[Efficacy of Distal Perfusion During Frozen Elephant Trunk Procedure:Continuous Perfusion Versus Intermittent Perfusion].

PURPOSE: To compare the effectiveness of continuous distal perfusion( CDP) with that of intermittent distal perfusion( IDP) during frozen elephant trunk( FET) procedures. METHODS: There were 54 patients in the CDP group and 15 patients in the IDP group. There were no significant differences in preoperative characteristics between the two groups, but dissection was more common in the IDP group than in the CDP group, and the maximum aneurysmal diameter was larger in the CDP group than in the IDP group. RESULTS: Emergency surgery was significantly more common in the IDP group than in the CDP group. Operating time, cardiopulmonary bypass time, lower body arrest time, and aortic cross-clamp time were significantly longer in the IDP group. Postoperative paraparesis occurred in one case in each group, and temporary paraparesis occurred in two cases in the CDP group, with no significant differences, including in mechanical ventilation time. There were two in-hospital deaths, one due to respiratory failure and one due to ischemic colitis, in the CDP group and one due to multiple organ failure in the IDP group. Postoperative liver and renal functions did not differ significantly between the two groups. CONCLUSION: IDP has proven to be almost as effective as CDP during FET for preventing spinal cord ischemia and maintaining respiratory, liver, and renal functions.

A rare case of an expanded perigraft seroma with heart failure after thoracic aortic surgery.

Perigraft seroma (PS) is an occasional complication of abdominal and femoral aortic graft implantation. We report a rare case with heart failure due to expanded PS compressing the right atrium 5 years after ascending aorta replacement for an acute type A aortic dissection. The PS was drained and sealed with biological tissue adhesive and wrapped using bovine xenopericardial sheet. We believe that mild hemorrhage through a vascular graft caused the expanded PS. Furthermore, wrapping vascular grafts using bovine xenopericardial sheet after sealing with biological tissue adhesive was effective for PS, particularly in cases in which it is impossible to use greater omentum. Learning objective: Cases of perigraft seroma (PS) after thoracic aortic repair have rarely been reported. The mechanism, indications, and treatments are unclear. We report a case of heart failure caused by expanded PS due to a small hemorrhage through a vascular graft. Furthermore, wrapping vascular grafts using bovine xenopericardial sheet after sealing with biological tissue adhesive may be effective for PS, particularly in cases where it is impossible to use the greater omentum.

[Initial and Long-term Results of Omental Flap Coverage for the Complications after Thoracic Aortic Aneurysm Repair].

OBJECTIVE: Here, we will review the initial remote results of omental flap coverage (OFC) after thoracic aortic aneurysm repair and report on its efficacy and problems. METHODS: We performed 567 thoracic aortic aneurysm surgeries from January 2007 to December 2021, including OFC in 16 patients( 2.8%, 10 males, mean age 65 years:range 30-82 years) who underwent OFC. RESULTS: OFC was performed in 14 cases of mediastinitis and 2 cases of perigraft seroma. 13 cases were performed at the same admission as the initial surgery, and 3 cases were performed after the discharge. The causative organisms of mediastinitis were methicillin-resistant Staphylococcus aureus (MRSA) in 4 cases, methicillin-resistant coagulase negative Staphylococcus( MRCNS) in 2 cases, Staphylococcus, Acinetobacter, Klebsiella, and methicillin-resistant Staphylococcus epidermidis( MRSE) in 1 case each, and unknown in 4 cases. All cases underwent successful reoperation with OFC alone, except in 1 case in which redo root replacement was performed for an anastomotic pseudoaneurysm. The overall hospital mortality was 31% (4 cases for MOF, 1 case for anastomotic hemorrhage). Of the 11 patients who were discharged alive, two died remotely (heart failure, senility), and no cases of reinfection were encountered. CONCLUSION: OFC is an effective treatment not only for mediastinitis but also for perigraft seroma while significantly reducing the risk of reinfection.

Prediction Models for Two Year Overall Survival and Amputation Free Survival After Revascularisation for Chronic Limb Threatening Ischaemia.

OBJECTIVE: The aim of this study was to create prediction models for two year overall survival (OS) and amputation free survival (AFS) after revascularisation in patients with chronic limb threatening ischaemia (CLTI). METHODS: This was a retrospective analysis of prospectively collected multicentre registry data (JAPAN Critical Limb Ischaemia Database; JCLIMB). Data from 3 505 unique patients with CLTI who had undergone revascularisation from 2013 to 2017 were extracted from the JCLIMB for the analysis. The cohort was randomly divided into development (2 861 patients) and validation cohorts (644 patients). In the development cohort, multivariable risk models were constructed to predict two year OS and AFS using Cox proportional hazard regression analysis. These models were applied to the validation cohort and their performances were evaluated using Harrell's C index and calibration plots. RESULTS: Kaplan-Meier estimates of two year OS and AFS post-revascularisation in the whole cohort were 69% and 62%, respectively. Strong predictors for OS consisted of age, activity, malignant neoplasm, chronic kidney disease (CKD), congestive heart failure (CHF), geriatric nutritional risk index (GNRI), and sex. Strong predictors for AFS included age, activity, malignant neoplasm, CKD, CHF, GNRI, body temperature, white blood cells, urgent revascularisation procedure, and sex. Prediction models for two year OS and AFS showed good discrimination with Harrell's C indexes of 0.73 (95% confidence interval [CI] 0.69 - 0.77) and 0.72 (95% CI 0.68 - 0.76), respectively CONCLUSION: Prediction models for two year OS and AFS post-revascularisation in patients with CLTI were created. They can assist in determining treatment strategies and serve as risk adjustment modalities for quality benchmarking for revascularisation in patients with CLTI at each facility.

[The Examination of Spring Back Force in Frozen Elephant Trunk;Matsui-Kitamura Stent versus J Graft Open Stent Graft].

OBJECTIVES: We examined the spring back force (SBF) in the frozen elephant trunk technique between patients receiving a Matsui-Kitamura stent (M group) or a J Graft Open Stent Graft (J group). METHODS: There were 11 cases in the M group and 10 cases in the J group. For all cases, we performed computed tomography( CT) scan and measured distal arch angle( DAA) and stent graft angle (SGA). RESULTS: There was no difference between groups with regards to patient characteristics. The insertion graft length[155±19 mm (M group) versus 138±17 mm (J group)]was significantly longer in the M group( p<0.05). In the J group, the SGA at 1 and 2 years postoperatively( 105°±18.5° and 114°±19.1°, respectively) were significantly increased compared to that at 1 month postoperatively (99.9°± 18.7°). In addition, the SGA in the J group was significantly larger than that in the M group during the postoperative period. CONCLUSIONS: The SBF in the J group was thought to be significantly larger than that in the M group. SBF was thought to be associated with the stent frame characteristic.

Preemptive angioplasty for contralateral leg stenosis following EXCLUDER Iliac Branch Endoprosthesis implantation.

The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE) device is designed to seal off a common iliac artery (CIA) aneurysm, preserving the internal iliac artery during endovascular aortic repair. We report the case of an 84-year-old man with isolated saccular right CIA aneurysm (35 mm) and a relatively small terminal aorta (24 mm). The IBE device was successfully placed, and intraoperative angiography revealed no leakage or delay. However, postoperative computed tomography revealed marked compression of the contralateral leg by a bridging component. Although his ankle-brachial index was preserved, its acute occlusion was judged highly possible; we decided to perform preemptive angioplasty. The angiography revealed the stenosis only in the left anterior oblique view, and angioplasty was uneventfully performed. The leg was successfully patent at 1-year follow-up. When compression by IBE and bridging component in the terminal aorta is expected, caution should be preserved at intraoperative angiography following the device deployment.

Rapidly Progressed Distal Arch Aneurysm with Distal Open Stent Graft-Induced New Entry Caused by "Spring-Back" Force.

The J Graft Open Stent Graft (JOSG) is used for the frozen elephant trunk procedure in Japan. We report a 70-year-old male who developed a rapidly progressing distal arch aneurysm caused by a distal stent graft-induced new entry (DSINE) 7 months after the procedure. The JOSG was originally implanted at the curved part of the distal arch. It created its initial DSINE on the greater curve and rapidly "sprang" back in 2 months. Urgent thoracic endovascular aortic repair fixed this serious complication. We should remember such rapid progression of DSINE by JOSG and treat its initial sign earlier.

[Constrictive Pericarditis with Intractable Ascites after Aortic Valve Replacement;Report of a Case].

We report a 68-year-old man, who developed refractory ascites of unknown cause after aortic valve replacement. He was diagnosed with constrictive pericarditis because of "dip-and-plateau" waveform findings via cardiac catheterization and operated with cardiopulmonary bypass. Following waffle procedure, we incised pericardium for decompression, so that pericardial mobility and diastolic dysfunction was improved. Postoperative computed tomography (CT) image also showed decrease of ascites fluid. We concluded that pericardiotomy is an established surgical procedure and is excellent indication to constrictive pericarditis.

What Did Endovascular Aortic Repair Bring for the Treatment Strategy of Abdominal Aortic Aneurysm?

Objective: We examined the effects of the introduction of endovascular aortic repair (EVAR) on treatment for abdominal aortic aneurysms (AAAs). Subjects: We compared patients in the following three periods: period I (January 2002-December 2006, 105 patients), period II (January 2007-December 2011, 242 patients, duration of 5 years after the introduction of EVAR), and period III (January 2012-December 2016, 237 patients, duration of 5 years after period II). We used the American Society of Anesthesiologists (ASA) classification for risk assessment. Results: In the Open repair (OR) group, the incidences of ASA class 2 increased and classes 3 and 4 decreased significantly in periods II and III compared with period I. In all periods, there were no in-hospital deaths. Suprarenal aortic cross-clamping was required in 18 patients (19.1%) in period III and 5 patients (6.3) in period I, and the difference was significant (P<0.05). In the EVAR group, no differences in age, sex, or ASA classification class were observed between periods II and III. In period II, one patient died due to aneurysm rupture during surgery. Significant differences were observed when comparing both groups in periods II and III: patients in the EVAR group were older (P<0.01) and the OR group had a higher proportion of ASA class 2 patients and the EVAR group had a higher proportion of ASA class 3 or 4 patients (P<0.01). Among all AAA surgeries, rupture occurred in 25 patients (23.8%) in period I, 18 patients (7.4) in period II, and 16 patients (6.8) in period III. The number of ruptures was significantly lower in periods II and III than in period I (P<0.01). Conclusions: The findings of this study suggest that EVAR should be indicated for high-risk patients and had the good outcome of AAA treatment. (This is a translation of Jpn J Vasc Surg 2018; 27: 27-32.).

[Emergent Thoracic Endovascular Aortic Repair and Subxiphoid Pericardiotomy for Retrograde Type A Acute Aortic Dissection with Cardiac Tamponade;Report of a Case].

Type A acute aortic dissection has a high rate of mortality. Emergent surgical repair is the gold standard treatment, but some patients cannot tolerate the open surgery. Here, we report an 82-year-old patient with a history of cerebral infarction and cerebral bleeding who presented with a depressed level of consciousness and who was in a state of shock. A computed tomography (CT) scan showed cardiac tamponade associated with retrograde type A aortic dissection(RAAD), with a primary entry tear at a distal site of the left subclavian artery. We therefore performed emergent primary entry closure with stent grafting using the Conformable Gore Tag device and emergent drainage of the cardiac tamponade with subxiphoid pericardiotomy. Postoperative CT scan showed complete closure of the primary entry tear and a completely thrombosed false lumen. Primary entry closure with stent grafting could be an effective option for RAAD that meets anatomical criteria.

[Marked Aneurysmal Expansion Caused by Type II Endoleaks Eight Years after Thoracic Endovascular Aortic Repair;Report of a Case].

We report a case of marked aneurysmal expansion by type II endoleaks 8 years after thoracic endovascular aortic repair. The preoperative chest computed tomography (CT) demonstrated the descending thoracic aorta of 95 mm with type II endoleak. We performed suture closure of 3 endoleaks and partial aneurysmorrhaphy via left thoracotomy under partial cardiopulmonary bypass. The postoperative CT showed no endoleak with shrinkage of the aneurysm. The patient was discharged on the 21th postoperative day uneventfully.

[Efficacy of Total Debranching Thoracic Endovascular Aortic Repair for the Re-operation of Aortic Arch Aneurysm].

Thoracic endovascular aortic repair (TEVAR) combined with all-neck-branch reconstruction (total debranching TEVAR)[td TEVAR] is applied to aortic arch aneurysms as a minimally invasive procedure to improve treatment results. We report the initial and long-term results of td TEVAR for the reoperation of aortic arch aneurysm. By September 2016, td TEVAR for reoperation had been applied in 5 cases. The reasons for the reoperation were dilation of the arch aneurysm after ascending aorta replacement in 4 cases and localized dissection of the proximal landing zone after zone 2 TEVAR in 1 case. We reconstructed the neck branches under cardiopulmonary bypass (CPB). At that time, we kept in mind to perform anastomosis with an artificial graft at just above the sinus of Valsalva by using a single aortic clamp. Both the 30-day operative mortality and CPB-related complication rates were 0%. One patient had paraparesis, and one had left upper limb ischemia. Our strategy of td TEVAR provided durable results in the patients who underwent reoperation for aortic arch aneurysms.

[Strategy of Thoracic Endovascular Aortic Repair for Uncomplicated Type B Aortic Dissection in Subacute and Chronic Phase;Interval From Onset and Maximum Diameter].

We classified 59 patients who underwent thoracic endovascular aortic repair for uncomplicated type B aortic dissection from April 2008 to April 2016 into 3 groups based on time from onset and maximum aortic diameter:SA (2weeks to 1 year since onset;n=29), C (>1 year since onset;n=17), and D(maximum aneurysm size≥60 mm;n=13). We used the Kaplan-Meier method tso analyze survival, major adverse cardiovascular event and the need for additional treatment. There was no significant difference in outcomes between the SA and C groups (p=0.998) or C and D groups (p=0.279), but the results in group D tended to be consistently inferior. The freedom from aneurysm rupture rate was inferior in this group, with a significant difference between groups C and D (p=0.044). The time from onset to the procedure and maximum aortic diameter were not significantly associated with the longterm outcomes;however, more aortic ruptures occurred in the group with maximum aortic diameter≥60 mm. Simultaneous treatment for re-entry closure or conventional surgical procedures should be considered for such cases.

[Clinical Results of Thoracic Endovascular Aortic Repair (TEVAR) for the Treatment of Aortic Arch Aneruysm].

Thoracic endovascular aortic repair( TEVAR) combined of neck branch reconstruction( debranching TEVAR:dTEVAR) is applied to aortic arch aneurysm for minimally invasive reduction and improvement of treatment results. We report the initial and long-term results of dTEVAR for the treatment of aortic arch aneurysm. TEVAR for zone 0-2 area was applied in 49 cases (Zone 0:1:2;8:5:36 cases). Total dTEVAR was applied in zone 1 cases and 2 dTEVAR was performed in zone 2 cases. One dTEVAR or TEVAR with simple coverage of left subclavian artery was applied in zone 2 cases. Operative mortality within 30 days was 0% and there was 1 case in hospital death due to coronary arterial rupture after percutaneous coronary intervention. Perioperative morbidity included 1 case(2.0%) spinal cord ischemia, 4( 8.2%)arm claudication. In long-term follow-up, 5 cases died during the observation period (stroke in 1 case, heart failure in 1, neoplasma in 2, unknown in 1), but not in aortic rupture. Secondary type1 endoleak occurred in 2 cases(4.1%). Graft occlusion for neck branch reconstruction was complicated with 3 cases(6.1%), however no complications related to the graft occlusion. Our strategy of TEVAR provided durable results in patients treated for aortic arch aneurysm, with few adverse events.

Long-term results of open stent-grafting using a Matsui-Kitamura stent to treat thoracic aortic aneurysm.

PURPOSE: We describe a retrospective study of initial and long-term outcomes with an open stent grafting (OSG) with a Matsui-Kitamura stent for treating thoracic aortic aneurysm. METHODS: Between August 2005 and September 2013, 50 patients with aortic arch disease extending to the descending aorta underwent OSG. Circulatory arrest with total cardiopulmonary bypass and selective cerebral perfusion were used, and the aorta was transected between the brachiocephalic and left subclavian artery. The stent-graft was inserted, sutured to a transected aortic edge, and anastomosed to a four-branched arch graft. Preoperative, operative, and short- and long-term postoperative data were obtained from the patients' medical records. RESULTS: The perioperative (within 30 days) mortality rate was 8%. Two patients (4%) had a stroke and 5 patients (10%) had a spinal cord injury resulting in paraplegia or paraparesis (1 patient each) or transient paraplegia (3 patients). Actuarial survival rates at 1, 3, 5, and 7 years postoperatively were 87.8%, 78.3%, 70.7%, and 65.3%, respectively; the rates of freedom from an aortic event were 100%, 89.1%, 82.2%, and 74.7%. There were no complications related to use of the stent-graft. CONCLUSION: Our OSG method provided durable results in patients treated for thoracic aortic aneurysm, with few adverse events.

Management strategy of isolated spontaneous dissection of the superior mesenteric artery.

OBJECTIVE: Isolated spontaneous dissection of the superior mesenteric artery (SMA) is very rare among of the visceral artery dissection and its treatment is not established. In this paper we present our experiences and consider the treatment of isolated SMA dissection. METHODS: A retrospective review of our cases from 2005 was performed. Clinical symptoms, radiologic findings and results were evaluated. There were 14 cases of visceral artery dissection, in which all cases were with SMA dissection. There were 12 males and 2 females with a mean age of 57 years (range 41-78 years). RESULTS: We categorized SMA dissection into the six types according to the Sakamoto's and Zerbib's classification. One patient with type VI underwent emergent endovascular surgery with stent. One patient with type VI received thrombectomy and intimectomy with open surgery. One patient with type II underwent aneurysmectomy due to enlarged dissected SMA 3 months later from onset. The other eleven patients were managed conservatively. At follow-up, the diameter of SMA did not enlarged and the length of the dissection significantly decreased to 20.7 ± 15.7 mm from 38.0 ± 15.1 mm at onset (p <0.01). After treatment, imaging indicated the following changes in classification: type I, one patient; type II, 4 patients; type IV, 4 patients; complete remodeling, one patient, all without any event during the follow-up period of 5-82 months. CONCLUSION: Most patients with isolated visceral artery dissection occurred in superior mesenteric artery and can be treated conservatively; however, endovascular or surgical procedures including laparotomy are indicated when there is suspicion of severe mesenteric ischemia. Because the dissection configuration will change, long term follow-up is necessary. (English translation of Jpn J Vasc Surg 2013; 22: 695-701).

[Long-term results of open stent-grafting applied with a Matsui-Kitamura( MK) stent in treatment of arch aneurysm].

We report the initial and long-term 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 2013, OSG for TAA was applied in 46 cases( male/female, 36/10, 54-86 years old, mean age 71). During deep hypothermic circulatory arrest with antegrade selective cerebral perfusion, stent graft was delivered through the transected proximal aortic arch, followed by arch replacement with a 4-branched prosthesis. Operative mortality within 30 days was 6.5%(respiratory failure in 1, multiple organ failure in 1and ischemic enteritis in 1) and there was 1 in hospital death due to brain stem infarction. Perioperative morbidity included 2( 4.3%) stroke, 5( 10.9%) spinal cord injuries( paraplegia in 1, paraparesis in 1 and transient paraparesis in 3). In long-term follow-up, survival was 86.8%, 77.2%, and 72.0% for 1, 3 and 5 years. Freedom from aortic event was 97.3%, 93.8% and 89.1% for 1, 3 and 5 years. Theseresults suggested the OSG method applied with a MK stent is a useful surgical procedure for the treatment of TAA.

Four-dimensional geometric assessment of tricuspid annulus movement in early functional tricuspid regurgitation patients indicates decreased longitudinal flexibility.

OBJECTIVES: Functional tricuspid regurgitation (FTR) is generally caused by the dilation of the tricuspid annulus (TA) and the tethering of tricuspid leaflets; however, it also occurs in patients without dilatation of the TA. The aim of this study was to develop and to use a four-dimensional tracking system, utilizing cardiac magnetic resonance imaging (MRI), and to assess TA flexibility in patients with early FTR without right ventricle dilation as a preliminary investigation for the mechanism of early FTR. METHODS: The structure and movement of the TA were examined in 20 healthy subjects and 19 FTR patients whose right ventricle was not dilated. We analysed the short axis and longitudinal movement of a mid-septal point (S), a mid-lateral point (L), a mid-anterior point (A) and a mid-posterior point (P) on the TA throughout the cardiac cycle. The tethering distance of the tricuspid leaflets and the integrated orbiting volume of the TA were also measured. RESULTS: The TA area (mm(2)) and AP and LS distances (mm) did not differ significantly between the two groups, but the longitudinally moving distances (mm) of the four points were significantly shorter in patients with FTR than in healthy subjects. Also, the mean tethering distance (mm) was significantly longer in patients with FTR than in healthy subjects (9.0 ± 1.5 vs 4.0 ± 1.3, respectively; P < 0.001), and the integrated volume (mm(3)) of the annular moving track, throughout the cardiac cycle, was significantly larger in healthy subjects than in patients with FTR (40 428 ± 10 951 vs 22 967 ± 6079, P < 0.001). CONCLUSIONS: The longitudinal flexibility of the TA in FTR patients was significantly less than that in the healthy subjects, and the tethering of the tricuspid leaflets occurred in FTR patients despite the absence of TA and RV dilation, which can be one triggering factor of early FTR. Four-dimensional geometric assessment, using cardiac MRI and the tracking program that we have developed, is capable of determining TA structure and flexibility.