Validity of direct bilateral axillary arterial cannulation in emergency surgery for acute type A aortic dissection.

BACKGROUND AND AIM OF THE STUDY: To assess the validity and long-term outcomes of direct bilateral axillary arterial cannulation for acute type A aortic dissection. METHODS: Between 2003 and 2020, 208 consecutive patients with acute type A aortic dissection underwent emergency surgical repair. Cardiopulmonary bypass was attempted to establish direct bilateral axillary arterial cannulation and bicaval drainage. Antegrade selective cerebral perfusion was established by axillary perfusion and direct cannulation of the left common carotid artery. RESULTS: Ascending aortic, partial arch, and extended total aortic arch replacement were performed in 50 (24.0%), 7 (3.4%), and 151 (72.6%) patients, respectively. Aortic root surgery and coronary artery bypass grafting were performed concomitantly in 23 and seven patients, respectively. Cardiopulmonary bypass was attempted only through bilateral axillary cannulation in all patients but was successful in 13 (6.3%) patients without bilateral axillary cannulation. No postoperative complications occurred related to this technique. There were seven hospital deaths (early mortality rate, 3.4%). Five patients had postoperative reoperation for bleeding, and nine (4.3%) were transferred to other hospitals due to postoperative permanent cerebral infarction, particularly two with arm ischemia. The 10-year survival rate of patients who underwent emergency surgical repair with this technique was 71.4%. CONCLUSIONS: Direct bilateral axillary arterial cannulation followed by selective cerebral perfusion was successful in 93.7% of patients and this may be an optimal solution for providing stable outcomes after emergency surgery for acute type A aortic dissection. However, we experienced two complications of arm ischemia, attention should be paid to potential arm ischemia.

[Subcutaneous Bronchogenic Cyst in the Anterior Chest Diagnosed before Coronary Artery Bypass Grafting:Report of a Case].

A 65-year-old woman was transported to our hospital by ambulance because of severe dyspnea. She had had a subcutaneous tumor on her anterior chest since her childhood. Coronary angiography revealed three vessel disease with significant stenosis in the left main trunk. Excision of anterior chest tumor, 70×60×50 mm in size, was performed before coronary artery bypass grafting( CABG). It was a unilocular cyst adhering to the sternum, and was composed of ciliated epitheliums, goblet cells and smooth muscle cells. Based upon the existence of smooth muscle cells, the tumor was diagnosed as bronchogenic cyst. CABG was performed through mid-sternum about two months after the tumor excision, and the postoperative course was uneventful.

Preoperative evaluation of aortic calcification by computed tomography in thoracic aortic disease.

BACKGROUND: Computed tomography (CT) is a useful tool for the identification of calcified lesions in the aorta. However, no quantitative evaluation has been established to assess the applicability of simple anastomosis preoperatively. We conducted this retrospective study to establish a reference range of maximal CT attenuation values for application of simple anastomosis. METHODS: A total of 122 consecutive patients underwent replacement of the thoracic aorta between 2007 and 2011, excluding those with acute aortic dissection. The patients were divided into two groups: those who underwent simple anastomosis (simple group: n = 105), and those who required endarterectomy before anastomosis (manipulation group: n = 17). The maximal CT attenuation values at the anastomosis site were calculated by imaging software. RESULTS: The mean maximal CT attenuation values (Hounsfield unit [HU]) was significantly higher in the manipulation group (638.1 ± 269.5 [166-1304]) than in the simple group (94.7 ± 171.5 [0-790]; p < .0001). The maximal CT attenuation values enabled us to predict the simple anastomosis with the area under the receiver operating characteristic curve of 0.96 (p < .0001). The cut-off value was 325 HU (sensitivity 94.1%, specificity 81.7%). The 10-year survival rate was significantly lower in the manipulation group (11.8%) than in the simple group (43.2%). In the multivariate analysis, age (hazard ratio [HR]: 1.073), hypertension (HR: 2.382), and maximal CT attenuation values (HR: 1.001) were independently associated with long-term mortality. CONCLUSIONS: Preoperative evaluation of the maximal CT attenuation values is a useful tool in predicting whether simple anastomosis is applicable or not. Maximal CT attenuation values is a risk factor for long-term mortality.

Perivascular Adipose Tissue Is a Major Source of Nitric Oxide in Saphenous Vein Grafts Harvested via the No-Touch Technique.

Background Saphenous vein grafts (SVGs) are broadly used in coronary artery bypass grafting despite their inferior patency compared with arterial grafts. Recently, the no-touch technique (NT), in which an SVG is harvested with a pedicle of perivascular adipose tissue (PVAT) without conduit distension, was shown to improve long-term patency compared with conventional preparation (CV), wherein outer tissue is removed with distension. The NT was also reportedly associated with reduced atherosclerosis. Although endothelial damage provoked by conventional distension may underlie poor patency when CV is performed, the precise mechanisms underlying the salutary effects of the NT have been unclear. Methods and Results Residual SVGs prepared with CV (CV-SVGs) or NT (NT-SVGs) were obtained during coronary artery bypass grafting. Nitric oxide (NO2-/NO3- (NOx)) levels after 24 hours of tissue culture were quantified. The protein expression and localization were analyzed. The isometric force of SVG strips was measured. NT-SVGs showed superior NOx production to CV-SVGs. PVAT generated the majority of NOx in NT-SVGs. PVAT highly expressed arginosuccinate synthase 1, a rate-limiting enzyme in the molecular circuit for NO synthesis, thereby continuously providing the substrate for NO. A substantial level of endothelial NO synthase was also expressed in PVAT. Pharmacological inhibition of arginosuccinate synthase 1 or endothelial NO synthase significantly suppressed the NOx production in NT-SVGs. PVAT induced vasorelaxation through NO production, even in the endothelium-denuded SVG strips. Conclusions Preserving PVAT was predominantly involved in the superior NOx production in NT-SVGs. Since NO plays crucial roles in suppressing atherosclerosis, this mechanism may greatly contribute to the excellent patency in NT-SVGs.

Huge Primary Cardiac Malignant Lymphoma in the Left Ventricle.

A 67-year-old man presented at the hospital with worsening exertional dyspnea. Echocardiography showed a tumor in the left ventricle (approximately 35 × 48 mm) that protruded into the left atrium and left ventricular outflow tract during systole. These findings suggested a high risk of sudden death resulting from aortic valve obstruction or tumor embolism. Surgical resection was performed. During the operation, the tumor was resected as completely as possible, together with part of the myocardium where it arose. Histopathologic examination showed diffuse large B-cell lymphoma. The patient received systemic chemotherapy and is alive after 1 year.