[Early to Long-term Results of Left Atrial Appendage Closure Using Clip Device in Patients with Atrial Fibrillation].

Oral anticoagulants for atrial fibrillation are the standard approach to prevent stroke in patients with atrial fibrillation. However, oral anticoagulant therapy carries the risk of cerebral infarction recurrence, not to mention hemorrhagic complications, even under appropriate drug therapy. Surgical treatments targeting the left atrial appendage include left atrial appendage closure( LAAO) and left atrial appendage resection (LAAR). Our hospital uses AtriClip (approved and available in Japan since 2018) as a device for LAAO, and we investigated the early and long-term results of LAAO using AtriClip in our hospital. As a result, stable early to long-term results were expected for left atrial appendage closure using AtriClip device, suggesting that it may be an option that can be considered as a method for preventing stroke in patients with atrial fibrillation. But further investigation is required in the future.

Relationship of acute type A aortic dissection and disseminated intravascular coagulation.

OBJECTIVE: Acute type A aortic dissection (ATAAD) is a critical disease presenting with disseminated intravascular coagulation (DIC). However, the relationship between the degree of DIC and false lumen conditions remains unclear. In the present study, we evaluated the degree of preoperative DIC and the outcomes of ATAAD treatment. METHODS: A total of 124 patients with ATAAD (70 men and 54 women) treated from January 2012 to January 2020 were included in the present study. The correlation between the preoperative Japanese Association for Acute Medicine (JAAM) DIC score and the false lumen diameter and length, measured using preoperative computed tomography, was examined retrospectively. The correlations were calculated using liner regression analysis. The level of statistical significance was set at P < .05. RESULTS: The patients were divided into two groups: a low JAAM DIC score group and a high JAAM DIC score group. The preoperative JAAM DIC scores in the high- and low-score groups were 4.8 ± 1.2 and 1.7 ± 2.3, respectively (P < .001). The 5-year survival rates and aortic event-free rates in the low-score group were favorable compared with the high-score group; however, the differences were not statistically significant (80.8% vs 54.5%, P = .065; 63.9% vs 59.8%, P = .15, respectively). The false lumen diameter in the ascending aorta was greater in the high-score group than that in the low-score group (P < .05). The JAAM DIC score correlated significantly with the ascending false lumen diameter and the dissection length (r = 0.32 and P < .001; r = 0.29 and P = .001, respectively). A high JAAM DIC score was associated with communicating-type ATAAD (P < .05). CONCLUSIONS: Our results suggest that high preoperative JAAM DIC scores are associated with a large false lumen and communicating-type ATAAD.

Early Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Increases the Success of Aortic Remodeling.

BACKGROUND: Type B aortic dissection (TBAD) is treated with thoracic endovascular aortic repair (TEVAR). However, the optimal timing of the surgical intervention remains unclear. We aimed to investigate whether the timing of TEVAR impacts aortic remodeling. METHODS: Forty-three patients with TBAD (31 men and 12 women) who had undergone surgical intervention with TEVAR between January 2014 and June 2021 were retrospectively evaluated. The relationship between the timing of TEVAR and success of aortic remodeling was assessed using linear regression analysis. Successful aortic remodeling was defined by a reduction of diametric ratio (false lumen/aorta) at 3 points (thoracic region, thoracoabdominal region, and abdominal region) and measured using computed tomography both pre- and post-operatively. The level of statistical significance was set at P < 0.05. RESULTS: The timing of TEVAR after symptom onset was defined as early (≤14 days, n = 27, group E) or late (≥15 days, n = 16, group L). The median duration from symptom onset to TEVAR in groups E and L were 3 days (interquartile range [IQR], 1.5-6 days) and 196 days (IQR, 89.8-252.3 days), respectively (P < 0.001). Patent type, rupture, malperfusion, and continuous pain were present preoperatively in 82%, 3.7%, 14.8%, and 33.3% of patients in group E, respectively, and in 37.5%, 0%, 6.3%, and 0% of patients in group L, respectively. In group E, thoracic aortic diameter and false luminal thickness were decreased significantly from pre- to post-operation (36.9 ± 12.4 vs. 35 ± 12.7 mm, P = 0.03; 13.6 ± 6.2 vs. 3.4 ± 4.5 mm, P < 0.001, respectively). Whereas, thoracic aortic diameter significantly increased, and false luminal thickness did not significantly change pre- and post-operation in group L (32.7 ± 9.5 vs. 37 ± 12.8 mm, P = 0.041; 9.1 ± 4.5 vs. 7.5 ± 9.5 mm, P = 0.4, respectively). CONCLUSIONS: Our results suggest that early intervention for TBAD with TEVAR increases the success of aortic remodeling.

Safety and efficacy evaluation of low-dose trimethoprim-sulfamethoxazole for prophylaxis of Pneumocystis pneumonia in HIV uninfected patients undergoing hemodialysis: a retrospective observational study.

BACKGROUND: Pneumocystis pneumonia (PCP) is a potentially life-threatening infection. Trimethoprim-sulfamethoxazole (TMP-SMX) is considered as the first regimen for PCP prophylaxis according to several guidelines. The recommended prophylactic dose of TMP-SMX has been determined based on patients with normal renal function, but the appropriate dosage for patients undergoing hemodialysis is unknown. The aim of this study was to investigate the efficacy and safety of low-dose TMP-SMX in patients undergoing hemodialysis. METHODS: HIV-uninfected adult patients who were undergoing hemodialysis and administered TMP-SMX for PCP prophylaxis, were included, and divided into standard-dose (≥6 single strength (SS, TMP-SMX 80 mg/400 mg tablets/week) and low-dose groups (< 6 SS tablets/week). The endpoints were cumulative incidence of PCP and cumulative discontinuation rate of TMP-SMX due to adverse events. For comparison of the groups, we employed the chi-squared test for categorical variables and the Mann-Whitney U test for continuous variables. Risk factors for the endpoints were evaluated using the Cox Fine and Gray method. RESULTS: The median age of the 81 patients included in the study was 67 years (IQR: 60-76 years), and 52 patients (64.2%) were men. No patients in either group developed PCP during the observation period. The yearly cumulative incidence of discontinuation was 12.1% (95% confidence interval [CI]: 0.027-0.29) in the low-dose group and 35.6% (95% CI: 0.20-0.52) in the standard-dose group (P = 0.019). The adjusted hazard ratio of the low-dose group compared to standard-dose group was 0.18 (95% CI: 0.04-0.86, P = 0.032). CONCLUSIONS: None of the study patients developed PCP, and the cumulative discontinuation rate of TMP-SMX due to adverse events was significantly lower in the low-dose group compared to that in the standard-dose group (P = 0.032). These results indicate that low-dose TMP-SMX is an appropriate regimen to maintain a balance between PCP prophylaxis and prevention of adverse events due to TMP-SMX administration. These findings can guide health care professionals to determine TMP-SMX dosage when considering PCP prophylaxis for patients undergoing hemodialysis.

[Less Invasive Surgical Closure of the Left Atrial Appendage for Cardiogenic Cerebral Embolism in a Patient with Dilated Cardiomyopathy].

Less invasive surgical closure of the left atrial appendage is recommended to prevent cardiogenic thromboembolism in patients with chronic non-valvular atrial fibrillation( Af) and other high-risk cardiac diseases such as dilated cardiomyopathy (DCM). We report a case of a 57-year-old man with Af and DCM. Catheter ablation for Af was contraindicated in this patient with a history of cardiogenic thromboembolism, and anticoagulation therapy was initiated. Despite anticoagulation therapy, the patient developed another ischemic stroke and we administered aggressive anticoagulation therapy resulting in successful resolution of the left atrial appendage thrombus. Less invasive surgical closure of the left atrial appendage was successfully performed, and thromboembolism has not recurred for one year postoperatively.

[Transthoracic Endovascular Aortic Repair for Malperfusion after Ascending Aortic Replacement for Stanford Type A Acute Aortic Dissection;Report of a Case].

A 53-year-old man was presented with Stanford type A acute aortic dissection. We first performed emergency ascending aortic replacement under selective cerebral perfusion with moderate hypothermia. He developed abdominal pain after the surgery. Six days after the 1st surgery, computed tomography revealed that the new entries were located in the distal anastomosis site and the distal aortic arch, and the true lumen of the aorta was obstructed by the false lumen and stenosis. Visceral malperfusion was diagnosed and emergent total debranching thoracic endovascular aortic repair (TEVAR) was planned. One proximal covered stentgraft and 2 distal bare stents were deployed.

A Case of Cardiogenic Stroke After Thoracoscopic Left Atrial Appendectomy.

Thoracoscopic left atrial appendectomy is a minimally invasive procedure for left atrial appendage occlusion in patients with non-valvular atrial fibrillation, particularly those at a great risk for both stroke and bleeding despite appropriate oral anticoagulant therapy. It serves as an alternative strategy for stroke risk reduction. Moreover, the oral anticoagulant therapy can be discontinued after the operation. However, we encountered a 74-year old male patient who developed cardiogenic stroke after thoracoscopic left atrial appendectomy. We report this case to introduce how we evaluate the risk of postoperative cardiogenic stroke by means of contrast-enhanced cardiac computed tomography (CT), and how we formulate the postoperative patient management strategy including short-term oral anticoagulation therapy by using results of cardiac CT.

Successful treatment with bortezomib and dexamethasone for proliferative glomerulonephritis with monoclonal IgG deposits in multiple myeloma: a case report.

BACKGROUND: Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) is a form of renal involvement by monoclonal IgG deposits that was found in mesangial, subendothelial or subepithelial regions. The distribution of glomerular deposits was completely different from that in monoclonal immunoglobulin deposition disease. PGNMID is reported to be rarely associated with a hematological malignancy. Previously, only five cases of PGNMID with multiple myeloma have been reported. However, the pathogenic relationship between PGNMID and multiple myeloma was unclear because a detailed description was not provided. We report that a patient with PGNMID associated with multiple myeloma was treated with bortezomib and dexamethasone and underwent the second renal biopsy after treatment, showing that chemotherapy was effective for PGNMID clinically and pathologically. CASE PRESENTATION: A 75-year-old man presented with progressive leg edema, had nephrotic range proteinuria, hypoalbuminemia, moderate renal failure, and occult blood in his urine. Electrophoresis results showed serum and urinary monoclonal spikes of IgGκ type immunoglobulin. A renal biopsy specimen showed lobular mesangial proliferation with mesangiolysis, glomerular micro-aneurysm, and endocapillary hypercellularity. Immunofluorescence results revealed strong granular capillary and mesangial staining for IgG1, C3 and κ light chain in glomeruli without tubular deposits of any immunoglobulin. Electron microscopy also showed dense granular deposits in subendothelial and mesangial areas. PGNMID associated with multiple myeloma (IgGκ type) was diagnosed on the basis of a subsequent bone marrow examination. Bortezomib and dexamethasone therapy significantly reduced proteinuria and elevated serum albumin level. Eight months later, the second renal biopsy showed no active lesions and that the IgG1 and κ light chain deposits had drastically disappeared. CONCLUSIONS: This is the first case of PGNMID with multiple myeloma successfully treated with bortezomib and dexamethasone in which comparative renal biopsies were performed before and after treatment. Our findings suggest the pathogenesis of PGNMID and therapeutic options for PGNMID.

[Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair;Report of a Case].

A 72-year-old man presented with aneurysms of the distal aortic arch and the distal descending aorta due to chronic type B aortic dissection. We first performed thoracic endovascular aortic repair (TEVAR) in the distal descending aorta, and the aneurysm was successfully excluded using a Gore Tag stentgraft. Seven days after TEVAR, computed tomography revealed retrograde type A aortic dissection occurring from the ascending aorta to the distal aortic arch. In emergency surgery, ascending aorta and total arch replacement were performed under selective cerebral perfusion with moderate hypothermia, and after coming off cardiopulmonary bypass, the distal aortic arch aneurysm was excluded using a Gore Tag stentgraft.

[Relapse of Mitral Regurgitation Due to Tethering after Valve Plasty with Edge-to-edge Repair;Report of a Case].

A 75-year-old woman with severe mitral regurgitation (MR) successfully underwent mitral valve plasty with edge-to-edge plasty and commissural annuloplasty. Three days after the operation, she was found to have moderate MR caused by tethering of the valve. Functional MR occurring as a complication of mitral edge-to-edge plasty could be treated conservatively.

[Thoracoscopic Left Atrial Appendectomy for a Patient with Thrombus in the Left Atrial Appendage after Anticoagulation Therapy;Report of a Case].

Thoracoscopic left atrial appendectomy for patients with non-valvular atrial fibrillation has been suggested as a new approach for preventing cardiogenic thromboembolism. While this procedure is effective in patients who suffer from thromboembolism even with anticoagulation therapy, it is contraindicated in patients with an existing left atrial appendage thrombus. We herein report a case of 61-yearold female with atrial fibrillation and recurrent cardiogenic thromboembolism. Left atrial appendage thrombus had been detected even under anticoagulation therapy. We decided to strengthen anticoagulation therapy and successfully resolved the left atrial appendage thrombus. Thus, thoracoscopic left atrial appendectomy was performed safely, and thromboembolism has never occurred since the operation.

[Total Endoscopic Left Atrial Appendectomy for Valvular Atrial Fibrillation;Report of a Case].

Total endoscopic left atrial appendectomy for non-valvular atrial fibrillation(Af) has been reported to be a safe and effective procedure to prevent cardiogenic thromboembolism and also discontinue oral anticoagulant therapy. On the other hand, open-heart surgery is generally indicated for valvular Af. We report the case of a 67-year-old male patient with valvular Af and recurrent episodes of cardiogenic thromboembolism who underwent total endoscopic left atrial appendectomy. He was diagnosed as having mitral valve stenosis and scheduled for surgery, but presented with cerebellar hemorrhage after warfarin was replaced with heparin in the preoperative phase. Consequently, the operation was cancelled. The case was considered as a good relative indication for total endoscopic left atrial appendectomy, which does not need a cardiopulmonary bypass, to prevent future cardiogenic thromboembolism. The operation was performed and the postoperative course was uneventful.

A comparison between stand-alone left atrial appendage occlusion and resection as a method of preventing cardiogenic thromboembolic stroke.

OBJECTIVE: The present study evaluated the differences between left atrial appendage occlusion (LAAO) and left atrial appendage resection (LAAR) in terms of the safety and efficacy. MATERIALS AND METHODS: From January 2018 to August 2022, 94 patients underwent a stand-alone LAAO, and 90 patients underwent stand-alone LAAR in our institution. All of these patients were included in this study. LAAO was performed via left mini-thoracotomy, and LAAR was performed via a left thoracoscopic approach. The patients' characteristics and perioperative and postoperative data were obtained by retrospectively reviewing their medical records. RESULTS: The mean age of the patients was 72.4 ± 10.2 (LAAO) and 66.2 ± 9.4 (LAAR) years old (P < 0.05). There were no marked differences in the mean duration of atrial fibrillation (AF) or the ratio of AF type between both groups. The average CHA2DS2-Vasc scores were 4.4 ± 1.6 (LAAO) and 2.7 ± 1.8 (LAAR) (P < 0.05), and the average HAS-BLED scores were 2.9 ± 1.0 (LAAO) and 2.2 ± 1.2 (LAAR) (P < 0.05). The mean operation time was 49 ± 20 min (LAAO) and 34 ± 15 min (LAAR) (P < 0.05). No substantial gaps were detected in preoperative echo-graphic findings between the groups. No significant differences were observed in the amount of intraoperative or postoperative bleeding or the rate of intraoperative massive bleeding events between the groups. Successful LAA closure was achieved in all cases in both groups. Approximately 50% of patients underwent concomitant left pulmonary vein isolation (LPVI) during surgery, indicating no significant differences between the groups (P = 0.872). The early mortality rate was 1.04% in the LAAO group and 0% in the LAAR group (P = 0.132). There was no significant difference in the rate of postoperative LAA stump thrombus between the groups (8.5% in the LAAO group and 6.7% in the LAAR group; P = 0.320). The mean follow-up period was 851 ± 500 (6-1618) days in the LAAO group and 1208 ± 357 (49-1694) days in the LAAR group. Postoperative stroke events were detected in 1 patient in each group (P = 0.432). There was no significant difference in the sinus rhythm recovery rate after LPVI between these groups (31.1% in the LAAO group and 28.6% in the LAAR group; P = 0.763). CONCLUSION: There were no significant differences between LAAO and LAAR in terms of the feasibility and the effectiveness as a method for stroke prophylaxis only to selected patients for both procedures, although further studies including the comparison between groups with the same backgrounds to confirm the authentic differences in the clinical results between these procedures.

Incidence of Acute Thrombosis After Surgical Left Atrial Appendage Occlusion for Atrial Fibrillation.

BACKGROUND: The clinical implications of acute phase thrombosis after surgical left atrial appendage (LAA) closure remain unclear. This study sought to determine the frequency, prognosis, and factors involved in thrombogenesis after surgical LAA occlusion. METHODS: In this study, data from patients who underwent 2 types of standalone surgical LAA closure (either resection or clipping) between July 2014 and March 2020 at a single center were analyzed. RESULTS: A total of 239 consecutive patients with atrial fibrillation underwent minimally invasive standalone surgical LAA occlusion (184 resection cases and 55 clipping cases). On postoperative day 2, electrocardiogram synchronized contrast-enhanced computed tomography (CT) was performed in 223 cases (93.3%), and echocardiography follow-up was performed in 16 cases when CT was contraindicated. Acute postoperative thrombus on the closed stump was detected in 35 cases (14.7%), of which 29 cases (15.8%) belonged to the resection group and 6 cases (10.9%) belonged to the clipping group. No significant difference was detected between the groups, and no significant predictors of acute-phase thrombosis were found. Thromboembolism occurred in 4 patients before postoperative imaging follow-up, and there was no evidence of thrombi in these patients on postoperative day 2 CT. Three months after the first CT, thrombi were no longer detected in 34 of 35 patients (97.1%). CONCLUSIONS: Thrombosis can occur after surgical LAA occlusion. Although the clinical significance is yet unclear, it may be reasonable to continue anticoagulation therapy until a lack of thrombosis is confirmed, unless there are contraindications.

Immunohistological analysis reveals IgG1-dominant immunophenotype of tubulointerstitial nephritis unassociated with IgG4-related diseases.

PURPOSE: Tubulointerstitial nephritis (TIN) has various etiologies, including IgG4-related disease (IgG4-RD), autoimmune diseases, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), and others. IgG4-positive plasma cell infiltration can occasionally be found in TIN unrelated to IgG4-RD. Therefore, there may be problems with usage of IgG4 immunostaining to differentiate between TIN with and TIN without IgG4-RD. This study aimed to compare the proportion of plasma cells that are positive for each IgG subclass and to clarify the predominant IgG subclass trends and clinical characteristics associated with IgG4-RD and non-IgG4-related interstitial nephritis. METHODS: The study enrolled 44 cases of TIN: 6 of IgG4-RD, 8 of autoimmune disease, 9 of AAV, and 21 of unknown disease group. In addition to clinical characteristics, IgG subclass composition of interstitial plasma cells was evaluated among 4 groups by immunohistochemistry. RESULTS: IgG1 was the predominant IgG subclass in TIN unrelated to IgG4-RD. In the IgG4-RD group, the IgG subclass rate was high in both IgG1 and IgG4. The rate of average IgG4-positive cells was significantly lower in the autoimmune disease group and unknown disease group compared with the IgG4-RD group. CONCLUSION: The present study revealed IgG1-dominant immune profiles of TIN unrelated to IgG4-RD. Further investigation is required to elucidate the clinicopathological differences between IgG1-dominant and IgG4-dominant groups in IgG4-RD.

Relationship between 2nd-generation angiotensin receptor blockers and the risk of hypotension in COVID-19 patients admitted to hospital.

It has not yet been established whether angiotensin II receptor blockers (ARB), statins, and multiple drugs affect the severity of COVID-19. Therefore, we herein performed an observational study on the effects of 1st- and 2nd-generation ARB, statins, and multiple drugs, on COVID-19 in patients admitted to 15 Japanese medical facilities. The results obtained showed that ARB, statins, and multiple drugs were not associated with the primary outcome (odds ratio: 1.040, 95% confidence interval: 0.688-0.571; 0.696, 0.439-1.103; 1.056, 0.941-1.185, respectively), each component of the primary outcome (in-hospital death, ventilator support, extracorporeal membrane oxygenation support, and admission to the intensive care unit), or the secondary outcomes (oxygen administration, disturbed consciousness, and hypotension, defined as systolic blood pressure ≤90 mmHg). ARB were divided into 1st- and 2nd-generations based on their approval for use (before 2000 and after 2001), with the former consisting of losartan, candesartan, and valsartan, and the latter of telmisartan, olmesartan, irbesartan, and azilsartan. The difference of ARB generation was not associated with the primary outcome (odds ratio with 2nd-generation ARB relative to 1st-generation ARB: 1.257, 95% confidence interval: 0.613-2.574). The odd ratio for a hypotension as one of the secondary outcomes with 2nd-generation ARB was 1.754 (95% confidence interval: 1.745-1.763) relative to 1st-generation ARB. These results suggest that patients taking 2nd-generation ARB may be at a higher risk of hypotension than those taking 1st-generation ARB and also that careful observations are needed. Further studies are continuously needed to support decisions to adjust medications for co-morbidities.

Inverted Thoracic Stent Graft Technique for Separation of a Stent Graft and Bare Stent Caused by Aortic Elongation.

INTRODUCTION: Component separation (CS) of the Zenith Dissection Endovascular Graft and Stent have been reported with some causes. However, CS caused by aortic elongation has not yet been reported. A long treatment range with the sacrifice of some intercostal arteries (ICAs) is sometimes needed when repairing CS because of the large difference in the diameter between the proximal and distal landing zones with a reverse taper. CASE PRESENTATION: A 78-year-old man, who underwent thoracic endovascular aortic repair (TEVAR) using a Zenith Dissection Graft and stents for acute type B aortic dissection 3 years and 8 months previously was admitted to our hospital with severe back pain. Contrast-enhanced computed tomography (CT) showed separation of the SG and bare stent, and aortic elongation. As there was a large difference in the diameter of the proximal and distal landing zones with a reverse taper, a long treatment range with the sacrifice of two large ICAs was needed. Thus, TEVAR using an inverted thoracic SG technique was performed in order to shorten the treatment range to preserve a large ICA and reduce the risk of paraplegia. Completion angiography showed that the separation was repaired with preservation of the large ICA. The postoperative course was uneventful, and he was discharged on postoperative day 10 with relief of his severe pain. At 1 year after secondary TEVAR, CT showed that the diameter of the descending aorta had decreased with no separation of the SGs. CONCLUSION: Deployment of an inverted thoracic SG for the treatment of CS of the Zenith Dissection Endovascular Graft and Stent is a feasible and effective procedure to preserve ICAs. An overlapping range of >1.5 times the length of a bare stent within an SG is needed to prevent CS of the Zenith Dissection Endovascular Graft and Stent caused by aortic elongation.

Aortic Remodeling After Stepwise External Wrapping for Type A Acute Aortic Dissection.

BACKGROUND: The optimal repair technique for type A acute aortic dissection is graft replacement; however, the treatment approach in high-risk patients remains controversial or suboptimal. METHODS: We have retrospectively analyzed a cohort of high-risk patients who were admitted to our center for type A acute aortic dissection and who were treated by a new surgical approach using artificial grafts (stepwise external wrapping) between January 2016 and January 2020. The primary endpoints included inhospital mortality and survival during follow-up. Secondary endpoints included the assessment of aortic remodeling after ascending aorta wrapping. RESULTS: Among the 134 patients admitted for type A acute aortic dissection, 43 patients underwent stepwise external wrapping. The mean patient age was 79.1 ± 6.8 years. The new standard European System for Cardiac Operative Risk Evaluation score was 64% ± 12%. There was one hospital death (2.3%). There were two major complications of persistent cerebral disorder (4.6%). Minor complications included temporary neurologic disorder (2.3%) and renal failure (2.3%). The intensive care unit and hospital stays were 2.8 ± 1.0 days and 11.7 ± 2.5 days, respectively. The follow-up survival rate was 95.3% ± 6.2% and 91% ± 10.2% at 1 and 3 years, respectively, after surgery. There was no aortic-related death during follow-up. At 1 year after surgery, complete remodeling of the ascending aorta was obtained in 30 patients (85.7%), and 5 patients (14.3%) showed partial remodeling. CONCLUSIONS: Our stepwise external wrapping technique was associated with excellent outcomes for high-risk patients with type A acute aortic dissection.

Successful hybrid repair for ruptured abdominal aortic aneurysm caused by type IIIa endoleak resulting from a disconnected contralateral limb.

The occurrence of a type IIIa endoleak after endovascular aortic repair is a rare, but crucial, complication leading to rupture. Treatment of a ruptured abdominal aortic aneurysm caused by a type IIIa endoleak can sometimes be challenging. We have reported the case of a 78-year-old man who had presented with a ruptured abdominal aortic aneurysm caused by a type IIIa endoleak resulting from disconnection of a contralateral limb. The patient underwent hybrid repair using manual reconnection of the limbs with laparotomy and an endovascular technique, including balloon occlusion of the infrarenal aorta and new contralateral limb deployment. We found this hybrid repair to be an effective and minimally invasive procedure when total endovascular repair would have been difficult.

Stepwise external wrapping procedure for type A intramural hematoma.

BACKGROUND: The optimal treatment for Stanford type A acute intramural hematoma remains controversial, especially in elderly or high-risk patients. METHODS: We have developed a new surgical approach using artificial grafts (stepwise external wrapping) for high-risk patients. The aim of this study is to report our results using the stepwise external wrapping procedure in the treatment of high-risk patients with type A intramural hematoma. Among the 129 patients admitted for type A intramural hematoma between January 2016 and January 2020, 49 patients underwent stepwise external wrapping. The mean patient age was 78 ± 7 years. The new standard European system for cardiac operative risk evaluation II was 54% ± 23%. The mean overall operation and cardiopulmonary bypass times were 96 ± 13 minutes and 35 ± 10 minutes, respectively. RESULTS: There were no hospital deaths. Two cases of temporary neurologic disorder, 1 case of renal failure, and 2 cases of wound infection occurred during the postoperative period. The intensive care unit and hospital stays were 2 ± 1 days and 10 ± 3 days, respectively. The thickness of intramural hematoma that had been the target of the stepwise external wrapping procedure decreased significantly from 18.0 ± 10.7 mm preoperatively to 5.2 ± 4.4 mm at 3 months after surgery (P < .05). The follow-up survival was 97.7% ± 4.4 % at 1 year after surgery and 89.8% ± 11.4% at 3 years after surgery. There was no aortic-related death during follow-up. CONCLUSIONS: Our stepwise external wrapping is a feasible alternative to conventional graft replacement for high-risk patients with type A intramural hematoma. The early and midterm outcomes of the procedure were satisfactory, but further careful follow-up is needed.