Distal Perfusion in Open Stent-Grafting / 日本心臓血管外科学会雑誌

<p><b>Objective</b> : We examined the utility of distal perfusion (DP) in open stent grafting (OSG) for the treatment of thoracic aortic aneurysm. <b>Methods</b> : Fifty patients who underwent OSG were categorized into two groups (the Non-DP group and the DP group) based on the presence or absence of distal perfusion in OSG. There was no statistically significant difference between the two groups with regard to patient characteristics. <b>Results</b> : There was no statistically significant difference between the two groups with regard to operation time, but, cardiopulmonary bypass time (178±22 min vs. 193±18 min ; <i>p</i> <0.01) and aortic cross clamp time (84±23 min vs. 106±19 min ; <i>p</i><0.01) were significantly longer in the DP group. Lower-body circulatory arrest time (46±11 min vs. 20±5 min ; <i>p</i><0.001) was significantly longer in the Non-DP group. Postoperative paraplegia and paraparesis occurred in one case each in the Non-DP group, whereas permanent spinal cord ischemia did not occur in the DP group. Postoperative intubation time (72.6±40.1 h vs. 40.1±34.7 h ; <i>p</i><0.05) was significantly longer in the Non-DP group. There were two in-hospital deaths due to stroke and respiratory failure in the Non-DP group, and one in-hospital death due to respiratory failure in the DP group. The postoperative maximum value of BUN (38.5±15.6 mg/dl vs. 30.8±9.8 mg/dl ; <i>p</i><0.05) and s-Cr (1.9±1.0 mg/dl vs. 1.3±0.4 mg/dl ; <i>p</i><0.01) were significantly higher in the Non-DP group. <b>Conclusion</b> : DP in OSG was an effective method for prevention of spinal cord ischemia, and for protection of respiratory and renal function.</p>

Recurrent of Aortic Coarctation in Extra-anatomical Bypass Surgery / 日本心臓血管外科学会雑誌

Recoarctation, systemic hypertension, aortic aneurysm and intracranial aneurysm are generally observed within a certain period after the surgical procedure for aortic coarctation, which is known as a systemic diseases caused by not only morphological abnormalities but also arterial functional abnormalities of artery. Here, we report a case who showed complications of recoarctation, hypertension and subarachnoid hemorrhage after surgery for aortic coarctation. A 17-year-old boy originally presented to our hospital with upper extremity systemic hypertension. Recoarctation after surgery for aortic coarctation was diagnosed in his childhood, following which hypertension was followed while he received continuous treatment with anti-hypertensive drugs. He was hospitalized with sudden headache and loss of consciousness. Since subarachnoid hemorrhage was diagnosed by computed tomography, clipping of intracranial aneurysms was performed. After the clipping procedure, he underwent percutaneous intravascular stenting angioplasty. However, the pressure gradient remained and sufficient dilatation was not obtained because of the hypoplastic anatomical distal aortic arch (from the left internal carotid artery to the site of recoarctation) due to the development of collateral circulation with rib notch. At age 21, extra-anatomical bypass (from the ascending aorta to the descending aorta) was performed because of persistent upper extremity systemic hypertension. However, systemic hypertension continued to require antihypertensive medication.

Initial and Mid-term Results of Thoracic Endovascular Repair (TEVAR)—Management of Left Subclavian Artery (LSA) during Zone 2 (Z2) Coverage— / 日本心臓血管外科学会雑誌

Between August 2008 and June 2012, 17 TEVAR procedures for thoracic aortic aneurysms (TAA) requiring Z2 coverage were performed at our institution. Patient age ranged from 46 to 82 years old (mean 69.4), 16 were male. Criteria for LSA revascularization at our institution are defined as either : 1) dominant left vertebral artery (VA), 2) absent or diminutive or occluded right VA, 3) no communication of bilateral VA, 4) bilateral carotid artery disease, 5) patent LIMA-coronary bypass, 6) if a long length of the thoracic aorta is covered. Devices utilized were Gore TAG (<i>n</i>=12) and TX2 (<i>n</i>=5). Deployment of the stent-graft (SG) was successful in 17 cases (100%) and complete thrombosis of the aneurysm or complete entry closure was achieved in 16 cases (94.1%). Axillo-axillar cross over bypass (Ax-Ax B) was performed in 5 cases (29.4%). There was no instance of cerebrospinal ischemia or hospital death and the mean follow-up was 22.9 month (range 5 to 46). One case was converted to open surgery due to secondary type 1 endoleak. There was no instance of Ax-Ax B graft occlusion or aneurysmal rupture. The initial and mid-term results of TEVAR requiring Z2 coverage were satisfactory, and we believe that our criteria for LSA revascularization played an important role in providing the satisfactory results.

Initial Results of Open Stent-Grafting Applied with a Matsui-Kitamura Stent in the Treatment of Thoracic Aortic Aneurysm / 日本心臓血管外科学会雑誌

We reporte the initial results of open stent-grafting (OSG) applied with a Matsui-Kitamura (MK) stent in the treatment of thoracic aortic aneurysm (TAA). From August 2005 to March 2011, OSG for TAA was applied in 35 cases (male/female, 29/6, 58∼86 years old, mean age 71). During deep hypothermic circulatory arrest with antegrade selective cerebral perfusion, the stent graft was delivered through the transected proximal aortic arch, followed by arch replacement with a 4-branched prosthesis. Concomitant procedures included 1 coronary artery bypass graft, 1 mitral valve replacement and 2 pacemaker implantations. Operative mortality within 30 days was 5.7% (respiratory failure in 1 and ischemic enteritis in 1). There was 1 in-hospital death due to brain stem infarction. Perioperative morbidity included 2 (5.7%) stroke, 5 (14.3%) spinal cord injuries (paraplegia in 1, paraparesis in 1 and transient paraparesis in 3) , and 1 (2.9%) temporary hemodialysis. Ten patients (28.6%) were intubated for more than 72 h. There was no complication with the graft-related incident. These initial results suggested the OSG method applied with a MK stent is a useful surgical procedure for the treatment of TAA.

Initial Results of Thoracic Endovascular Repair with the Gore TAG Device Evaluated by the Japan SCORE System / 日本心臓血管外科学会雑誌

We report the initial results of thoracic endovascular repair using the Gore TAG device (TAG) used in treatment of thoracic aortic aneurysms (TAA), and evaluate initial outcome based on the Japan SCORE (JS) system. From August 2008 to July 2009, thoracic aortic endovascular repair (TEVAR) for TAA was applied in 27 cases (men/women, 22/5, 53-88 years old, mean age 70.5). Locations included the distal arch in 7 cases, proximal descending TAA (dTAA) in 12 cases and middle or distal dTAA in 8 cases. Deployment of a stent-graft (SG) was successful in 27 cases (100%) and complete thrombosis of the aneurysm or complete entry closure was achieved in 26 cases (96.3%). There was 1 type 2 endoleak (3.7%), 2 iliac arterial injuries (7.4%) and 2 cases of temporary hemodialysis (7.4%). There was no occurrence of paraplegia or hospital death. The 30-day mortality rate and major complication rate examined by the Japan SCORE (JS) system did not show any statistical differences between the TEVAR group and the open repair (OR) group, however the data were higher in the TEVAR group, although not statisfically in the OR group. The OR group had a high complication incidence in comparison with the TEVAR group. Based on evaluation by the JS system, the initial results suggest that TAG for the treatment of TAA is superior to conventional open surgery.