[Emergency Operation for Impending Rupture of Syphilitic Aortic Aneurysm with Left Coronary Ostial Stenosis:Report of a Case].

Syphilis is known as a cause of syphilitic aortitis. Chronic inflammation leads to formation of syphilitic aneurysm which often is found at the ascending aorta. If the inflammation spreads to the aortic root, stenosis of coronary ostium or aortic valve regurgitation are caused. We report a case that impending rupture of syphilitic aneurysm at ascending aorta with stenosis of left coronary ostium. The patient is a 49 years old male, and his chief complaint was chest pain which gradually became stronger. Computed tomography (CT) identified a large ascending aneurysm with a maximum diameter of 66 mm. The serum rapid plasma regain( RPR) test and the fixed Treponema pallidum latex agglutination( TPLA) test were positive. We diagnosed impending rupture of aneurysm, and performed emergency ascending aorta replacement. The aortic aneurysm was strongly adherent to the surrounding tissues. Pathological findings showed mesaortitis, which was consistent with syphilitic aneurysm. We started oral administration of amoxicillin hydrate from postoperative day 8. The patient did well, and was discharged on postoperative day 18. During his hospitalization, we performed enhanced coronary CT, and found stenosis of left coronary ostium. But he had no symptoms, so he got percutaneous coronary intervention after his discharge. Now the number of patients of syphilis is increasing in Japan. So it is important to know its characteristics and proper treatment.

[Multi-stage Operations to Thrombose a False Lumen for Chronic Aortic Dissection:Report of a Case].

A 72 years old man underwent hemiarch replacement for acute aortic dissection of Stanford type A at the age of 62 years. Entry remained at the aortic arch, and the false lumen was patent to the terminal aorta. After 10 years, his aortic aneurysm was enlarged to 55 mm. Redo total arch replacement and open stent graft was performed. False lumen of thoracic descending aorta was thrombosed, but thoracoabdominal segment was patent. Two years later, he developed distal stent graft induced neo entry (dSINE). To achieve aortic reconstruction, thoracic endovascular aortic repair (TEVAR) of combined covered stent graft and metal bare stent was performed to the terminal aorta. Three months later, covered stent graft to left renal artery and coil emboli to false lumen, and abdominal endovascular aortic repair( EVAR) was performed. After these procedures, the false lumen was almost thrombosed.

[Stent Grafting for Aortic Dissection].

The purpose of stent graft for aortic dissection is to terminate antegrade blood flow into the false lumen through primary entry. Early intervention for primary entry makes excellent aortic remodeling and emergent stent grafting for complicated acute type B aortic dissection is supported as a class I. On the other hand stent grafting for chronic aortic dissection is controversial. Early stent grafting is considered with in 6 months after on-set if the diameter of the descending aorta is more than 40 mm. Additional interventions for residual false lumen on the downstream aorta are still required. Stent graft for re-entry, candy-plug technique, and double stenting, other effective re-interventions were reported. Best treatment on the basis of each anatomical and physical characteristics should be selected in each institution. Frozen elephant trunk is alternative procedure for aortic dissection without the need to take account of proximal anatomical limitation and effective for acute type A aortic dissection.

Transaortic stent grafting of a Kommerell diverticulum arising from a right-sided aortic arch.

In this article, we report the case of a 68-year-old woman who presented with shortness of breath. Respiratory function tests showed a slightly obstructive physiology. Computed tomography (CT) results revealed an aberrant left subclavian artery and a Kommerell diverticulum arising from a right-sided aortic arch that was compressing the trachea and the surrounding tissues. A median sternotomy was performed with the patient under circulatory arrest with moderate hypothermia, and a transaortic stent graft was inserted to exclude the Kommerell diverticulum. The aberrant left subclavian artery was ligated and an axillo-axillar bypass was constructed. Postoperative CT showed complete exclusion of the Kommerell diverticulum without an endoleak. The patient's breathing difficulty was resolved, and she was discharged uneventfully. This procedure should be considered as an alternative strategy for exclusion of Kommerell diverticulum.

[Aortoplasty with autologous pulmonary patch for the ascending aortic stenosis after interrupted aortic arch repair].

We experienced a case of ascending aortic stenosis after interrupted aortic arch repair. At the first operation in the neonatal period, diameter of the aortic annulus was 4.8 mm and no subvalvular stenosis was presented. Aortic arch was reconstructed with conventional technique of extended end-to-end anastomosis. Although ascending aortic stenosis was observed at the time, that had not been severe, however, the stenosis was exacerbated with time. At the catheterization 9 months after the operation, pressure gradient between aortic root and descending aorta was 72 mmHg. Therefore reoperation was carried out. Ascending aortoplasty using aoutologous pulmonary patch was performed. Pulmonary artery was repaired with aotologous pericardial patch. Despite mild pulmonary stenosis was observed, the postoperative course was favorable.

Total arch repair using supra-aortic debranching technique with banding of the ascending aorta for endovascular stent graft fixation.

Endovascular stenting requires a satisfactory landing zone that guarantees fixation and sealing of the proximal part of the endograft. We report total arch repair using supra-aortic debranching technique with banding of the ascending aorta for endovascular graft fixation. An 85-year-old man presented with hoarseness of voice. A fusiform aneurysm with a maximum transverse diameter of 62 mm on the aortic arch was identified by computed tomographic angiography. Supra-aortic arch debranching of the 3 neck vessels using a trifurcated graft and coronary arterial bypass grafting were performed while closely monitoring the regional cerebral oxygen saturation. The ascending aorta was dilated to 41 mm; we successfully reduced this to a mean outer diameter of 36 mm by banding the aorta using an expanded polytetrafluoroethylene surgical membrane. The endovascular procedure was performed 17 days after surgical intervention. The patient was extubated immediately after endovascular stent placement and spent 1 day in intensive care with no signs of transient or permanent neurologic events. A postoperative computed tomographic scan did not reveal any evidence of endoleak. The banding of the ascending aorta for endovascular graft fixation could facilitate endovascular aortic arch repair and provide an alternative treatment for high-risk patients.

Epicardial atrial mapping can predict elimination of chronic atrial fibrillation after the box pulmonary vein isolation during mitral valve surgery.

BACKGROUND: The pulmonary veins (PV) and posterior left atrium (LA) may contribute to the occurrence and maintenance of atrial fibrillation (AF). We evaluated whether simple epicardial electrophysiological mapping can predict elimination of chronic AF after the box PV isolation procedure. METHODS AND RESULTS: Using a computerized 48-channel mapping system, we performed intraoperative atrial mapping in 16 patients with chronic AF associated with mitral valve (MV) disease. Patients' ages ranged from 48 to 76 years (mean, 61.4 years). AF duration ranged from 1 to 16 years (mean, 7.5±5.4 years). Simple box PV isolation was performed during the MV operation. Regular and repetitive activation was found in the LA of 12 of 16 patients, and irregular and chaotic activation was found in both atria in 4 of 16 patients; 12 patients with regular and repetitive activation of the LA were treated by box PV isolation and the other 4 patients with irregular and chaotic activation in both atria did not recover sinus rhythm after this procedure. AF-free rate was significantly higher in patients with regular and repetitive activation of the LA (P<0.01). CONCLUSIONS: Box PV isolation was effective in the treatment of chronic AF associated with MV disease. Epicardial atrial mapping may predict elimination of AF after the box PV isolation.

Comparative study of Japanese frozen elephant trunk device for open aortic arch repairs.

OBJECTIVE: We performed a multicenter prospective comparative study to determine the impact of a Japanese frozen elephant trunk device on total arch replacement compared with conventional repair without it. METHODS: Between 2016 and 2019, a total of 684 patients (frozen elephant trunk procedure; n = 369; conventional repair, n = 315) from 41 institutions were enrolled. The 2 procedures were selected according to each center's strategy. RESULTS: The frozen elephant trunk procedure was applied more for aortic dissection, whereas the conventional repairs were predominantly performed for aneurysms. In the former, only hypothermic circulatory arrest time was reduced among the intraoperative parameters. Although there were no differences in the 30-day and in-hospital mortality rates (0.8% and 1.6%, respectively, for the frozen elephant trunk procedure vs 0.3% and 0.6%, respectively, for conventional repair), the neurologic complication rates were significantly higher in stroke (5.7% vs 2.2%; P = .022) and paraplegia (1.6% vs 0%; P = .023). In the propensity score matching analyses using 11 variables, statistical significance disappeared in the differences for mortality and neurologic morbidity (stroke and paraplegia/paraparesis) rates of 194 patients of each group, although they were still higher for the frozen elephant trunk procedure. CONCLUSIONS: The early outcomes of total arch replacement with the frozen elephant trunk procedure were acceptable despite its higher prevalence of emergency or redo surgery, which was comparable to that of the conventional repair. This procedure had higher rates of spinal cord injury than the conventional repair, which is a disadvantage of this approach.

New method for absolute spinal cord ischemia protection in rabbits.

OBJECTIVE: This study aims to establish a superior procedure to prevent spinal cord damage after severe spinal cord ischemia during aortic surgery. We examined the synergistic effect of topical hypothermia of the spinal cord combined with radical scavenger infusion into the clamped segment of the aorta to prevent spinal cord damage in an animal model. METHODS: Spinal cord ischemia was induced in rabbits by clamping the aorta between the renal artery and aortic bifurcation for 30 minutes. Rabbits were divided into four groups of 16 each: group I, sham-operated; group II, edaravone (6 mL, 4°C, 1 mg/kg); group III, saline (6 mL, 4°C) with transvertebral cooling pads; group IV, edaravone (6 mL, 4°C, 1 mg/kg) and transvertebral cooling pads. Solutions were injected into the clamped segment of the aorta. Postoperative assessments included the Tarlov score, spinal cord histopathology, and measurement of malondialdehyde levels in the spinal cord tissue. RESULTS: At 48 hours after reperfusion, the mean Tarlov scores in groups I, II, III, and IV were 4.0, 1.5, 1.9, and 4.0, respectively. The mean number of normal motor neurons was significantly higher in groups I (54.1) and IV (53.7) than in groups II (32.8) and III (36.3; P < .001). The mean malondialdehyde level in groups I (19.8 nmol/mL) and IV (22.6 nmol/mL) was significantly lower than in groups II (64.8 nmol/mL) and III (60.9 nmol/mL; P < .001). At 168 hours after reperfusion, the mean Tarlov scores in groups I, II, III, and IV were 4.0, 1.1, 1.3, and 4.0, respectively. The mean number of normal motor neurons was significantly higher in groups I (52.9) and IV (50.8) than in groups II (22.4) and III (25.9; P < .001). The mean malondialdehyde level in groups I (20.7 nmol/mL) and IV (23.4 nmol/mL) was significantly lower than in groups II (68.9 nmol/mL) and III (61.6 nmol/mL; P < .001). CONCLUSION: In a rabbit model with aortic clamping up to 30 minutes, which consistently produces complete paraplegia in rabbits, spinal cord damage was partially reduced by topical cooling with transvertebral cooling pads or the injection of edaravone into the clamped segment of aorta, but was more effectively protected by a combined use of these two strategies.

Surgical Treatment for Primary Mycotic Aneurysms Using Endovascular Therapy, Focusing on Patient Selection: Single-Center Experience.

Background: Mycotic aneurysms (MAs) are relatively rare but life-threatening. Some recent reports have described the use of endovascular therapy for their treatment; however, this still is a controversial treatment, and a definite target population has not been determined. Methods: We performed surgery on 34 patients with MAs from March 2005 to March 2019. Twenty patients who underwent open surgery (OS) first comprised the OS group, and 14 patients who underwent endovascular therapy first comprised the stent-graft (SG) group. We analyzed between-group differences, long-term outcomes, and risk factors for death retrospectively. Patients in the OS group had a higher initial white blood cell count than those in the SG group (p = 0.047). The SG group had more patients with a low albumin concentration (≤2.0 mg/dL) than did the OS group (p = 0.026). Results: There were no significant differences in the operative mortality rates between the groups (p = 0.773). Additional procedures were required more often in the SG than the OS group (p = 0.0013). The overall survival rate as estimated by the Kaplan-Meier method was 88% at 1 month, 67% at 1 year, 57% at 3 years, and 45% at 10 years. In the univariable analysis, chronic obstructive pulmonary disease (COPD) was a risk factor for death (p = 0.003). Conclusions: Endovascular therapy for MAs produced reasonable outcomes when patient selection was based on the activity level, nutritional condition, and degree of inflammation. Endovascular therapy may become an option for patients with a low albumin concentration or COPD despite the fact that additional procedures may be needed.

Successful endovascular repair of spontaneous aortic rupture early postpartum.

Endovascular repair of pregnancy-associated aortic disease is controversial because the long-term result is still unclear. We report a rare case of early postpartum spontaneous aortic rupture that was successfully treated by endovascular repair, with a good midterm result. Multiangle thin-slice images of contrast-enhanced computed tomography revealed a very small rupture point. It was successfully repaired by minimally invasive treatment.

Stented balloon fenestration before entry repair using the frozen elephant trunk technique for chronic aortic dissection.

Endovascular fenestration on the abdominal aorta is effective for preventing visceral malperfusion in aortic dissection. We report a case of stented balloon fenestration before residual entry repair using the frozen elephant trunk technique for chronic aneurysmal dissection after ascending aortic replacement for DeBakey I aortic dissection. We recognized poor communication between the true lumen and false lumen in the abdominal aorta, and visceral perfusion depended almost entirely on the proximal large entry. Therefore, we scheduled catheter angioplasty on the small re-entry before upstream entry closure. After balloon angioplasty using a PTA catheter, a 10-mm × 4-cm self-expandable stent was deployed at the re-entry. We performed open surgery 5 days after angioplasty. Computed tomography after entry repair showed complete thrombosis of the false lumen on the descending aorta, and the celiac and superior mesenteric arteries were supplied via the abdominal re-entry stent. Stented balloon fenestration before entry repair using frozen elephant trunk with chronic aortic dissection was effective for preventing visceral malperfusion.

Endovascular repair for three-channelled aortic dissection.

Surgical repair of extensive thoracic aortic disease induced by repeated aortic dissection is challenging due to its invasive nature in some cases. We report a rare case of successful endovascular repair of a dissected 3-channelled thoracic aortic aneurysm using the PETTICOAT (provisional extension to induce complete attachment) technique and false-lumen embolization (the candy-plug technique). The PETTICOAT technique improved visceral flow, and the false lumen of the aneurysm was completely thrombosed by the candy-plug technique. This minimally invasive combination technique might be a good option for the treatment of complex dissected thoracic aorta.

A pitfall of false lumen embolization in chronic aortic dissection: intimal injury caused by the embolization device edge.

We report a case of intimal injury caused by the occluder device in the false lumen (FL) after treatment of refractory chronic aortic dissection with FL embolization. We speculate that the intimal injury was due to the disproportionate stress from the FL. We covered the new entry by an additional stent graft in the true lumen. The deployment of a stent device in both lumens at the level of embolization might be indispensable for FL embolization.

Impact of the size mismatch between saphenous vein graft and coronary artery on graft patency.

BACKGROUND: The saphenous vein graft (SVG) is widely used in coronary artery bypass grafting because of its availability and ease of use. However, the patency rate of the SVG grafted to the right coronary artery (RCA) is poor. Diameter mismatch between the coronary artery and SVG is an important cause of graft occlusion. In this study, we assessed how the degree of diameter mismatch affects SVG patency. METHODS: We reviewed the records of 123 patients who underwent aorto-right coronary artery bypass grafting with an SVG. The patency rate of the SVG, SVG diameter, RCA diameter and SVG-RCA diameter ratio (SR ratio) was assessed based on angiography and CT. RESULTS: The mean SVG diameter was 3.61 ± 0.72 mm, the mean RCA diameter was 1.57 ± 0.32 mm and the mean SR ratio was 2.37 ± 0.57. Cumulative patency rate of the SVG was 95.5 % at the early phase, 85.2 % at 1 year, and 70.2 % at 5 years. Multivariate analysis showed that the SR ratio was an independent predictor of SVG occlusion. The cutoff value of the SR ratio was 2.8, calculated from the point of maximal specificity (81.2 %) and sensitivity (64.7 %), and the area under the ROC curve was 0.734. When the SR ratio was ≤2.8, the 3-year patency rate was 86.1 %. CONCLUSIONS: A mismatch between SVG diameter and RCA diameter has an impact on the patency rate of the SVG. Evaluation of the saphenous vein before surgery and selection of a graft to minimize mismatch should improve SVG patency.

Early- and mid-term aortic remodelling after the frozen elephant trunk technique for retrograde type A acute aortic dissection using the new Japanese J Graft open stent graft.

OBJECTIVES: We previously performed the frozen elephant trunk (FET) technique for acute type A aortic dissection to try to improve the long-term prognosis. In this study, we report the mid-term results of the FET technique for treating retrograde type A acute aortic dissection using a new device, the J Graft open stent graft (JOSG). METHODS: Between January 2008 and December 2015, 24 patients (mean age: 59.3 ± 13.9 years) underwent total arch replacement with the FET technique using the JOSG for retrograde type A acute aortic dissection. All patients had at least 1 year of follow-up imaging. RESULTS: The average outer diameter of the JOSG was 28 ± 2.8 mm (range: 25-35 mm). The average position of the distal edge of the JOSG was Th 6.6 ± 1.1. The cumulative survival rate at 1 year was 91.6%. Postoperative computed tomography 1 year after surgery showed that complete thrombosis was present in all patients at the level of the distal edge of the stent graft and the aortic valve. At the diaphragmatic level, complete thrombosis was seen in 14 (70%) patients, the false lumen was patent in most patients (90%) at the superior mesenteric artery level. CONCLUSIONS: The use of the FET technique with the JOSG for retrograde type A acute aortic dissection provides good outcomes. With the proper use of the JOSG, it is possible to expand the true lumen and eliminate antegrade false-lumen flow, resulting in good aortic remodelling. Furthermore, there should be obliteration of the false lumen from the stent graft to the aortic valve, and this might reduce long-term complications.

Management of cerebral malperfusion in surgical repair of acute type A aortic dissection.

OBJECTIVES: Cerebral malperfusion for patients with acute type A aortic dissection (AAAD) remains an unsolved problem. The present study aimed to evaluate our management of cerebral perfusion and identify predictors of perioperative cerebral malperfusion in patients undergoing surgical repair of AAAD. METHODS: Between January 2004 and December 2015, 137 consecutive patients with AAAD underwent aortic replacement at Tsuchiya General Hospital. The status of the dissected supra-aortic branch vessels (SABVs) was classified as patent or thrombosis by preoperative computed tomographic angiography. Intraoperative cerebral perfusion was monitored by transcutaneous carotid echo and regional oxygen saturation. In cases with neurological symptoms or cerebral malperfusion, quick cerebral perfusion was immediately started using a quick cutdown technique. We assessed clinical outcomes, including mortality and complications, and analysed predictors of early mortality and cerebral malperfusion. RESULTS: The early mortality rate was 8.0%. Postoperative cerebral injury was observed in 4 patients (2.9%). Nineteen patients had perioperative cerebral malperfusion. There were no postoperative cerebral injuries in the patients in whom intraoperative cerebral malperfusion was corrected. Multivariable analysis revealed that preoperative shock (odds ratio [OR] 22.60, P < 0.0001) and extension of dissection to the abdominal aorta (OR 9.31, P = 0.0064) were significant risk factors for early mortality. Preoperative neurological symptoms (OR 12.40, P = 0.0006) and partial or complete thrombosis of the SABV (OR 64.10, P < 0.0001) were identified as independent predictors of perioperative cerebral malperfusion. CONCLUSIONS: Perioperative cerebral perfusion should be carefully managed, especially in the patients with preoperative neurological symptoms or partial or complete thrombosis of the SABV.

Endovascular Repair by Graft-to-Graft Bridging in a Patient with Marfan Syndrome.

We report a case of chronic aortic dissection in a patient with Marfan syndrome in which we performed thoracic endovascular repair after aortic root replacement, total arch replacement with open stent grafting and thoracoabdominal aortic repair. We consider that endovascular repair of the dissected descending aorta in a patient with Marfan syndrome can be effective when graft-to-graft bridging is performed as the "finishing procedure".