Clinical features and prognosis of patients with and without diabetes mellitus undergoing endovascular aortic aneurysm repair.

BACKGROUND: This study aimed to compare the clinical features and prognoses of patients with and without diabetes mellitus (DM) who underwent endovascular repair for aortic aneurysm (AA). METHODS: We analyzed the clinical database of a prospective multicenter study, registering 929 patients who underwent their first endovascular AA repair in Japan between January 2016 and June 2018. The baseline characteristics and prognoses (including all-cause mortality and cardiovascular events) after repair were compared between the DM and non-DM groups. Prognoses were also compared between the groups after propensity score matching. RESULTS: In total, 226 patients (24.3%) had DM. Compared with non-DM patients, DM patients had higher pack-years of smoking (P = 0.011), higher body mass index (P = 0.009), lower high-density lipoprotein cholesterol levels (P = 0.038), higher triglyceride levels (P = 0.025), and lower left ventricular ejection fraction (P = 0.005). Meanwhile, the low-density lipoprotein cholesterol and blood pressure levels showed no significant intergroup difference (all P > 0.05). DM patients had a higher prevalence of myocardial infarction (P = 0.016), history of coronary revascularization (P = 0.015), and lower extremity artery disease (P = 0.019). Lesion characteristics and procedures were similar between the groups (all P > 0.05). DM patients had a higher risk of all-cause mortality and cardiovascular events than non-DM patients (both P < 0.001). Subsequent propensity score matching also demonstrated that DM patients had a significantly lower rate of overall survival (P = 0.001) and freedom from cardiovascular events (P = 0.010). The Kaplan-Meier estimates at 1 year for the overall survival were 85.6% (95% confidence interval [CI], 80.9% to 90.5%) and 94.3% (95% CI, 91.7% to 97.0%) for patients with and without DM, respectively. The corresponding estimates for freedom from cardiovascular events were 79.8% (95% CI, 74.5% to 85.5%) and 87.7% (95% CI, 84.2% to 91.3%), respectively. CONCLUSIONS: Among patients undergoing endovascular AA repair, those with DM had more cardiovascular risk factors. DM patients had a higher incidence rate of all-cause mortality and cardiovascular events. Matching analysis indicated that DM per se would be a risk factor for poor prognoses after AA repair.

[Bentall Procedure and Total Arch Replacement with an Open Stentgraft after Ascending Aortic Replacement for Acute Type A Aortic Dissection].

A 40-year-old man underwent ascending aortic replacement for acute type A aortic dissection. Eight years later, Bentall procedure and total arch replacement with an open stentgraft (OSG) were performed due to enlargement of the aortic root and distal arch dissection as well as exacerbation of aortic valve incompetence. The computed tomography(CT) taken at 22 months postoperatively showed better stentgraft expansion than that immediately after the operation, reduction in the diameter of the distal aortic arch, and thrombosis of the false lumen from the aortic arch to the entire descending aorta. However, the CT taken at 33 months postoperatively revealed a new entry to the distal end of the stentgraft and blood flow in the false lumen. Although OSG is useful for extensive aortic aneurysm, strict follow-up is necessary in OSG for aortic dissection.

Effect of antifibrinolytic therapy with tranexamic acid on abdominal aortic aneurysm shrinkage after endovascular repair.

OBJECTIVE: The long-term outcomes of endovascular abdominal aortic aneurysm repair (EVAR) remain to be determined, but patients with aneurysm shrinkage after EVAR appear to have a good prognosis. We previously observed that antiplatelet therapy is a risk factor for lack of aneurysm shrinkage, a finding suggesting that coagulation and fibrinolysis play roles in shrinkage. We therefore studied the effect of antifibrinolytic therapy with tranexamic acid (TXA) on aneurysm shrinkage after EVAR. METHODS: From May 2007 to May 2012, EVAR was performed in 187 patients, 165 of whom had an enhanced computed tomographic evaluation 6 months after their procedure. Six of the 165 patients were excluded from the study because they had a type Ia endoleak or coil embolization to treat a type II endoleak ≤ 6 months after EVAR. Of the remaining 159 patients, 110 underwent EVAR before we started to use TXA in our centers. TXA therapy (1500 mg/d for 6 months) began in January 2011, and 48 patients completed the treatment regimen. Patients not treated with TXA were compared with those given TXA. Analyses to identify risk factors for lack of aneurysm shrinkage were performed. RESULTS: No patient had a thromboembolic event. There were no significant differences between the no-TXA and TXA groups in demographics, aneurysm characteristics, prosthesis implanted, type II endoleak occurrence during EVAR or 1 or 6 months afterward, or aneurysm shrinkage at 1 month. However, at 6 months after EVAR, the TXA group had significantly greater aneurysm shrinkage (P = .035) and a significantly higher percentage of patients with >4 mm in shrinkage (P = .010). Multiple regression analysis showed aneurysm diameter, type II endoleak 6 months after EVAR, and TXA treatment were independently associated with aneurysm shrinkage or lack of shrinkage. CONCLUSIONS: Antifibrinolytic therapy with TXA was associated with aneurysm shrinkage after EVAR. Studies to identify the dosage of TXA that is optimally safe and effective in this application, as well as investigations of the best timing and route (parenteral vs oral) for TXA administration, are warranted.

[Pulmonary leiomyosarcoma treated with surgery; report of a case].

Primary pulmonary leiomyosarcoma is a rare malignant tumor of the lungs. A 79-year-old woman showed a mass of 9 cm in diameter in a chest X-ray and computed tomography (CT) scan. A malignant tumor was suspected and left lower lobectomy was performed. From pathological findings, pulmonary leiomyosarcoma was diagnosed. The disease stage was pT2N0M0, p0d0e0pm0 (p0), pIB. From histopathological findings, the tumor appeared to be high grade, but no recurrences have occurred 2 years postoperatively and surgical treatment was considered effective.

Primary adenocarcinoma of the trachea resected using percutaneous cardiopulmonary support (PCPS).

We encountered one very rare case of primary adenocarcinoma of the trachea. The patient was a 72-year-old woman who was hospitalized immediately following significant dyspnea and mental confusion. A computed tomography scan of her chest revealed a 14x13x11 mm tumor in the trachea. After establishing artificial respiration, a tracheal tubular resection was immediately performed using percutaneous cardiopulmonary support (PCPS). A postoperative pathological examination led to the patient being diagnosed with primary adenocarcinoma of the trachea, and she was treated with adjuvant chemotherapy. Since then, for approximately 1 year and 6 months we have detected no relapse.

Resection of a cardiac tumor extending into the inferior vena cava presenting as Budd-Chiari syndrome.

This report describes the successful treatment of a case of cardiac adenocarcinoma with the clinical presentation as Budd-Chiari syndrome. Complete surgical excision of the atriocaval mass was successfully achieved under deep hypothermic circulatory arrest. Histopathological diagnosis of this tumor was tubular adenocarcinoma with positive immunostaining by carcinoembrionic antigen. Subsequent systemic search could not detect any evidence of extra-cardiac primary site and distant metastatic lesion. A 2-year follow-up without any adjuvant therapy revealed no sign of recurrence.

Mitral valve repair for mitral insufficiency due to infective endocarditis in a patient with idiopathic thrombocytopenic purpura.

A 63-year-old woman with an 18-year history of idiopathic thrombocytopenic purpura (ITP) was admitted with a persistent fever of unknown cause. Blood culture was positive for alpha-Streptococcus and echocardiography revealed severe mitral regurgitation and vegetation on the mitral valve. After antimicrobial therapy for six weeks, she underwent mitral valve repair using a Cosgrove ring. The platelet count increased and remained stable by perioperative treatment with intravenous high-dose gamma-globulin and platelet transfusion without steroids therapy or splenectomy. The hospital course was uneventful. Perioperative high-dose gamma-globulin therapy and platelet transfusion for the cardiac operation were useful to increase and maintain the platelet count for an ITP patient complicated with infective endocarditis.

Congenital pericardial defect associated with ruptured type A aortic dissection.

Congenital pericardial defect is a rare and little-known anomaly. Here we describe the unique clinical presentation of a 64-year-old man with partial defect of the left pericardium associated with ruptured acute type A aortic dissection manifesting massive left hemothorax. In this patient, the pericardial defect played the role of a pericardial draining window, which incidentally prevented the heart from cardiac tamponade. Emergent surgery was successfully performed with a prosthetic graft replacement.

Left ventricular-free wall rupture after successful coronary intervention: report of a case.

We experienced the case of a left ventricular-free wall rupture (LVFWR) following successful coronary intervention for acute myocardial infarction (AMI). A 73-year-old woman was hospitalized because of chest oppression that had been continuing for 8 days. She was diagnosed to have AMI, and percutaneous coronary intervention (PCI) was performed. PCI was successful. However, immediately following PCI, she developed electromechanical dissociation secondary to tamponade because of blow-out-type LVFWR. The perforation tear was initially closed by a direct suture, followed by reinforcement using bovine pericardium patches sealed with GRF glue. The patient died of irreversible brain damage on postoperative day 3, but no re-bleeding or aneurysmal dilatation was detected at autopsy.

Off-pump axillo-coronary artery bypass grafting with porcelain aorta.

Coronary artery bypass grafting (CABG) in patients with severely diseased ascending aorta has been associated with high risk for cerebral vascular accidents due to atheromatous embolism. In this situation, aortic no-touch techniques are widely employed as most important surgical strategy to prevent these complications. A case of 75-year-old man with effort angina associated with porcelain ascending aorta was reported here. He successfully underwent off-pump axillo-coronary bypass grafting with saphenous vein graft and has remained uneventful during his follow-up period. The off-pump axillo-coronary artery bypass grafting seemed to be an appropriate procedure for coronary revascularization with severely diseased ascending aorta.