[Repair of Traumatic Brachiocephalic Artery Pseudoaneurysm by Open Surgery:Report of a Case].

The patient is a 56-year-old man. He fell while playing golf and sustained a contusion on his right chest. He fell into hemorrhagic shock during surgery for a right clavicle fracture at a nearby hospital and required cardiac resuscitation. Computed tomography( CT) scan revealed left pneumothorax and right hemothorax, and a contrast-enhanced CT scan revealed a pseudoaneurysm at the brachiocephalic artery origin. He underwent surgery three weeks later. Surgery was performed through a median sternotomy and partial arch replacement (zone 2) with antegrade cerebral perfusion under moderate hypothermia. He was discharged on postoperative day 10 without significant complications.

Long-term Results of Valve-Sparing Aortic Root Replacement and Aortic Cusp Repair.

BACKGROUND: Long-term results of valve-sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation are unclear. METHODS: VSRR by reimplantation was performed in 363 patients. Tricuspid aortic valve (TAV) and bicuspid aortic valve were found in 285 and 71 patients, respectively. RESULTS: Aortic cusp repair was performed in 268 patients. Of patients with TAV 129 had central plication of the Arantius node, 36 had free margin resuspension, and 71 had reinforcement. Mean follow-up was 71.4 months. Among TAV patients freedom from aortic valve reoperation at 10 and 15 years was 85.1% and 78.3%, respectively. Freedom from aortic valve reoperation at 10 years was lower in patients with cusp prolapse than without (77.4% vs 93.2%, P = .007). The overall freedom from more than mild aortic regurgitation at 10 and 15 years was 72.4% and 64.0%, respectively. It was also significantly greater in patients without cusp prolapse (78.4% vs 67.7%, P = .02). As for the cusp repair technique the freedom from aortic valve reoperation at 10 years was significantly better in patients who underwent only resuspension or reinforcement techniques compared with patients who underwent only central plication technique (100% vs 72.8%, P = .008). CONCLUSIONS: Long-term results of VSRR with aortic cusp repair were satisfactory. The resuspension technique appears to be useful for repairing aortic cusp prolapse in patients with TAV.

Japanese single-center experience of abdominal aortic aneurysm repair over 20 years: should open or endovascular aneurysm repair be performed first?

PURPOSE: The present study analyzed the outcomes of our experience with abdominal aortic aneurysm (AAA) repair over 20 years using endovascular aortic repair (EVAR) with commercially available devices or open aortic repair (OAR) and reviewed our surgical strategy for AAA. METHODS: From 1999 to 2019, 1077 patients (659 OAR, 418 EVAR) underwent AAA repair. The OAR and EVAR groups were compared retrospectively, and a propensity matching analysis was performed. RESULTS: EVAR was first introduced in 2008. Our strategy was changed to an EVAR-first strategy in 2010. Beginning in 2018, this EVAR-first strategy was changed to an OAR-first strategy. After propensity matching, the overall survival in the OAR group was significantly better than that in the EVAR group at 10 years (p = 0.006). Two late deaths due to AAA rupture were identified in the EVAR group, although there were no significant differences between the OAR and EVAR groups with regard to the freedom from AAA-related death at 10 years. The rate of freedom from aortic events at 10 years was significantly higher in the OAR group than in the EVAR group (p < 0.0001). CONCLUSION: The rates of freedom from AAA-related death in both the OAR and EVAR groups were favorable, and the rate of freedom from aortic events was significantly lower in the EVAR group than in the OAR group. Close long-term follow-up after EVAR is mandatory.

Spinal cord ischemia after elective endovascular abdominal aortic aneurysm repair in a patient with multiple occlusions of the intercostal and internal iliac arteries.

Spinal cord ischemia (SCI) after endovascular abdominal aortic aneurysm repair is a rare but devastating complication. Occlusion of the artery of Adamkiewicz or feeders to the collateral network for spinal cord circulation (such as the subclavian, intercostal, lumbar, and internal iliac arteries) is associated with the onset of SCI. We present a case of monoplegia owing to SCI after elective endovascular abdominal aortic aneurysm repair with coil embolization of the left internal iliac artery in an elderly patient with a history of arteriosclerosis obliterans and aortic dissection, preoperatively occluding multiple intercostal arteries and the right internal iliac artery.

Acute Kidney Injury Affects Mid-Term Outcomes of Thoracoabdominal Aortic Aneurysms Repair.

The effect of acute kidney injury (AKI) on mid-term outcomes following thoracoabdominal aortic aneurysm (TAAA) repair is not well known. We hypothesized that postoperative AKI would reduce mid-term survival and aimed to analyze the effect of AKI on mid-term outcomes after TAAA repair. This retrospective study identified 294 consecutive TAAA repairs at Kobe University Hospital from October 1999 to March 2019. Patients with preexisting end-stage renal disease that required hemodialysis (n = 11) and patients who died intraoperatively (n = 2) were excluded. Finally, 281 patients were analyzed. AKI was defined according to Kidney Disease: Improving Global Outcomes guidelines (KDIGO) classification. Of the 281 patients, 178 (63.3%) developed AKI, of which 98 (34.9%) had mild, 34 (12.1%) had moderate, and 46 (16.4%) had severe AKI. Twenty-six patients (12.8%) required renal replacement therapy after surgery. Twenty-three in-hospital deaths (8.2%) were recorded, including 2 (0.7%) without AKI, 0 (0%) with mild AKI, 1 (0.4%) with moderate AKI, and 20 (7.1%) with severe AKI (p < .001). The 4-year survival was 91.9 ± 3.0% for no AKI, 91.3 ± 3.2% for mild AKI, 72.4 ± 8.5% for moderate AKI and 32.6 ± 7.4% for severe AKI (p < .001). Multivariable Cox-hazard regression analysis demonstrated that moderate and severe AKI, older age and emergency surgery were significant risk factors for mid-term survival. In patients undergoing TAAA repair, severe AKI was associated with an increase in in-hospital mortality and both moderate and severe AKI were negatively associated with mid-term survival. Preventing moderate/severe AKI may improve mid-term survival after TAAA repair.

Impending paradoxical embolism.

An impending paradoxical embolism (IPDE) is seldom observed in clinical practice. We report a case of IPDE in a 67-year-old female with severe dyspnea and hypotension, which was detected and successfully treated with emergent cardiac surgery. The optimal treatment is still controversial. We believe that emergent surgery always should be considered in patients with IPDE. .

[Does Surgeons' Experience Affect the Surgical Outcomes of Total Arch Replacement?]

OBJECTIVES: Total arch replacement( TAR) is used to be a complicated and quite invasive aortic procedure. To perform TAR safely and effectively under all circumstances, we have constructed standardization of the procedures of TAR. The aim of this study is to analyze the impact of surgeons' experience on surgical outcome of TAR to evaluate our standardization. METHODS: From January 2008 to December 2020, 346 consecutive patients (mean age 73.6±10.2) underwent elective TAR through a median sternotomy at our institute. TAR was performed by three types of surgeon classified by their experience( A:over 20 years, B:15~20 years, C:under 15 years). The surgical outcomes were examined. Our standard approach include( 1) meticulous selection of arterial cannulation site and type of arterial cannula;(2) antegrade selective cerebral perfusion;(3) maintenance of minimal tympanic temperature between 20 ℃ and 23 ℃;(4) early rewarming just after distal anastomosis;(5) maintaining fluid balance below 1,000 ml during cardiopulmonary bypass. RESULTS: The operative cases were 227 in A, 86 in B and 33 in C. Surgeon A operated more complicated TAR with higher operative risk compared with B and C. The hospital mortality and major complication rate was not significant difference among surgeons( hospital mortality A:3.5%, B:2.3%, C:3.0%). Multivariate analysis showed the surgeons' experience was not associated with hospital mortality and major complications. Long-term outcomes were also compatible among three groups. CONCLUSIONS: Our standardization for TAR seemed to be an useful approach to eliminate the impact of surgeon experience on surgical outcomes if the type of surgeon was appropriately selected according to the level of operative difficulty.

Surgical outcomes of acute type A aortic dissection in patients undergoing cardiopulmonary resuscitation.

OBJECTIVES: The surgical indications for acute type A aortic dissection (AAAD) in patients in cardiopulmonary arrest remain controversial. Outcomes of AAAD for patients who underwent cardiopulmonary resuscitation (CPR) were evaluated. METHODS: Between 2004 and 2018, of the 519 patients who underwent AAAD repair, 34 (6.6%) required CPR before or on starting AAAD repair. The patients were divided into 2 groups, survivors (n = 13) and nonsurvivors (n = 21), to compare the early operative outcomes, including mortality and neurological events. RESULTS: The major cause of cardiovascular collapse requiring CPR was aortic rupture/cardiac tamponade (n = 21 [61.8%]), followed by coronary malperfusion (n = 12 [35.3%]) and acute aortic valve regurgitation (n = 3 [8.8%]). There were 3 (23.1%) patients in the survivors group and 11 (52.4%) in the nonsurvivors group who required ongoing CPR at the beginning of AAAD repair (P = .039). Of these patients, 1 survivor and 6 nonsurvivors could not achieve return of spontaneous circulation after pericardiotomy (P = .045). Although the duration from onset or arrival to the operating room was similar (P = .35 and P = .49, respectively), overall duration of CPR was shorter in survivors (10 minutes [range, 7.5-16 minutes] vs 16.5 minutes [range, 15-20 minutes]; P = .044). All survivors without any neurological deficits showed return of spontaneous circulation after pericardiotomy. Multivariate regression modeling showed that CPR duration >15 minutes was a significant risk factor for in-hospital mortality (P = .0040). CONCLUSIONS: CPR duration beyond 15 minutes may be a contraindication for AAAD repair. Moreover, we should reconsider surgery for patients who cannot achieve return of spontaneous circulation after pericardiotomy.

Efficacy of entry exclusion strategy for DeBakey type III retrograde Stanford type A acute aortic dissection.

OBJECTIVES: Resection of a primary entry tear is essential for the treatment of Stanford type A acute aortic dissection (AAAD). In DeBakey type III retrograde AAAD (DBIII-RAAAD), resection of the primary entry tear in the descending aorta is sometimes difficult. The frozen elephant trunk technique and thoracic endovascular aortic repair (TEVAR) enable the closure of the primary entry in the descending aorta. The aim of this study was to investigate the efficacy of resection or closure of primary entry, i.e. entry exclusion, in patients with DeBakey type III retrograde-AAAD. METHODS: The medical records of 654 patients with AAAD who underwent emergency surgery between January 2000 and March 2019 were retrospectively reviewed, and 80 eligible patients with DeBakey type III retrograde-AAAD were divided into the excluded (n = 50; age, 62 ± 12 years) and residual (n = 30; age, 66 ± 14 years) groups according to postoperative computed tomography angiographic data of the false lumen around the primary entry. The excluded group was defined as having a postoperative false lumen at the level of the elephant trunk or thrombosis of the endograft including primary entry. Patients with early false lumen enhancement around the elephant trunk or an unresected primary entry tear after isolated hemiarch replacement were included in the residual group. The early and long-term surgical outcomes were compared between the groups. RESULTS: The in-hospital mortality rate was 8% (6/80), with no significant difference observed between the excluded and the residual groups (10% and 7%, respectively; P > 0.99). Ninety-five percentage of the patients (20/21) achieved entry exclusion with stent grafts including the frozen elephant trunk procedure and TEVAR. Spinal cord ischaemia was not observed in either group. The cumulative overall survival at 5 years was comparable between the 2 groups (76% and 81% in the excluded and residual groups, respectively; P = 0.93). The 5-year freedom from distal aortic reoperation rate was significantly higher in the excluded group (97%) than in the residual group (97% vs 66%; P = 0.008). CONCLUSIONS: Not only resection but also closure using the entry exclusion approach for DeBakey type III retrograde-AAAD utilizing new technologies including the frozen elephant trunk technique and TEVAR might mitigate dissection-related reoperations.

Thoracic endovascular repair for retrograde acute type A aortic dissection as an alternative choice.

OBJECTIVE: The purpose of this study was to determine the clinical outcomes of thoracic endovascular aortic repair in 8 patients with acute type A aortic dissection with an entry tear in the descending aorta. SUBJECTS AND METHODS: From January 2016 to December 2018, eight patients (mean age 76 years; range 54-92 years) were treated by thoracic endovascular aortic repair due to high operative risk for conventional open repair. All patients had significant comorbidities, and two had critical organ malperfusion due to aortic dissection. Surgical outcomes were retrospectively reviewed. RESULTS: All procedures were technically successful with complete coverage of the entry tear. The proximal landing zone was Zone 1 in 2, Zone 2 in 1, Zone 3 in 4, and Zone 4 in 1 patient. Patients requiring Zone 1 and 2 thoracic endovascular aortic repair underwent aortic arch bypass simultaneously. Mean operation time was 132 min. There were no hospital deaths and no serious complications, including stroke and spinal cord ischemic injury. All patients had complete thrombosis and shrinkage of the false lumen in the ascending aorta before discharge. During up to 36-month follow-up (mean 20 ± 12 months), there were no adverse aortic events except one who died due to ischemic colitis 4 months after the procedure. CONCLUSION: Thoracic endovascular aortic repair could be a useful alternative surgical option for patients with retrograde acute type A aortic dissection with an entry in the descending aorta who are not suitable for conventional open surgery. Careful follow-up of such patients is mandatory.

Mid-term outcomes of valve-sparing root reimplantation with leaflet repair.

OBJECTIVES: Valve repair for aortic insufficiency (AI) requires a tailored surgical approach determined by the leaflet and aortic disease. In this study, we used a repair-oriented system for the classification of AI, and we elucidated long-term outcomes of aortic root reimplantation with this classification system. METHODS: From 1999 to 2018, a total of 197 patients underwent elective reimplantation (mean age: 52.7 ± 17.7 years; 80% male). The aortic valve was tricuspid in 143 patients, bicuspid in 51 patients and quadricuspid in 3 patients. A total of 93 patients had type I AI (aortic dilatation), 57 patients had type II AI (cusp prolapse) and 47 patients had type III AI (restrictive). In total, 104 of the 264 patients (39%) had more than 1 identified mechanism. RESULTS: In-hospital mortality was 0.5% (1/197). Mid-term follow-up (mean follow-up duration: 5.5 years) revealed a late mortality rate of 4.2% (9/197). Aortic valve reoperation was performed on 16 patients (8.0%). Rates of freedom from aortic valve replacement and freedom from aortic valve-related events at 10 years of follow-up were 87.0 ± 4.0% and 60.6 ± 6.0%, respectively; patients with type Ib AI (98.3 ± 1.7%; 80.7 ± 7.5%) had better outcomes than patients with type III AI (59.6 ± 15.6%; 42.2 ± 13.1%, P = 0.01). In patients with types II and III AI who had bicuspid aortic valves, rates of freedom from aortic valve-related events at 5 years of follow-up were 95.2 ± 4.7% and 71.7 ± 9.1%, respectively (P = 0.03). CONCLUSIONS: This repair-oriented system for classifying AI could help to predict the durable aortic valve repair techniques. Patient selection according to the classification is particularly important for long-term durability. CLINICAL TRIAL REGISTRATION NUMBER: B190050.

Thoracic endovascular aortic repair for acute type B aortic dissection complicated by total occlusion of the abdominal aorta.

A 72-year-old man presenting with lower body malperfusion and complete paralysis was transferred for emergency treatment of a complicated acute type B aortic dissection. Enhanced computed tomography showed occlusion of the true lumen inside the abdominal aorta due to compression of the false lumen, accompanied by a Crawford extension type IV thoraco-abdominal aortic aneurysm. The primary entry tear was located at the level of the tenth thoracic vertebra above the aneurysm. Emergency thoracic endovascular aortic repair was performed to cover the entry tear and to regain perfusion of the lower body. Efforts to perform retrograde insertion of a guidewire from the femoral arteries to pass the occluded abdominal aorta were unsuccessful. A through-and-through guidewire technique between the left brachial artery and the right femoral artery was performed to deliver a Zenith TX-2 stent graft from the right femoral artery. After closure of the primary entry tear, complete recovery from the occlusion of the abdominal aorta was obtained 6 h after the onset. His paralysis recovered completely, and the postoperative course was uneventful without reperfusion injury.

Replacement of the descending thoracic aortic aneurysm with partial cardiopulmonary bypass in the era of endovascular repair.

OBJECTIVES: Although the advent of thoracic endovascular aortic repair (TEVAR) has provided an alternative treatment option for descending thoracic aortic aneurysm (DTAA), open repair still plays a crucial role in DTAA repair. The purpose of this study was to re-evaluate the operative and long-term outcomes of open repair with partial cardiopulmonary bypass, compared to the results of TEVAR with a proximal landing zone of 3 or 4. METHODS: Between 2007 and 2017, open repair was performed for 44 patients and TEVAR for 282 patients. Acute aortic dissection and open proximal anastomosis under circulatory arrest were excluded. Perioperative and long-term follow-up data were analyzed. RESULTS: In-hospital mortality rate (4.5% vs 3.2%, p = 0.42), and frequencies of spinal cord injury and neurological deficit showed no significant differences between the open repair and TEVAR groups (p = 0.41, 0.25, respectively). The propensity score-matched analysis showed similar cumulative survival (p = 0.23), but significantly higher reintervention rates for the repaired segment in the TEVAR group than in the open repair group (p = 0.0054). Twenty-two (7.8%) TEVAR patients required re-interventions for the repaired segment. Of those, 17 patients underwent additional TEVAR and 5 patients needed open conversion surgery with partial cardiopulmonary bypass. Reintervention rates for the repaired segment were significantly higher in the TEVAR group than in the open repair group (p = 0.012). CONCLUSIONS: Open repair DTAA using partial cardiopulmonary bypass showed operative outcomes comparable to TEVAR and lower reintervention rates, and thus remains an acceptable procedure for selected patients in this era of endovascular repair.

Results of Surgical Repair of Hilar Renal Artery Aneurysm to Preserve Renal Blood Flow.

Objective: Surgical indications and procedures for hilar renal artery aneurysm (HRAA) are controversial in terms of invasiveness and feasibility. Catheter treatment is minimally invasive but leads to renal dysfunction due to renal infarction. This study aims to investigate the results of surgical repair of HRAA. Method: Fourteen patients (58.7±11.6 years old, 7 male) who underwent surgical repair of HRAA were retrospectively reviewed. Nine patients (64%) developed HRAA in the right renal artery, and the mean maximum aneurysmal diameter was 25.9±10.3 mm. HRAA was exposed via the extraperitoneal approach. HRAA was resected completely, and reconstruction of renal arteries was performed by direct closure in two, direct anastomosis in nine, and interposition of saphenous vein graft in three patients. Results: The average operation and renal ischemic times were 186±49 and 35±16 min, respectively. No operative death occurred, and postoperative renal function at the time of discharge had not deteriorated (creatinine, 0.74±0.15 mg/dl). During the follow-up periods (4.7±5.1 years), there was no death, no new introduction of hemodialysis, and no recurrence of renal artery aneurysm. Conclusion: Surgical repair of HRAA remains a valid option because of its operative safety, preservation of renal function, and long-term feasibility and patency.

Does Endovascular Abdominal Aortic Repair Change Psoas Muscle Volume?

BACKGROUND: Because endovascular abdominal aortic repair (EVAR) lowers the lumbar arterial blood flow, we hypothesized that the volume of the psoas muscle decreases after surgery. When internal iliac artery (IIA) embolization is performed, the lumbar arterial blood flow further decreases; therefore, we also hypothesized that the decrease in the volume of the psoas muscle becomes more significant. This study was performed to assess the volume change in the psoas muscle after EVAR. METHODS: Fifty-three consecutive patients who underwent EVAR from January 2016 to December 2016 were included. The psoas muscle volume was measured by preoperative and postoperative computed tomography (CT). Postoperative CT scans were performed 6-12 months after EVAR. Axial CT images with a 2-mm slice thickness were used to measure the psoas muscle volume. Data were transferred to a 3-dimensional workstation, and the psoas muscle volume was measured. RESULTS: In the EVAR group, the volume of the psoas muscle decreased by an average of 5.8 mL (4.6%) from 114.8 ± 32.0 mL preoperatively to 109.0 ± 30.3 mL postoperatively (P < 0.01). There was a significant difference in the change in the psoas muscle volume between patients with and without IIA embolization (embolization group: preoperative 118.1 ± 31.0 mL, postoperative 107.5 ± 29.2 mL, mean volume change rate -8.8%; nonembolization group: preoperative 114.0 ± 32.3 mL, postoperative 109.4 ± 30.7 mL, mean volume change rate -3.6%; P < 0.05). CONCLUSIONS: The psoas muscle volume is reduced with EVAR. Moreover, when the IIA is embolized, the psoas muscle volume is further reduced.

Management of retrograde type A IMH with acute arch tear/type B dissection.

The incidence of intramural hematomas (IMH) in acute dissection (AD) patients varies between 6% and 30% in the literature, most frequently involving only the descending aorta (58%) than the arch or ascending aorta (42%). In this setting, IMH that initiate in the descending aorta, but extend into the arch or ascending aorta have been described, and referred to as a retrograde type A IMH. In these patients the risk of neurological or cardiac complications are high, and therefore an open surgical or hybrid approach has been proposed as the most appropriate. Nevertheless, the endovascular management of such lesions in surgically unfit patients for open surgery have been offered with acceptable outcomes, although the risk of landing in an unsuitable proximal landing zone is evident. In conclusion, retro-TAIMH is an acute aortic syndrome and should be managed as such. The recommended treatment strategy is open surgery for treating ascending or arch involvement, and TEVAR/medical, based on a complication-specific approach, for those with only descending localization. In those patients in whom retro-TAIMH is associated with an acute B dissection presenting with a proximal entry tear located into the descending aorta, a TEVAR represents an option treatment.

Midterm outcomes of thoracic endovascular repair for uncomplicated type B aortic dissection with double-barrel type.

OBJECTIVE: The midterm outcomes and aortic remodeling after thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (TBAD) were evaluated. METHODS: Forty-seven patients (mean age 66 ± 12 years) who underwent TEVAR for uncomplicated TBAD with double-barrel type from January 2012 to December 2017 were retrospectively analyzed. The indication for TEVAR for entry closure was a maximum aortic diameter > 40 mm with a patent false lumen. Twenty-six patients (55.3%) had TEVAR in chronic phase, over 6 months after the onset of aortic dissection. RESULTS: There was no hospital death or serious complication. During follow-up (mean 35 ± 16 months), overall 3-year survival was 95.6 ± 3.1%. A significant trend was observed with a higher rate of shrinkage of overall aortic diameter, expansion of the true lumen, and shrinkage of the false lumen more proximally from the stent graft-covered site. Rate of aortic shrinkage in chronic with aortic diameter more than 50 mm was lower compared with the other (proximal: 33.3% vs. 80-100%, distal 0-16.7% vs. 50-52.9%). Rate of aortic dilation distally to the stent graft-covered site was 28% in chronic compared with 5% in non-chronic. Adverse events were mainly due to distal aortic dilation, and 3-year freedom from all adverse events was 79.8 ± 6.5%. CONCLUSIONS: Favorable aortic remodeling of the proximal stent graft-covered site could be expected even in the chronic phase if preoperative aortic dilation over 50 mm is unaccompanied. Careful follow-up focusing on dilation of the distal aortic segment is mandatory especially in patients who underwent TEVAR in chronic phase.

Comparative study of the frozen elephant trunk and classical elephant trunk techniques to supplement total arch replacement for acute type A aortic dissection†.

OBJECTIVES: In patients with acute type A aortic dissection, the use of the frozen elephant trunk (FET) procedure with total arch replacement (TAR) has been indicated for emergency operations to obtain thrombosis of the distal false lumen (FL). However, data comparing the FET and the classical elephant trunk (CET) procedures, including the incidences of mortality, morbidity, spinal cord injury and aortic remodelling, have not yet been reported. The goal of this study was to compare the early outcomes of TAR with the FET and the CET procedures. METHODS: The past 7 years of medical records of 323 patients with type A aortic dissection who underwent emergency surgery were reviewed retrospectively, and 148 patients who underwent TAR were shortlisted for the study. First, the patients were divided into 2 groups, the CET group (n = 115; age 65 ± 12 years) and FET group (n = 33; 67 ± 11 years), to compare the early operative outcomes, including mortality and morbidity. Second, 86 patients (CET 56; FET 30) fulfilling the inclusive criteria (inserted length of elephant trunk ≥5 cm, involvement of dissection at the descending aorta and sufficient computed tomographic evaluation at ≥6 months after the operation) were compared to evaluate the patency and diameter of the FL at each segment of the downstream aorta. RESULTS: The in-hospital mortality rate was 8.1% (12/148), without significant differences between the 2 groups (CET 8.7% vs FET 6.1%; P = 1). No spinal cord ischaemia was encountered in either group. The incidence of postoperative FL patency at the level of the left lower pulmonary vein was 30% in the FET group, which was significantly lower than that in the preoperative state (73%) and in the CET group (77%). The downsizing of the aortic diameter at the distal edge of the CET or the FET, the left lower pulmonary vein and the coeliac axis was significant in the FET group 6 months after TAR. CONCLUSIONS: According to our initial experience, the FET compared to the CET procedure showed comparable early complications and an advantage concerning FL thrombosis and aortic remodelling at early follow-up examinations.

Surgical Outcome of Abdominal Aortic Aneurysm Replacement in Patients with Connective Tissue Disorders under 30 Years of Age.

Objectives: Abdominal aortic aneurysm (AAA) in patients <30 years old is relatively rare. We retrospectively analyzed patients <30 years who received an AAA replacement. Materials: Among 3,003 patients who received an AAA replacement during the last 40 years, 10 patients <30 years old were retrospectively reviewed. All patients suffered from a connective tissue disease: eight from Marfan syndrome and two from Loeys-Dietz syndrome. Five patients had a history of cardiovascular surgery. Aortic pathologies were a dissection type in eight patients and a non-dissection type in two. All patients received a graft replacement of infrarenal AAA, with a bifurcated graft in six patients and a straight graft in four. Results: Except for cases that were urgent and emergent, rapid aneurysm expansion was noted in all cases. Mean AAA diameter at surgery was 46.7±9.2 mm. No hospital mortality was recorded. Eight patients required 10 additional cardiovascular surgeries: two root replacements, two total arch replacements, two descending aortic replacements, and four thoracoabdominal replacements. Conclusion: AAA replacement in patients <30 years is safe. In younger patients with a connective tissue disease, AAA should be included in the routine medical check-up, and earlier surgical indication should be considered for its rapid expansion.

Surgery for a Late Type IIIb Endoleak From a Fabric Tear of an Excluder Stent Graft.

An 85-year-old male patient, who had undergone endovascular abdominal aortic aneurysm repair (EVAR) using the Gore Excluder stent graft 10 years ago, was referred for intermittent abdominal pain. He also received coil embolization of the lumbar arteries for a persistent type II endoleak, resulting in continued aneurysmal dilation at 4, 6, and 8 years after the EVAR. The maximum size of the aneurysm sac was dilated from the initial size of 49 mm × 55 mm to 78 mm × 90 mm, and the contrast medium was observed around the proximal portion of the stent graft, suggesting the presence of a type Ia or II endoleak. Because the definite cause of the dilation was unclear and adequate proximal landing zone was not available to deploy an aortic cuff, emergent laparotomy was indicated to treat this symptomatic aneurysm dilation. A type IIIb endoleak due to fabric disruption of the main body was diagnosed, and the bleeding was controlled using a fibrin sealant patch. To reinforce the hemostasis site from the inside of the stent graft, a 28 mm × 3-cm Excluder aortic cuff was deployed inside the main trunk next day. At 1-year follow-up, his condition was stable without evidence of reexpansion of the aneurysmal sac.