The outcomes and cost analysis of open repair and endovascular aneurysm repair for abdominal aortic aneurysms: a single-center experience in Japan.

PURPOSE: Japan has adopted its own reimbursement system, which differs from other countries in terms of its diagnostic procedure combination (DPC) methods. However, there are few reports on the cost analysis of open repair and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms in Japan. We aimed to evaluate the long-term outcomes and cost-effectiveness of these two procedures. METHODS: This study included patients who underwent open repair (n = 224) and EVAR (n = 87) between January 2012 and December 2022. After propensity score matching, we compared the two groups. RESULTS: The drug and blood products, procedures, and DPC costs were significantly higher in the open repair group (p < 0.001) than in the EVAR group. The surgical equipment and total costs were significantly higher in the EVAR group than in the open repair group (p < 0.001). There was no significant difference in the 5-year survival rate (88.5% in the open repair group vs. 72.0% in the EVAR group; p = 0.33) and freedom from re-intervention rate at 5 years (93.1% in the open repair group vs. 89.9% in the EVAR group; p = 0.15) between the two groups. CONCLUSIONS: Open repair is more cost-effective than EVAR. The cost-effectiveness of EVAR may therefore depend on the cost of the endograft.

Long-term results of the frozen elephant trunk technique in primary chronic type B aortic dissection.

OBJECTIVES: The aim of this study is to analyze long-term results of the total aortic arch replacement with the frozen elephant trunk technique for primary chronic type B aortic dissection. METHODS: Among 322 patients who had the frozen elephant trunk technique, 43 (13.4%) patients (median age, 64.0 years) with primary chronic type B aortic dissection were analyzed. The patients underwent surgery at a median of 27.0 months after the onset of aortic dissection. The false lumen was patent in 30 (69.8%) patients preoperatively. RESULTS: Two patients suffered paraplegia and another died of cerebral infarction. Complete thrombosis of the peri-stent false lumen was achieved in 36 (83.7%) patients. Overall survival, freedom from aortic events, and freedom from aortic reintervention were 83.5%, 37.2%, and 42.2% at 5 years, respectively. Survival rates of the patients with or without aortic events were 75.0% and 95.8% at 5 years (Log-rank, p = 0.22). Late aortic events occurred in 19 (44.2%) patients including distal stent graft-induced new entry, type Ib endoleak, and false lumen dilation. The ratio of the stent graft diameter to the preoperative short axis diameter of the true lumen (hazard ratio, 1.90; 95% confidence interval, 1.01-3.59), and the maximal diameter of a postdissection aneurysm (1.07; 1.01-1.12) were the significant multivariate risk predictors of late aortic events. CONCLUSIONS: Late aortic events occurr fairly frequently, and new strategies need to be explored to enhance the effectiveness of this procedure in the future.

[Complete Disruption of the Left Main Bronchus Treated with Extracorporeal Membrane Oxygenation Support and Pneumonectomy].

A 60-year old woman, sandwiched between two boats was brought to our hospital with severe respiratory failure. She was in pre-shock and there was extensive cutaneous emphysema from the face to abdomen. She required respirator support and bilateral chest tubes for hemopneumothorax. On the patient's 3rd hospital day, she received venovenous extracorporeal membrance oxgenation( ECMO) due to sudden ventilatory failure. The bronchofiberscopy revealed complete disruption of the left main bronchus and occlusion of the right one owing to blood clot and sputum. Because of significant destruction of the left main bronchus, we didn't attempt bronchoplasty, and performed left pneumonectomy under veno-venous (VV)-ECMO. The postoperative course was uneventful, and she was discharged after 30 days with satisfactory outcome.

Impact of the Barthel Index Score and Prognosis on Patients Undergoing Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement.

BACKGROUND: Few studies have compared the Barthel Index (BI) score and postoperative outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). We aimed to examine the relationship between the BI score and postoperative outcomes in patients who underwent TAVR and SAVR.Methods and Results: The study included patients who underwent SAVR between January 2014 and December 2022 (n=293) and patients who underwent TAVR between January 2016 and December 2022 (n=312). We examined the risk factors for long-term mortality in the 2 groups. The mean (±SD) preoperative BI score was 88.7±18.0 in the TAVR group and 95.8±12.3 in the SAVR group. The home discharge rate was significantly lower in the SAVR than TAVR group. The BI score at discharge was significantly higher in the SAVR than in TAVR group (86.2 vs. 80.2; P<0.001). Significant risk factors for long-term mortality in the TAVR group were sex (P<0.001) and preoperative hemoglobin level (P=0.008), whereas those in the SAVR group were preoperative albumin level (P=0.04) and postoperative BI score (P=0.02). The cut-off point of the postoperative BI score determined by receiver operating characteristic curve analysis was 60.0. CONCLUSIONS: The BI score at discharge was a significant risk factor for long-term mortality in the SAVR group, with a cut-off value of 60.0.

Left ventricular mass and valve performance after surgical and transcatheter aortic valve replacement: a single-center experience from Japan.

Background: There are few reports on the postoperative left ventricular mass (LVM), aortic valve area (AVA), and pressure gradient (PG) after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) in Japan. We aimed to compare the postoperative LVM, AVA, stroke volume (SV), PG, and long-term outcomes between patients undergoing SAVR and TAVR procedures from single center in Japan. Methods: This was a retrospective cohort study. We included 107 patients who underwent simple SAVR between January 2012 and May 2022 (SAVR group, n=107) and 274 who underwent TAVR between January 2016 and May 2022 (TAVR group, n=274). The overall mean follow-up periods was 28.8±25.9 months (median: 24 months; range, 0.03-117 months). Results: The aortic valve mean PG (mmHg) was significantly smaller in the TAVR group than in the SAVR group (P<0.001). The AVA index (cm2/m2) was significantly larger in the TAVR group than in the SAVR group (P<0.001). The SV index (mL/m2) was significantly smaller in the SAVR group than in the TAVR group (P=0.02). The LVM index (LVMI) (g/m2) was significantly smaller in the SAVR group than in the TAVR group (P<0.001). The incidence of mild or higher postoperative paravalvular leak (PVL) and pacemaker implantation were significantly higher in the TAVR group. The 5-year postoperative mortality, re-hospitalization, and major adverse cerebral and cardiovascular events (MACCEs) were significantly better in the SAVR group. Conclusions: The postoperative aortic valve PG, AVA, and SV were better in the TAVR group; however, LVM regression and postoperative outcomes were better in the SAVR group.

[Surgical Outcomes Prior to Antibiotics Administration for Infective Endocarditis].

OBJECT: We examined the surgical outcomes for infective endocarditis (IE) at our institution. METHODS: Between January 2012 and March 2022, we operated on 43 patients who diagnosed active IE. We decided to perform surgery after antibiotics administration for at least two weeks. RESULTS: The mean age was 63.9 years old, and 28 male were included. The affected valves were 12 aortic valves, and 26 mitral valved and five multi valves, the causative microorganisms were Staphylococcus aureus 14 patient, Staphylococcus spp. 3 patients, Streptococcus spp. 17 patients, Enterococcus spp. 3 patients, and others 6 patients. One patient underwent aortic valve repair, and 17 patients underwent aortic valve preplacement. Twenty four underwent mitral valve repair, and eight underwent mitral valve replacement. The duration of preoperative antibiotics administration was 27.7±2.1 days (median 28 days). There were six in-hospital death (motality 14.0%). The five-years survival rate was 78.1% and the freedom from cardiac events at five years was 88.4%. CONCLUSION: The strategy for preoperative management and timing of surgery for IE patients at our institution was appropriate.

Surgically-treated hemoptysis and alveolar hemorrhaging resulting from severe mitral regurgitation: A case report.

Cardiac etiologies of hemoptysis are less common. One such etiology includes mitral regurgitation. In patients with hemoptysis and unilateral consolidation, careful chest auscultation and cardiac assessment may assist in making an early diagnosis.

Open abdominal management after ruptured abdominal aortic aneurysm repair: from a single-center study in Japan.

PURPOSE: We investigated the utility of the open abdominal management (OA) technique for ruptured abdominal aortic aneurysm (rAAA). METHODS: Between January 2016 and August 2021, 33 patients underwent open surgery for rAAA at our institution. The patients were divided into OA (n = 12) and non-OA (n = 21) groups. We compared preoperative characteristics, operative data, and postoperative outcomes between the two groups. The intensive care unit management and abdominal wall closure statuses of the OA group were evaluated. RESULTS: The OA group included significantly more cases of a preoperative shock than the non-OA group. The operation time was also significantly longer in the OA group than in the non-OA group. The need for intraoperative fluids, amount of bleeding, and need for blood transfusion were significantly higher in the OA group than in the non-OA group. Negative pressure therapy (NPT) systems are useful in OA. In five of the six survivors in the OA group, abdominal closure was able to be achieved using components separation (CS) technique. CONCLUSIONS: NPT and the CS technique may increase the abdominal wall closure rate in rAAA surgery using OA and are expected to improve outcomes.

The effect of posterior pericardiotomy after thoracic aortic surgery.

BACKGROUND: Postoperative pericardial effusion is common after cardiovascular surgery. We aimed to examine the effectiveness of posterior pericardiotomy in reducing the incidence of postoperative pericardial effusion and postoperative atrial fibrillation after thoracic aortic surgery. METHODS: This study included 201 patients who underwent thoracic aortic open surgery between January 2014 and November 2021. We compared surgical outcomes between patients who underwent posterior pericardiotomy and those who did not. RESULTS: The group that did not undergo posterior pericardiotomy had significantly longer mechanical ventilation duration than the group who did, both in the overall (p = 0.005) and in the propensity-matched cohorts (p = 0.001). The lengths of intensive care unit and hospital stays were significantly longer in the group that did not undergo posterior pericardiotomy compared to the group that did, both in the overall and in the propensity-matched cohorts. The occurrence of postoperative atrial fibrillation and stroke did not differ significantly between the two groups. The amount of pericardial drainage was not significantly lower in the group that underwent posterior pericardiotomy in the overall cohorts (p = 0.09), but the difference was significant in the propensity-matched cohorts (p = 0.04). The amount of mediastinal drainage was significantly lower in the group that underwent posterior pericardiotomy, both in the overall cohorts (< 0.001) and in the propensity-matched cohort (< 0.001). Late pericardial tamponade occurred significantly more frequently in the group that did not undergo posterior pericardiotomy than in the group that did, both in the overall (p = 0.03) and in the propensity-matched cohorts (p = 0.03). CONCLUSIONS: Posterior pericardiotomy has no effect on reducing postoperative atrial fibrillation after thoracic aortic surgery. However, posterior pericardiotomy reduced the occurrence of late pericardial tamponade, length of ICU stay, length of hospital stay, and mechanical ventilation duration after surgery.

Surgical Management of Infective Endocarditis Complicated With Acute Cerebral Infarction　- Preoperative Management Using Modified Rankin Scale and Sequential Organ Failure Assessment (SOFA) Score.

Background: The optimal timing of surgery for infective endocarditis (IE) with acute cerebral infarction (CI) remains controversial. We examined the surgery policy at Ise Red Cross Hospital after negative blood cultures and antibiotic administration for at least 2 weeks. Methods and Results: Thirty-nine IE patients who underwent surgery between 2012 and 2020 were divided into Groups S (n=13; with acute CI) and N (n=26; without acute CI). Patients with IE who underwent conservative treatment were classified as group C (n=16). At the time of IE diagnosis, the modified Rankin Scale (mRS) score was significantly higher in Group S than Group N (mean [±SD] 3.9±0.6 vs. 2.8±1.3; P=0.009). However, there was no significant difference between Groups S and N moments before surgery (3.0±1.5 vs. 2.1±1.5, respectively; P=0.10) or at discharge (2.7±0.8 vs. 2.6±0.9, respectively; P=0.89). There were no significant differences in the Sequential Organ Failure Assessment (SOFA) score between groups. There were no differences in intra- and postoperative outcomes between Groups S and N. In Group C, the mRS score was significantly higher at discharge than in Group S (2.7±0.8 vs. 4.4±0.8, respectively; P<0.001), and long-term results were poor (P=0.004). Conclusions: Preoperative management and the timing of surgery for IE patients using the mRS and SOFA scores at our institution were reasonable.

Treatment Strategies for Improving the Surgical Outcomes of Ruptured Abdominal Aortic Aneurysm: Single-Center Experience in Japan.

Objective: We aimed to examine the surgical outcomes of ruptured abdominal aortic aneurysm cases at our hospital and considered strategies for improvement. Material and Methods: We examined the preoperative characteristics of hospital mortality, postoperative complications, and long-term outcomes of 91 surgical cases of ruptured abdominal aortic aneurysm performed between January 2009 and December 2020 at our hospital. Results: Of the 91 cases, 24 died at the hospital (mortality, 26.3%). Mortality was mostly due to hemorrhage/disseminated intravascular coagulation and intestinal necrosis. Ten patients required preoperative aortic clamp by thoracotomy or insertion of intra-aortic balloon occlusion, and eight of them died. Ten patients required open abdominal management due to abdominal compartment syndrome, and five of them died. There was no significant difference between the two groups in terms of the long-term results of the open repair and abdominal endovascular aneurysm repair (EVAR). Conclusion: To improve the surgical outcomes of ruptured abdominal aortic aneurysms, it is necessary to start surgery immediately. Therefore, the choice of surgical method (open surgery or EVAR) should be based on the resources and discretion of the hospital. To prevent postoperative intestinal necrosis, risk factors for acute compartment syndrome should be considered, and open abdominal management should be introduced.

Clinical outcomes of limited repair and conservative approaches in older patients with acute type A aortic dissection.

BACKGROUND: Surgical indication and the selection of surgical procedures for acute type A aortic dissection in older patients are controversial; therefore, we aimed to examine the surgical outcomes of acute type A aortic dissection in older patients. METHODS: From January 2012 through December 2019, 174 patients underwent surgical repair for acute type A aortic dissection. We compared the surgical outcomes between the older (≥ 80 years old) and below-80 (≤ 79 years old) age groups. Additionally, we compared the outcomes between the surgical and conservative treatment groups. RESULTS: The primary entry was found in the ascending aorta in 51.6% and 32.8% of the older and below-80 groups, respectively (p = 0.049). Ascending or hemiarch replacement was performed in all older group patients and 57.3% of the below-80 group patients (total arch replacement was performed in the remaining 42.7%; p < 0.001). Hospital mortality rates were similar in both groups. The significant risk factors for hospital mortality were age, preoperative intubation, cardiopulmonary bypass time, and postoperative stroke. The 5-year survival rates were 48.4% ± 10.3% (older group) and 86.7% ± 2.9% (below-80 group; p < 0.001). The rates of freedom from aortic events at 5 years were 86.9% ± 8.7% (older group) and 86.5% ± 3.9% (below-80 group; p = 0.771). The 5-year survival rate of the conservative treatment subgroup was 19.2% ± 8.0% in the older group, which was not significantly different from that of the surgical treatment subgroup (p = 0.103). CONCLUSION: The surgical approach did not achieve a significant survival advantage over conservative treatment and may not always be a reasonable treatment of choice for older patients.

[To Improve the Results of Surgery for Stanford Type A Acute Aortic Dissection:Strategy for Organ Malperfusion].

OBJECTIVES: We presented the results of surgery for Stanford type A acute aortic dissection at our hospital and described strategies for organ malperfusion (especially brain malperfusion). RESULTS: From January 2012 to December 2019, we underwent 174 patients of Stanford type A acute aortic dissection at our hospital. There were 47 patients( 27.0%) with postoperative cerebral infarction (stroke group). Compared to the non-stroke group, the stroke group had significantly more cases of persistent central nervous system malperfusion before surgery and had more intraoperative bleeding and blood transfusion. The hospital mortality was 23.4% in the stroke group and 3.9% in the non-stroke group( p<0.001). As a result of multivariate analysis, risk factors for hospital mortality were preoperative endotracheal intubation, long-term cardiopulmonary bypass time and postoperative stroke. The risk factor for postoperative stroke was preoperative central nervous system malperfusion. CONCLUSIONS: As a strategy for cerebral malperfusion, it is useful to use the right axillary artery blood supply and the isolated cerebral perfusion method.

Impact of the Frozen Elephant Trunk Technique on Total Aortic Arch Replacement.

BACKGROUND: The frozen elephant trunk (FET) technique can facilitate the distal anastomosis of total arch replacement (TAR); therefore, the technique is increasingly being used in TAR cases. However, identifying suitable patients remains controversial. This study analyzes the outcome of TAR using FET and clarifies the indications for using FET. METHODS: Patients who underwent TAR between January 2008 and December 2018 were enrolled and divided into 2 groups: that is, patients treated with conventional TAR (cTAR group, n = 39) and those treated with TAR using FET (TAR-FET group, n = 76). Early and late outcomes were compared. RESULTS: The mean operation time was significantly shorter in the TAR-FET group (447.0 ± 82.1 min) than in the cTAR group (509.4 ± 123.9 min) (P < 0.01). Likewise, circulatory arrest time was significantly shorter in the TAR-FET group (29.0 ± 7.8 min) than in the cTAR group (64.2 ± 20.2 min) (P < 0.001). Postoperative renal function tended to be preserved in the TAR-FET group. Recurrent nerve palsy was less frequent in the TAR-FET group (9.2%) compared with the cTAR group (25.6%) (P < 0.05). Patients with chronic aortic dissection tended to undergo reintervention more frequently following TAR using the FET technique. CONCLUSIONS: The FET technique contributed to save operation and circulatory arrest times during TAR and seemed less invasive in terms of renal function and less-frequent recurrent nerve palsy. Considering posttreatment reintervention, however, care should be taken in its application to chronic aortic dissection.

Understanding Vascular Anatomy is Key to Successful Endovascular Treatment of Pancreaticoduodenal Artery Aneurysms.

Pancreaticoduodenal artery aneurysm (PDAA) is a rare disease without treatment guidelines. We present two patients with PDAA. The first patient was a 70-year-old man with a pseudoaneurysm in the anterior superior pancreaticoduodenal artery (ASPDA), for which we achieved exclusion by endovascular coil embolization. The second patient was a 63-year-old woman with a PDAA in the ASPDA with celiac axis obstruction. Endovascular coil embolization of the aneurysm and the ASPDA was successful without visceral organ ischemia. Endovascular treatment is effective for PDAAs, but careful evaluation of collateral circulation is vital in PDAAs with celiac axis obstruction.

Hybrid Therapy for Mycotic Aortic Aneurysm with Stent-Graft and Video-Assisted Thoracoscopic Debridement.

Treating mycotic aortic aneurysm with thoracic endovascular aortic repair (TEVAR) remains controversial because of sustained infection post-treatment. In this study, an 83-year-old man, who had a ruptured mycotic thoracic aortic aneurysm, underwent salvage TEVAR. However, because an abscess appeared in the aneurysm on follow-up computed tomography, video-assisted thoracoscopic debridement (VATD) followed by continuous drainage was performed next and was successful in eliminating the infection from the abscess. Although frozen elephant trunk and proximal aortic arch repair were further required owing to another pseudoaneurysm, there was no sign of recurrent infection thereafter. The combination of TEVAR and VATD can be effective in treatment of mycotic aortic diseases in selected patients.

Thoracic endovascular aortic repair for the treatment of ruptured acute type B aortic dissection.

PURPOSE: To evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) for ruptured acute type B aortic dissection (r-ATBAD). MATERIALS AND METHODS: The study included 18 patients (15 men and 3 women) who underwent TEVAR for r-ATBAD in two institutions between 1997 and 2017. The mean patient age was 74 ± 10 years. The false lumen was patent in 13 patients (72%) and was mostly thrombosed in 5 patients (28%). Three patients had malperfusion of aortic branches. Eight patients (44%) were in circulatory shock. RESULTS: Eleven patients (61%) died during or following TEVAR during admission. The causes of death were aortic rupture (n = 6), sepsis (n = 2), cerebral hypoxia (n = 1), pneumonia (n = 1), and renal failure (n = 1). Statistical analysis showed that dissection extending to the infrarenal level was significantly related to death from aortic rupture (P = 0.013). Early adverse events were observed in 12 patients (67%). One patient died from a non-aorta-related cause (sepsis) after discharge. The overall survival rate at 1 year was 39%. After discharge, an aorta-related adverse event (intimal injury) was observed in one patient. The adverse event-free survival rate at 1 year was 17%. CONCLUSIONS: Our results indicate that TEVAR for r-ATBAD is associated with high mortality and morbidity. More advanced strategies may be required to improve the outcome.

Thoracic endovascular aortic repair for retrograde type A aortic dissection.

OBJECTIVE: The efficacy of thoracic endovascular aortic repair (TEVAR) for retrograde type A aortic dissection (r-TAAD) with the entry tear in the descending aorta has not been clarified. METHODS: The medical records of 31 patients who underwent TEVAR for r-TAAD at three institutions between May 1997 and January 2016 were retrospectively reviewed. RESULTS: The mean age of the patients (30 men and 1 woman) was 64 ± 11 years. The entry tear was located in the descending thoracic aorta in all patients. Seven patients (23%) had dissection-related complications. The false lumen of the ascending aorta was patent in 13 patients (42%) and thrombosed in 18 (58%). The maximum diameter of the ascending aorta was 45 ± 4 mm. TEVAR was performed in the acute phase in 24 patients (77%) and in the subacute phase in 7 (23%). Only one patient (3%) died of aortic rupture within 30 days after TEVAR. Early aorta-related adverse events were observed in eight patients (26%), of whom five underwent additional interventions. The mean follow-up period was 99 ± 69 months. There were no late aorta-related deaths, although five patients died of other causes during follow-up. Overall survival rates at 1 year, 5 years, and 10 years were 97%, 93%, and 80%, respectively. Late aorta-related adverse events were observed in seven patients (23%), of whom five underwent additional interventions. Aorta-related event-free survival rates at 1 year, 5 years, and 10 years were 58%, 58%, and 51%, respectively. CONCLUSIONS: TEVAR for r-TAAD seems promising in terms of survival. However, the incidence of postoperative aorta-related adverse events is not negligible, so careful selection of patients is important. In addition, close follow-up is mandatory after TEVAR to avoid catastrophic consequences.

Retrograde Ascending Dissection After Thoracic Endovascular Aortic Repair Combined With the Chimney Technique and Successful Open Repair Using the Frozen Elephant Trunk Technique.

The chimney technique can be combined with thoracic endovascular aortic repair (TEVAR) to both obtain an appropriate landing zone and maintain blood flow of the arch vessels. However, surgical repair becomes more complicated if retrograde type A aortic dissection occurs after TEVAR with the chimney technique. We herein report a case involving a 73-year-old woman who developed a retrograde ascending dissection 3 months after TEVAR for acute type B aortic dissection. To ensure an adequate proximal sealing distance, the proximal edge of the stent graft was located at the zone 2 level and an additional bare stent was placed at the left subclavian artery (the chimney technique) at the time of TEVAR. Enhanced computed tomography revealed an aortic dissection involving the ascending aorta and aortic arch. Surgical aortic repair using the frozen elephant trunk technique was urgently performed. The patient survived without stroke, paraplegia, renal failure, or other major complications. Retrograde ascending dissection can occur after TEVAR combined with the chimney technique. The frozen elephant trunk technique is useful for surgical repair in such complicated cases.