Delayed surgery for acute type A aortic dissection: a retrospective review of an alternative surgical strategy in the COVID-19 era.

BACKGROUND: During the coronavirus disease (COVID-19) pandemic, medical resources have often been limited to emergency surgeries. This study aimed to evaluate our experience with delayed surgery for acute type A aortic dissections (ATAADs). METHODS: A retrospective study was conducted on 33 patients who underwent surgery for ATAADs between January 2020 and December 2021. The patients were divided into two groups: patients treated within 12 h of arrival (E group; N = 21) and those treated > 12 h after arrival (D group; N = 12) with strict antihypertensive therapy until surgery. RESULTS: The plasma fibrinogen levels on arrival were lower in the D group than in the E group (174.3 ± 109.1 vs 293.4 ± 165.4, p = 0.038). The time to surgery from symptom onset was longer in the D group than in the E group (4 ± 1 h vs. 86 ± 108 h, p < 0.001). There was one case (3%) of mortality and seven cases (21%) of cerebral infarctions in the E group. There was no significant difference in the intraoperative data and quantity of blood transfused between the two groups. CONCLUSION: Thus, delayed surgery for ATAAD with appropriate preoperative management may be an alternative surgical strategy in the COVID-19 era.

Simple and secure thrombectomy without circulatory arrest for acute pulmonary embolism.

BACKGROUND: Surgical pulmonary artery thrombectomy is a well-established emergency treatment for massive pulmonary embolism (PE) in which fibrinolysis or thrombolysis are not effective. However, surgery for massive PE that requires peripheral pulmonary artery thrombus removal remains challenging. We established a simple and secure pulmonary artery thrombectomy method using cardiopulmonary bypass and cardiac arrest. In this procedure, the surgical assistant arm, typically used for coronary artery bypass grafting, is used to obtain a feasible working space during thrombectomy. CASE PRESENTATION: We present seven consecutive massive PE cases that were treated with the present surgical method and successfully weaned from cardiopulmonary bypass or extracorporeal membrane oxygenation postoperatively. CONCLUSIONS: This procedure can be used to prevent right ventricular failure after surgery as surgeons can remove the peripheral thrombus with clear vision up to the second branch of the pulmonary artery.

Retrograde in situ branched stent grafting for a patient with type V thoracoabdominal aortic aneurysm.

We have presented the case of a 76-year-old patient with a type V thoracoabdominal aortic aneurysm treated by retrograde in situ branched stent grafting to the superior mesenteric artery (SMA). Via a 9-cm, median laparotomy, a percutaneous transhepatic gallbladder drainage needle was inserted from the distal part of the first jejunal artery to the origin of the SMA. After stent graft placement into the aorta, the graft was retrogradely punctured using the percutaneous transhepatic gallbladder drainage needle. The SMA ischemic time was 6 minutes. The puncture site was dilated, and a small, covered stent was deployed. Postoperative computed tomography scanning showed no endoleak with sac regression.

Right-Sided Chylothorax: A Case Report of an Uncommon Manifestation After Cervical Debranching Thoracic Endovascular Aneurysm Repair.

A 70-year-old man was admitted to our hospital with a thoracic aortic aneurysm. He underwent elective thoracic endovascular aneurysm repair with left common carotid artery-left subclavian artery bypass via the left supraclavicular approach. During the bypass, the thoracic duct was injured and ligated. On postoperative day 3, the patient complained of dyspnea. Chest radiography revealed a massive right-sided pleural effusion. On postoperative day 5, he was diagnosed with right-sided chylothorax and underwent chest tube insertion. The next day, a left-sided chylothorax was noted, and chest tube drainage was performed. Conservative management, including nil per os and subcutaneous octreotide (300 µg/day) injection, was carried out for 2 weeks; subsequently, the chylothorax improved. This report highlights the diagnostic challenge of right-sided chylothorax after debranching thoracic endovascular aneurysm repair.

Directing a dispersion cannula tip toward the aortic root during thoracic aortic arch surgery does not adversely affect cardiac function.

INTRODUCTION: Neurologic complications of open thoracic aortic surgery are devastating problems in patients with severely diseased aortas. This study aimed to clarify whether directing the aortic cannula tip toward the aortic root affects the postoperative cardiac function in patients undergoing open thoracic aortic surgery. METHODS: A total of 16 patients who underwent total or partial arch replacement between January 2014 and April 2019 were enrolled and divided into two groups. Ascending aorta perfusion was performed by placing the cannula tip toward the aortic root (reversed direction group, seven patients) or toward the aortic arch (standard direction group, nine patients). Intraoperative and perioperative data, including mortality, morbidity, and postoperative cardiac function, were compared between the groups. RESULTS: There were no hospital deaths or stroke events in either group. The aortic cross-clamping time was 102.4 ± 20.3 minutes in the reversed direction group and 87.1 ± 9.9 minutes in the standard direction group (p = 0.049). Furthermore, the intubation time was 28.4 ± 12.9 hours in the reversed direction group and 12.4 ± 6.8 hours in the standard direction group (p = 0.022). Both times were significantly longer in the reverse direction group. Postoperative serum creatine kinase-MB levels were significantly lower in the reversed direction group (6.2 ± 3.3 U/L vs 13.3 ± 4.8 U/L, respectively, p = 0.006). The cardiac output and cardiac index did not significantly differ. CONCLUSIONS: Directing the aortic cannula tip toward the aortic root does not adversely affect the postoperative cardiac function after aortic arch surgery.

[Aortic Root Partial Reconstruction Combined with Intraoperative Aortic Dissection:Report of a Case].

A 73-year-old woman with Valsalva aneurysm and mitral regurgitation was introduced to our department. We performed combined operation including aortic root partial repair and mitral valve repair. After wenning from cardiopulmonary bypass, intraoperative aortic dissection was confirmed by transesophageal echocardiography from the ascending aorta to the descending aorta, entry was near to proximal anastomosis line of the ascending aorta. To avoid heart failure, the ascending aorta wrapping by prothesis graft was performed to protect from urgent rupture postoperative at first stage. According to contrast computed tomography (CT) findings, location of entry was correspond with aortic clamping. We performed partial aortic replacement including innominate artery reconstruction for her at fourth day postoperative for treating aortic dissection at second stage. Postoperative course was uneventful.

Urgent repair of postinfarct ventricular septal rupture with ECPELLA support: A case report.

A 74-year-old woman developed inferior myocardial infarction due to right coronary artery occlusion and underwent percutaneous coronary intervention. Two days later, echocardiography revealed ventricular septal rupture, and Impella CP was inserted to avoid emergency surgery. However, the patient's hemodynamics deteriorated rapidly, necessitating additional venoarterial extracorporeal membranous oxygenation support with concomitant Impella support (ECPELLA). The ventricular septal rupture was surgically repaired using the extended sandwich technique via a right ventricular approach; the ascending aorta was clamped with the clampable portion of the Impella. The patient was successfully weaned from the Impella 3 days postsurgery. This case suggests that urgent surgery with ECPELLA support could be a useful option for patients with ventricular septal rupture, even in severe cases wherein emergency surgery is unavoidable.

Aortic root and total arch replacement in a patient with prior ascending aortic repair for type-A aortic dissection.

A 63-year-old man was admitted to our hospital owing to the shortness of breath. He had undergone ascending aortic repair for acute type-A aortic dissection 14 years ago. In the previous surgery, the primary entry of the ascending aorta had been resected using direct end-to-end anastomosis after transecting the ascending aorta at the level of the entry and gluing the false lumen using a gelatin-resorcin-formalin glue. The anastomosis site on the ascending aorta had been reinforced using Teflon felt strips. The patient developed heart failure owing to severe aortic regurgitation caused by aortic root dilatation. Since the aortic arch was also dilated, he underwent aortic arch and root replacement. The distinctive difficulties experienced during surgery owing to the prior ascending aortic direct repair have been highlighted in this report.

Infected aortic pseudoaneurysm repair using autologous common femoral artery patch and fascia.

Using autologous common femoral artery and external oblique muscle fascia is a simple and reliable option for repairing infected aortic pseudoaneurysms. Reoperation of infected pseudoaneurysms is challenging and requires secure aortic repair with complete infection eradication. Here, we report two cases of infected pseudoaneurysms in the ascending aorta cannulation site after cardiac surgeries. Common femoral arteries and fascia were harvested in the same lesion as repair materials. The aortic pseudoaneurysms were repaired under deep hypothermic circulatory arrest. Femoral arterial patches were reinforced with circumferential aponeurosis strips. There was no infection recurrence or repair site dilatation in the long-term follow up of both patients.

A Case of Periaortic Lymphoma Mimicking Complicated Type B Acute Aortic Dissection: A Pitfall in the Endovascular Surgery Era.

We report a case of periaortic lymphoma mimicking Stanford type B acute aortic dissection treated for impending rupture by thoracic endovascular aortic repair. Although no endoleak was detected, the aneurysm enlarged continuously. Repeat computed tomography scans showed that an aortic aneurysm-like structure around the stent graft had enlarged irregularly. Histopathological examination revealed diffuse large B-cell malignant lymphoma. Post-chemotherapy, the aneurysm-like structure disappeared without any fistula or rupture. In open surgery, differentiating between aneurysms and malignancy is easy under direct vision; however, in the endovascular surgery era, this is a pitfall because no surgical specimen of the lesion can be obtained.

Concomitant Revascularization Using Ascending Aortic Rerouting in Coral Reef Aortic Syndrome.

Coral reef Aortic Syndrome can result in significant visceral and lower limb ischemia. We present a 72-year-old male with postprandial abdominal pain and intermittent claudication. Computed tomography demonstrated a calcified plaque occluding the thoracoabdominal aorta. Additionally, the celiac axis was stenotic, and the superior mesenteric artery was completely occluded. The origin of the inferior mesenteric artery was aneurysmal. Aortic rerouting from the ascending to the infrarenal aorta was performed. The superior mesenteric artery was reconstructed with a saphenous vein, and the inferior mesenteric artery was divided and anastomosed directly to the aortic bypass. The procedure resulted in complete relief from the ischemic symptoms.

Two Surgical Patients with Paget-Schroetter Syndrome Presenting with Atypical Pathophysiology: Non-Effort Thrombosis.

Paget-Schroetter syndrome (PSS) is an upper extremity thrombosis occurring in the axillary and subclavian veins. PSS is also known as "effort thrombosis," because it is usually associated with repetitive and strenuous activities of the upper limbs. We present 2 patients with atypical PSS, so-called "non-effort thrombosis," who were not involved in vigorous activities. They underwent thoracic outlet decompression through the infraclavicular approach without concomitant venoplasty. They were discharged without postoperative anticoagulant therapy. Venography and computed tomography after surgery revealed successful recanalization of the subclavian vein in each case. We highlight the characteristic pathophysiology of "non-effort thrombosis," an atypical PSS entity.

Total arch replacement for aortic arch aneurysm with coexisting middle aortic syndrome.

INTRODUCTION: Middle aortic syndrome (MAS) combined with thoracic aortic aneurysm (TAA) is a rare vascular disease. One stage open surgery to treat this condition, becomes a challenge for our cardiovascular surgery. PRESENTATION OF CASE: A 69-year-old man presented with a saccular type aortic arch aneurysm, shaggy aorta and severe atherosclerotic stenosis of the thoracoabdominal aorta with middle aortic syndrome and aberrant right subclavian artery, renovascular hypertension, renal dysfunction, and intermittent claudication of both legs. Total arch replacement procedure was performed under a cardiopulmonary bypass using aortic inflow from the right axillary artery and a femoro-femoral crossover bypass graft to avoid malperfusion of the lower body. Before weaning from the cardiopulmonary bypass, we established an extra-anatomical bypass from the ascending aortic graft to the femoro-femoral crossover bypass graft. 3D-CT showed patency of bypass graft without any sign of stenosis postoperative. The patient's postoperative course was uneventful and he was discharged from hospital with improvements in intermittent claudication, hypertension, and renal dysfunction. DISCUSSION: Although open surgery including graft bypass for MAS is more invasive than endovascular treatment, it could be performed successfully to preventing from intraoperative complication or complications postoperatively. CONCLUSION: Combined operation of total arch replacement and a bypass from the ascending aorta to the bifemoral arteries is alternative for MAS combined with TAA.

Outcomes of Pulmonary Embolectomy for Acute Pulmonary Embolism.

BACKGROUND: Acute pulmonary embolism (PE) is a major threat to the health and lives of hospitalized patients. This study was conducted to clarify the real-world outcomes of pulmonary embolectomy.Methods and Results:Retrospective investigation of 355 patients who underwent pulmonary embolectomy for acute PE was conducted using the Japanese Cardiovascular Surgery Database. Risk factors for operative death within 30 days after pulmonary embolectomy and major adverse cardiovascular events (MACE), including operative death, postoperative stroke and postoperative coma, were analyzed. Cardiopulmonary resuscitation (CPR) was required preoperatively in 27.6%, and preoperative veno-arterial extracorporeal membrane oxygenation was performed in 26.5%. Urgent or emergency operation was performed in 93% of patients. Operative mortality rate was 73/355 (20.6%). Incidence of MACE was 97/355 (27.3%). In univariate analysis, preoperative predictors of death were obesity, renal dysfunction, chronic obstructive pulmonary disease, liver injury, recent myocardial infarction, shock, refractory shock, CPR, heart failure, inotrope use, poor left ventricular function, preoperative arrhythmia and tricuspid regurgitation. In multivariate analysis, independent risk factors for operative death were heart failure (P=0.013), poor left ventricular function (P=0.007), and respiratory failure (P=0.001). Poor left ventricular function (P=0.033), preoperative CPR (P=0.002) and respiratory failure (P=0.007) were independent risk factors for MACE. CONCLUSIONS: The outcomes of pulmonary embolectomy were acceptable, considering the urgency and preoperative comorbidities of patients. Early triage of patients with hemodynamically unstable PE is important.

Selection and Determination of Treatment for the Spontaneous Isolated Dissection of the Superior Mesenteric Artery.

Objective: This study aimed to clarify the selection and determination of appropriate treatment for acute symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). Methods: Data from 10 consecutive patients, who were diagnosed with symptomatic SIDSMA using computed tomography angiography and were managed in our hospital from January 2010 to October 2015, were retrospectively collected and analyzed. Results: There were nine males and one female; mean patient age was 50.3 (range, 35-64) years. All patients experienced acute abdominal pain, and three patients experienced concomitant vomiting. Only one patient exhibited symptoms of suspected peritonitis and intestinal ischemia. Three patients showed improved abdominal pain before admission to our hospital. One patient experienced severe abdominal pain that could not be managed using morphine; he underwent right external iliac to superior mesenteric artery bypass with a great saphenous vein graft. No patient presented with intestinal necrosis. All patients survived, and no patient developed complications during the follow-up period of up to 42 (24.5±16.5) months. Conclusion: Conservative management appears to be the most feasible treatment for SIDSMA. However, open surgery can be performed in patients presenting with any symptoms of intestinal ischemia.

[Surgical Treatment for Myocardial Rerupture after Repair of Post Infarction Left Ventricular Free Wall Rupture].

A 73-year-old man was admitted for cardiac tamponade by oozing type left ventricular free wall rupture associated with acute myocardial infarction. Transthoracic echocardiography demonstrated moderate pericardial effusion and the presence of pseudoaneurysm within posterior wall. He went into shock with a systolic blood pressure of 60 mmHg. After introducing percutaneous cardiopulmonary support and intraaortic balloon pump, the sutureless repair was performed immediately. After having rehabilitation for right-sided hemiparesis, an elective pseudoaneurysm repair was planned. While a waiting an operation, 7 weeks later, he went into shock again with chest pain. Echocardiography and computed tomography demonstrated much amount of pericardial bloody effusion on the posterior aspect and 1.5 cm defect on the pseudoaneurysm wall. Emergently a patch closure with a bovine pericardium was performed using cardiopulmonary bypass under ventricular fibrillation through a left thoracotomy. Postoperative course was uneventful.

Improved Outcomes for Ruptured Abdominal Aortic Aneurysms Using Integrated Management Involving Endovascular Clamping, Endovascular Replacement, and Open Abdominal Decompression.

Objective: Endovascular repair has become the treatment of choice for ruptured abdominal aortic aneurysms (RAAAs). To improve surgical outcomes, preoperative management is important. In 2011, we introduced integrated management, which involves endovascular aneurysm repair, stabilization of hemodynamics by endovascular clamping, and open abdominal decompression to address abdominal compartment syndrome (ACS). Methods: To evaluate the efficacy of this management strategy, 62 patients who had undergone emergency surgery for an RAAA were analyzed retrospectively: group A (n=39), where an old strategy was used, and group B (n=23), where integrated management was introduced. Patient characteristics and 30-day mortality rates were compared between the two groups. Results: The average patient age was 67.7 years and 74.7 years for groups A and B, respectively (P=0.032). Group B patients required more frequent use of vasopressors (P=0.035). Other patient characteristics did not differ between the two groups. The duration of surgery was significantly shorter in group B than in group A (P=0.001). The total amount of transfused blood did not differ between the two groups. No patients showed symptoms of ACS. Early mortality rates were 12.8% and 8.7% in groups A and B, respectively. The number of wound infections was significantly fewer in group B than in group A. Conclusion: Although group B patients were significantly older and had a higher rate of vasopressor use, early mortality was improved in both groups. Morbidity was significantly better in group B with respect to the duration of surgery and number of wound infections than in group A.

Surgical Management of Mycotic Aortic Aneurysms.

Purpose: A mycotic aneurysm is an uncommon disease associated with a high mortality rate when managed surgically. This study reviewed our experiences in the surgical management of mycotic aortic aneurysms. Methods: In total, 26 patients who underwent surgery for a mycotic aneurysm were retrospectively reviewed. The mycotic aneurysms involved the thoracic aorta in 9 patients, the thoracoabdominal aorta in 4 patients, and the abdominal aorta in 13 patients. An overt aortic rupture in the mediastinum or retroperitoneal space was detected in 4 patients. Patients were classified into one of two groups, febrile or afebrile, and background characteristics, surgical intervention, and early and late mortalities were all compared. Results: There were 19 patients who underwent open surgery, and 7 patients underwent endovascular repair. No significant differences in the clinical characteristics were found between the two groups; however, the incidence of postoperative complications was significantly higher in the febrile group than in the afebrile group (P=0.024). Overall mortality was 15.4% (4/26), and 30-day mortality was 7.7% (2/26). Conclusion: Although febrile patients had a higher incidence of postoperative complications, surgical mortality from a mycotic aneurysm was within an acceptable range. Each patient should be thoroughly evaluated and treated on a case-by-case basis, using conventional open repair, endovascular repair, or a combination of both approaches.

[Aortic Stenosis Combined with Cold Agglutinin Disease].

Cardiac surgery on a patient with cold agglutinin disease is high risk for thromboembolism due to hypothermia perioperative. A 75-year-old woman with cold agglutinin disease underwent aortic valve replacement for severe aortic stenosis. Cold antibody was detected by preoperative screening test for blood transfusion. In order to prevent thromboembolic event during the operation, we maintained rectal temperature at around 36 degrees centigrade during the cardiopulmonary bypass by warming blood in the bypass circuit. Furthermore, antegrade warm blood cardioplegia was injected intermittently for keeping cardiac arrest. There was no thromboembolic event perioperatively.

[Heparin-induced Thrombocytopenia after Total Arch Replacement].

A 71-year-old man underwent total arch replacement for the true aortic arch aneurysm. On the post-operative day (POD) 10, right hemiplegia and motor aphasia occurred, and it was revealed that there were multiple cerebral infarction in brain computer tomography scan and magnetic resonanse imaging. Furthermore, platelet count has declined significantly from POD 15, so we suspected that heparin-induced thrombocytopenia might occurred. Then, we stopped continuous injection of heparin and administered argatroban and warfarin. In blood examinations, anti-platelet factor 4(PF4)/ heparin antibody measured by latex turbidimetry significantly increased at 5.2 U/ml, and specific immunoglobulin G for PF4/ heparin was also significantly high( optical density 2.334, cut off 0.400). Measurement of platelet derived microparticles produced by stimulation using various dose of heparin( functional assay) indicated typical pattern observed in heparin-induced thrombocytopenia. Thereafter, platelet count recovered and the patient recovered without another thromboembolic event.