The open-first strategy is acceptable for ruptured abdominal aortic aneurysm even in the endovascular era.

PURPOSE: To examine the surgical findings of ruptured abdominal aortic aneurysm (RAAA) based on the open-first strategy in the last decade, and to analyze the predictors of in-hospital mortality for RAAA in the endovascular era. METHODS: The subjects of this retrospective study were 116 patients who underwent RAAA repair, for whom sufficient data were available [25% female, median age 76 (70-85) years]. Sixteen (13.8%) patients were managed with endovascular aneurysm repair (EVAR) and 100 patients (86.2%) were managed with open surgical repair (OSR). RESULTS: Univariate analysis identified base excess (BE) (odds ratio [OR] 0.88; 95% confidence interval [CI] 0.79-0.96; p = 0.006), and preoperative cardiopulmonary arrest (CPA) [OR] 15.4; 95% [CI] 1.30-181; p = 0.030), BE (OR 0.88; 95% CI 0.79-0.96; p = 0.006), shock index (OR 2.44; 95% CI 1.01-5.94; p = 0.050), lactic acid (Lac) (OR 1.18; 95% CI 1.02-1.36; p = 0.026), and blood sugar (BS) > 215 (OR 3.46; 95% CI 1.10-10.9; p = 0.034) as positive predictors of hospital mortality. CONCLUSIONS: The findings of this study suggest that a first-line strategy of OSR for ruptured AAAs is acceptable. Poor preoperative conditions, including a high shock index, CPA, low BE, high Lac, and a BS level > 215 mg/dl, were identified as predictors of hospital mortality, rather than the procedures themselves.

Short- and mid-term outcomes of the frozen elephant-trunk procedure for degenerative aortic arch aneurysm.

PURPOSE: The frozen elephant-trunk (FET) procedure is used widely in total aortic arch replacement (TAR) surgery; however, its safety, effectiveness, and long-term outcomes compared with those of the conventional elephant trunk (cET) procedure for degenerative aneurysms are unclear. METHODS: Between July, 2011 and August, 2019, 126 patients underwent elective total aortic arch replacement at our institution. We compared the short- and mid-term outcomes of 60 patients who underwent the FET procedure (FET group) with those of 66 patients who underwent cET (cET group). RESULTS: The in-hospital mortality rate tended to be lower in the FET group than in the cET group (p = 0.12). There were two cases of paraplegia (3.3%) in the FET group and in none in the cET group. The all-cause mortality at the 3-year follow-up did not differ significantly between the groups (p = 0.31). The FET group required more unexpected interventions at the surgical site in the mid-term period. CONCLUSIONS: FET was associated with a shorter operative time and lower surgical mortality than cET. Although the mid-term total aortic arch replacement outcomes of FET were acceptable, careful imaging observation is necessary because reinterventions were required more frequently.

The blood sugar level can predict preoperative shock in patients with a ruptured abdominal aortic aneurysm even when the patient's condition appears stable.

PURPOSE: This observational retrospective study aimed to identify preoperative blood test data capable of predicting preoperative shock in ruptured abdominal aortic aneurysm (rAAA). METHODS: A total of 104 patients who underwent surgery for rAAA between 2007 and 2018 were reviewed. Preoperative shock, defined as a shock index (heart rate/blood pressure) exceeding 1.5 or a maximum blood pressure < 80 mmHg, was observed in 44 patients (42%). RESULTS: Blood sugar (BS) (odds ratio [OR] 1.02; p < 0.001), C-reactive protein (CRP) (OR 0.57; p = 0.005), and hemoglobin (OR 0.60; p = 0.001) levels were identified as independent positive predictors of preoperative shock, and a BS level ≥ 300 mg/dl (OR 13.2; 95% CI 3.56-48.6; p < 0.001) was identified as a positive predictor of preoperative shock. The receiver operating characteristics curve analysis for BS showed that the area under the curve for the predicted probabilities was 0.84, and at a cut-off value of 215 mg/dl, the sensitivity of minimum BS for predicting preoperative shock was 86% with a specificity of 79%. CONCLUSIONS: The BS level is as an independent predictor of preoperative shock in patients with rAAA. Patients with preoperative BS levels ≥ 300 mg/dl have an extremely high risk of preoperative shock.

[Superior Mesenteric Artery Bypass Grafting from the Ascending Aorta Using a Saphenous Vein Graft for Treatment of Acute Aortic Dissection with Abdominal Malperfusion:Report of a Case].

A 50-year-old man presented with abdominal pain and numbness in the right leg. He was diagnosed with type A acute aortic dissection with malperfusion of the superior mesenteric artery(SMA) and the right external iliac artery. Before median sternotomy, we made median celiotomy and anastomosed a saphenous vein graft to SMA. After cardio-pulmonary bypass was instituted, perfusion to the saphenous vein graft was started. After the central repair, we selected the vascular graft of the ascending aorta as the inflow of SMA bypass because leading the vein graft to the external iliac artery was difficult due to obesity and intestinal edema. The graft flow was favorable with 100 ml/minute. He was discharged on postoperative day 56 without any abdominal complications. Some reports suggested that early reperfusion improved the outcomes of surgery for acute aortic dissection with mesenteric ischemia. The ascending aorta may be a viable alternative as an inflow of SMA bypass when the iliac artery is inappropriate.

False Aneurysm Formation at Both Anastomotic Sites after Descending Aortic Replacement for Aortic Coarctation.

Prosthetic graft interposition is performed in some patients with coarctation of the aorta (CoA), and all procedures for treating CoA are associated with a risk of aneurysm formation at the site of repair. A 53-year-old woman underwent coarctectomy and descending aortic replacement with a 16-mm Dacron graft for CoA when she was 18 years old. Thirty years later, she was referred to our hospital for a false aneurysm at the proximal anastomotic site, and total arch replacement was performed to resect the false aneurysm. One year after the operation, follow-up computed tomography revealed a dissecting aneurysm on the descending aorta, originating from the distal anastomotic site, namely the first 16-mm Dacron graft and the native descending aorta. The length between the branch of the arch graft and the dissecting aneurysm was adequate for endovascular repair, which was successfully performed.

[Dehiscence of the Pericardial Patch, after Surgical Treatment of Active Infective Aortic Valve Endocarditis with Reconstruction of the Aortic Annulus Using a Glutaraldehyde-treated Autologous Pericardium].

A 50-year-old man was admitted with fever and chill sensation 6 months ago. Transthoracic echocardiography (TTE) showed left and right coronary cusp prolapses and a thickened tissue of the aortic curtain. Congestive heart failure due to active infective aortic valve endocarditis was diagnosed, and he underwent aortic valve replacement. The aortic annulus was reconstructed using a glutaraldehydetreated autologous pericardium. Six months after surgery, TTE showed severe aortic regurgitation and saccular change in the aortic annulus. Transesophageal echocargiography showed some echo free space from left to noncoronary cusp and abnormal movement of the prosthetic valve annulus. Intraoperative examination showed dehiscence of the pericardial patch from the aortic wall, but no finding of infection. Aortic valve rereplacement was performed with reconstruction of the aortic annulus using a bovine pericardium. To prevent the dehiscence of the pericardial patch from the aortic wall, sutures fixing the prosthetic valve were passed from outside of the aortic wall.

Prognosis after non-surgical therapy for acute type A aortic dissection.

BACKGROUND: Immediate surgery to save life is the recommended treatment for Stanford type A acute aortic dissection (AAAD). METHOD: The present study comprised 35 patients admitted with AAAD who were considered inappropriate candidates for surgery or declined surgery. The mean age was 84.5 ± 9.6 years. Eight patients who were considered inappropriate candidates for surgery due to severe stroke in 2 patients or hemodynamic instability in 6. Twenty-seven patients aged 88.0 ± 5.9 years who declined surgery, predominantly due to advanced age. RESULTS: The overall in-hospital mortality was 51.4%. Mortality among patients that declined surgery or were considered inappropriate candidates for surgery were 37% and 100%, respectively. Causes of death among patients that declined surgery were cardiac tamponade in 6 and aortic rupture in 4. Mid-term survival among patients who refuse surgery, including in-hospital death, were 51.6 ± 10% and 34.5 ± 10%, on the other hand, Mid-term survival in hospital survivors were 81.9 ± 9% and 54.8 ± 14%. The causes of death among the discharged patients were senility in three, malignant tumor in two, pneumonia, aortic rupture, and unknown cause in one each. CONCLUSIONS: Mortality from AAAD is 51.4%, including inappropriate candidates for surgery. When patients were evaluated as suitable candidates for surgical intervention but subsequently refused the surgical procedure, in-hospital mortality was 37%. Long-term survival of hospital survivor was acceptable. These data can be a benchmark for patient and patient's family to select medical therapy for AAAD in consideration with the patient's will.

Posterior Reversible Encephalopathy Syndrome After Thoraco-Abdominal Aortic Replacement.

Introduction: Induced hypertension, administered peri-operatively during thoraco-abdominal aortic intervention, is one of the most effective methods to maintain spinal cord perfusion pressure. Posterior reversible encephalopathy syndrome or reversible cerebral vasoconstriction syndrome is a rare encephalopathy, possibly caused by excessive hypertension, usually encountered in the obstetric or cerebrovascular department. Report: A 61 year old man underwent open surgery for repair of an extent II dissecting thoraco-abdominal aneurysm. Several attempts at spinal drainage tube insertion one day prior to surgery failed. The Adamkiewicz artery was anastomosed by bypass, and transcranial motor evoked potentials were generally stable. Initially, no apparent neurological abnormality was observed after surgery; however, paraplegia occurred on post-operative day 1. The patient's mean arterial pressure increased from > 85 mmHg to > 95 mmHg. His systolic blood pressure occasionally exceeded 170 mmHg. On post-operative day 3 he became blind. A serial imaging test revealed cerebral oedema of both posterior lobes and segmental constriction of the vertebral and basilar arteries. Posterior reversible encephalopathy syndrome with reversible cerebral vasoconstriction syndrome was diagnosed from the clinical context and imaging tests. Despite treatment with magnesium and calcium channel blockers, the patient's visual acuity remained poor. Discussion: Excessive induced hypertension for spinal cord protection could rarely lead to cerebral vascular dysfunction, resulting in irreversible neurological damage. Awareness of this rare but devastating complication may help in early diagnosis, potentially mitigating permanent sequelae.

Differences of mid-term outcomes in debranching thoracic endovascular aortic repair between zone 0 and zone 1-2 landing.

OBJECTIVE: Debranching thoracic endovascular aortic repair (d-TEVAR) for zone 0 landing (Z0-TEVAR) remained challenging in aortic arch aneurysms. This study aimed to compare the mid-term outcomes between Z0-TEVAR and Z1/2-TEVAR to assess the appropriateness of Z0-TEVAR as the first-line therapy for aortic arch aneurysms in high-risk patients. METHODS: Medical records of 200 patients who underwent d-TEVAR from 2007 to 2019 were retrospectively reviewed. Of these, 40 patients who underwent Z0-TEVAR (70% males; the median age of 82 years) and 160 Z1/2-TEVAR (78% males; the median age of 77 years) were compared. In each group, 39 patients were matched using propensity scores (PS) to adjust for differences in patient backgrounds. RESULTS: Freedom from all-cause mortality (p < 0.001), aorta-related mortality (p < 0.001), and stroke (p = 0.001) were significantly lower in Z0-TEVAR than in Z1/2-TEVAR. Freedom from reintervention was similar between the two groups (p = 0.326). Type A dissection post-TEVAR was observed in 3 (7.5%) of Z0-TEVAR, but none in Z1/2-TEVAR (p = 0.006). Pneumonia was also more frequent in Z0-TEVAR (n = 8, 30%) than Z1/2-TEVAR (n = 4, 2.5%) (p < 0.001). PS matching also yielded worse outcomes (all-cause mortality, p = 0.017; aorta-related mortality, p = 0.046; and stroke, p = 0.027) in Z0-TEVAR than Z1/2-TEVAR. CONCLUSIONS: Higher mid-term mortality and stroke rates after Z0-TEVAR were confirmed by PS matching. Z0-TEVAR would be an alternative for high-risk patients with arch aneurysms requiring zone 0 landing but not a reliable method.

Surgical outcomes of thoracic endovascular aortic repair for retrograde Stanford type a dissection.

OBJECTIVES: The optimal indications and contraindications for thoracic endovascular aortic repair of retrograde Stanford type A acute aortic dissection (R-AAAD) are not well known. The goal of this study was to determine the outcomes of thoracic endovascular aortic repair for R-AAAD at our institution and to discuss optimal indications. METHODS: The medical records of 359 patients admitted to our institution for R-AAAD between December 2016 and December 2022 were reviewed, and 83 patients were finally diagnosed with R-AAAD. We selected thoracic endovascular aortic repair as an alternative, considering the anatomy of aortic dissection and the risk to patients undergoing open surgery. RESULTS: Nineteen patients underwent thoracic endovascular aortic repair for R-AAAD. No in-hospital deaths or neurologic complications occurred. A type Ia endoleak was detected in 1 patient. All other primary entries were successfully closed. All dissection-related complications, such as cardiac tamponade, malperfusion distal to the primary entry and abdominal aortic rupture, were resolved. One patient required open conversion for intimal injury at the proximal edge of the stent graft; all other ascending false lumens were completely thrombosed and contracted at discharge. During the follow-up period, no aortic-related deaths or aortic events proximal to the stent graft occurred. CONCLUSIONS: The indications for thoracic endovascular aortic repair were expanded to low-risk and emergency cases at our institution. The early- and midterm outcomes of thoracic endovascular aortic repair for R-AAAD were acceptable. Further long-term follow-up is required.

Role of initial medical treatment and effectiveness of thoracic endovascular aortic repair for acute type A aortic dissection with thrombosed false lumen.

OBJECTIVES: The optimal treatment for acute type A aortic dissection (AAAD) with thrombosed false lumen (T-FL) of the ascending aorta remains controversial. The goal of this study was to evaluate clinical outcomes of initial medical treatment (IMT) and the effectiveness of thoracic endovascular aortic repair (TEVAR) for AAAD with T-FL. METHODS: We retrospectively analysed 60 patients with AAAD with T-FL. Emergency aortic repair was performed in 33 patients, and IMT was selected in 27 uncomplicated patients with ascending aortic diameter < 50 mm and ascending T-FL thickness ≤ 10 mm. RESULTS: Among the 27 patients who received IMT, 14 had intramural haematomas at admission; however, new ulcer-like projections appeared in 7 (50%) during hospitalization. Before discharge, 12 (44%) were given medical treatment only, and 15 (56%) required delayed aortic repair including TEVAR in 8 and open repair in 7. The median interval from onset to delayed repair was 9 days, and significantly more patients received TEVAR compared to those receiving emergency repair (53% vs 21%; P = 0.043). Between the TEVAR (n = 15) and the open repair (n = 33) groups, 1 (7%) 30-day death occurred in the TEVAR group, whereas no in-hospital deaths occurred in the open repair group. During the median follow-up time of 24.8 months, no aorta-related death was observed, and there were no statistically significant differences in the rate of freedom from aortic events (TEVAR: 92.8%/3 years vs open repair: 88.4%/3 years; P = 0.871). CONCLUSIONS: Our management, using a combination of emergency aortic repair, IMT and delayed aortic repair for AAAD with T-FL, achieved favourable clinical outcomes. Among the selected Japanese patients, IMT with repeated multidetector computed tomography could detect a new intimal tear that could be closed by TEVAR in some cases. Using EVAR for this pathology resulted in acceptable early and midterm outcomes. Further investigations are required to validate the safety and efficacy of this management procedure.

Lower-profile stent graft reduces the risk of embolism during thoracic endovascular aortic repair in shaggy aorta.

OBJECTIVES: This study aimed to reveal the association between lower-profile stent graft (LPSG) and embolism during thoracic endovascular aortic repair for non-dissecting distal arch and descending thoracic aortic aneurysm. METHODS: This study reviewed data of 35 patients who underwent thoracic endovascular aortic repair with LPSG (27 males; age: 77 ± 9.2 years) and 312 who underwent thoracic endovascular aortic repair with conventional-sized stent graft (CSSG) (247 males; age: 77 ± 7.4 years) from 2009 to 2021. RESULTS: The rate of total embolic events was significantly lower in the LPSG group (0/35 [0%]) than the CSSG group (34/312 [11.2%]) (P = 0.035). Shaggy aorta (odds ratio: 5.220; P < 0.001) were identified as positive embolic event predictors. The rate of total embolic events in 68 patients with shaggy aorta (12 in LPSG/56 in CSSG) was significantly lower in the LPSG group (0/12 [0%]) than the CSSG group (19/56 [34%]) (P = 0.015). The rate of total embolic events in 279 patients with the non-shaggy aorta (23 in LPSG/256 in CSSG) reveals no difference between the 2 groups (0 [0%]/16 [6.3%]) (P = 0.377). CONCLUSIONS: LPSG usage could reduce embolism in thoracic endovascular aortic repair, and the difference was more pronounced in patients with the shaggy aorta. LPSG might be beneficial in preventing embolism in thoracic endovascular aortic repair for patients with a shaggy aorta.

Multiple endocrine neoplasia type 1 in Japan: establishment and analysis of a multicentre database.

OBJECTIVE: Multiple endocrine neoplasia type 1 (MEN1) is less well recognized in Asian countries, including Japan, than in the West. The clinical features and optimal management of MEN1 have yet to be clarified in Japan. The aim of this study was to clarify the clinical features of Japanese patients with MEN1. DESIGN/PATIENTS: We established a MEN study group designated the 'MEN Consortium of Japan' in 2008, and asked physicians and surgeons to provide clinical and genetic information on patients they had treated. Of 680 registered patients, 560 were analysed. MEASUREMENTS: Clinical and genetic features of Japanese patients with MEN1 were examined. RESULTS: Primary hyperparathyroidism, gastroenteropancreatic neuroendocrine tumours (GEPNET), and pituitary tumours were seen in 94·4%, 58·6% and 49·6% of patients, respectively. The prevalence of insulinoma was higher in the Japanese than in the West (22%vs 10%). In addition, 37% of patients with thymic carcinoids were women, while most were men in western countries. The MEN1 mutation positive rate was 91·7% in familial cases and only 49·3% in sporadic cases. Eight novel mutations were identified. Despite the availability of genetic testing for MEN1, the application of genetic testing, especially presymptomatic diagnosis for at-risk family members appeared to be insufficient. CONCLUSIONS: We established the first extensive database for Asian patients with MEN1. Although the clinical features of Japanese patients were similar to those in western countries, there were several characteristic differences between them.

Impact of postoperative patient-prosthesis mismatch as a risk factor for early structural valve deterioration after aortic valve replacement with Trifecta bioprosthesis.

BACKGROUND: Several studies have reported high rates of structural valve deterioration (SVD) in the Trifecta valves. Herein, we analyzed the midterm results of the Trifecta valve and risk factors for early SVD. METHODS: We retrospectively reviewed the records of 110 patients who had undergone Trifecta implantation between January 2012 and December 2017. RESULTS: We encountered seven cases of Trifecta valve failure. We performed a redo aortic valve replacement in five patients and a transcatheter aortic valve replacement in two patients. The SVD rate was 4.8% at 5 years and 6.6% at 7 years. The mean pressure gradient and peak velocity on the first postoperative echocardiogram in patients with SVD were higher than those in patients without SVD. The SVD rates with and without patient-prosthesis mismatch (PPM) were 2.8% and 12.6% at 5 years and 2.8% and 20.0% at 7 years. PPM is a risk factor for SVD. Noncoronary cusp tears were observed in all patients who had undergone redo surgery. CONCLUSIONS: The most common cause of SVD was noncoronary cusp tear. Patients with PPM are at high risk of developing SVD.

Advanced proliferative diabetic retinopathy and macular edema in acromegaly: a case report and literature review.

We describe the multimodal management of a patient with proliferative diabetic retinopathy and diabetic macular edema associated with active acromegaly. A 61-year-old Japanese female who had had type 2 diabetic mellitus for > 10 years complained of deteriorated eyesight. She had distinct acromegalic features, and her visual acuity was 0.05 (right) and 0.4 (left) because of sub-capsular cataracts and proliferative diabetic retinopathy with macular edema. Anti-vascular endothelial growth factor treatments, cataract surgeries and retinal direct laser photocoagulation were performed together with gradual glycemic control with basal insulin to prevent worsening of the visual impairment. She was given an injection of a long-acting somatostatin analog (octreotide LAR) and began taking three bolus mealtime insulin shots with basal insulin beginning 1 month before undergoing a trans-sphenoidal adenomectomy. After this successful surgery, her blood glucose levels immediately decreased, and the rapid-acting insulin at mealtimes was discontinued with the observation of normal growth hormone and insulin-like growth factor (IGF)-1 levels, suggesting that her acromegaly was in remission. Her visual acuity improved without a worsening of diabetic retinopathy. Since the increased IGF-1 production in systemic circulation and local vitreous fluids may be one of the aggravating factors for diabetic retinopathy, our patient's acromegaly complicated with severe retinopathy presented an opportunity for multimodal management in close collaboration with an ophthalmologist, neurosurgeon, and endocrinologist. Our literature review revealed that the estimated prevalence of diabetic retinopathy in cases of acromegaly associated with diabetes mellitus is 12.5-42.9%.

Effects of Low-Dose Tolvaptan for Fluid Management After Cardiovascular Surgery.

Background: Perioperative management of body fluid levels after cardiovascular surgery with cardiopulmonary bypass is essential. Fluid management using tolvaptan with conventional diuretics is effective in maintaining urine output without worsening renal function. This study aimed to improve the in-out balance in the early perioperative phase using low-dose tolvaptan (3.75 mg/day). Methods and Results: This prospective, single-center, randomized, open-label study included 199 patients who underwent cardiovascular surgery with cardiopulmonary bypass in Kobe City Medical Center General Hospital between September 2018 and December 2020. Treatment with tolvaptan and loop diuretics (tolvaptan group; 99 patients) was compared with treatment with loop diuretics alone (control group; 100 patients) to evaluate achievement of preoperative body weight as the primary outcome. Secondary outcomes were urine volume, the incidence of worsening renal function (WRF), and postoperative paroxysmal atrial fibrillation (POAF). There was no significant difference between groups in the return to preoperative body weight on postoperative Day 6. The tolvaptan group had significantly increased urine volume (2,530 vs. 2,150 mL/day) and decreased total furosemide dose (24 vs. 32 mg) compared with the control group. No significant differences were observed in the development of WRF and POAF between the 2 groups. Conclusions: Although low-dose tolvaptan administration did not shorten the time to achieving preoperative body weight, it did significantly increase urine volume without WRF and POAF.

Aggressive use of prophylactic cerebrospinal fluid drainage to prevent spinal cord ischemia during thoracic endovascular aortic repair is not supportive.

OBJECTIVES: We investigated whether prophylactic preoperative cerebrospinal fluid drainage (CSFD) was effective in preventing spinal cord ischemia (SCI) during thoracic endovascular aortic repair of degenerative descending thoracic aortic aneurysms, excluding dissecting aneurysms. METHODS: We retrospectively reviewed the medical records of patients who underwent thoracic endovascular aortic repair involving proximal landing zones 3 and 4 between 2009 and 2020. RESULTS: Eighty-nine patients with preemptive CSFD [68 men; median (range) age, 76.0 (71.0-81.0) years] and 115 patients without CSFD [89 men; median (range) age, 77.0 (74.0-81.5) years] were included in this study. Among them, 59 from each group were matched based on propensity scores to regulate for differences in backgrounds. The incidence rate of SCI was similar: 8/89 (9.0%) in the CSFD group and 6/115 (5.2%) in the non-CSFD group (P = 0.403). Shaggy aorta (odds ratio, 5.13; P = 0.004) and iliac artery access (odds ratio, 5.04; P = 0.005) were identified as positive predictors of SCI. Other clinically important confounders included Adamkiewicz artery coverage (odds ratio, 2.53; P = 0.108) and extensive stent graft coverage (>8 vertebrae) (odds ratio, 1.41; P = 0.541) were not statistically significant. Propensity score matching yielded similar incidence of SCI: 4/59 (6.8%) in the CSFD group and 3/59 (5.1%) in the non-CSFD group (P = 0.697). CONCLUSIONS: Aggressive use of prophylactic CSFD was not supportive in patients without complex risks of SCI.