelet count at the end of surgery. Results There was no statistically significant difference in the intraoperative PC volume between the two groups. The Sonoclot PF parameter, PF, was moderately correlated with platelet count at the end of surgery (r=0.5449, p=0.009), and the TEG6s PF parameter showed a strong correlation with platelet count at the end of surgery (r=0.7744, p<0.001). Conclusion There was no statistically significant difference in platelet transfusion volume between the Sonoclot and TEG6s in this study. The correlation between the PF of the Sonoclot and platelet count was moderate. This study suggests that PF of Sonoclot may be a potentiating indicator of PF.

An Obligatory Role of Perivascular Adipose Tissue in Improved Saphenous Vein Graft Patency in Coronary Artery Bypass Grafting.

The gold standard graft for coronary artery bypass grafting (CABG) is the internal thoracic artery (ITA), and the second recommendation is the radial artery. However, complete revascularization with arterial grafts alone is often difficult, and the saphenous vein (SV) is the most commonly used autologous graft for CABG, because it is easier to use without restriction for the length of the graft. On the other hand, the patency of SV grafts (SVGs) is poor compared with that of arterial grafts. The SVG is conventionally harvested as a distended conduit with surrounding tissue removed, a procedure that may cause vascular damage. A no-touch technique of SVG harvesting has been reported to result in improved long-term patency in CABG comparable to that when using the ITA for grafting. Possible reasons for the excellent long-term patency of no-touch SVGs are the physical support provided by preserved surrounding perivascular adipose tissue, preservation of the vascular wall structure including the vasa vasorum, and production of adipocyte-derived factors. In this review, we discuss recent strategies aimed at improving the performance of SVGs, including no-touch harvesting, minimally invasive harvesting and mechanical support using external stents.

The impact of postoperative cerebrospinal fluid drainage on neurological improvement following thoracic aortic and thoracoabdominal aortic surgery.

Background: Various preventive measures and treatment methods exist to prevent paraplegia during thoracic aortic surgery. Postoperative cerebrospinal fluid drainage (CSFD) is one of the treatment options when paraplegia occurs. This study aimed to evaluate the neurological efficacy of postoperative CSFD in patients undergoing thoracic aortic and thoracoabdominal aortic surgery. Methods: We analyzed perioperative data from 85 patients who underwent perioperative CSFD for thoracic and thoracoabdominal aortic surgery between January 2006 and December 2022, focusing on neurological changes. A total of 61 patients (72%) received preoperative CSFD, and 24 patients (28%) received postoperative CSFD. Perioperative neurological data were analyzed with a focus on perioperative changes. Results: In the postoperative CSFD group, the manual muscle test (MMT) score before CSFD was 0.8, that just after CSFD was 2.4, and that at discharge was 3.0. Therefore, postoperative CSFD improved MMT scores compared with preoperative CSFD. The mean time between surgery completion and postoperative CSFD implantation was 9.8 hours. However, 6 (25%) of the patients who developed postoperative paraplegia and underwent early postoperative CSFD remained paraplegic without any improvement. In the preoperative CSFD group, there was only one case (2%) of postoperative paraplegia. Conclusions: Postoperative CSFD improved the neurological prognosis of individuals undergoing thoracic aortic and thoracoabdominal aortic surgery. However, 25% of the patients remained paraplegic despite postoperative CSFD.

Partial arch replacement of type A aortic dissection after thoracic endovascular aortic repair for type B dissection.

BACKGROUND: Stent graft-induced new entry (SINE), defined as the stent graft-induced formation of a new entry point for blood to enter an area, is increasingly being observed after thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection worldwide. We herein describe a case of Stanford type A aortic dissection due to proximal SINE after TEVAR for Stanford type B dissection. CASE PRESENTATION: This case involved a 58-year-old man with type A aortic dissection due to SINE. Six years previously, he had developed severe back pain and was diagnosed with type B aortic dissection after computed tomography examination. Because the primary entry was positioned at the descending aorta, we conducted TEVAR for exclusion of the entry with a GORE TAG conformable thoracic aortic graft. He was thereafter followed by our hospital. Six years later, he developed jaw pain and was examined at another hospital. He was transferred to our hospital because of the possibility of type A dissection. Computed tomography revealed type A aortic dissection with proximal site SINE. Emergency partial arch replacement was conducted, and he was discharged on postoperative day 27. Because the entry was at the lesser curve of the arch, we excluded the entry and conducted partial arch replacement. CONCLUSIONS: In this case, proximal SINE occurred 6 years after TEVAR. Because SINE may occur even in the long term after TEVAR, careful follow-up is necessary.

A case of multiple median sternotomy for infection and expanding hematoma in 10 years.

BACKGROUND: After a median sternotomy, mediastinitis may develop, necessitating reopening of the chest. Rarely, reoperation due to hematoma after cardiovascular surgery is experienced. In the present case, we experienced a patient who initially had mediastinitis, but later developed a chronic hematoma and underwent multiple surgeries. CASE PRESENTATION: The patient was a 40-year-old man who underwent aortic valve replacement for a bicuspid aortic valve and a graft for a dilated ascending aorta. Postoperatively, he developed hematoma in the anterior mediastinum on multiple occasions with repeated episodes of infection that required multiple median sternotomies. CONCLUSIONS: We reported our experience with a rare case of multiple median sternotomies. In the early stage, mediastinitis due to infection was observed, and in the late stage, mediastinal dilatation due to hemorrhage was observed.

Outcomes of Vascular Surgery Performed Jointly With Other Departments.

OBJECTIVE: The purpose of this study is to evaluate the results of vascular surgery performed at our hospital, a tertiary emergency general hospital, in patients undergoing surgery in other departments. The results of the study were reviewed. METHODS: The study included cases in which cardiovascular surgery was performed at the request of other departments over a 15-year period from January 2006 to October 2022. Patient backgrounds, departments that requested surgery, surgical procedures, use of extracorporeal circulation, and surgical techniques were reviewed. Patients with femoral artery exposure or ECMO removal during transcatheter aortic valve implantation (TAVI) requested by cardiology were excluded. RESULTS: There were 58 vascular surgery cases requested by other departments during the study period. The age was 63±14 years, 43 (74%) were male and 15 (26%) were female. The departments of the patients were urology in 29 (50%), gastroenterology in 18 (31%), orthopedics in seven (12%), emergency department in three (5%), and obstetrics and gynecology in one (2%). The following surgical procedures were performed: tumor resection and reconstruction due to tumor invasion of the inferior vena cava in 27 cases (47%), bypass to secure intraperitoneal arterial blood flow in 15 cases (26%), bypass during resection of the femoral tumor in four cases (7%), hemostasis due to trauma in three cases (5%), intraperitoneal hemostasis in three cases (5%), thrombectomy in two cases (3%), and others in four cases (7%). Extracorporeal circulation was used in six (10%) of the patients. CONCLUSION: A 15-year case study of vascular surgery supports operations requested by other departments at our hospital. All reconstructed sites were open at the time of discharge.