Stent Graft Migration Due to Structural Failure Nine Months After Thoracic Endovascular Aortic Repair Using Valiant Navion.

Objective: This report presents a case of stent graft migration that was suspected to have occurred due to failure of the Valiant Navion device (Medtronic Inc., Santa Rosa, CA, USA). This case was rare because the broken device was removed from the living patient and examined directly. Case report: A 69 year old man who had previously undergone thoracic endovascular aortic repair (TEVAR) with arch vessel debranching (axillo-axillary bypass with left common carotid artery bypass) for distal arch aneurysm experienced stent graft (SG) migration 9 months after the primary surgery. Total arch replacement was performed, and the migrated SG was removed. The broken stent ring and suture seams were then found. The patient was discharged on post-operative day 41 and followed up in the outpatient department. Discussion: Stent graft migration is a relatively rare complication after TEVAR and associated with type I or III endoleak, which can result in serious outcomes. In this case, it was suspected that migration had occurred after TEVAR due to structural failure of the Valiant Navion device; similar cases have been reported previously, suggesting a structural problem with the device. Therefore, other patients treated with the Navion device in the future will require careful follow up.

Surgeon-modified endovascular grafts for treating ruptured arch aneurysm due to proximal endograft failure after thoracic endovascular aneurysm repair combined with total debranching.

Generally, proximal endograft failure after total arch debranching and thoracic endovascular repair (TEVAR) is one of the most difficult problems because re-sternotomy poses extremely high risks to patients with high surgical risk. Herein, we report an endovascular technique using surgeon-modified endovascular grafts for a patient with ruptured arch aneurysm caused by type Ia endoleak following total arch debranching and TEVAR.

[Surgery for Flail Chest with Titanium Plates after Cardiopulmonary Resuscitation;Report of a Case].

A 74-year-old woman was admitted for the management of nausea with hyponatremia. On the 19th day of hospitalization, the patient developed cardiac arrest and needed cardiopulmonary resuscitation (CPR). CPR was successful but the patient developed multiple rib fractures with flail chest by CPR. Because of persistent dyspnea, surgery for fixing of the fractured ribs was performed using 4 titanium plates, with prompt improvement of the flail chest after the operation.

Predictive Factors for Abdominal Aortic Aneurysm Shrinkage One Year after Successful Endovascular Aneurysm Repair.

BACKGROUND: Often, we experience cases of aneurysm shrinkage and no aneurysm shrinkage after successful endovascular aortic aneurysm repair, without postoperative endoleaks. We studied these cases to ascertain the predictive factors for aneurysm shrinkage. METHODS: From 2007 to 2014, we selected 255 cases that comprised aneurysm shrinkage (>4 mm) and no-shrinkage cases (shrinkage from 0 to 4 mm). Excluding 36 cases of endoleaks, 43 cases without 1-year follow-up computed tomography scan, and 3 cases of aortic dissection, we assessed 93 cases of aneurysm shrinkage (S group) and 80 cases of no aneurysm shrinkage (N group) at 1-year follow-up. RESULTS: No significant differences were found in sex, comorbidities (diabetes mellitus, chronic kidney disease, hemodialysis, and malignancy), and medications (antiplatelet drugs, anticoagulant drugs, steroids, and statins). Advanced age was a strong negative predictive factor for aneurysm shrinkage (N: 75.0 ± 1.0 vs. S: 72.1 ± 0.9 years; P = 0.023), and intraoperative endoleaks were more frequent in the N group (N: 31.3 vs. S: 9.7%; P = 0.001). Neck thrombus was more likely in the N group (N: 17.5 vs. S: 7.5%; P = 0.045), but it had a strong correlation with intraoperative endoleaks (P = 0.008). In the multivariate analysis, patient age and intraoperative endoleaks were predictive factors for aneurysm shrinkage. CONCLUSIONS: Advanced age and intraoperative endoleaks were negative predictive factors for aneurysm shrinkage at 1-year follow-up after successful endovascular treatment without postoperative endoleaks.

[Infectious Endocarditis due to Methicillin-sensitive Bovine Staphylococcus aureus;Report of a Case].

A 19-year-old male patient was admitted to our hospital after developing infectious endocarditis associated with methicillin-sensitive bovine Staphylococcus aureus septicemia. Brain magnetic resonance imaging confirmed occipital lobe cerebral bleeding. An echocardiogram showed severe mitral regurgitation with vegetation on the posterior mitral leaflet. We performed mitral valve replacement. However, a hepatic artery aneurysm and a ruptured splenic artery aneurysm was found on the 5th postoperative day and coil embolization was accordingly performed. The patient suffered repeated cerebral bleeding and received external decompression. He was discharged on the 92nd day after the valve replacement. Our case is rare in that methicillin-sensitive bovine Staphylococcus aureus isolated from human is extremely unusual especially complicated by multiple peripheral aneurysms. This is the 1st reported case of methicillin-sensitive bovine Staphylococcus aureus isolated from human in the Japanese literature.

Treatment of isolated ascending aortic aneurysm by off-pump epiaortic wrapping is safe and durable.

OBJECTIVES: Isolated ascending aortic aneurysm (iAA) is usually treated by open graft repair requiring sternotomy, cardiopulmonary bypass (CPB) and cardioplegia. This approach carries significant mortality in older patients or those presenting with comorbidities. We report an original series of patients presenting with iAA and treated with epiaortic wrapping by using a synthetic mesh. This less invasive aortic repair technique allows reducing the aortic diameter to a predefined value and is performed without CPB. METHODS: Data from patients presenting with an iAA and treated with the wrapping technique (WT) by polypropylene/polyester mesh from November 2006 to July 2015 were collected. The end-points that were analysed included maximal aortic transverse diameter, perioperative mortality and morbidity, survival, freedom from reinterventions and aortic valve function during follow-up. The maximal aneurysm transverse diameter was analysed based on contrast-enhanced computed tomography (CTA) or magnetic resonance (MR) performed preoperatively, and during the follow-up. RESULTS: The off-pump WT was used in 33 cases with no perioperative mortality. The median radiological follow-up was 33.47 (range: 1-106) months. Overall, the WT achieved a 30% diameter reduction. The mean preoperative and postoperative ascending aortic transverse diameter was 5.5 cm [standard deviation (SD): 0.6] and 3.7 cm (SD: 0.30), respectively (P = 0.001). In addition, CTA or MR follow-up showed stable diameters at the level of the aortic root and the distal ascending aorta. No death occurred during the follow-up. At 5 years, the estimated freedom rate from reinterventions of the aortic root and ascending aorta was 94%. CONCLUSIONS: This series shows that the WT with a polypropylene/polyester mesh allows safe off-pump treatment of patients with iAA. Mid- and long-term results are promising. This technique could be an attractive alternative, especially for patients unfit for aortic surgery with CPB and cardioplegia.

The Gore Hybrid Vascular Graft in renovisceral debranching for complex aortic aneurysm repair.

OBJECTIVE: This study reports our initial experience with the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) for staged hybrid open renovisceral debranching and endovascular aneurysm repair in patients affected by thoracoabdominal aortic aneurysms and pararenal abdominal aortic aneurysms (PAAAs). METHODS: Between December 2012 and December 2013, we analyzed outcomes of 13 patients who underwent open surgical debranching of renovisceral vessels for thoracoabdominal aortic aneurysm and PAAAs. All patients were considered at high risk for conventional surgery. Inclusion criterion was treatment by open surgical debranching of at least one visceral artery (renal artery, superior mesenteric artery [SMA], or celiac trunk [CT]) using the GHVG. In a second step, the aortic stent graft was implanted to exclude the aneurysm. If required, parallel grafts to the remaining visceral arteries were deployed in the same procedure. One patient had a symptomatic descending thoracic aortic aneurysm and another had a ruptured PAAA. Perioperative measured outcomes were immediate technical success rate, mortality, and morbidity. Median follow-up was 24.8 months (range, 0-15; mean, 8.2; standard deviation, 4 months). RESULTS: All open surgical debranching of renovisceral vessels were completed as intended. GHVG was used to revascularize 20 visceral vessels in 13 patients with a mean of 1.54 vessels per patient. Six renal arteries (30%; 2 right and 4 left), 9 SMAs (45%), and 5 CTs (25%) were debranched. In nine of 13 (66%) patients, other renovisceral arteries were addressed with chimney/periscope, Viabahn Open Revascularization Technique, and end-to-side anastomosis. Two of 13 patients (15%) died of bowel ischemia. Neither patient had GHVG revascularization to the SMA or CT. Perioperative complications occurred in three patients (23%; 1 renal hematoma, 1 respiratory insufficiency, and 1 small-bowel ischemia related to a SMA GHVG thrombosis). At 24 months, estimated survival was 85%, and estimated primary and secondary patency were 94% and 100%, respectively. CONCLUSIONS: This limited series extracted from a more consistent hybrid procedure experience showed a mortality rate similar to most recent reports. Technical feasibility and the short-term patency rate of the GHVG for renovisceral debranching during staged hybrid open and endovascular procedures were satisfactory. Use of GHVGs may represent a useful revascularization adjunct to minimize visceral ischemia in these challenging patients.

Acute pericarditis with cardiac tamponade induced by pacemaker implantation.

An 87-year-old woman was diagnosed with third-degree atrioventricular block and underwent pacemaker implantation. On postoperative day 12, she experienced cardiac tamponade that was suspected on computed tomography to be caused by lead perforation; therefore, we performed open-heart surgery. However, we could not identify a perforation site on the heart, and drained a 400-mL exudative pericardial effusion. Subsequently, we diagnosed the pericardial effusion as due to pericarditis induced by pacemaker implantation. It is sometimes difficult to distinguish pericarditis from pacemaker lead perforation, so both should be included in the differential diagnosis.

[Bilateral pulmonary artery occlusion due to primary pulmonary artery sarcoma; report of a case].

60-year-old female who complained of severe dyspnea was admitted with a diagnosis of massive pulmonary embolism. An emergency operation was undertaken due to right side heart failure. Under extracorporeal circulation with beating heart, large, white and smooth surface mass which was originated from right pulmonary artery was removed. Pathology of the mass showed low differentiated sarcoma. No evidence of other primary lesion by positron emission tomography-computed tomography (PET-CT) suggested primary pulmonary artery sarcoma. We scheduled total resection of the right lung, however postoperative CT showed large mass occupying from right pulmonary artery to main pulmonary trunk. Palliative chemo radiation therapy was introduced. Pulmonary artery sarcoma mimicking pulmonary thromboembolism is so malignant that the diagnosis and treatment should not be delayed.

[Marfan-like aortic aneurysm syndrome; A surgical experience with Loeys-Dietz syndrome].

A 17-year-old female patient complaining of chest pain was transferred to our hospital to treat annuloaortic ectasia associated with severe aortic valve insufficiency. She underwent a valve sparing operation with graft replacement of the ascending aorta and the proximal portion of the aortic arch. After the 1st operation, she was diagnosed with Loeys-Dietz syndrome (LDS), which is recently described as an autosomal dominant aortic aneurysm syndrome caused by heterozygous mutations in the transforming growth factor-beta receptor type 1 and 2 genes. Only 2 months after the 1st operation, she developed heart failure due to recurrence of aortic regurgitation. Computed tomography (CT) scan showed an expansion of the aortic arch. Total arch replacement using the elephant trunk technique and aortic valve replacement were performed successfully 4 months after the 1st operation. The rapidly progressive nature of the aortic disease in patients with LDS underscores the importance of meticulous surveillance of the entire aorta and the need for early surgical management.