Risk factors in the treatment of abdominal aortic aneurysms in the endovascular ERA.

PURPOSE: Endovascular aneurysm repair (EVAR) is a minimally invasive treatment that is becoming standard in abdominal aortic aneurysm treatment. We examine the risk factors of death by comparing the short-term results of abdominal aortic aneurysm by open surgical repair with EVAR. METHODS: We performed elective abdominal aortic aneurysm treatment on 122 cases during the period from January 2008 to December 2009. Seventy one cases were treated with open surgical repair while 51 cases were treated with EVAR. RESULTS: Compared to the open surgical repair group, the EVAR group was significantly older and had a higher complication rate and past laparotomy rates. No significant difference in hospital deaths was observed between the two groups. Two deaths with thromboembolism due to shaggy aorta were observed in the EVAR group. Two cases in the open surgical repair group developed postoperative myocardial infarction and one death was observed. Both patients underwent coronary artery treatment using drug eluting stents (DES) prior to surgery. CONCLUSION: Shaggy aorta has a high possibility of causing thromboembolism and EVAR should not be performed unless there is a considerable reason. In cases in which coronary artery treatment is performed with DES in recent days, EVAR is more preferable.

String-sign in left internal thoracic artery is associated with regression in left main trunk stenosis after coronary artery bypass.

The left internal thoracic artery (LITA) is the conduit of choice for coronary artery bypass (CABG) due to favorable long-term patency. Uncommonly, diffuse narrowing like a string without significant stenosis of an anastomosis is observed in the LITA graft (called "string sign"). Isolated left main trunk (LMT) diseases were reported to regress in some cases. However, the relationship between "string sign" and the regression of solitary LMT disease remains unknown.We retrospectively studied 40 consecutive patients with isolated LMT stenosis who underwent CABG using LITA and who underwent angiography before and after operation (31 males, 9 females, mean age, 65.0 years). The patients were divided into 2 groups according to the postoperative angiographic outcomes of the LITA graft: one group included patients with "string sign" (6 patients), the other group consisted of patients with a patent LITA graft (34 patients).There were no significant differences in clinical backgrounds between the two groups. The 2 groups showed similar quantitative % coronary artery stenosis of the LMT before operation (77.5% versus 76.8%) and the observation period was similar in both groups. Coronary angiography after CABG revealed that % stenosis of the LMT in patients with "string sign" was significantly less than that in patients with a patent LITA graft (41.7 ± 26% versus 82.5 ± 11%, P < 0.001). Regression in LMT was significantly more frequently observed in the "string sign group". Furthermore, ostial stenosis was more frequent in patients with "string sign". "String phenomenon" of the LITA graft is one of the signs related to the regression of LMT stenosis, and especially in ostial stenosis of the LMT.

Metabolic syndrome predicts 10-year mortality in non-diabetic patients following coronary artery bypass surgery.

BACKGROUND: Metabolic syndrome (MetS) is a risk factor for cardiovascular disease and mortality, but, the relationship between MetS and survival after coronary artery bypass grafting (CABG) remains unclear. METHODS AND RESULTS: The outcomes of patients with and without MetS were analyzed. Patients who had undergone CABG at Juntendo University Hospital between January 1984 and December 1992 were enrolled. The survival search was performed by the end of 2000. The patients were categorized by the existence of preoperative MetS using the modified American Heart Association/National Heart, Lung, and Blood Institute (AHA/NHLBI) definition with body mass index instead of waist circumference. MetS was present in 551 (46.6%) patients and absent in 632 (53.4%). Preoperative MetS was associated with long-term poor prognosis in terms of all-cause death (hazard ratio (HR) 1.34; 95% confidence interval (CI) 1.03-1.74; p=0.028) and cardiac death (HR 2.31; 95% CI 1.36-3.92; p=0.002) in non-diabetic patients. These differences in the mortality of the 2 groups were more obvious after 10 years. However, among the patients with diabetes, the presence of MetS was not related to long-term mortality. CONCLUSIONS: Preoperative MetS predicted increased all-cause and cardiac mortality, especially after 10 years, in non-diabetic patients undergoing CABG.

Mild or moderate ischemic mitral regurgitation in patients undergoing off-pump coronary artery bypass grafting.

BACKGROUND: There has been a debate, whether mild or moderate ischemic mitral regurgitation (IMR) should be repaired at the time of coronary bypass surgery. We assessed the early and midterm outcomes of patients with mild or moderate IMR who underwent isolated off-pump coronary artery bypass grafting (OPCAB). METHODS: We retrospectively reviewed records of 602 patients who underwent OPCAB between April 2001 and July 2004. Of those, 96 patients had mild or moderate MR (IMR group), and 506 had none or trivial MR (no IMR group). Preoperative and postoperative characteristics were compared between the groups. Furthermore, fates of grade of MR and functional status were investigated in patients with IMR. RESULTS: The preoperative mean New York Heart Association (NYHA) classes were 2.7 +/- 1.0 and 2.4 +/- 0.9 in the IMR and no IMR groups, respectively (p < 0.01). Operative mortality was similar between groups (1.0% in the IMR group and 0.4% in no IMR group, p = 0.41). The cumulative survival rate for the IMR group was 93.7% at 1 year and 90.1% at 4 years. The mean NYHA class was 1.1 +/- 0.4 (p < 0.0001) at 28.8 +/- 11.4 months after operation for the IMR group. The mean grade of mitral regurgitation diminished (from 2.2 +/- 0.4 to 1.1 +/- 0.6, p < 0.0001) soon after operation in patients with IMR, and remained so (1.1 +/- 0.8, p < 0.0001) during the follow-up period. CONCLUSIONS: Mild or moderate IMR could be improved with isolated OPCAB. The early and midterm functional outcomes of these patients were favorable.

Early and midterm results of off-pump coronary artery bypass grafting.

BACKGROUND: Early outcomes of off-pump coronary artery bypass grafting have been documented by numerous studies. However, there have been few reports concerning midterm outcomes after off-pump coronary artery bypass grafting. METHODS: We retrospectively reviewed the records of 602 consecutive patients (24.8% female) who underwent isolated off-pump coronary artery bypass grafting between April 2001 and July 2004. Mean age was 66.7 +/- 9.3 years. Mean Canadian Cardiovascular Society score was 2.5 +/- 0.9. Early postoperative angiograms were evaluated during the same period of hospitalization. Midterm outcomes, including overall patient survival, freedom from cardiac death, and freedom from the combined endpoint of cardiac events, were evaluated. RESULTS: The average number of distal anastomoses per patient was 3.6 +/- 1.4. The average operation time was 286.1 +/- 72.1 minutes. Long segmental reconstruction of the left anterior descending coronary artery was performed in 218 patients (36.2%). Total arterial grafting was performed in 466 patients (77.4%). Thirty-day mortality was 0.5%. Overall patency rate for all grafts and anastomoses was 97.5% and 97.6%, respectively. Mean follow-up time was 2.9 +/- 1.0 years. Cumulative patient survival at 5 years was 87.9% +/- 2.4%. Freedom from cardiac death was 97.7% +/- 0.6% at 5 years. Freedom from the combined endpoint of cardiac events was 83.8% +/- 2.3% at 5 years. CONCLUSIONS: Early and midterm outcomes after off-pump coronary artery bypass grafting have acceptable mortality and cardiac events rates, with favorable early graft patency rates.

Transapical aortic cannulation for cardiopulmonary bypass in type A aortic dissection operations.

OBJECTIVE: The femoral artery is the customary site for arterial cannulation for cardiopulmonary bypass in treating type A aortic dissections. However, because of concerns regarding complications caused by retrograde perfusion, the number of surgeons who prefer using the axillary artery as the site for cannulation is increasing. However, axillary artery cannulation also involves some problems. Thus we prefer transapical aortic cannulation for repair of type A aortic dissection. METHODS: Transapical aortic cannulation was performed in 138 patients (83 men and 55 women; mean age, 60.1 years; 129 acute and 9 chronic; 120 hemiarch repair and 15 total arch replacement) with type A aortic dissection. A 1-cm incision is made in the apex of the left ventricle, and a 7-mm soft and flexible cannula is passed through the apex and across the aortic valve until positioned in the ascending aorta transesophageal echocardiographic guidance. RESULTS: There were no cases in which conversion to cannulation of another artery was necessary. In all cases cardiopulmonary bypass flow was sufficient (>2.5 L/m(-2)/min(-1)). There were no malperfusion events. Eight (5.8%) patients had cerebrovascular accidents. Twenty-six (18.8%) patients died in the hospital of complications not related to transapical aortic cannulation. CONCLUSIONS: Our results show that transapical aortic cannulation is safe and useful for repair of type A aortic dissection. There are advantages to transapical aortic cannulation, such as simple and quick cannulation technique, sufficient antegrade aortic flow, and the reliability of true lumen perfusion with decreased risk of stroke and malperfusion.

In situ bilateral skeletonized internal thoracic arterial grafting for left-side myocardial revascularization using an off-pump technique.

The aim of this study was to review the clinical and angiographic outcomes of in situ skeletonized bilateral internal thoracic artery (ITA) grafting for left coronary arterial revascularization using an off-pump technique in 144 consecutive patients. We also assessed the difference between left and right ITA grafting to the left anterior descending coronary artery (LAD). Arrangement of the bilateral ITAs (grafting of the left/right ITA to the LAD) was decided according to the coronary anatomy and quality of the grafts. Early postoperative angiograms were evaluated in 110 patients. The average numbers of anastomoses and bilateral ITA anastomoses per patient were 3.4 and 2.3, respectively. There were no surgical deaths or sternal infection. The left and right ITA were anastomosed to the LAD in 106 (73.6%) and 38 (26.4%) patients, respectively. There were no differences in preoperative conditions and postoperative complications between the left ITA and right ITA to LAD groups. The patencies of the left and right ITAs were 99.1 and 100%, respectively. In situ skeletonized bilateral ITA grafting for left-side revascularization using an off-pump technique was shown to be feasible, producing excellent early clinical and angiographic outcomes. Furthermore, arrangement of bilateral ITAs did not affect outcomes.

Emergency conversion in off-pump coronary artery bypass grafting.

Emergency conversion to cardiopulmonary bypass in off-pump coronary artery bypass grafting is recognized to increase operative mortality and morbidity. We conducted a retrospective review of 616 consecutive patients who were planned for off-pump coronary artery bypass grafting from April 2001 to July 2004. Fourteen patients (2.3%) required emergency conversion to cardiopulmonary bypass. Operative mortality was 13.3% in the conversion group and 1.2% in the non-conversion group (P<0.001). The incidence of reoperation for bleeding was 7.1% and 1.0%, respectively (P=0.032) and that of respiratory failure was 35.7% and 3.3%, respectively (P<0.001). Multivariable analysis showed that mitral regurgitation and chronic obstructive pulmonary disease were predictors of emergency conversion with all causes except for bleeding, and that mitral regurgitation and no use of a heart positioning device were predictors of emergency conversion due to hemodynamic compromise during distal anastomosis of the circumflex artery territory. In conclusion, emergency conversion in off-pump coronary artery bypass grafting increases operative mortality and morbidity. Mitral regurgitation and chronic obstructive pulmonary disease are risk factors for emergency conversion. Use of a heart positioning device decreases hemodynamic compromise during anastomosis of the circumflex artery territory.

Long segmental reconstruction of diffusely diseased left anterior descending coronary artery with left internal thoracic artery with or without endarterectomy.

BACKGROUND: The diffusely diseased left anterior descending coronary artery (LAD) remains a challenge for both interventional cardiologists and cardiac surgeons. In this study we assessed the surgical outcomes obtained from coronary artery reconstruction, with or without endarterectomy, for a diffusely diseased LAD. METHODS: Two hundred and fifty patients were treated with an extended LAD reconstruction, with or without endarterectomy, as part of coronary artery bypass grafting to achieve complete revascularization. The left internal thoracic artery (LITA) was used to reconstruct the LAD in all patients. There were 197 men and 53 women. The mean age was 65.1 +/- 9.0 years. Coronary artery reconstruction was performed without endarterectomy in 183 patients (73.2%) and with endarterectomy in 67 patients (26.8%). The off-pump technique was used in 204 patients (81.6%). RESULTS: The operative mortality was 1.6%. Perioperative myocardial infarction was observed in 6.4% of the patients. The mean LAD incision length was 4.3 +/- 1.7 cm. The patency rate of the LITA to LAD was 98.6% by early angiographic examination (mean, 7.5 +/- 2.6 postoperative days). There were 3 late cardiac-related deaths at a mean follow-up of 21.2 +/- 10.7 months. The actuarial survival was 92.0% at 45 months. Freedom from death or cardiac events was 88.1% at 45 months. CONCLUSIONS: Coronary artery reconstruction, with or without endarterectomy, using the left internal thoracic artery for a diffusely diseased LAD can be performed with acceptable early and midterm results.

Total arterial myocardial revascularization using composite and sequential grafting with the off-pump technique.

BACKGROUND: Multiple arterial myocardial revascularizations are increasingly undertaken using off-pump techniques; however, various arterial grafting techniques are utilized. This study aimed to review the outcome of combining arterial composite and sequential grafting with off-pump techniques. METHODS: We retrospectively reviewed the records of 107 consecutive patients who underwent coronary bypass surgery with off-pump and arterial composite grafting techniques between April 2001 and March 2004. The left internal thoracic artery (LITA) was harvested in all patients, and the right internal thoracic artery (RITA), the radial artery (RA), and the gastroepiploic artery (GEA) were harvested in 69 patients, in 83 patients, and in 53 patients, respectively. Early postoperative angiograms were evaluated in 97 patients. RESULTS: There were 488 distal anastomoses, an average of 4.5 per patient. Forty-four in situ LITAs were used as LITA Y-composite grafts with a free RITA (n = 19), RA (n = 24), or free GEA (n = 1). Forty-three in situ RITAs were used as RITA-RA grafts (n = 42) or a RITA-GEA graft (n = 1). Twenty-one in situ GEAs were used as composite grafts with the RA (n = 17) or a free RITA (n = 4). There were no hospital deaths. The patency of the LITA was 100%, and that of the RA was 97.3%, while patencies of both in situ and free RITA and GEA were 100%. During the follow-up period (mean: 22.1 months), there were 3 late deaths, but none were cardiac related. CONCLUSIONS: Total arterial revascularization with composite and sequential grafting is a safe and effective technique in patients undergoing off-pump coronary artery bypass surgery.

Effect of pravastatin on progression of coronary atherosclerosis in patients after coronary artery bypass surgery.

BACKGROUND: Although the anti-atherosclerotic effects of HMG-CoA reductase inhibitors are well known, their specific effect on saphenous vein grafts after coronary artery bypass graft (CABG) operation is not well documented and has not been studied in Japan, so the aim of the present prospective randomized controlled study involving 27 Japanese institutions was to investigate the effects of pravastatin on the progression of atherosclerosis in such grafts and native coronary arteries after CABG. METHODS AND RESULTS: A total of 303 patients who had undergone CABG were randomly assigned to either the pravastatin group (n =168) or the control group (n = 167). Paired coronary angiograms were obtained at baseline and at the end of 5-year follow-up in 182 (60%) patients. The low-density lipoprotein cholesterol concentration significantly decreased in the pravastatin group from 141.4 mg/dl to 113.7 mg/dl (-19.6%), compared with 141.1 mg/dl to 133.7 mg/dl (-5.2%) in the control group (p < 0.001). Although there was no significant difference in the quantitative coronary angiography measurements between the 2 groups, the global change score indicated a significant pravastatin-mediated reduction in plaque progression (p < 0.01). CONCLUSIONS: Pravastatin can potentially reduce atherosclerotic progression in both the bypass graft and native coronary arteries of patients after CABG.

Coronary artery and graft spasm after off-pump coronary artery bypass grafting.

We report a case of a 52-year-old man with severe coronary artery and graft spasm after triple-vessel off-pump coronary artery bypass grafting. Emergent coronary angiography was performed to identify the location and severity of the spasm. Intracoronary injections of several vasodilators failed to relieve the spasm. Observational treatments including intra-aortic balloon pump and inotropic drugs to increase coronary flow were performed until the spasm resolved. The patient recovered and was discharged. A follow-up coronary angiography revealed patent native coronary artery and bypass grafts without evidence of residual spasm.

Coronary endarterectomy and stent removal in patients with in-stent restenosis.

BACKGROUND: In-stent restenosis (ISR) remains the major limitation of coronary stent implantation. Controversies exist regarding optional treatment for ISR. Recently, we developed aggressive surgical options, coronary endarterectomy and stent removal, in this complex setting. METHODS: Between April 2001 and March 2004, 11 consecutive patients who presented with angina and angiographically severe ISR were treated with coronary endarterectomy and stent removal with concomitant multivessel coronary bypass grafting. There were 10 men and 1 woman. The age ranged from 43 to 75 years old (mean 64.1 +/- 9.6 years). The mean number of target vessel interventions was 1.6 +/- 0.7. Data were analyzed retrospectively. RESULTS: The target vessel was the left anterior descending artery (LAD) in all patients. The mean interval from the last intervention was 4.8 +/- 1.9 months. The mean number of target vessel interventions was 1.6 +/- 0.7. The mean LAD incision length was 57.3 +/- 11.0 mm. The left internal mammary artery (LIMA) was grafted in situ, as an on-lay patch. Procedural success without in-hospital complications was achieved in all cases, except one patient with low output syndrome. Postprocedure angiography demonstrated that all LIMA patches and LAD arteries were patent and left ventricular functions were preserved. CONCLUSIONS: Coronary endarterectomy and stent removal with on-lay LIMA patch is a safe and effective technique used in patients with ISR involving diffuse target vessel disease.

Surgical treatment for primary cardiac leiomyosarcoma causing right ventricular outflow obstruction.

A 55-year-old man was admitted to another hospital because of dry cough and dyspnea that rapidly worsened before admission. Chest computed tomography revealed a low-density mass that nearly obstructed the main pulmonary arterial trunk. Pulmonary thromboembolism was suspected and treated with catheter-directed thrombolysis therapy. Despite optimal thrombolysis and anticoagulant therapy, his symptoms persisted. He was referred for further examination and possible surgery for presumed pulmonary thromboembolism. The mass appeared more likely to be a tumor than a thrombus on careful analysis of the magnetic resonance imaging. At surgery, the anterior wall of the main pulmonary arterial trunk, the pulmonary valve, annulus, and the right ventricular outflow tract were all invaded by what was found to be a tumor and were resected under conventional cardiopulmonary bypass. The resected area was reconstructed with a 25-mm-diameter bioprosthetic valve and Xenomedica patch. Final pathological diagnosis was primary cardiac leiomyosarcoma involving the pulmonary valve. Postoperative course was uneventful, and he was discharged 11 days after surgery without adjuvant therapy because he refused it. Ten months later, the patient was well, but a chest X-ray revealed some coin lesions in the bilateral lung fields that were thought to be metastatic tumor.

Off-pump coronary artery bypass grafting in patients with renal dysfunction.

BACKGROUND: Renal dysfunction is a predictor of increased morbidity and mortality after coronary artery bypass grafting, whether it is dialysis-dependent or not. Several studies have shown the efficacy of off-pump technique in reducing morbidity and mortality in patients with renal dysfunction. However, the actual effect of renal dysfunction in off-pump coronary artery bypass grafting has not been well understood. METHODS: We conducted a retrospective review of 402 consecutive patients undergoing off-pump coronary artery bypass grafting from April 2001 to June 2003. Sixty-eight patients had chronic renal dysfunction (group A); 19 patients were dialysis-dependent; 334 patients had normal renal function (group B). Operative variables, morbidity, and mortality were compared between the two groups. Furthermore, multivariable analysis was performed to identify predictors for short-term survival. RESULTS: Preoperative characteristics were similar in the two groups. Blood transfusion rate was higher in group A than group B (57.4% and 25.7%, respectively; p < 0.001). In-hospital mortality was similar (1.5% and 1.2% in group A and B, respectively; p = 0.853). Multivariable analysis revealed that unstable angina, low ejection fraction, peripheral vascular disease and redo surgery are significant risk factors for poor early result of off-pump coronary artery bypass grafting. CONCLUSIONS: Early outcomes of off-pump coronary artery bypass grafting in patients with renal dysfunction were comparable to those in patients with normal renal function. Renal dysfunction is not a predictor of poor early outcomes after off-pump coronary artery bypass grafting.

Coronary endarterectomy and stent removal after iatrogenic perforation.

Coronary perforation is a rare complication of percutaneous coronary intervention. We report a case of type 3 coronary artery perforation after stenting of the left anterior descending coronary artery. Pericardiocentesis was required to treat cardiac tamponade and prolonged balloon inflation did not stop the bleeding. Urgent surgical intervention with coronary endarterectomy, removal of the stent, and bypass grafting using the left internal mammary artery to the left anterior descending artery was successful. Complete removal of stent with endarterectomy is a feasible option for perforation as a complication of coronary stenting.

Venous coronary artery bypass grafting: late results of a 15-year actuarial follow-up in 486 patients.

PURPOSE: The aim of this study was to clarify the long-term results of venous coronary artery bypass grafting in Japanese patients. METHODS: The study population included 492 patients who underwent venous coronary artery bypass procedures at the Department of Cardiothoracic Surgery of Juntendo University from January 1984 to December 1989. The great majority of patients, 420 of 492 (85.4%), were males, and the mean patient age was 61.1 years (range: 32-82 years). The disease conditions included single-vessel disease in 32 patients (6.5%), double-vessel disease in 111 patients (22.6%), triple-vessel disease in 251 patients (51.2%), and 50% or more stenosis of the left main coronary artery in 98 patients (19.9%). A mean of 2.4 grafts was used per patient. RESULTS: The 15-year survival rate was 57.7%. The 15-year actuarial cardiac survival and cardiac event-free survival were 81.3% and 51.3%, respectively. The 15-year actuarial freedom from reoperation and myocardial infarction were 87.5% and 92.1%, respectively. Of 192 patients who died during the follow-up period, 62 deaths were due to cardiac causes (32.3%), 43 were due to malignant neoplasms (22.4%), and 25 were due to cerebral vascular accidents (13.0%). CONCLUSION: The prognosis of Japanese patients undergoing coronary artery bypass grafting may therefore be more favorable than that of Western patients. In addition, diabetes mellitus was an independent risk factor for both cardiac death and cardiac events.

Off-pump long onlay bypass grafting using left internal mammary artery for diffusely diseased coronary artery.

Surgical treatment of a diffusely diseased coronary artery has been considered a relative contraindication for off-pump coronary artery bypass grafting. To our knowledge, long onlay-patch grafting with off-pump coronary artery bypass grafting has not been described. Two sets of Octopus 3 tissue stabilizers were placed longitudinally along the target coronary artery. This allowed us to perform surgical angioplasty and bypass grafting without cardiopulmonary bypass support (double Octopus technique). We report our early experience with off-pump long onlay bypass grafting in patients with a diffusely diseased coronary artery using double Octopus tissue stabilizers. Diffusely diseased coronary artery; off-pump coronary artery bypass grafting; coronary artery reconstruction; coronary artery bypass grafting; onlay patch anastomosis

Fibrin glue and bioabsorbable felt patch for intraoperative intractable air leaks.

OBJECTIVE: We worked to devise a new way to prevent postoperative persistent air leaks in high-risk pulmonary surgery patients. METHODS: From November 1993 to June 2002, 60 patients with difficult to control intraoperative pulmonary air leakage were treated using bioabsorbable polyglycolide felt patches soaked in fibrin glue to cover the leakage site. RESULTS: After application, the felt patch adhered tightly to the lung surface without peeling off, enabling good leakage closure with only 2 ml of fibrin glue used. Air leakage was controlled successfully in 52 (86.7%) of the 60. Four of the 8 patients in whom this method failed to stop air leakage also developed mild pyothorax, with 2 requiring a second operation by video-assisted thoracic surgery. Leakage was eventually controlled in all patients, with no postoperative deaths relating to air leakage. CONCLUSIONS: Fibrin-glue-soaked bioabsorbable felt patches effectively seal intraoperative intractable air leaks. Felt patch use may increase the risk of postoperative infection. It should be considered for use on patients with fistulas that cannot be controlled by direct closure or otherwise intraoperatively and who may potentially develop uncontrollable air leakage postoperatively.