Radiation Dose Reduction During EVAR: Results from a Prospective Multicentre Study (The REVAR Study).

OBJECTIVE: To evaluate radiation exposure in standard endovascular aneurysm repair (EVAR) using intra-operative guidance with pre-operative computed tomographic angiography (CTA) fusion and strict ALARA guidelines in a modern hybrid room. MATERIAL AND METHODS: Between February and November 2016, consecutive patients with AAA undergoing EVAR with a bifurcated device in a hybrid room under fusion imaging guidance were prospectively enrolled in six aortic centres from the United States (n = 1), Europe (n = 4), and Japan (n = 1). Demographic data including body mass index (BMI), indirect dose area product (DAP), cumulative air kerma (CAK), variables influencing dose delivery, and contrast media volume were collected. RESULTS: 85 patients (90.4% males) were included. The median age was 75 (IQR 69-81), with a median BMI of 27.4 (IQR 24.7-30.6). Median DAP and CAK were 14.7 (IQR 10.0-27.7) Gy·cm2 and 107 (IQR 68.0-189.0) mGy, respectively. The median contrast volume was 47 mL (IQR 35-70) (equivalent to 14.1g of iodine [IQR 10.5-21.0]). Median DAP per centre was 28.1 (n = 16, IQR 12.6-47.1), 15.9 (n = 11, IQR 11.9-22.5), 14.2 (n = 12, IQR 10.9-25.7), 20.2 (n = 18, IQR 7.0-39.5), 10.3 (n = 27, IQR 8.2-14.7) and 26.5 (n = 1) Gy·cm2. In multivariable analysis, collimation was the only factor that was significantly associated with DAP reduction, (coefficient = -0.014 per percentage of collimation, 95% CI -0.019 to -0.008, p < .001). CONCLUSIONS: With adherence to the ALARA principle and routine application of fusion imaging guidance for EVAR, low radiation exposure compared with the published literature can be achieved in a real world setting.

[Retrograde Stanford type A aortic dissection treated by thoracic endo-vascular aortic repair (TEVAR) after ascending aortic replacement].

A 77-year-old woman was admitted to a hospital with complaints of back pain, nausea and vomiting for 4 days. She underwent enhanced aortic computed tomography (CT) and was diagnosed with Stanford type A acute aortic dissection. Then she was transferred to our hospital. CT showed aortic dissection spreading from the ascending aorta up to the abdominal aorta and an intimal tear located at the descending thoracic aorta. Although the false lumen of the ascending aorta was thrombosed, emergency ascending aorta replacement and aortic valve replacement were performed, because pericardial effusion and severe aortic regurgitation were found by echocardiography. Postoperative enhanced CT showed an intimal tear and residual flow in the false lumen from the distal arch to the descending aorta. So an additional thoracic endo-vascular aortic repair (TEVAR) procedure was performed to close the entry tear 20 days after the 1st operation. She uneventfully left our hospital on the 15th postoperative day.

[Intraoperative aortic dissection].

Intraoperative aortic dissection is a rare complication of open heart operations. Once dissection has occurred, great caution is required because of high mortality rate. We reported 4 cases of intraoperative aortic dissection. The incident rate was 0.08%, and the most common site of aortic injury was the aortic cannulation site( 3/4 patients). Intraoperative epiaortic echography is effective in diagnosis. All cases underwent graft replacement of the ascending aorta. The postoperative course was uneventful. Both prompt recognition and appropriate surgical management are mondatory to improve operative outcome.

[Vascular Behçet disease presenting large right coronary artery pseudoaneurysm after percutaneous coronary intervention( PCI): report of a case].

A 37-year-old man was diagnosed with angina pectoris and underwent percutaneous coronary intervention(PCI) procedure for right coronary artery in other hospital. Five months after PCI procedure, he was admitted to the hospital because of fever, chest pain and respiratory discomfort. He was diagnosed as having a large right coronary artery pseudoaneurysm which was about 40 mm in diameter. He was transfered to our hospital. We did coronary artery bypass grafting(CABG)[ saphenous vein graft (SVG)-#3] and pseudoaneurysm closure, and he left our hospital on 37 post-operative day. After discharge from our hospital, he developed iliocecal ulcer, oral aphtha, folliculitis and arthralgia and was diagnosed with Behçet disease. Seven months after the 1st surgery, proximal anastomosis site of SVG was ruptured and presented huge ascending aorta pseudoaneurysm. We performed autologous pericardial patch plasty on ascending aorta, and covered there with omentum flap. He uneventfully left our hospital on 19 post-operative day.

[Thoracic and cardiovascular surgery in Jehovah's Witness].

A Jehovah's Witness who requires thoracic and cardiovascular surgery represents a challenge to both the surgeon and the patient because of the patient's refusal to accept blood transfusion. We reported 15 cases of Jehovah's Witness patients from 43 to 80 years of age who underwent cardiac operations or thoracic vascular operations. There was 1 emergency operation case and 2 re-do operation cases. Erythropoietin and serum albumin injections were allowed to be used in some cases. The mean pre-operative haemoglobin level in these patients was 12.3 g/dl. The mean postoperative lowest haemoglobin level was 9.2 g/dl. The mean haemoglobin level at the point of leaving hospital was 11.4 g/dl. There were no postoperative complications and no operative deaths. We successfully performed the thoracic and cardiovascular operations on Jehovah's Witnesses, including emergency cases, safely without blood transfusion. The most important thing is a careful and safe operative technique which reduces perioperative bleeding as much as possible.