[Two-debranching Thoracic Endovascular Aortic Repair for Thoracic Aortic Aneurysm Complicated by Idiopathic Thrombocytopenic Purpura;Report of a Case].

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease in which the number of platelets decreases due to auto-antibodies against platelets. We report that thoracic endovascular aortic repair (TEVAR) was successfully performed for a thoracic aortic aneurysm complicated by ITP. The patient was a man of 77 years of age. He had a history of splenectomy due to ITP. He was admitted to our hospital with an aneurysm of the aortic arch that enlarged to a maximum minor axis of 63 mm. An operation was planned. Because of ITP, it was judged that replacement of the aortic arch using a cardio-pulmonary pump would be associated with a high risk of bleeding. Thus, 2-debranching TEVAR was selected and performed with no hemorrhagic complications. He was discharged from the hospital on the 12th day after surgery. We believe that 2-debranching TEVAR is effective for reducing perioperative bleeding in patients with ITP.

Clinical and Morphological Outcomes in Endovascular Aortic Repair of Abdominal Aortic Aneurysm Using GORE C3 EXCLUDER: Comparison between Patients Treated within and Outside Instructions for Use.

BACKGROUND: The goals of this study were to evaluate mid-term outcome in endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) using a GORE C3 EXCLUDER and compare results between patients treated within and outside the instructions for use (IFU). METHODS: Over a 3-year period spanning October 2013 to September 2016, consecutive patients undergoing EVAR for AAA using the C3 EXCLUDER at Tokyo Medical University Hospital were registered on a prospectively maintained database. The data thus obtained were retrospectively analyzed. RESULTS: A total of 109 AAA patients underwent EVAR using the C3 EXCLUDER. The median follow-up duration was 729 days (interquartile range, 542-1,069 days). Technical success was achieved in 98.2% of cases. Adjunctive, unplanned proximal cuff-extender implantation was required in 8 patients (9.2%). Of the total number, 29 (24.8%) were categorized as being treated outside the IFU. No significant difference was observed in freedom from overall mortality or aneurysm-related mortality between patients treated within and outside the IFU. Freedom from reintervention tended to be lower in patients treated outside the IFU. There was aneurysm sac shrinkage (≥5 mm) in 30.3% and 39.1%; stable aneurysm sac in 69.7% and 56.3%; and aneurysm sac expansion (≥5 mm) in 0% and 4.7% of cases at 1 and 2 years, respectively. No significant difference was observed in aneurysm sac shrinkage between patients treated within and outside the IFU. CONCLUSIONS: The C3 EXCLUDER showed good clinical performance and aneurysm sac shrinkage, regardless of whether the patient was treated within or outside the IFU. The results suggest, however, that in those treated outside the IFU, precise planning, careful operative procedure, and subsequent follow-up are required to obtain short-term and mid- to long-term success in EVAR for AAA using the C3 EXCLUDER.

Amiodarone Provides Long-Lasting Local Anesthesia and Analgesia in Open-State Mouse Nociceptors.

Local anesthetics with long-lasting effects and selectivity for nociceptors have been sought over the past decades. In this study, we investigated whether amiodarone, a multiple channel blocker, provides long-lasting local anesthesia and whether adding a TRPV1 channel activator selectively prolongs sensory anesthetic effects without prolonging motor blockade. Additionally, we examined whether amiodarone provides long-lasting analgesic effects against inflammatory pain without TRPV1 channel activator co-administration. In the sciatic nerve block model, 32 adult C57BL/6J mice received either bupivacaine, amiodarone with or without capsaicin (a TRPV1 agonist), or vehicle via peri-sciatic nerve injection. Sensory and motor blockade were assessed either by pinprick and toe spread tests, respectively. In another set of 16 mice, inflammatory pain was induced in the hind paw by zymosan injection, followed by administration of either amiodarone or vehicle. Mechanical and thermal sensitivity and paw thickness were assessed using the von Frey and Hargreaves tests, respectively. The possible cardiovascular and neurological side effects of local amiodarone injection were assessed in another set of 12 mice. In the sciatic nerve block model, amiodarone produced robust anesthesia, and the co-administration of TRPV1 agonist capsaicin prolonged the duration of sensory blockade, but not that of motor blockade [complete sensory block duration: 195.0 ± 9.8 min vs. 28.8 ± 1.3 min, F (2, 21) = 317.6, p < 0.01, complete motor block duration: 27.5 ± 1.6 min vs. 21.3 ± 2.3 min, F (2, 22) = 11.1, p = 0.0695]. In the zymosan-induced inflammatory pain model, low-dose amiodarone was effective in reversing the mechanical and thermal hypersensitivity not requiring capsaicin co-administration [50% withdrawal threshold at 8 h (g): 0.85 ± 0.09 vs. 0.25 ± 0.08, p < 0.01, withdrawal latency at 4 h (s) 8.5 ± 0.5 vs. 5.7 ± 1.4, p < 0.05]. Low-dose amiodarone did not affect zymosan-induced paw inflammation. Local amiodarone did not cause cardiovascular or central nervous system side effects. Amiodarone may have the potential to be a long-acting and nociceptor-selective local anesthetic and analgesic method acting over open-state large-pore channels.

Pitfalls of Retrograde Cardioplegia Cannulation: Left Atrium Dissection.

Left atrial dissection is a rare complication of cardiac surgery. We present a case of left atrial dissection that occurred during a partial arch repair for Stanford acute type A aortic dissection. Because no entry was found in the left atrium by transesophageal echocardiography, and there were no issues weaning from cardiopulmonary bypass, we decided that no surgical intervention was necessary. Transthoracic echocardiography and computed tomography showed the remaining dissection on postoperative day 7; however, on postoperative day 14, it had completely disappeared.

A Double-Blind Randomized Controlled Trial to Determine the Preventive Effect of Hangekobokuto on Aspiration Pneumonia in Patients Undergoing Cardiovascular Surgery.

PURPOSE: This study aimed to assess whether hangekobokuto (HKT) can prevent aspiration pneumonia in patients undergoing cardiovascular surgery. METHODS: We performed a single-center, double-blinded, randomized, placebo-controlled study of HKT in patients undergoing cardiovascular surgery. JPS HKT extract granule (JPS-16) was used as HKT. The primary endpoint was defined as the prevention of postoperative aspiration pneumonia. The secondary endpoints included complete recovery from swallowing and coughing disorders. RESULTS: Between August 2014 and August 2015, a total of 34 patients were registered in this study. The rate of subjects with postoperative aspiration pneumonia was significantly lower in the HKT group than in the placebo group (p = 0.017). In high-risk patients for aspiration pneumonia, the rate was significantly lower in the HKT group than in the placebo group (p = 0.015). The rate of subjects with swallowing disorders tended to be lower in the HKT group than in the placebo group (p = 0.091), and in high-risk patients, the rate was significantly lower in the HKT group than in the placebo group (p = 0.038). CONCLUSIONS: HKT can prevent aspiration pneumonia in patients undergoing cardiovascular surgery. In high-risk patients for aspiration pneumonia, HKT can prevent aspiration pneumonia and improve swallowing disorders.

Impact of preservation of the latissimus dorsi muscle through a left anteroaxillary thoracotomy on spinal cord protection in descending thoracic and thoraco-abdominal aortic operations†.

OBJECTIVES: The presence of collateral network circulation to the spinal cord, which is reflected in the repair of a descending thoracic aortic aneurysm (dAo) and a thoraco-abdominal aortic aneurysm (TAAo), has been demonstrated in clinical and animal experimental data. The latissimus dorsi muscle (LDM) including the thoracodorsal artery might be one of the major sources of this collateral network. The objective of this study was to evaluate the impact on spinal cord safety of a left anteroaxillary thoracotomy with minimal muscle division including preservation of the LDM in surgery for dAo and TAAo. METHODS: Sixty-nine patients [64 (23-85) years old; 56 men] who underwent surgical repair for dAo and TAAo were divided into 2 groups: 29 [65 (23-84) years old] with an anteroaxillary thoracotomy with LDM preservation (PL group) and 40 [61 (28-85) years old] with a lateral thoracotomy without LDM preservation (NL group). RESULTS: Aortic repairs were performed at the dAo in 30 patients including 14 in the PL group vs 16 in the NL group and at the TAAo in 39 patients including 15 in the PL group vs 24 in the NL group. There were 2 (2.9%) 30-day deaths; 2 (7.9%) in the PL group vs none in the NL group (P = 0.173). No strokes occurred. In patients with a femoro-femoral partial cardiopulmonary bypass with mild hypothermia, the incidence of loss of signal of motor-evoked potentials (>50%) was significantly lower in the PL group; 5.6% vs 31.8% (P = 0.039). The frequency of signal reduction of the remaining motor-evoked potential after surgery was also significantly lower in the PL group: 3.7% vs 25% (P = 0.040). Subsequently, the rate of spinal cord complications were lower in the PL group: 3.4% vs 12.5% (P = 0.188). CONCLUSIONS: The left anteroaxillary thoracotomy with minimal incision of the muscles including the LDM might have potential advantages for spinal cord protection via preserved intramuscular collateral circulations to the spinal cord in dAo/TAAo open repairs.

Four-year experience with the Endurant stent-graft for abdominal aortic and common iliac artery aneurysms in 50 consecutive Japanese patients.

BACKGROUND: To evaluate the 4-year results of the Endurant stent-graft in the treatment of abdominal aortic aneurysm (AAA) or common iliac artery aneurysm (CIAA). METHODS: Between June 2012 and January 2014, 50 consecutive Japanese AAA and CIAA patients were treated with the Endurant stent-graft at Tokyo Medical University Hospital. RESULTS: Estimated freedom from overall mortality, aneurysm-related mortality, and secondary interventions at 4 years was 61.7%, 97.9%, and 78.6%, respectively. At 4 years, the maximum sac diameter decreased by >5 mm in 24% of the patients, remained stable in 52%, and increased by >5 mm in 24%. The average aneurysm sac reduction was 0.4 to 1.3 mm within 5 years. Multivariate analyses detected female gender (HR: 7.40, P=0.021) and type IV endoleak (HR: 5.34, P=0.009) as a significant risk factor for secondary intervention. CONCLUSIONS: Four-year clinical outcomes of the Endurant stent-graft remained positive in Japanese patients with AAA and CIAA, although 24% of the patients needed a secondary intervention. The aneurysm sac was stable in most of the patients, whereas the aneurysm sac reduction was small. These results suggest that careful imaging follow-up must be continued to determine the durability of the Endurant stent-graft in patients with small aneurysm sac reduction.

The Effect of Hachimi-Jio-Gan (Ba-Wei-Di-Huang-Wan) on the Quality of Life in Patients with Peripheral Arterial Disease - A Prospective Study Using Kampo Medicine.

Objective: To assess whether Hachimi-jio-gan (HJG), a preparation of Kampo medicine (traditional Japanese medicine), improves quality of life (QOL) in patients with peripheral arterial disease (PAD). Materials and Methods: Among the patients with PAD being followed in the Department of Cardiovascular Surgery at Tokyo Medical University Hachioji Medical Center, those with intermittent claudication (IC) and in stable condition regarding PAD severity were registered. We registered the patients from April 2014 to March 2015. We administered HJG extract for 6 months to the patients. The primary endpoint was Walking Impairment Questionnaire (WIQ) score, which was approved as an indicator of QOL of the patient with PAD. We assessed WIQ score both before and after administration of the HJG. Results: We analyzed 14 patients. WIQ items of pain, distance, and speed improved significantly. Furthermore, the median of the total score of WIQ improved significantly from 162.5 points to 308.0 points. All patients showed improvement in the total score and 7 patients out of 14 patients (50%) showed a remarkably effective improvement in score of more than 100 points. Conclusion: HJG might improve the QOL in patients with IC due to PAD.