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.

[Thoracoabdominal aortic aneurysm repair with preservation of the diaphragm and intercostal muscles].

In thoracoabdominal aortic aneurysm (TAAA) repair, postoperative respiratory complication is a major problem. TAAA repair was performed in a 75-year-old man. The computed tomography showed a TAAA (Crawford type IV) with shaggy descending thoracic aorta. Stomach and small intestine were compressed by the TAAA with resultant appetite loss. And reduced respiratory function was observed. In such a case thoracotomy is usually required for operation. However, we applied the extra pleural dissection without thoracotomy, and the diaphragm and intercostal muscles were preserved. Using the selective abdominal organ perfusion, graft replacement was performed between iliac arteries and descending aorta. The postoperative course was uneventful, and respiratory function was preserved.

Effect of type II endoleaks and antiplatelet therapy on abdominal aortic aneurysm shrinkage after endovascular repair.

OBJECTIVE: Endovascular repair of abdominal aortic aneurysm (EVAR) has been shown to be safe, and its use is increasing rapidly, but the long-term results of this procedure remain unclear. A decrease in the diameter of the aneurysm sac is considered to represent successful exclusion of the aneurysm from the circulation, but it has been reported that aneurysm shrinkage occurs in only about 60% of patients who have undergone EVAR. We analyzed several factors to determine whether they were related to aneurysm shrinkage after EVAR. METHODS: From March 2007 to January 2010, EVAR was performed in 65 patients, 58 of whom underwent an enhanced computerized tomographic evaluation 6 months after the procedure. One patient was found to have a type Ia endoleak and was excluded from the study. In the remaining 57 patients, univariate and multiple regression analyses were used to determine whether there was a relationship between aneurysm shrinkage and various patient characteristics, aneurysm dimensions, and procedural outcomes. Aneurysm shrinkage was defined as a decrease in diameter of at least 4 mm. RESULTS: On univariate analysis, a lack of aneurysm shrinkage by 7 days and 6 months after EVAR was significantly associated with hyperlipidemia, ongoing multiagent antiplatelet therapy with clopidogrel, ticlopidine, or cilostazol as well as aspirin, length of the proximal neck of the aneurysm, preprocedure maximum aneurysm diameter, and the presence of a type II endoleak. On multiple regression analysis, only multiagent antiplatelet therapy and type II endoleak were significantly related to a lack of aneurysm shrinkage 6 months after EVAR. Multiagent antiplatelet therapy and type II endoleak 6 months after EVAR were not significantly associated with each other. CONCLUSION: Patients with a persistent type II endoleak and patients undergoing multiagent antiplatelet therapy are at an increased risk of a lack of aneurysm shrinkage 6 months after EVAR.

[Left ventricular free wall rupture in an elderly patient; report of a case].

We successfully repaired left ventricular free wall rupture in a 91-year-old woman. She was admitted to our hospital because of consciousness loss. Blood pressure was only 60 mmHg on arrival. Contrast-enhanced computed tomography (CT) demonstrated massive pericardial effusion and transmural contrast defect of the left ventricular lateral wall in the delayed phase. Upon surgery there was massive clot around the heart. A localized infracted area on the left ventricular lateral wall was exposed using off-pump coronary artery bypass (OPCAB) technique. There was mild bleeding only during diastolic phase. Three mattress sutures of 3-0 prolene with Teflon felt strips were placed to control the bleeding under beating heart. A sheet of collagen and fibrin glue was also applied. Postoperative course was uneventful. This type of left ventricular rupture could be less invasively repaired by off-pump technique. As far as we investigated, this is the oldest patient of ventricular free wall rupture successfully repaired.

Atrial natriuretic peptide protects against ischemia-reperfusion injury in the isolated rat heart.

BACKGROUND: Atrial natriuretic peptide (ANP), a stimulator of particulate guanylate cyclase, has been found to protect against reoxygenation-induced hypercontracture in isolated cardiomyocytes by increasing cyclic guanosine monophosphate synthesis. The purpose of this study was to investigate the cardioprotective effects of ANP against ischemia-reperfusion injury in isolated rat hearts. METHODS: Twenty-four hearts were perfused with ANP at 0.01, 0.1, and 1 micromol/L or without ANP (n = 6 each) in normoxic conditions. Because 0.1 micromol/L ANP induced a threefold increase in cyclic guanosine monophosphate release into the coronary effluent without any effect on cardiac function, we used the 0.1 micromol/L ANP dose for ischemia-reperfusion studies. Eighteen hearts were subjected to 15 minutes of normothermic global ischemia followed by 15 minutes of reperfusion. The hearts were divided into three groups (n = 6 each). RESULTS: In group 1, ANP was added before ischemia. In group 2, ANP was added to the reperfusate. Hearts were untreated in the control group. In group 1, the postischemic recovery of cardiac output, coronary flow, and cyclic guanosine monophosphate release was similar to the control group. In group 2, the recovery of cardiac output was significantly better than the control group (82.1% +/- 9.8% vs 61.8% +/- 6.8%, respectively, p < 0.01) with a similar trend to recovery of coronary flow (90.7% +/- 8.5% vs 79.3% +/- 11.8%, respectively). The improved cardiac function was closely related to a significant increase in postischemic cyclic guanosine monophosphate release. CONCLUSIONS: Administration of ANP at the time of reperfusion protects the myocardium from ischemia-reperfusion injury. The concentrations of administration must not only increase the release of cyclic guanosine monophosphate release, but also lack negative inotropic effects.

Endovascular treatment of perigraft seroma after open abdominal aortic aneurysm repair: report of a case.

Perigraft seroma is a rare complication after open abdominal aortic aneurysm (AAA) repair. We successfully treated large seroma after expanded polytetrafluoroethylene (ePTFE) aortobiiliac graft repair endovascularly. The patient was an 81-year-old lady with the history of five times laparotomy. She could not take any food because of vomiting. Contrast enhanced computed tomography (CT) revealed giant seroma compressing small intestine. Total relining of the graft with a Excluder(TM) endoprosthesis and open drainage of the seroma was performed. After the surgery, she became asymptomatic and seroma disappeared by CT 2 years later. This modality would be a good option for this rare complication.

Endovascular management for ruptured Stanford B acute aortic dissection.

Surgery for a complicated Stanford B acute aortic dissection, such as rupture or malperfusion, is still a challenge. We undertook endovascular therapy for ruptured Stanford B acute aortic dissection in two patients. A homemade stent graft was deployed in an 84-year-old woman with a massive mediastinal hematoma; and an aortic extender of Excluder was used for a 76-year-old man with left hemothorax. Both patients recovered without major complications. Careful follow-up is mandatory. Endovascular therapy for a ruptured Stanford B acute aortic dissection seems feasible and efficient.

Repair of a pararenal abdominal aortic aneurysm with bilateral renal artery stenosis using a rapid infusion pump for renal perfusion: report of a case.

A 73-year-old man with a history of hypertension and drug-induced hepatitis underwent surgical treatment of an enlarging pararenal abdominal aortic aneurysm (PRAAA) with bilateral renal artery stenosis, found on enhanced computed tomography (CT). His preoperative renal function was normal. We divided the right renal artery and used a 6-mm expanded polytetrafluoroethylene (ePTFE) tube graft for the anastomosis. Renal artery perfusion was achieved by a rapid infusion pump set at 200 ml/min. The left renal artery was reconstructed and perfused in the same way. The abdominal aorta was cross-clamped just distal to the superior mesenteric artery and a Y-graft was anastomosed. The ePTFE grafts were connected to the Y-graft and bilateral renal artery circulation was re-established. The renal ischemic time was 1 h 25 min and the urine output during reconstruction was 80 ml. Postoperatively, his serum blood urea nitrogen and serum creatinine levels increased slightly, but normalized within 3 days. This case report shows that this method of renal artery perfusion could prove useful for complex renal artery reconstructions.

Spontaneous abdominal aortic dissection treated by endovascular stent grafting: report of a case.

A spontaneous abdominal aortic dissection is very rare. We experienced this rare entity in a 37-year-old man. He was successfully treated by endovascular stent grafting, including coil embolization of the inferior mesenteric artery. The pseudolumen was completely thrombosed and it shrank without any endoleak 3 months later. This modality is thus considered to be a good alternative to open surgical repair, even though a long-term follow-up is mandatory.