Association of simple renal cysts to aneurysm sac shrinkage in true thoracic aortic aneurysms after thoracic endovascular aortic repair.

BACKGROUND: An increased prevalence of thoracic aortic aneurysms (TAA) has been demonstrated in patients with simple renal cysts (SRC); patients with SRC have a less elastic aortic wall than those without SRC. The purpose of this study was to evaluate aneurysm sac shrinkage after thoracic endovascular aortic repair (TEVAR) for true TAA in patients with and without SRC. METHODS: One hundred three patients with true aneurysms of the thoracic aorta who underwent TEVAR at our university hospital from November 2013 to December 2021 were included in this study. Aneurysm sac size was compared between that on baseline preoperative computed tomography and that on postoperative computed tomography scans at 1 year. A change in aneurysm sac size ≥5 mm was considered to be significant, whether due to expansion or shrinkage. RESULTS: The patients were divided into two groups: those with SRC (46 patients [45%]) and those without SRC (57 patients [55%]). At 1 year, there was a significant difference in the proportion of aneurysm sac shrinkage between patients with SRC and those without SRC (23.9% vs 59.6%; P < .001). Patients with SRC showed significantly less aneurysm sac shrinkage than those without SRC (-1.8 ± 5.6 mm vs -5.1 ± 6.6 mm; P = .009). Univariable and multivariable analyses showed that the initial sac diameter (odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P = .002) and the presence of SRC (odds ratio, 0.15; 95% confidence interval, 0.06-0.40; P < .001) were positively and negatively associated with aneurysm sac shrinkage after TEVAR, respectively. CONCLUSIONS: The presence of a SRC was independently associated with failure of aneurysm sac shrinkage after TEVAR for true TAA. This suggests that the presence of a SRC may be a predictor for the failure of aneurysm sac shrinkage after TEVAR.

Relationship between the aortic root Z-score and degree of translamellar mucoid extracellular matrix accumulation.

PURPOSES: A retrospective analysis was performed to compare the pathological findings and aortic root Z-score in patients with and without connective tissue disease (CTD). METHODS: Twenty-two patients {47.5 [15-85] years old, 18 males} underwent surgery for aortic root dilatation without aortic dissection: 10 {40 [16-59] years old} with CTD and 12 {57.5 [15-85] years old} without CTD (non-CTD; p = 0.049). Systemic hypertension (p = 0.043) and the degree of preoperative aortic regurgitation (p = 0.017) were higher in the non-CTD patients than in the CTD patients. RESULTS: The diameters of the sinotubular junction (STJ) (p = 0.048) and ascending aorta (Asc.Ao.) (p = 0.020) and the Z-scores of the STJ (p = 0.027) and Asc.Ao. (p = 0.009) were significantly higher in the non-CTD patients than in the CTD patients. The degree of translamellar mucoid extracellular matrix accumulation (T-MEMA) of the Asc.Ao. was significantly higher in the non-CTD patients than in the CTD patients (p = 0.037) and was significantly correlated with the Z-scores of the aorta (R = 0.746, p < 0.01 in the sinus of Valsalva and R = 0.382, p = 0.031 in the Asc.Ao.), although there was no significant correlation between the diameter of the STJ and that of Asc.Ao. CONCLUSIONS: In non-CTD patients, not only the aortic root but also Asc.Ao. tended to dilate with age, and a significant correlation between the Z-scores of the aorta root and the Asc.Ao. and the degrees of T-MEMA was observed.

Inter-operative determination of the aortic root and cusp geometry associated with the aortic regurgitation grade.

PURPOSES: To perform successful aortic valve plasty (AVP) and valve-sparing root replacement (VSRR), a sufficient understanding of the aortic root and cusp geometry is required. Several key parameters of the aortic root and cusp geometry were, therefore, measured intraoperatively. METHODS: Forty-nine patients (63.1 ± 16.6 y.o., 40 males) were measured during the surgeries. The patients were divided into 3 groups; including patients with no or mild aortic valve regurgitation (AR) (n = 13), moderate AR (n = 18), and severe AR (n = 18). RESULTS: There were no significant differences in the body surface area (1.72 ± 0.19 m2) among the 3 groups (p = 0.858). The effective height (EH) and geometric height (GH) of right coronary cusp were smaller than those of the others (EH: p = 0.068, GH: p < 0.01). The insertion line length (ILL) and free margin length (FML) of each leaflet tended to be significantly longer according to the AR grade(ILL: p < 0.01, FML: p < 0.01). The FML/AVJ ratios were significantly different (p < 0.01). The FML/ILL ratios were constant with the ratio of 0.88 ± 0.1(p = 0.624). CONCLUSIONS: Although the ILL and FML tended to increase with the AR grade, the FML/ILL ratio remained constant. For successful AVP and VSRR, adequately maintaining the FML/ILL ratio is necessary to prevent remarkable cusp prolapse while also preserving its favorable cusp motion.

Simple renal cyst and its association with sac shrinkage after endovascular aneurysm repair for abdominal aortic aneurysms.

OBJECTIVE: Patients with abdominal aortic aneurysm (AAA) frequently have simple renal cyst (SRC), a common manifestation of connective tissue degeneration. This study aimed to determine whether SRC is a risk factor for failure of sac shrinkage after endovascular aneurysm repair (EVAR). METHODS: Between October 2013 and May 2017, there were 155 consecutive patients with an infrarenal AAA or a common iliac artery aneurysm who underwent EVAR with the GORE C3 Excluder (W. L. Gore & Associates, Flagstaff, Ariz) at Tokyo Medical University Hospital. All these patients were registered in a prospectively maintained database. Any kidney lesion >5 mm in diameter, with no evidence of contrast enhancement or septation and with low attenuation, was defined as SRC. A change in sac size of >5 mm from baseline was considered significant. The patients were divided into those with SRC and those without SRC, and sac shrinkage at 1 year and 2 years was compared. The presence of SRC was assessed with respect to being a risk factor for failure of sac shrinkage at 1 year using univariate and multivariable logistic regression analysis. RESULTS: The patients were divided into two groups: those with SRC (92 patients [59.0%]) and those without SRC (63 patients [41.0%]). At 1 year and 2 years, significant differences were observed in the proportion of sac shrinkage between patients with SRC and those without SRC (19.2% vs 42.4% [P = .003] and 19.6% vs 53.3% [P = .001], respectively). Patients with SRC showed significantly less sac shrinkage than those without SRC at 1 year and 2 years (-2.0 ± 5.5 mm vs -4.4 ± 6.2 mm [P = .002] and -1.8 ± 6.3 mm vs -6.4 ± 8.6 mm [P = .005], respectively). Multivariable analysis demonstrated that SRC (odds ratio, 0.28; 95% confidence interval, 0.12-0.63; P = .002) and initial sac size (odds ratio, 1.05; 95% confidence interval, 1.01-1.09; P = .027) were positive and negative risk factors for sac shrinkage, respectively. CONCLUSIONS: The presence of SRC is a risk factor for failure of sac shrinkage after EVAR. This suggests that AAA in patients with SRC has a more degenerated wall than in those without SRC. The property of the aneurysm wall may be associated with sac shrinkage after EVAR.

Clinical and Morphological Outcomes in Endovascular Aortic Repair of Abdominal Aortic Aneurysm Using GORE C3 EXCLUDER: Comparison between Patients Treated within and Outside Instructions for Use.

BACKGROUND: The goals of this study were to evaluate mid-term outcome in endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) using a GORE C3 EXCLUDER and compare results between patients treated within and outside the instructions for use (IFU). METHODS: Over a 3-year period spanning October 2013 to September 2016, consecutive patients undergoing EVAR for AAA using the C3 EXCLUDER at Tokyo Medical University Hospital were registered on a prospectively maintained database. The data thus obtained were retrospectively analyzed. RESULTS: A total of 109 AAA patients underwent EVAR using the C3 EXCLUDER. The median follow-up duration was 729 days (interquartile range, 542-1,069 days). Technical success was achieved in 98.2% of cases. Adjunctive, unplanned proximal cuff-extender implantation was required in 8 patients (9.2%). Of the total number, 29 (24.8%) were categorized as being treated outside the IFU. No significant difference was observed in freedom from overall mortality or aneurysm-related mortality between patients treated within and outside the IFU. Freedom from reintervention tended to be lower in patients treated outside the IFU. There was aneurysm sac shrinkage (≥5 mm) in 30.3% and 39.1%; stable aneurysm sac in 69.7% and 56.3%; and aneurysm sac expansion (≥5 mm) in 0% and 4.7% of cases at 1 and 2 years, respectively. No significant difference was observed in aneurysm sac shrinkage between patients treated within and outside the IFU. CONCLUSIONS: The C3 EXCLUDER showed good clinical performance and aneurysm sac shrinkage, regardless of whether the patient was treated within or outside the IFU. The results suggest, however, that in those treated outside the IFU, precise planning, careful operative procedure, and subsequent follow-up are required to obtain short-term and mid- to long-term success in EVAR for AAA using the C3 EXCLUDER.

Extracorporeal membrane oxygenation after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension.

BACKGROUND: Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH) but can result in respiratory and cardiac complications that may require extracorporeal membrane oxygenation (ECMO). We reviewed our experience with ECMO in patients undergoing PEA. METHODS AND RESULTS: Between January 2012 and August 2015, 35 patients underwent PEA for CTEPH. In all, four patients (11%) required veno-arterial (V-A) ECMO support due to severe cardiac and respiratory failure, including severe reperfusion pulmonary edema and persistent pulmonary hypertension. No significant differences in preoperative characteristics were found between patients who required ECMO and those who did not require ECMO. ECMO support was associated with a significantly higher incidence of postoperative respiratory complications, a longer intensive care unit stay, increased in-hospital mortality, residual pulmonary hypertension, and postoperative balloon pulmonary angioplasty (BPA). The postoperative mean pulmonary artery pressure and pulmonary vascular resistance were significantly higher in patients requiring ECMO. All patients requiring ECMO were successfully weaned off ECMO support (100%), and three of them were discharged from the hospital alive (75%). CONCLUSIONS: Patients with CTEPH may benefit from ECMO after PEA for cardiac and respiratory complications. A prompt decision to use V-A ECMO is critical for a successful outcome in these patients.

Early clinical outcomes of right ventricular outflow tract reconstruction with small caliber bovine jugular vein conduit (Contegra®) in small children.

This study reviewed early clinical outcomes of right ventricular outflow tract reconstruction with Contegra® valved conduits in pediatric patients. Between April 2013 and July 2014, thirteen pediatric patients underwent right ventricular outflow tract reconstruction with Contegra valved conduits. The size of the implanted conduits were 12 mm in 5 patients, 14 mm in 3, 16 mm in 3, and then 2 patients were implanted with bicuspidized conduits for downsizing the conduit to 9 and 10 mm in each. Follow-ups were completed in all patients. One conduit was explanted 7 days after a neonatal biventricular repair for Ebstein's anomaly and pulmonary atresia, timed to be at the point of conversion to a single ventricular palliation. Among the 5 patients who developed significant pulmonary insufficiency and/or conduit stenosis, 3 patients exhibited persistent pulmonary hypertension. Both the bicuspidized conduits resulted in early pulmonary insufficiency. One patient implanted with a ring-supported conduit developed coronary artery stenosis, caused by suppression between the ring of the implanted conduit and the annulus of the mechanical vale. Although the small caliber Contegra valved conduit might be an alternative to RVOT reconstruction, the indication should be carefully considered. More than mild pulmonary hypertension, and low body weight at operation of less than 3.0 kg caused early conduit dysfunction.

The Role of Common Femoral Artery Endarterectomy in the Endovascular Era.

BACKGROUND: The purpose of this study was to review our experiences treating peripheral artery disease (PAD) by common femoral artery endarterectomy (CFE) with and without endovascular therapy (EVT), and to describe the role of CFE in the endovascular era. METHODS: We retrospectively reviewed a contemporary series of 38 limbs from January 2010 to September 2014. Clinical outcomes of primary patency, assisted primary patency, limb salvage, and survival were analyzed with the Kaplan-Meier method. Multivariable perioperative predictors of primary patency were identified using the stepwise Cox proportional hazards regression model. RESULTS: Hemodynamic success was achieved in 36 of the 38 limbs (95%). The mean ankle brachial pressure index improved significantly, rising from 0.56 ± 0.04 preoperatively to 0.89 ± 0.04 postoperatively (P = 0.0001). Overall primary and assisted primary patency rates, respectively, were 90% and 100% at 12 months and 85% and 94% at 24 months. There was no significant difference in primary patency rate between isolated CFE and hybrid CFE plus EVT. Both limb salvage and survival rates were 97% at 12 months and 97% at 24 months. Multivariate Cox regression analysis revealed that no clinical or perioperative risk factors were predictive of decreased primary patency. CONCLUSIONS: CFE is a safe, effective, and durable procedure for common femoral artery disease, and hybrid CFE plus EVT can be a valid alternative to open surgical bypass for multilevel occlusive artery disease. These observations stress that CFE plays a vital role in the management of PAD even in the endovascular era.

The application of all-autologous three-sinus repair for supravalvular pulmonary stenosis.

Various surgical techniques have been proposed for the repair of supravalvular pulmonary stenosis (SVPS) in pediatric populations. Whereas growth potential should be promised, excessive expansion under the presence of undiminished high pulmonary arterial pressure should be avoided. The authors applied all-autologous three-sinus repair, the so-called modified Brom or Myers technique, to SVPS and examined the midterm outcomes. Between March 2010 and March 2012, 15 patients (8 boys) with a median age of 12 months who had SVPS underwent all-autologous three-sinus repair. Of the 15 patients, 13 (87 %) had previously undergone pulmonary artery (PA) banding for treatment of high pulmonary vascular resistance. Two patients (13 %) had Noonan syndrome. A follow-up evaluation was completed for all the patients, and the median follow-up period was 13.5 months (range, 1 month to 2.4 years). No mortalities occurred. The diameter of the stenotic part at the main PA increased from 47.0 ± 14.1 % (range 29.1-70.0 %) of the normal PA diameter at the preoperative evaluation to 108.9 ± 25.7 % (range 58.9-148.1 %) at 6 months, and then to 104.7 ± 11.4 % (range 87.7-134.1 %) 1 year after the operation. The estimated mean pressure gradient across the main PA decreased from 76.2 ± 12.2 mmHg (range 57.8-108.2 mmHg) at the preoperative evaluation to 11.3 ± 12.0 mmHg (range 1.4-49.0 mmHg) at 6 months, and then to 6.4 ± 5.5 mmHg (range 2.0-19.4 mmHg) 1 year after the operation. No patients showed moderate or greater pulmonary insufficiency. The midterm outcomes after supravalvular pulmonary stenosis by all-autologous three-sinus repair were acceptable. Although a long-term follow-up evaluation is mandatory, application of this technique may provide a just enough growth of the reconstructed main pulmonary artery with symmetric pulmonary valve geometry.

Impact of preoperative identification of the artery of Adamkiewicz on spinal cord injury after descending aortic and thoracoabdominal aortic repair.

Background: Some recent reports have demonstrated that preoperative Adamkiewicz artery (AKA) identification and its targeted reconstruction has provided satisfactory outcomes with respect to spinal cord protection. This paper investigates the impact of preoperative identification of the AKA on reducing the incidence of spinal cord injury (SCI) in open repair (OR) and endovascular repair (EVR) of descending thoracic aortic (dTA) and thoracoabdominal aortic aneurysm (TAA) repair. Methods: The clinical data of patients with dTA and TAA treated between 2011 and 2022 were investigated. A total of 256 patients comprising of 201 males and 55 females, with a mean age of 72.1±10.0 years, were included. OR was used in 102 patients and EVR in 154 patients whose distal landing zone was below T8, all of which needed preoperative identification of the AKA. Results: The AKA was identified in 207 (80.9%) patients, and was located in the level between T8 and T12 in 81.2%. In OR, the responsible arteries, including the identified AKA, were promptly reconstructed in 66 (64.7%) patients. In EVR, 65 (42.2%) patients had the AKA covered by an endovascular prosthesis. Deaths prior to 30 days occurred in seven (2.7%, four in OR and three in EVR) patients. In OR, SCI occurred in six (5.9%) patients including three (2.9%) with paraplegia and three (2.9%) with paraparesis, whereas in EVR ten (6.5%) patients had SCI, including two (1.3%) with paraplegia and eight (5.2%) with paraparesis. The incidence of SCI was significantly higher in patients with the AKA covered than those without it covered [13.8% (9 of 65) vs. 1.1% (1 of 89); P=0.002], whereas no significant differences were found between patients with or without the AKA reconstructed. Conclusions: Preoperative identification of the AKA was useful enough to determine treatment strategies with less likelihood of SCI in both OR and EVR for dTA and TAA pathologies.

Complete Resection of a Cavoatrial Metastatic Liposarcoma under Hypothermic Circulatory Arrest.

A patient underwent surgical resection twice for primary and metastatic dedifferentiated liposarcomas. Computed tomography revealed a tumor mass at the cavoatrial junction. Prompt surgical resection of the tumor with thrombectomy was successfully performed using cardiopulmonary bypass with hypothermic circulatory arrest. Despite the poor prognosis of metastatic or recurrent liposarcoma, the patient has survived for 8 years since the first tumor resection.

Significance of perioperative intrasac pressure in sac shrinkage after endovascular abdominal aneurysm repair.

BACKGROUND: Endovascular aneurysm repair (EVAR) results in a marked reduction of intrasac pressure, which is the likely cause of aneurysm sac shrinkage. We evaluated the change of intrasac pressure during operation and its association with aneurysm sac shrinkage one year after EVAR. METHODS: This study included 113 patients undergoing EVAR using the Gore C3 Excluder at our university hospital between March 2016 and December 2020. A direct intrasac pressure was measured before and after stent deployment. The Pressure Index (PI) was defined as the ratio of intrasac pressure to systemic blood pressure. RESULTS: Patients were divided into two groups: patients with aneurysm sac shrinkage (N.=33, 29%) and those without (N.=80, 71%). Systolic and diastolic PI after stent graft deployment were significantly higher in patients with aneurysm sac shrinkage than those without, respectively (systolic PI, 64.6±13.9% vs. 58.1±12.0%, P=0.014; diastolic PI, 103.8±24.7% vs. 96.4±12.9%, P=0.039). Multivariable analysis revealed post-deployment systolic PI as an independent risk factor predictive of aneurysm sac shrinkage (odds ratio 1.04; 95% CI 1.01-1.08; P=0.016). CONCLUSIONS: Although systolic intrasac pressure, described as systolic PI, was an independent risk factor for aneurysm sac shrinkage, contrary to our expectation, it was significantly higher in patients with aneurysm sac shrinkage than those without. This seemingly contradictory result may be explained by the properties of an aneurysm sac, which influence the change of intrasac pressure.

Preoperative planning for transaortic septal myectomy using cardiac computed tomography in patients with subaortic septal hypertrophy associated with aortic stenosis: case series.

Background: Electrocardiogram-gated cardiac computed tomography (CT) imaging enables a more accurate understanding of the patient's cardiac anatomy. Preoperative planning for transaortic septal myectomy (TASM), based on cardiac CT, may be useful in patients with subaortic septal hypertrophy associated with severe aortic stenosis (AS). Case summary: Two elderly patients (age >80 years) with subaortic septal hypertrophy associated with AS underwent surgical aortic valve replacement (SAVR) and concomitant TASM after preoperative planning based on cardiac CT. Both patients showed subaortic septal hypertrophy with blood flow acceleration, left ventricular (LV) hypercontractility, and a short distance from the coaptation point of the mitral valve to the septum, resulting in possible dynamic LV outflow tract (LVOT) obstruction after resolution of AS. Optimal mid-diastolic images, selected from the 70-80% phase, were used for preoperative TASM planning. Planned sizes for myectomy based on multi-planar reconstruction were 10 × 26 × 9 mm (width × length × depth) and 10 × 25 × 9 mm for patient 1 and 2, respectively, while resected tissue size was 10 × 24 × 8 mm and 9 × 24 × 8 mm in patient 1 and 2, respectively. After TASM procedure, SAVR was performed with bioprosthetic valve. Postoperative course of both patients was uneventful with no evidence of complete atrioventricular block, septal perforation, or blood flow acceleration at the LVOT. Discussion: Preoperative planning based on cardiac CT images is safe and useful for guiding adequate myectomy and preventing associated complications in patients with subaortic septal hypertrophy associated with AS.

Balloon pulmonary angioplasty followed by pulmonary endarterectomy: Combination treatment for high-surgical-risk patients with chronic thromboembolic pulmonary hypertension.

OBJECTIVES: Our goal was to evaluate the combined effects of balloon pulmonary angioplasty (BPA) followed by pulmonary endarterectomy (PEA) to treat high-surgical-risk patients with chronic thromboembolic pulmonary hypertension (CTEPH). METHODS: This study included 58 patients with CTEPH who had pulmonary vascular resistance of ≥1000 dyn·s/cm5, mean pulmonary arterial pressure (mPAP) of ≥45 mmHg or mPAP of 38-44 mmHg with comorbidities. Of these, 21 patients underwent the combined therapy of BPA followed by PEA (BPA group) and 37 underwent direct PEA (non-BPA group). Preoperative and postoperative results were compared between the 2 groups. An early postoperative composite event comprised the postoperative use of extracorporeal membrane oxygenation or intra-aortic balloon pump, in-hospital death, rescue BPA, prolonged ventilation, tracheostomy, prolonged stay in the intensive care unit, deep sternal wound infection and cerebral infarction. RESULTS: Before the first intervention (before BPA or direct PEA), patients in the BPA group had a higher mPAP than those in the non-BPA group. After undergoing BPA before PEA, the BPA group demonstrated significantly decreased mPAP and pulmonary vascular resistance (43 vs 52 mmHg, P < 0.001; 636 vs 965 dyn·s/cm5, P = 0.003, respectively) and significantly increased cardiac output (4.1 vs 3.5 l/min, P = 0.041). Notably, the number of patients with the early postoperative composite event was significantly lower in the BPA group than in the non-BPA group (4.8% vs 35.1%, P = 0.011). CONCLUSIONS: Compared with direct PEA, the combination therapy of BPA followed by PEA can be a feasible and effective risk-reduction strategy for high-surgical-risk patients with CTEPH.

Current status of surgical treatment for acute aortic dissection in Japan: Nationwide database analysis.

OBJECTIVE: To clarify the current status of surgical treatment of acute aortic dissection (AAD) in Japan through the Japan Cardiovascular Database analysis. METHODS: In total, 7194 patients who underwent surgical treatment for AAD in 2021, including type A (TAAAD) (n = 6416) and type B (TBAAD) (n = 778), were investigated. RESULTS: The median age was 70 years, with patients older than age 80 years constituting 21.7% and 23.4% of TAAAD and TBAAD cases. Emergency admission was 88.5% and 78.5%. Shock was found in 11.8% and 6.0%. Rupture/impending rupture occurred in 10.7%/6.0% and 24.0%/11.1%, respectively. Branch malperfusion was complicated in 10.4% and 25.2%. Open repairs were performed in 97.7% and 20.3%, whereas endovascular repairs were performed in 2.3% and 79.7%, respectively. In the increased prevalence of endografting procedures, neurological complications and renal failure occurred frequently after open repair with frozen elephant trunk for 29.9% and 50.3%. The operative mortality rate was 9.8% and 11.5% for open repair and 8.1% and 10.0% for endovascular repair. In patients with TAAAD, age older than 80 years, preoperative critical comorbidities, classical dissection, and coexisting chronic vital organ diseases were independent risk factors for mortality. In frozen elephant trunk procedures, neurologic complications and renal failure were frequent. The operative mortality was higher during the superacute phase within 1 or 2 hours from onset to arrival and between arrival and surgery. CONCLUSIONS: The current status of surgical treatments for AAD including the increased prevalence of endografting of thoracic endovascular aortic repair and frozen elephant trunk were demonstrated with favorable outcomes in the Japan Cardiovascular Database analyses.

Extended Aortic Repair for Acute Type A Aortic Dissection with Rupture and Malperfusion Complicated with Ehlers-Danlos Syndrome.

The patient was a 54-year-old gentleman with sudden chest pain. He suffered from cardiac tamponade and malperfusion of the left carotid artery and the right lower extremity due to acute type A aortic dissection. Rupture of the aortic root and a huge entry from the transverse arch to the proximal descending aorta were found. Extended repairs of valve-sparing root replacement and total arch replacement with frozen elephant trunk were successfully performed. He was discharged without any complications. He was finally diagnosed as having vascular Ehlers-Danlos syndrome by a genetic examination.

Association of neutrophils, lymphocytes, and neutrophil-lymphocyte ratio to overall mortality after endovascular abdominal aortic aneurysm repair.

BACKGROUND: The purpose of this study was to determine the predictive ability of neutrophilia, lymphocytopenia, and neutrophil-lymphocyte ratio (NLR) for overall mortality after EVAR for AAA. METHODS: Data on patients with AAA treated by EVAR between March 2012 and December 2016 were obtained from a prospectively maintained EVAR database at Tokyo Medical University Hospital, Tokyo, Japan. The NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. A cut-off value of total WBC count, neutrophil count, lymphocyte count, and NLR was determined according to a receiver operating characteristic (ROC) curve. Univariate and multivariate analyses were performed using the Cox proportional hazard analyses to account for the time at risk. RESULTS: One hundred seventy-eight patients were included in this study after selection based on the exclusion criteria. The subjects consisted of 150 men and 28 women with a mean age of 77.5 years (range: 51-89 years). A ROC curve analysis determined the optimal cut-off values of preoperative total WBC, neutrophils, lymphocytes, and NLR for predicting overall mortality with 7,050 /µL, 4,012 /µL, 1,312 /µL, and 3.19, respectively. On univariate and multivariate analyses, octogenarian, obesity, COPD, active cancer, and lymphocytopenia or NLR were detected as independent predictors for overall mortality. CONCLUSIONS: Specific leukocyte populations, such as lymphocyte count and NLR, are useful biomarkers to predict overall mortality in patients undergoing EVAR for AAA, suggesting that WBC count and its subsets, which are easy to perform a test, may be used to stratify patients at risk for poor prognosis following EVAR.

Esophageal Submucosal Giant Hematoma Detected After Mitral Repair Using Transesophageal Echocardiography.

Transesophageal echocardiography (TEE) is a necessary diagnostic tool for cardiac surgery, including for intraoperative evaluation of the morphology and function of each structure. On the other hand, many complications caused by insertion and manipulation of the TEE probe have been reported, such as gastrointestinal injuries and hematoma, as well as esophageal perforation. Here, we report a case in which a large submucosal esophageal hematoma was found on the fourth postoperative day after surgery using TEE for mitral regurgitation. The patient was an 81-year-old man who underwent mitral valve replacement for mitral regurgitation. On the fourth postoperative day, anorexia and blood-tinged sputum were observed. A computed tomography (CT) scan of the chest displayed a giant esophageal submucosal hematoma. When performing TEE, to avoid complications, it is important to handle the TEE probe with care and to avoid leaving the device at the same site for long periods of time.

Nutcracker Phenomenon with Menorrhagia in a Woman with Marfan Syndrome.

Nutcracker phenomenon (NCP) refers to left renal vein compression at the superior mesenteric artery origin involving hematuria and dysuria due to the compression of the renal venous return and pelvic congestion syndrome caused by the compression of the gonadal venous return. A leptosomatic woman (body mass index, 19 kg/m2) presented with NCP and Marfan syndrome accompanied by severe menorrhagia. Vascular ultrasonography revealed reversed flow in the left ovarian vein. Preoperative computed tomography revealed a sharp aortomesenteric angle and short aortomesenteric distance. After controlling her menstrual period via oral contraception, she underwent valve-sparing surgery for aortic root dilation, which spontaneously subsided the menorrhagia.

Surgical treatment for secondary aortoesophageal fistula.

BACKGROUND: Aortoesophageal fistula (AEF) is a relatively rare condition that is often life-threatening. Secondary AEF is a complication of previous surgery, which can be more critical and challenging than primary AEF. The number of secondary AEF is increasing due to increase in the number of thoracic endovascular aortic repair (TEVAR). Although TEVAR has become a successful alternative surgical strategy for thoracic aortic aneurysms, secondary AEF after TEVAR might be critical than other secondary AEF because of severe adhesion between the esophagus and residual thoracic aortic wall. METHODS: This study analyzed six patients with secondary AEF who were treated at Tokyo Medical University Hospital between 2011 and 2016. These participants included four patients who had undergone TEVAR and two who had undergone total arch replacement. RESULTS: Although they were subsequently hospitalized for a long period, open surgical repair was completed in two patients who had undergone total arch replacement. TEVAR alone was performed in two patients who had undergone TEVAR and they were discharged without major complications shortly. Combined repair of TEVAR as a bridge to open surgery was planned for two patients who had undergone TEVAR. However, reconstruction of the aorta and esophagus could not be completed in these patients due to severe adhesions, and they died during hospitalization. CONCLUSIONS: Definitive open repair was successfully performed in patients with secondary AEF after total arch replacement. However, in the patients with secondary AEF after TEVAR, severe adhesion between the aorta and esophagus led to difficulty in performing a successful definitive open repair. The strategy for secondary AEF should, therefore, be decided considering the etiology of secondary AEF. In secondary AEF after TEVAR, definitive open repair is difficult to complete because of catastrophic complication, and palliative treatment using TEVAR without reconstruction of aorta and esophagus can be an alternative.