RÉSUMÉ
We report on a case of a distal aortic arch aneurysm with severe shaggy aorta treated by two-stage hybrid surgery without complications. The patient was a 67-year-old man. The thoracic aortic aneurysm was identified on computed tomography imaging by his treating physician during routine follow-up for lung cancer. The patient was referred to our hospital for further investigation and treatment. The aneurysm had a maximum diameter of 68 mm with severe shaggy aorta. Based on these findings, the risk of cerebral infarction and spinal cord ischemia was considered very high. The patient underwent total arch replacement with elephant trunk, using a brain isolation technique for this initial surgery. The postoperative course was uneventful and thoracic endovascular aortic repair（TEVAR) was performed 26 days after the initial surgery. The patient was discharged on post-operative day 38, without complications.
RÉSUMÉ
Objective: We examined complications of the downstream aorta after the frozen elephant trunk (FET) procedure. Methods: Complications were diagnosed in eight patients: true aneurysm alone in five patients; type A aortic dissection in two patients; and both true aneurysm and type B aortic dissection in one patient. Results: Elective surgery was performed in seven patients. Five patients received a Matsui-Kitamura stent graft (MKS) and three patients received a J Graft Open Stent Graft (JGOSG). The FET procedure was successfully applied in all cases. Over the long term, dilatation of the descending thoracic aorta (dTA) alone was identified in two patients and dilatation of the dTA and migration was identified in three patients using the MKS. Complications of graft kinking and migration were seen in one patient and distal stent graft-induced new entry in two patients using the JGOSG. Thoracic aortic stent graft repair was successfully performed for complications in seven patients. Conclusion: For the improvement of clinical results, FET devices need to offer flexibility and appropriate radial force.
RÉSUMÉ
Aortoiliac occlusive disease (AIOD) can be difficult to treat. We performed aorto-uni-iliac (AUI) stent-grafting with external-iliac artery crossover bypass in 3 cases of extensive AIOD (mean age 69 years). Lesions were TASC II type D in 2 and D+A in 1. Mean ankle-brachial index of diseased side was 0.52. Bare stent placement for iliac stenosis was also done in 2 cases. All cases were a technical success with no complications. Mean operation time was 123 min and mean hospital stay was 11 days. We have been keeping good patency. We consider it an effective treatment option for AIOD.
RÉSUMÉ
We report a case of operations using a hybrid technique for repeated extensive aortic aneurysm. A 71-year-old man had extensives aneurysms of the aortic arch and descending aorta. In the first operation, he had undergone thoracoabdominal aortic replacement with island repair for thoracoabdominal aortic aneurysm (Crawford type 3) at age 64. Six years later, computed tomography showed an aortic aneurysm around the region of the island repair and penetrating atherosclerotic ulcer (PAU). Therefore, he underwent abdominal debranching and thoracic endovascular aortic repair (TEVAR) at 70 years old. At the same time, he had an extensive aortic arch aneurysm. Considering the complicated surgical history and the affected region, we judged that conventional graft replacement was difficult. So, in the third operation, we performed TEVAR for the descending aorta at 71 years old. One month later, total arch replacement (TAR) with a frozen elephant trunk (FET) was performed (4th operation). The patient was discharged home 22 days after the 4th operation. This strategy of operations using hybrid techniques for extensive aortic aneurysm may be useful in high risk cases of surgical procedures and postoperative complications.
RÉSUMÉ
<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>
RÉSUMÉ
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.
RÉSUMÉ
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.
RÉSUMÉ
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.
RÉSUMÉ
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.
RÉSUMÉ
Positron emission tomography (PET) is an established imaging tool in oncology that has also been used in infectious and inflammatory diseases. PET combined with computed tomography (PET/CT) can be used to visualize metabolic activity with precise localization. We report an infant with late presentation of poststernotomy mediastinitis, the diagnosis and localization of which was confirmed by PET/CT. An 8-month old infant, who had undergone the Jatene procedure and right ventricle outflow reconstruction 6 months prior, was admitted for inflammation surrounding the superior aspect of the healed scar. Cultures from the wound grew methicillin-resistant <i>Staphylococcus aureus</i> (MRSA). Although the only symptom was discharge from the wound, and there were no other signs or symptoms suggestive of severe general infection, substernal abscess was suspected by magnetic resonance imaging. Since PET/CT revealed high accumulation of 18-fluorodeoxyglucose at the substernal region, the diagnosis of MRSA mediastinitis was made, which was confirmed by subsequent surgical treatment.
RÉSUMÉ
A 79-year-old man was transferred to our hospital because of massive hematemesis. Contrast-enhanced CT scan demonstrated extravasation of contrast medium into the jejunum. Therefore, we diagnosed primary aortoenteric fistula and performed an emergency operation. At surgical exploration, the jejunum was closely adherent to the normal-sized aorta. The fistula was present between the anterior wall of the aorta and the jejunum. Operative reconstruction was performed with <i>in-situ</i> grafting and a pedicled omentum flap was placed around the graft. The postoperative course was uneventful, and there has been no evidence of infection during the follow-up period of 1 year.
RÉSUMÉ
We here report two cases of successfully treated secondary aorto or iliac arterial-enteric fistula after graft replacement for abdominal aortic aneurysm. Case 1: A 80-year-old man who complained massive anal bleeding had undergone Y-shaped graft replacement for abdominal aortic aneurysm 22 years previously. Computed tomography demonstrated an aneurysm and hematoma formation at the anastomosis of the right graft limb and the right common iliac artery. Preoperative angiography showed no leak of contrast medium at the distal anastomosis of the right graft limb. A presumptive diagnosis of secondary iliac arterial enteric fistula was made, therefore, we performed an emergency operation. Extra-anatomic bypass preceded the removal of the right graft limb, partial resection and direct reconstruction of the ileum by the retroperitoneal approach. His postoperative course was uneventful and he was discharged on the 19th postoperative day. Case 2: A 77-year-old man who had received Y-shaped graft replacement of an abdominal aortic aneurysm 9 years previously was transferred to our hospital because of sudden onset epigastralgia and massive hematemesis. Gastroduodenoscopy revealed a fresh blood clot in the third portion of the duodenum where it was compressed by for surrounding pulsatile environment. An emergency computed tomography showed aneurysm formation without extravasation of contrast medium in the duodenum at the proximal anastomosis of the prosthetic graft. A secondary aortoenteric fistula was highly suspected and emergency operation was performed. Extra-anatomic bypass preceded the removal of the graft body, infrarenal aortic stump closure, duodenal closure and the greater omentum was used to fill defects. He underwent successful staged abdominal wall closure due to bowel edema making primary closure impossible. His postoperative course was uneventful and he was discharged on the 26th postoperative day.
RÉSUMÉ
A 54-year-old man, involved in a motor vehicle collision, was transferred to our hospital. He was hemodynamically stable. A CT scan of the chest demonstrated traumatic aortic dissection and a mediastinal hematoma with hemothorax of left side. Endovascular aortic repair using a homemade device was immediately performed, and a completion angiogram revealed complete exclusion of the aortic injury, with no extravasation. A postoperative CT scan revealed satisfactory placement of the endograft, with no extravasation. The patient was discharged on the 13th postoperative day. Endovascular aortic repair was useful and minimally invasive therapy in this case for the treatment of traumatic thoracic aortic rupture.
RÉSUMÉ
A 65-year-old patient underwent successful transluminally placed endoluminal prosthetic grafts (TPEGs) of a descending thoracic aortic aneurysm (dTAA). Two hours after TPEGs, the patient suddenly complained of chest, back pain and right leg pain. Angiography and computed tomography showed acute type B aortic dissection. Re-TPEGs was immediately performed, and the entry was successfully closed. This case suggests that TPEGs for the treatment of acute aortic dissection may be useful for selected patients.
RÉSUMÉ
Infra-renal abdominal aortic aneurysms were electively treated by bifurcated endovascular stent grafts (Power Web<sup>TM</sup> system, Endologix Co., USA) at 5 Japanese centers. The stent grafting (SG) was applied for candidates nominated by the selection committee after informed consent was obtained according to the IRB in each center. The delivery success rate of 60 patients (53 males) was 96.7%. There were 2 patients with type I endoleaks, resulting in a technical success rate of 93.3%. The operation time of 193±55min and blood loss of 440±240g were significantly shorter and less, respectively in the SG group when compared with 303±88min and 1, 496±2, 025g in 97 patients (83 males) treated by conventional open surgery. Endoleaks were detected in 4 patients (type I: 3, type II: 1) by CT scan taken at the time of discharge or 1 month after SG procedure. Type I endoleak was observed in patients with short and severely angulated SG landing zones. Renal artery obstruction, and temporary buttock pain caused by internal iliac artery occlusion occurred, but there was no hospital death. In 56 patients excluding an SG-unrelated death and a dropout from surveillance, there was no secondary endoleak or marked adverse events at all except 1 SG limb occlusion during a 6-month follow up period. The aneurysm size shrank in 26 patients and remained unchanged in 30 patients. No aneurysm enlargement was observed. The Power Web<sup>TM</sup> system is appropriate for minimally invasive surgery for abdominal aortic aneurysms. Long-term follow-up studies will follow.
RÉSUMÉ
A 51-year-old woman suffered from a sudden onset of anterior chest pain and was referred to our hospital on the suspicion of an anginal attack. The exercise ECG showed findings of an anterior lesion and ischemia. Coronary angiography also revealed left anterior descending branch fistula and circumflex branch fistula connecting to the main pulmonary artery trunk. Direct closure was performed for both intra-pulmonary openings under cardiopulmonary bypass. The postoperative course was uneventful and the patient did not show any precordial pain. Coronary angiography showed no coronary organic narrowing, but contrast medium remained in the fistulae although there was no left to right shunt. Ligation of the fistulae had to be performed simultaneously to confirm complete obstruction of the coronary-pulmonary arterial fistulae. The antiplatlet agent is administered to the patient to prevent occurring myocardial infarction caused by thrombus which might be formed in fistulae.
RÉSUMÉ
This is a case report of a rare combination of a single coronary artery and a coronary artery fistula. An 8-year-old girl was asymptomatic with a grade II continuous murmur in the third left intercostal space. Selective coronary angio-graphy revealed that a single coronary artery arising from the left aortic sinus was dilated and ended as a fistula to the outflow tract of the right ventricle. At operation, the fistula could not be exposed on the surface of the heart. On cardiopulmonary bypass, the aorta was clamped, and the fistula was closed by direct suture in the right ventricle. The postoperative course was uneventful with no complications.
RÉSUMÉ
In a consecutive series of 160 surgically treated abdominal aortic aneurysm, four patients with acute aortic thrombotic occlusion of an abdominal aortic or iliac aneurysm were encountered. Three of four aneurysms were 7cm in diameter or smaller. Also, 3 of 4 patients had chronic occlusive disease of legs. Our mortality rate was 75%. The recommendation is made that all abdominal aortic aneurysms be resected if there is substantial associated distal occlusive disease.
RÉSUMÉ
A 44-year-old woman with over 20 years history of rheumatic heart disease developed progressive heart failure from aortic stenosis and mitral restenosis after open mitral commissurotomy. In December, 1986, she underwent aortic and mitral valve replacements with Medtronic Hall prosthesis (aortic: 21mm, mitral: 27mm). Following an eventful recovery, she was discharged from the hospital and continued on a regimen of Coumadin. In February, 1991, the patient developed chest and back pain, which necessitated her emergency admission to our clinic. During the coronary examination, the aortic prosthetic occluder was not moving, fixed in the opening position, lasting from one to several minutes. She underwent emergency operation for replacement of the defective valve. At operation, we noted the pannus formation into the valve orifice on the inflow side of aortic prosthesis. She made a satisfactory recovery and has enjoyed good health since that time.
RÉSUMÉ
A cervical aortic arch is a very rare congenital malformation of aortic arch. A case is reported of a 42-year-old woman with an extensive circular aneurysm of a left-sided cervical aortic arch. The arch aneurysm was successfully removed surgically and replaced with woven Dacron graft. Histologic examination of the aneurysm revealed atherosclerosis and intimal defect.