Pre-emptive Aortic Side Branch Embolization during Endovascular Aneurysm Repair Using the Excluder Stent-Graft System: A Prospective Multicenter study.

PURPOSE: To evaluate the effectiveness and safety of pre-emptive transcatheter arterial embolization (P-TAE) for aortic side branches (ASBs) to prevent Type 2 endoleaks (EL2) before endovascular aneurysm repair (EVAR) using the Excluder stent-graft system (Excluder). MATERIALS AND METHODS: In this prospective, multicenter study, 80 patients (mean age, 79.1 years [SD ± 6.7]; 85.0% were men; mean aneurysmal sac diameter, 48.4 mm [SD ± 7.4]) meeting the eligibility criteria were prospectively enrolled from 9 hospitals. Before EVAR, P-TAE was performed to embolize the patent ASBs originating from the abdominal aortic aneurysm. Contrast-enhanced computed tomography (CT) was performed at 1 month and 6 months after EVAR. The primary endpoint was EL2 incidence at 6 months, and the secondary endpoints were aneurysmal sac diameter changes at 6 and 12 months, P-TAE outcomes, adverse events related to P-TAE, reintervention, and aneurysm-related mortality. RESULTS: All patients successfully underwent P-TAE without serious. Coil embolization was successful in 81.6% of ASBs. EL2 incidence at 6 months was identified in 18 of 70 (25.7%) patients. Aneurysmal sac diameter shrinkage (≥5 mm) was observed in 30.0% of patients at 6 months and in 40.9% at 12 months. Only 1 patient required reintervention for EL2 within 1 year of EVAR; aneurysm-related deaths were not observed. CONCLUSIONS: P-TAE for ASBs before EVAR using Excluder is a safe and effective strategy. It aids in achieving early aneurysmal sac shrinkage and reduces EL2 reintervention at 1 year after EVAR.

[Papillary Fibroelastoma on the Tricuspid Valve: Report of a Case].

68-year-old male was diagnosed as a cardiac tumor detected by echocardiography, incidentally. He was asymptomatic but the tumor was removed surgically for the diagnostic therapy. It was diagnosed as a papillary fibroelastoma (PFE) clinically and pathologically. He was discharged from the hospital without any complication. PFE on the tricuspid valve is uncommon benign tumor of the heart. Because it is at risk of embolic events, we think it should be operated even if it exists the right side of the heart.

Risk factors for a persistent type 2 endoleak after endovascular aneurysm repair.

PURPOSE: To investigate the natural course of type 2 endoleaks (T2Es) and to identify the risk factors associated with a persistent T2E after endovascular aneurysm repair (EVAR). METHODS: The medical records of patients who underwent EVAR for the treatment of an atherosclerotic abdominal aortic aneurysm between October 2006 and December 2011 at our institute were reviewed. T2Es were diagnosed by contrast-enhanced computed tomography within 4 weeks of EVAR, and patients were followed up at 6 and 12 months. In cases where a T2E was detected, the blood vessels responsible for the T2E were identified and statistically analyzed for their association with a persistent T2E. RESULTS: We identified T2Es in 111 of 469 patients within 4 weeks of undergoing EVAR. During the follow-up, 41 patients (36.9 %) showed spontaneous resolution of their T2E. The percentage of patients with a T2E was 75.4, 69.2 and 58.0 % at 6, 12 and 24 months, respectively. T2E caused by defects in multiple vessels and T2E associated with the fourth lumbar artery were identified as risk factors associated with a persistent T2E in the univariate analysis. In the multivariate analysis, T2E caused by multiple vessels was identified as the only independent risk factor for a persistent T2E. CONCLUSIONS: We identified T2E caused by multiple vessel failure as an independent risk factor for persistent T2E.

[Intraoperative evaluation for residual mitral valve regurgitation; usefulness of the retrograde cardioprotective beating test].

Intraoperative evaluation is important for successful mitral valve plasty (MVP). We performed a saline injection test and a retrograde cardioprotective beating test (RC-beating test) for intraoperative evaluation. The concept of the RC- beating test is evaluation of residual mitral valve regurgitation( MR) under cardiac beating. A 66-year-old man with severe MR underwent MVP. The P3 chorda was ruptured and we performed quadrangular resection. The saline injection test showed trivial regurgitation. We then performed the RC-beating test and it revealed severe leakage from the posterior commissure(PC). Since the PC had a sclerotic change, another quadrangular resection was performed. Moreover,as the anterior leaflet( A3) was slightly elongated, the region was resected in an obtuse-angled triangle shape and repaired by suturing the edges. The final RC-beating test showed no residual leakage. The RC-beating test is useful for detecting residual mitral valve leakage.

Side branch embolization before endovascular abdominal aortic aneurysm repair to prevent type II endoleak: A prospective multicenter study.

PURPOSE: The purpose of the study was to evaluate the efficacy and safety of pre-emptive transcatheter arterial embolization (P-TAE) of aortic side branches to prevent type II endoleak in patients with abdominal aortic aneurysm after endovascular abdominal aneurysm repair (EVAR). MATERIALS AND METHODS: This multicenter, prospective, single-arm trial enrolled 100 patients with abdominal aortic aneurysm from nine hospitals between 2018 and 2021. There were 85 men and 15 women, with a mean age of 79.6 ± 6.0 (standard deviation) years (range: 65-97 years). P-TAE was attempted for patent aortic side branches, including the inferior mesenteric artery, lumbar arteries, and other branches. The primary endpoint was late type II endoleak incidence at 6 months post-repair. Secondary endpoints included changes in aneurysmal sac diameter at 6- and 12 months, complications, re-intervention, and aneurysm-related mortality. Aneurysm sac changes at 6- and 12 months was compared between the late and no-late type II endoleak groups. RESULTS: Coil embolization was successful in 80.9% (321/397) of patent aortic side branches, including 86.3% of the inferior mesenteric arteries, 80.3% of lumbar arteries, and 55.6% of other branches without severe adverse events. Late type II endoleak incidence at 6 months was 8.9% (8/90; 95% confidence interval: 3.9-16.8%). Aneurysm sac shrinkage > 5 mm was observed in 41.1% (37/90) and 55.3% (47/85) of the patients at 6- and 12-months post-EVAR, respectively. Patients with late type II endoleak had less aneurysm sac shrinkage than those without type II endoleak at 12 months (-0.2 mm vs. -6.0 mm; P = 0.040). No patients required re-intervention for type II endoleak, and no aneurysm-related mortalities occurred. CONCLUSION: P-TAE is safe and effective in preventing type II endoleak, leading to early sac shrinkage at 12 months following EVAR.

Venous drainage for minithoracotomy approach in an adult with interrupted inferior vena cava.

For atrial septal defect closure via right minithoracotomy in an adult patient with infra-hepatic interruption of the inferior vena cava with azygos connection, an alternative venous cannulation strategy was applied. In addition to bicaval cannulations to the femoral vein and the internal jugular vein, a 20 Fr straight cannula draining the hepatic vein was added to the proximal IVC through the right atrium wall via a working port. A bloodless operative field in the right atrium was afforded with bicaval encircling. Preoperative imaging test of the continuity of the IVC was important planning cardiac surgery with peripheral cannulations.

Morphological predictor of remodelling of the descending thoracic aortic false lumen that remains patent after repair of acute type A dissection.

OBJECTIVES: Some patients achieve complete recovery through false lumen remodelling in the descending aorta after surgery for acute type A aortic dissection. Our goal was to investigate the relationship between false lumen remodelling during later postoperative stages and quantitative analysis of the true lumen shape during the early postoperative stages. METHODS: We examined 88 surgical patients between January 2007 and December 2016. Three points of the descending aorta were assessed from the 6th (T6), the 9th (T9) and the 11th (T11) vertebral levels. The shape of the true lumen was evaluated during the early postoperative stages, and false lumen remodelling 1 year after surgery was the end point. The parameters obtained by evaluating the shape of the true lumen comprised the first principal component analysis using elliptic Fourier analysis, the minor diameter ratio and the ratio of the area of the true lumen to that of the descending aorta, and the number of contact points on the true lumen wall during the early stages. RESULTS: Using univariate analysis, we detected significant differences in the first principal components, the minor diameter ratio, the area ratio and the number of contact points at each thoracic vertebral level (P < 0.05). The cut-off value of the minor diameter ratio was 0.55, and the area ratio was 0.48 as determined by analysis of the receiver operating characteristic. Multivariable logistic analysis indicated that the first principal component was the most significant predictor from the proximal to the middle descending aorta. CONCLUSIONS: Quantitative evaluation of shape of the true lumen in the early postoperative stages after surgery for acute type A dissection can serve as a viable predictor for false lumen remodelling in later stages. Furthermore, the first principal component could serve as a more astute predictor than other quantitative parameters according to multivariate analysis.

New predictor of aortic enlargement in uncomplicated type B aortic dissection based on elliptic Fourier analysis.

OBJECTIVES: This study aimed to re-examine the conventional predictive factors for dissected aortic enlargement, such as the aortic and false lumen diameter and to consider whether the morphological elements of the dissected aorta could be predictors by quantifying the 'shape' of the true lumen based on elliptic Fourier analysis. METHODS: A total of 80 patients with uncomplicated type B aortic dissection were included. The patients were divided into 'Enlargement group' and 'No Change group.' Between the 2 groups, the mean systolic blood pressure during follow-up, aortic and false lumen maximum diameters, and analysed morphological data were compared using each statistical method. RESULTS: The maximum aortic and false lumen diameters were significantly larger in the Enlargement group than in the No Change group (39.3 vs 35.9 mm; P = 0.0058) (23.5 vs 18.2 mm; P = 0.000095). The principal component 1, which is the data calculated by elliptic Fourier analysis, was significantly lower in the Enlargement group than in the No Change group (0.020 vs - 0.072; P = 0.000049). The mean systolic blood pressure ≥130 mmHg, aortic diameter, false lumen diameter and principal component 1 were included in the Cox proportional hazard model as covariates to determine the significant predictive variable. Principal component 1 demonstrated the only significance with aortic enlargement on multivariate analysis (odds ratio = 0.32; P = 0.048). CONCLUSIONS: The analysed and calculated morphological data of the shape of the true lumen can be more effective predictive factors of aortic enlargement of type B dissection than the conventional factors.

Stress echocardiographic assessment of mitral valve function repaired using rough-zone trimming.

BACKGROUND: We invented novel mitral valve repair technique; rough-zone trimming procedure (RZT) for anterior mitral valve prolapse. Prolapse site was resected in obtuse triangle shape and sutured edges to creates deep coaptation and improves regurgitation. Though it is simple and reproducible technique, functional mitral stenosis is a risk. Valve function and hemodynamics were investigated using dobutamine stress echocardiography (DSE) in patients after mitral valve repair using RZT. METHODS: Patients underwent RZT for the anterior mitral valve (AML, n = 10), quadrangular resection (QR) of the posterior mitral valve (PML; n = 4), RZT + QR of bileaflet valves (bileaflet; n = 4) and healthy individuals (control; n = 10) and were assessed by DSE (doses up to 20 µg/Kg/min). Echocardiographic data including mitral valve area (MVA), mitral valve mean pressure gradient (MVmeanPG), and systolic pulmonary artery pressure (sPAP) were measured at rest and at peak stress. RESULTS: Rest/stress MVA (cm(2)), MVmeanPG (mmHg) and sPAP (mmHg) were 2.8 ± 0.4 and 3.4 ± 0.3, 3.3 ± 1.1 and 7.4 ± 4.1, and 25.7 ± 4.7and 49.1 ± 4.1, respectively, in the AML group. Dobutamine stress increased all parameters but not to pathological levels. The results were similar to those of the other groups after mitral valve repair, whereas MVA was larger and MVmeanPG was lower in the control than in the AML group. CONCLUSIONS: Valve repair using RZT does not pathologically obstruct the mitral valve, either at baseline or during dobutamine stress, and does not affect valve hemodynamics and reserve.

Esophago-Pleural Fistula Caused by Compression Necrosis In a Patient With Acute Type B Aortic Dissection.

Esophago-pleural fistula associated with thoracic aortic aneurysm is a rare and lethal complication. We report the case of a 62-year-old male who suffered from esophago-pleural fistula 56 days after thoracoabdominal aortic surgery. Contrasted CT showed that the fistula occurred at the level of the esophagus compressed by rapid dilatation of thoracic aorta and endoscopy revealed no ischemic signs on esophageal mucosa, demonstrating that the cause of esophago-pleural fistula was compression necrosis due to rapid dilatation of the thoracoabdominal aortic aneurysm.