A Comparison of Outcomes Based on Vessel Type (Native Artery vs. Bypass Graft) and Artery Location (Below-Knee Artery vs. Non-Below-Knee Artery) Using a Combination of Multiple Endovascular Techniques for Acute Lower Limb Ischemia.

BACKGROUND: To evaluate outcomes of endovascular treatment (EVT) using a combination of multiple endovascular techniques for acute lower limb ischemia (ALLI) and to compare outcomes based on vessel type and artery location. METHODS: A total of 95 consecutive patients with ALLI (mean age, 72.0 years; 65 males; 104 lower limbs) who received emergency EVT using a combination of multiple endovascular techniques including thrombolysis, aspiration thrombectomy, stenting, and balloon angioplasty with or without surgical thromboembolectomy, between January 2005 and December 2017 were included. Vessel type was classified into native artery occlusion (native occlusion) and bypass graft occlusion (graft occlusion), including prosthetic and vein graft. Additionally, native arteries were categorized into below-knee occlusion and non-below-knee occlusion. Technical success, perioperative death (POD), ALLI-related death, amputation, amputation-free survival (AFS), and complications were compared according to vessel type (native occlusion vs. graft occlusion) and artery location (below-knee occlusion vs. non-below-knee occlusion). RESULTS: Of all patients with ALLI, 16.8% underwent a single endovascular technique, whereas 83.2% underwent a combination of multiple endovascular techniques. The technicalsuccess, POD, and ALLI-related death rates in the total number of patients were 94.7%, 11.6%, and 4.2%, respectively. A total of 67 patients (75 limbs) and 28 patients (29 limbs) were classified as having native occlusion and graft occlusion (prosthetic, 24 limbs; vein, 5 limbs), respectively. No significant differences in technical success (native occlusion: 92.5% vs. graft occlusion: 100%), POD (14.9% vs. 3.6%), and ALLI-related death (6.0% vs. 0%) were noted between native occlusion and graft occlusion. However, the 30-day AFS rate of native occlusion was significantly lower than that of graft occlusion (75.2% vs. 96.3%, P=0.01). The amputation rate (P=0.03) and AFS rate (P=0.03) of below-knee occlusion were significantly worse for below-knee occlusion patients than for non-below-knee occlusion patients. CONCLUSIONS: EVT using multiple endovascular techniques for ALLI is effective and safe. A combination of multiple endovascular techniques is crucial for successful treatment. However, native occlusion may have a lower AFS rate than graft occlusion, and below-knee occlusion may have a higher risk of amputation than non-below-knee occlusion.

An Extremely Rare Complication: Abdominal Aortic Aneurysm Rupture Caused by Migration of a Zenith Main Body Years After Repair of the Suprarenal Stent Separation.

PURPOSE: To report an unusual case of an abdominal aortic aneurysm (AAA) rupture caused by migration of a Zenith stent-graft main body years after its separation from the suprarenal stent. CASE REPORT: A 72-year-old man underwent endovascular aneurysm repair with a Zenith stent-graft for an infrarenal AAA in year 2000. At that time, a femorofemoral bypass was performed because the left external iliac and common femoral arteries were dissected during treatment. In 2013, follow-up computed tomography (CT) showed disconnection of the uncovered proximal stent, which led to a type Ia endoleak. An additional Zenith main body and Large Palmaz XL balloon-expandable stent were deployed; the endoleak disappeared. In 2016, the patient had abdominal pain, and emergency CT showed AAA rupture caused by migration of the first main body deployed in 2000 under the distal edge of the contralateral (left) leg of the additional main body from 2013, which led to a type IIIa endoleak between the 2 main bodies. A converter and iliac legs were deployed to successfully seal the type IIIa endoleak. The patient remains well 18 months after the second repair; CT scans document stable stent-grafts and no endoleak. CONCLUSION: Physicians should be aware of the potential risk for AAA rupture caused by late main body migration after treatment for suprarenal stent separation from a Zenith stent-graft.

[Coronary Artery Revascularization with V-composite Saphenous Veins Graft in a Bad Ascending Aorta;Report of a Case].

A 77-year-old male with many comorbidities underwent off pump coronary artery bypass grafting. A severely atherosclerotic ascending aorta was revealed by preoperative computed tomography(CT) and epiaortic echography during operation. Therefore, V-composite saphenous vein grafting was adopted for non left anterior descending artery (LAD) coronary lesions in addition to left internal thoracic artery-left anterior descending artery bypass grafting. He was discharged with no complications and all grafts were confirmed to be patent by postoperative CT. V-composite saphenous vein grafting for avoiding cerebrovascular complications might be one of the useful options in coronary artery revascularization for non-LAD lesions in elderly patients or those with many comorbidities, especially with a severely atherosclerotic ascending aorta.

Impairment of flow-mediated dilation correlates with aortic dilation in patients with Marfan syndrome.

Marfan syndrome is an inherited disorder characterized by genetic abnormality of microfibrillar connective tissue proteins. Endothelial dysfunction is thought to cause aortic dilation in subjects with a bicuspid aortic valve; however, the role of endothelial dysfunction and endothelial damaging factors has not been elucidated in Marfan syndrome. Flow-mediated dilation, a noninvasive measurement of endothelial function, was evaluated in 39 patients with Marfan syndrome. Aortic diameter was measured at the aortic annulus, aortic root at the sinus of Valsalva, sinotubular junction and ascending aorta by echocardiography, and adjusted for body surface area (BSA). The mean value of flow-mediated dilation was 6.5 ± 2.4 %. Flow-mediated dilation had a negative correlation with the diameter of the ascending thoracic aorta (AscAd)/BSA (R = -0.39, p = 0.020) and multivariate analysis revealed that flow-mediated dilation was an independent factor predicting AscAd/BSA, whereas other segments of the aorta had no association. Furthermore, Brinkman index had a somewhat greater influence on flow-mediated dilation (R = -0.42, p = 0.008). Although subjects who smoked tended to have a larger AscAd compared with non-smokers (AscA/BSA: 17.3 ± 1.8 versus 15.2 ± 3.0 mm/m(2), p = 0.013), there was no significant change in flow-mediated dilation, suggesting that smoking might affect aortic dilation via an independent pathway. Common atherogenic risks, such as impairment of flow-mediated dilation and smoking status, affected aortic dilation in subjects with Marfan syndrome.

Circulating transforming growth factor ß-1 level in Japanese patients with Marfan syndrome.

Marfan syndrome (MFS) is an inherited connective tissue disorder mainly caused by the fibrillin-1 mutation. Deficient fibrillin-1 is thought to result in the failed sequestration of transforming growth factor ß (TGFß) and subsequent activation of the TGFß signaling pathway, suggesting that the circulating TGFß level may be elevated in MFS, although its accurate measurement is complex due to ex vivo release from platelet stores upon platelet activation. We measured the plasma TGFß1 levels of 32 Japanese MFS patients (22 medically untreated, 10 treated, 20 males, 30.1 ± 9.6 years old) and 30 healthy volunteers (19 males, 29.5 ± 5.8 years old) by ruthenium-based electrochemiluminescence platform (ECL). PF4 was also measured by enzyme immunoassay (EIA) as a platelet degranulation marker. There was no significant difference in the mean plasma TGFß1 level between the MFS group (1.31 ± 0.40 ng/mL) and controls (1.17 ± 0.33 ng/mL) (P = 0.16, NS). Also, there was no significant difference between the untreated (1.24 ± 0.37 ng/mL) and treated (1.46 ± 0.45 ng/mL) MFS patients (P = 0.15, NS). We also measured PF4, which showed wide deviations but no significant difference between the two groups (P = 0.50). A difference in circulating TGFß1 levels between MFS patients and controls was not detected in this Japanese population. Circulating TGFß1 is not a diagnostic and therapeutic marker for Japanese MFS patients, although our findings do not eliminate the possible association of TGFß with the pathogenesis of MFS.

A novel transit-time flow metric, diastolic resistance index, detects subcritical anastomotic stenosis in coronary artery bypass grafting.

Objective: Transit time flow measurement (TTFM) can detect critical anastomotic stenosis during coronary artery bypass grafting. However, the identification of subcritical stenosis remains challenging. We hypothesized that diastolic resistance index (DRI), a novel TTFM metric, is more effective in evaluating subcritical stenosis than the currently available TTFM metrics. DRI is used to measure changes in the diastolic versus systolic resistance of distal anastomosis. Methods: A total of 123 coronary bypass anastomoses in 35 patients were prospectively analyzed. During coronary artery bypass grafting, the mean graft flow (Qmean), pulsatility index, and diastolic filling were obtained. DRI was calculated using the intraoperative recordings of TTFM and arterial pressure. Postoperatively, stenosis of anastomoses was categorized into successful (<50%), subcritical (50%-74%), and critical (≥75%) via multidetector computed tomography scan. Results: In total, 93 (76%), 13 (10%), and 17 (14%) anastomoses were graded as successful, subcritical, and critical, respectively. DRI and diastolic filling could distinguish subcritical from successful anastomoses (P < .01 and < .01, respectively), whereas Qmean and pulsatility index could not (P = .12 and .39, respectively). The receiver operating characteristic curves were established to evaluate the diagnostic ability for detecting ≥50% stenosis. In left anterior descending artery grafting (n = 55), DRI had the highest area under the curve (0.91), followed by diastolic filling (0.87), Qmean (0.74), and pulsatility index (0.65). Conclusions: DRI and diastolic filling had a reliable diagnostic ability for detecting ≥50% stenosis during coronary artery bypass grafting. In left anterior descending artery grafting, DRI had a more satisfactory detection capability than other TTFM metrics.

[UT modification of the "David-V" procedure].

Valve-sparing aortic root reimplantation with creation of pseudosinuses, so-called "David-V" procedure,is a promising surgical choice to treat annuloaortic ectasia (AAE). We have developed a simple modification of this procedure, which facilitates exposure and also enables good adjustment of the native aortic root anatomy and the graft. In this article we describe our original technique and its mid-term results.

Outcomes of abdominal aortic aneurysm repairs: Endovascular vs open surgical repairs.

BACKGROUND: Operative mortality after endovascular aneurysm repair (EVAR) has been reported as lower than open surgical repair (OSR) for abdominal aortic aneurysm (AAA) in randomized controlled trials. However, many cohort studies have demonstrated similar mortality rates for both procedures. We compared operative mortality between EVAR and OSR, at our institution. METHODS: All AAA operations from 2012 to 2017 were reviewed, and baseline characteristics were collected. Outcomes included 30-day mortality, operative data, complications, length of hospital stay (LOS), costs, re-intervention, and survival rates were compared. A multivariable analysis with unbalanced characteristics was performed. RESULTS: We had a total of 162 patients, 100 having OSR and 62 for EVAR. The EVAR group was older, with higher ASA classification. Thirty-day mortality rate did not significantly differ (0/100 for OSR and 2/62 (3%) for EVAR; p = 0.145), while the EVAR group had less blood loss, shorter operative times, and LOS, but higher re-intervention rates (adjusted hazard ratio 6.4 (95%CI: 1.4, 26.8)). Survival rates did not significantly differ between the groups. EVAR cost approximately 1-million yen more. CONCLUSIONS: OSR had low 30-day mortality rate in selected low-risk patients whereas EVAR had less blood loss, shorter operative times, LOS and could be done in high-risk patients with low 30-day mortality but with higher re-intervention rate.

Negative pressure wound therapy for left ventricular assist device-related mediastinitis: two case reports.

We report two cases of successful use of negative pressure wound therapy (NPWT) to control of left ventricular assist device (LVAD)-related mediastinitis. It is difficult to treat mediastinitis in patients who have undergone LVAD implantation, because it is impossible to remove the infected artificial materials from the mediastinal space. This report indicates that NPWT might become the preferred therapeutic option for control of mediastinitis in patients who have undergone LVAD implantation.

Repetitive aortic dissection in a patient with giant cell arteritis.

Giant cell arteritis is reportedly associated with thoracic aortic aneurysm and acute aortic dissection. We encountered a patient with giant cell arteritis who suffered acute aortic dissection three times within a short period. A pathological specimen of the ascending aorta taken at surgery for type A acute aortic dissection revealed the typical features of giant cell arteritis. Giant cell arteritis patients might be at greater risk of acute aortic dissection than healthy individuals.

Computational fluid dynamics simulations of flow distribution and graft designs in apicoaortic bypass.

OBJECTIVE: Apicoaortic bypass has double outlets and its graft design is similar to that of a left ventricular assist device (LVAD). The left ventricular apex to the descending aorta (LV-DsAo) bypass is widely used in apicoaortic bypass. In contrast, the left ventricular apex to the ascending aorta (LV-AsAo) bypass is standard in LVAD surgery. This study aimed to evaluate the graft designs of apicoaortic bypass and their effects on flow distribution and energy loss (EL). METHODS: A simulation study using computational fluid dynamics was performed on the geometry and hemodynamics data obtained from a 30-year-old patient who underwent a LV-DsAo bypass. The ratio of the cardiac output (CO) through the ascending aorta (AsAo) and apicoaortic conduit was set at 50:50, 30:70, and 10:90. Regional blood flow (RBF) and EL were calculated for the different distribution ratios. As an alternative to the LV-DsAo bypass, a virtual LV-AsAo bypass surgery was performed, and each parameter was compared with that of the LV-DsAo bypass. RESULTS: At a distribution ratio of 50:50, the RBF to the head and EL were 16.4% of the total CO and 62.0 mW in the LV-DsAo bypass, and 32.3% and 81.5 mW in the LV-AsAo bypass, respectively. The RBF to the head decreased with the CO through the AsAo in the LV-DsAo bypass, but it was constant in the LV-AsAo bypass. The EL increased inversely with the CO through the AsAo in both graft designs. CONCLUSION: The regional blood flow distribution was different, but the trend of the EL which increased inversely with the CO through the AsAo was similar between the LV-DsAo and LV-AsAo bypasses.

Characteristics of Inter-Arm Difference in Blood Pressure in Acute Aortic Dissection.

BACKGROUND: An inter-arm difference in blood pressure (IADBP) is characteristic of acute aortic dissection (AAD), but the importance of which arm exhibits lower blood pressure (BP) and the mechanism underlying IADBP are not well understood. METHODS: We identified consecutive patients with chest and/or back pain and suspected acute cardiovascular disease whose BP had been measured in both arms. We retrospectively compared the characteristics of such patients with AAD (n=93) to those without AAD (non-AAD group, n=122). Additionally, we separately compared patients with type A AAD (TAAD group, n=58) or type B AAD (TBAD group, n=35) to the non-AAD group. The characteristics analyzed were patient background and IADBP-related factors, including systolic BP (SBP) in the right arm (R) and left arm (L), and R-L or L-R as IADBP. Computed tomography (CT) findings of AD extending to the brachiocephalic artery (BCA) and/or left subclavian artery (LSCA) were examined in patients with an IADBP. RESULTS: In a comparison of the TAAD group and non-AAD group, the prevalences of R <130 mm Hg (38% vs. 19%, p=0.009), L-R >15 mm Hg (19% vs. 8%, p=0.047), L-R >20 mm Hg (14% vs. 4%, p=0.029) were higher in the TAAD group. Multivariate analysis showed that L-R >15 mm Hg with R <130 mm Hg was independently associated with TAAD (OR 25.97, 95% CI 2.45-275.67, p=0.007). However, IADBP-related factors were not associated with TBAD. AAD patients with L-R >20 mm Hg all had TAAD, and all aortic dissection extended to the BCA just before the right common carotid artery on CT. CONCLUSIONS: IADBP was characterized by R

Histological properties of oscillating intracardiac masses associated with cardiac implantable electric devices.

BACKGROUND: There have been a few cases of echogenic cardiac implantable electric device (CIED) lead-associated oscillating intracardiac masses (ICMs) in leads imaged by echocardiography. The histological properties of ICMs could help clarify the etiological diagnosis. Although there is extensive literature on mass size, the histological properties of such masses have not been characterized. The aim of this research was to clarify the histological features of oscillating ICMs in CIED patients. METHODS: Preoperative echocardiography was performed in all candidates for CIED removal. In the patients with ICMs, specimens were obtained by 3 methods: direct tissue collection during open-heart surgery; tissue collection together with the CIED lead during transvenous extraction; and tissue collection by catheter vacuum during transvenous CIED removal. A standard histopathological examination of ICM tissue was performed. RESULTS: A total of 106 patients underwent lead removal in our institute (April 2009-March 2018); 14 patients had an ICM (13.2%), and 7 specimens were obtained in patients with CIED lead-related ICM. Following histological examination, 2 types of ICM were identified: one mainly composed of thickened endocardium (EN type; 3 patients), and the other mainly an aggregate of inflammatory cells as a neutrophil cell (NC type; 4 patients). CONCLUSIONS: Two histological types of intracardiac masses, including a thickened endocardium type and a neutrophil cell type, were identified. These classifications might help make an accurate histological diagnosis of lead-associated intracardiac masses.

Surgical procedure for targeting arrhythmogenic substrates in the treatment of ventricular tachycardia associated with cardiac tumors.

BACKGROUND: Complete tumor resection is a standard strategy in the surgical treatment of ventricular tachycardia (VT) associated with cardiac tumors. Recently, an intraoperative electroanatomic mapping system (CARTO) has enabled surgeons to target the localized arrhythmogenic substrate for partial resection and/or cryoablation in nonresectable cardiac tumors. OBJECTIVE: The purpose of this study was to evaluate the surgical procedures and late outcomes of the treatment of VT associated with cardiac tumors. METHODS: We examined six patients (age 1-65 years) who had undergone surgical treatment of VT associated with cardiac tumors between 2010 and 2016. The 4 pathologies of the cardiac tumors were lipoma 2, fibroma 2, hemangioma 1, and lymphoma 1. Intraoperative epicardial mapping using CARTO was performed in 5 patients(80%). Surgical procedures and long-term outcomes were evaluated. RESULTS: Arrhythmogenic substrates with abnormal electrograms, such as fractionated or late potential, were identified locally or circumferentially beside the tumor in every patient. Complete tumor resection with cryoablation was performed in 3 patients. Two patients underwent partial tumor resection with cryoablation. Cryoablation without tumor resection was performed in 1 patient. No mortality and morbidity occurred. Additional catheter ablation was required in 2 patients to treat occurrence of nonclinical VT and induction of clinical VT during hospital stay. Mean follow-up time was 90 ± 52.5 months. There was no recurrence of clinical VT. CONCLUSION: The outcomes of surgical treatment of VT associated with cardiac tumors were excellent. Intraoperative CARTO mapping was beneficial to eliminate the VT substrates associated with nonresectable cardiac tumors.

Long-term outcomes of endovascular aortic aneurysm repair with the Zenith AAA endovascular graft: a single-center study.

PURPOSE: To present long-term results obtained with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) using the Zenith AAA endovascular graft from a single institution. MATERIALS AND METHODS: Between 2007 and 2013, 95 consecutive patients (median age 77 years) underwent EVAR using Zenith. Data were prospectively collected and retrospectively analyzed until 2019. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA-related death. Secondary outcomes were freedom from late (> 30 days) re-intervention and surgical conversion, and freedom from aneurysm sac growth (> 5 mm). RESULTS: The initial technical success rate was 96.8%. There were no deaths or intraoperative conversions. Overall survival at 1, 3, 5, and 10 years was 90.8%, 81.7%. 74.3%, and 57.2%, respectively. AAA rupture occurred in one patient (1.1%). Freedom from AAA-related death was 100% during the follow-up period. Freedom from aneurysm sac growth at 1, 3, 5, and 10 years was 98.8%, 86.4%, 76.9%, 53.0%, respectively. Freedom from late re-intervention and open surgical conversion at 1, 3, 5, and 10 years was 98.9%, 88.9%, 86.7, and 57.9%, respectively. CONCLUSION: EVAR with Zenith endografts represents a safe and durable means of AAA repair, and risk of rupture and aneurysm-related death are low.

[In situ replacement with cryopreserved homografts for infected aortic prostheses].

Although the incidence is rare, aortic prosthetic graft infection represents one of the most serious and challenging complications for cardiovascular surgeons. The basic strategy in the management of aortic graft infection consists of excision of the infected graft, debridement, reconstruction of the distal blood supply, and prolonged antibiotic therapy. As the most reliable procedure, in situ replacement with cryopreserved allografts has been used in our institution since 1998. The overall in-hospital mortality was 43%, higher than in other reports, because of a higher rate of thoracic cases and longer history before surgical intervention in previous reports. All but one survivor have been free from recurrent infection. In situ replacement with a cryopreserved allograft appears to be the best method, although an allograft is not an omnipotent material in patients with abscess formation. Preoperative drainage and irrigation, and allograft replacement with concomitant use of the omentum, would improve the outcome in the future.

Endovascular Treatment Strategy Using Catheter-Directed Thrombolysis, Percutaneous Aspiration Thromboembolectomy, and Angioplasty for Acute Upper Limb Ischemia.

PURPOSE: To evaluate the usefulness and safety of endovascular treatments for acute upper limb ischemia (AULI) by using multiple techniques, and to compare catheter-directed thrombolysis (CDT) and percutaneous aspiration thromboembolectomy (PAT) as initial procedures. MATERIALS AND METHODS: The study included 18 patients (4 men and 14 women) with AULI, who underwent a total of 20 sessions of endovascular treatment using various endovascular techniques between January 2005 and April 2016. The patients were initially treated with CDT [n = 9, CDT-based group (C-G)], PAT [n = 6, PAT-based group (P-G)], or angioplasty (n = 3). In case of residual emboli, we performed additional endovascular techniques. We assessed technical success, clinical success, and complications. Additionally, we compared the urokinase dosage between the groups. RESULTS: The mean patient age was 74.4 years. Technical and clinical success was obtained in all patients. Among the 18 patients, 1 underwent CDT only, 2 underwent PAT only, 1 underwent angioplasty only, and 14 underwent multiple techniques. Two patients from the C-G experienced major complications (cerebellar hemorrhage 1; pseudo-aneurysm in a branch of the ulnar artery 1). The mean urokinase dosage was lower in the P-G than in the C-G (40,000 vs. 246,667 IU; Mann-Whitney U test, P = 0.004). CONCLUSION: Endovascular treatment is effective and safe for AULI. A combination of multiple endovascular techniques is important for successful treatment. PAT is suggested as an initial procedure among endovascular techniques, in terms of a lower dosage of urokinase and a lower complication rate. LEVEL OF EVIDENCE: IV, Case-control studies.