Two-Stage Endovascular Aneurysm Repair with Preemptive Embolization: A Retrospective Study.

BACKGROUND: Type II endoleak is the most common complication of endovascular aneurysm repair. Retrograde perfusion from the aneurysmal sac side branch to the aneurysmal sac, including the inferior mesenteric artery and lumbar arteries, is associated with adverse events after endovascular aneurysm repair, such as aneurysm sac enlargement, reintervention, rupture, and abdominal aortic aneurysm-related death. Preemptive embolization of the aneurysmal sac side branch before endovascular aneurysm repair is an effective and safe procedure for preventing type II endoleak and reducing the size of the aneurysmal sac. Since 2019, we have been conducting preemptive embolization of the inferior mesenteric artery and lumbar arteries. Thus, we intended to work on a two-stage endovascular aneurysm repair in which embolization and endovascular aneurysm repair are performed on separate days, owing to concerns about prolonged operative time and increased contrast media use and radiation exposure from performing endovascular aneurysm repair simultaneously. This study aimed to evaluate the effects of a two-stage endovascular aneurysm repair. METHODS: This retrospective study included 114 cases of endovascular aneurysm repair (95 men and 19 women) for AAA performed at our hospital between January 2019 and December 2022. Inferior mesenteric artery and lumbar artery embolization were performed simultaneously with endovascular aneurysm repair (simultaneous group) in 49 cases, and two-stage embolization was performed (two-stage group) in 30 cases. The primary endpoints included the occurrence of T2EL during follow-up and the embolization rate of the IMA or LAs. RESULTS: Type II endoleak did not occur in the two-stage group (follow-up period: 35 ± 6.2 months), whereas it was observed in 8.2% of patients more than 6 months after EVAR in the simultaneous group (follow-up period: 28 ± 5.5 months). While the total operative time was 340 ± 111.2 min in the simultaneous group, the durations for embolization and endovascular aneurysm repair in the two-stage group were 169 ± 35.5 min and 135.0 ± 26.4 min (total time 304 ± 31.2 min, P = 0.21), respectively, indicating a reduction in the total time required for the 2 techniques. The total amounts of contrast media used in the simultaneous and two-stage groups were 200.0 ± 179.2 mL and 182.0 ± 51.2 mL (P = 0.42), respectively, and the corresponding total radiation doses were 2502.4 ± 690.5 mGy and 2114.6 ± 351.2 mGy (P = 0.28), respectively, showing a decrease in both in the two-stage group. The lumbar artery embolization rates were 74.3% and 87.9% (P < 0.01) in the simultaneous and two-stage groups, respectively, indicating a significant difference. CONCLUSIONS: Two-stage endovascular aneurysm repair with preemptive embolization of the inferior mesenteric artery and lumbar arteries may be an effective strategy for reducing type II endoleak occurrence, overall operative time, contrast use, and overall radiation exposure.

Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A.

OBJECTIVE: Total arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury. METHODS: We evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA. RESULTS: The surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow. CONCLUSIONS: FeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

Endovascular treatment of a tuberculous aneurysm of the pararenal abdominal aorta leading to an aortoduodenal fistula.

This case report describes the presentation of a 79-year-old woman with no significant past medical history diagnosed with a saccular aneurysm with an aortoduodenal fistula. An emergency endovascular aneurysm repair was performed. Although the postoperative course was uneventful, 10 months after endovascular aneurysm repair, the patient died of miliary tuberculosis from mycotic aneurysms. Mycotic aneurysms are uncommon, and mycotic aneurysms caused by Mycobacterium tuberculosis are even rarer. Therefore, we believe our study makes a significant contribution to the literature given the rarity of the condition and suggests the importance of maintaining a high index of suspicion for tuberculosis as a possible cause of aortoduodenal fistula in primary mycotic aneurysm.

Bilateral Trans-Septal Approach to Right Lung Cancer Invading the Left Atrium.

We describe a 69-year-old woman with primary lung cancer in the right lower lobe invasive to the left atrium (LA) via the pulmonary vein (PV). The tumor in the LA measured 30 × 26 mm, and to avoid critical embolism preoperative induction therapy was not performed. The patient underwent right thoracotomy under cardiopulmonary bypass (CPB), and the atrial septum was incised via the right atrium. The tumor was placed out of the LA, followed by lobectomy. For right lung tumors invading the LA, the bilateral trans-septal approach is useful for confirming the surgical margin.

[Repeated Hemoptysis after Thoracic Endovascular Aortic Repair for Ruptured Thoracic Aortic Aneurysm with Hemoptysis;Report of a Case].

In recent years, re-rupture due to endoleaks after thoracic endovascular aortic repair (TEVAR) for ruptured thoracic aortic aneurysms has become a problem. Hemoptysis has been reported in patients after pneumocentesis. We report a patient who developed delayed hemoptysis not related to endoleak after TEVAR. An 80-year-old male underwent emergent TEVAR due to a ruptured thoracic aortic aneurysm accompanying sudden hemoptysis. Eleven days after the operation, recurrent hemoptysis was noted, but contrast-enhanced computed tomography (CT) revealed no endoleak or re-rupture. Bronchoscopy demonstrated hemorrhage from the left upper lobe. As hemostasis was difficult by conservative treatment, left upper lobectomy was performed. The aortic rupture hole exhibited thrombus, and there was no hemorrhage. On histopathological examination of the resected lung, formation accompanied by severe intra-alveolar fibrosis and cholesterin clefts, and marked foreign body reactions in the interstitium and small blood vessels of the lung were observed. Cholesterol embolism is associated with not only organ ischemia due to microembolism, but also immunological mechanisms. Thus, cholesterol embolism due to aorta-derived cholesterin may have led to the delayed pulmonary hemorrhage. Differentiation from re-rupture due to endoleaks is important.

A case of the Starr-Edwards ball valve (Model 6120) in the mitral position for 45 years.

A 59-year-old male who had undergone mitral valve replacement with the Starr-Edwards ball valve Model 6120 (S-E ball valve) 45 years ago was admitted to our hospital for hemolytic anemia and heart failure. Echocardiography revealed that there was no valve dysfunction but paravalvular leakage between the annulus of P2 and the sewing ring of the Starr-Edwards ball valve. He underwent mitral valve replacement. The S-E ball valve was successfully replaced with bileaflet mechanical valve. The explanted S-E ball valve was free from signs of structural valve degeneration. This case shows one of the longest durability of the S-E ball valve in mitral position in the world.

[Vascular Behçet disease presenting large right coronary artery pseudoaneurysm after percutaneous coronary intervention( PCI): report of a case].

A 37-year-old man was diagnosed with angina pectoris and underwent percutaneous coronary intervention(PCI) procedure for right coronary artery in other hospital. Five months after PCI procedure, he was admitted to the hospital because of fever, chest pain and respiratory discomfort. He was diagnosed as having a large right coronary artery pseudoaneurysm which was about 40 mm in diameter. He was transfered to our hospital. We did coronary artery bypass grafting(CABG)[ saphenous vein graft (SVG)-#3] and pseudoaneurysm closure, and he left our hospital on 37 post-operative day. After discharge from our hospital, he developed iliocecal ulcer, oral aphtha, folliculitis and arthralgia and was diagnosed with Behçet disease. Seven months after the 1st surgery, proximal anastomosis site of SVG was ruptured and presented huge ascending aorta pseudoaneurysm. We performed autologous pericardial patch plasty on ascending aorta, and covered there with omentum flap. He uneventfully left our hospital on 19 post-operative day.

[Thoracic and cardiovascular surgery in Jehovah's Witness].

A Jehovah's Witness who requires thoracic and cardiovascular surgery represents a challenge to both the surgeon and the patient because of the patient's refusal to accept blood transfusion. We reported 15 cases of Jehovah's Witness patients from 43 to 80 years of age who underwent cardiac operations or thoracic vascular operations. There was 1 emergency operation case and 2 re-do operation cases. Erythropoietin and serum albumin injections were allowed to be used in some cases. The mean pre-operative haemoglobin level in these patients was 12.3 g/dl. The mean postoperative lowest haemoglobin level was 9.2 g/dl. The mean haemoglobin level at the point of leaving hospital was 11.4 g/dl. There were no postoperative complications and no operative deaths. We successfully performed the thoracic and cardiovascular operations on Jehovah's Witnesses, including emergency cases, safely without blood transfusion. The most important thing is a careful and safe operative technique which reduces perioperative bleeding as much as possible.