Cerebral Protection With Deep Hypothermic Circulatory Arrest During Total Arch Replacement Using the Arch-First Technique for Acute Aortic Dissection.

OBJECTIVES: Stroke remains a serious complication after total arch replacement (TAR). To prevent this, deep hypothermia is commonly employed during TAR. We evaluated the effectiveness of cerebral protection using deep hypothermic circulatory arrest (DHCA) during TAR with the arch-first technique, focusing particularly on patients with acute aortic dissection (AAD). METHODS: This retrospective study included 109 consecutive patients with AAD who underwent emergency TAR using the arch-first technique under DHCA, and 147 patients with non-ruptured aneurysm who underwent scheduled TAR using the same technique between October 2009 and July 2022. We reviewed these patients for major adverse events, including stroke and 30-day mortality after surgery. We also analyzed the impact of clinical variables and anatomical features on the occurrence of newly developed stroke after TAR in patients with AAD. RESULTS: A newly developed stroke after TAR occurred in 11 (10.1%) patients with AAD. These were attributed to embolism in eight patients, malperfusion in two patients (including one who had been comatose), and low output syndrome in one patient. A stroke occurred in 3 (2.0%) patients with aneurysm, all due to embolism (P = 0.005). The DHCA time was 37 ± 7 minutes for patients with AAD and 36 ± 6 minutes for patients with aneurysm (P = 0.122). The 30-day mortality rate was 10 (9.2%) for patients with AAD and 2 (1.4%) for patients with aneurysm (P = 0.003). In our multivariable analysis, arch vessel dissection with a patent false lumen (double-barreled dissection) was the only significant predictor of newly developed stroke after TAR for AAD (odds ratio, 33.02; P < 0.001). CONCLUSIONS: Patients with aneurysm undergoing TAR using the arch-first technique under DHCA experienced significantly better outcomes, in terms of newly developed stroke and 30-day mortality, than those with AAD. Cerebral protection with DHCA during TAR using the arch-first technique continues to be a viable option. Newly developed stroke in patients undergoing TAR for AAD appears to be associated with air emboli deriving from the residual dissection with a patent false lumen in the repaired arch vessels.

Efficacy of Preemptive Embolization of Sac Branches During Endovascular Aneurysm Repair Using N-butyl-2-cyanoacrylate.

OBJECTIVE: A type 2 endoleak (T2EL) is the most frequently occurring endoleak type after endovascular aneurysm repair (EVAR). Residual T2ELs may cause aneurysm rupture; however, the management of a T2EL remains controversial. This study evaluated sac branch preemptive embolization using N-butyl-2-cyanoacrylate, aiming to prevent T2ELs and sac shrinkage. METHODS: Twelve consecutive patients underwent elective preemptive embolization during EVAR at our hospital between August 2018 to March 2019. Their demographic information, operative details, and sac diameters were examined at 6 months after EVAR. RESULTS: No procedural complications were observed. There were no in-hospital deaths among the 12 patients. Sac shrinkage was observed in this cohort (53.8-52.1 mm, p = 0.01). A total of 33 lumbar arteries were occluded with this procedure, and 2 patients had residual T2ELs at 6 months. CONCLUSIONS: A T2EL in preemptive sac branch embolization during EVAR has advantages in terms of safety and reduction. Although no clear evidence is available for the management of T2ELs, this study proposes a new standard to prevent it and improve the long-term outcomes after EVAR. However, embolization remains imperfect and further research is necessary.

Successful redo open thoracoabdominal aortic aneurysm surgery in a patient with vascular Ehlers-Danlos syndrome: A case report.

We report a case of a 63-year-old woman diagnosed with vascular Ehlers-Danlos syndrome (vEDS) who survived two prophylactic surgeries for the dilatation of a thoracoabdominal aortic aneurysm. She initially developed acute type B aortic dissection at the age of 44 years. Five years later, her dissected descending aorta was enlarged to 54 mm; thus, the descending aorta was replaced as the first surgery. Fortunately, the intra- and post-operative courses were uneventful. Fourteen years post her first surgery, the dissected thoracoabdominal aorta distal to the graft expanded to 53 mm; however, no anastomotic leakage was observed. Genetic testing revealed a COL3A1 abnormality, confirming the diagnosis of vEDS. Thoracoabdominal aorta replacement using deep hypothermia circulatory arrest was performed because of the high risk of aortic aneurysm rupture. The second surgery was performed without complications, and no complications were observed 13 months post-surgery. The major reason for a successful surgery in this patient was the relatively low vascular fragility associated with vEDS. This case demonstrates that there may be considerable individual differences in vascular fragility in patients with vEDS. Thus, surgical repair, along with endovascular therapy, might still be a beneficial option for patients with vEDS having large aortic aneurysms and a high risk of rupture. Learning objective: Prophylactic surgery for vascular lesions in Ehlers-Danlos syndrome (vEDS) is generally not recommended because of its high vascular fragility. However, if a patient with vEDS has an aortic aneurysm that is at a very high risk of rupture, aggressive treatment is a plausible option as there may be considerable individual differences in vascular fragility among patients with vEDS.

Open after endovascular repair for previous extra anatomic bypass of adult coarctation.

BACKGROUND: During follow-up, aneurysm formation in adults with coarctation of aorta has been reported after undergoing extra-anatomical aortic bypass grafting. Endovascular repair was a reasonable treatment option but there were still complications. CASE PRESENTATION: A 48-year-old male who underwent extra-anatomical aortic bypass grafting, presented with severe back pain and hemoptysis. He had a diagnosed pseudoaneurysm with concealed rupture at the bypass grafting. He underwent endovascular repair and coil embolization. A postsurgical CT-angiogram showed there was extravasation from stent into the pseudoaneurysm. An open repair with endovascular stent removal instead of restenting was performed.

Successful Medical Treatment for Aortoesophageal Fistula after Thoracic Endovascular Aortic Repair.

Aortoesophageal fistula is a fatal disease that requires surgical treatment. Due to the patient's wishes, we chose medical treatment for aortoesophageal fistula after thoracic endovascular aortic repair for a pseudoaneurysm in the distal anastomotic site after total aortic arch replacement. Satisfactory early and long-term outcomes were obtained with complete fasting and appropriate antibiotics.

Nitric Oxide Inhalation and V-V ECMO for Severe Respiratory Failure after Acute Type A Aortic Dissection Surgery.

A 65-year-old man was admitted to our hospital with acute type B aortic dissection that extended into both common iliac arteries with an occluded right common iliac artery and large bullae in bilateral upper lung fields. Femoro-femoral arterial bypass surgery with an artificial blood vessel was performed. Two days postoperatively, acute type B aortic dissection progressed to acute type A aortic dissection. Emergency total arch graft replacement (TAR) was performed through a median sternotomy on the same day. Immediately following TAR, the patient experienced hypoxemia. Acute respiratory distress syndrome (ARDS) was diagnosed following TAR for acute aortic dissection with pneumonia. Nitric oxide inhalation (NOI) therapy was commenced at 20 ppm from the fourth day post-surgery. However, 6 d following TAR, he developed bilateral pneumothorax due to ruptured bullae requiring chest tube management and thoracoscopic left upper lobe bullectomy. Eight days following TAR, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was initiated and NOI therapy was completed. V-V ECMO was withdrawn 18 d after TAR. Postoperatively, after 2 years 3 months, the patient remains ambulatory without assistance, walking to the outpatient clinic.