Impact of Hemoglobin Level, White Blood Cell Count, Renal Dysfunction, and Staphylococcus as the Causative Organism on Prediction of In-Hospital Mortality from Infective Endocarditis.

Infective endocarditis (IE) is a highly fatal disease in cases of delayed diagnosis and treatment, although its incidence is low. However, there have been few single-center studies in which the risk of in-hospital death from IE was stratified according to laboratory findings on admission and the organism responsible for IE. In this study, a total of 162 patients who were admitted to our hospital during the period from 2009 to 2021, who were suspected of having IE according to the modified Duke classification, and for whom IE was confirmed by transesophageal echocardiography were retrospectively analyzed. Patients were observed for a mean-period of 43.7 days with the primary endpoint being in-hospital death. The in-hospital death group had a lower level of hemoglobin (Hb), higher white blood cell (WBC) count, lower level of estimated glomerular filtration rate (eGFR), and higher frequency of Staphylococcus being the causative agent than those in the non-in-hospital death group. In overall multivariate analysis, Hb, WBC count, eGFR, and Staphylococcus as the causative agent were identified to be significant prognostic determinants. IE patients with Hb < 10.6 g/dL, WBC count > 1.4 × 104/µL, eGFR < 28.1 mL/minute/1.7 m2, and Staphylococcus as the causative agent had significantly and synergistically increased in-hospital death rates compared to those in other IE patients. Low level of Hb, high WBC count, low eGFR, and Staphylococcus as the causative agent of IE were independent predictors of in-hospital mortality, suggesting that these 4 parameters may be combined to additively stratify the risk of in-hospital mortality.

Injection of n-Butyl-2-Cyanoacrylate into the Abdominal Aortic Aneurysm Sac during Endovascular Aortic Repair to Prevent Type II Endoleaks Caused by Lumbar Arteries.

PURPOSE: To evaluate midterm results of whether the strategy to occlude target lumbar arteries using n-butyl-2-cyanoacrylate (nBCA) injection during endovascular aneurysm repair (EVAR) reduced the incidence of Type II endoleak (T2EL) after EVAR. MATERIALS AND METHODS: Between 2013 and 2020, 187 patients underwent EVAR; 106 in the treatment group received nBCA injection during EVAR, whereas 81 in the historical control group did not. The incidence of T2EL at 7 days, need for reintervention, and post-EVAR aneurysmal shrinkage were compared between the groups. RESULTS: Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL (2.8% vs 28.4%; P < .0001) and decreased aneurysmal diameter was observed at 1 year after EVAR (-5.2 vs -3.8 mm; P = .034). In multivariate analysis, nBCA injection (odds ratio [OR], 0.04; P = .001) and younger age (OR, 0.92; P = .036) were significantly associated with a reduced incidence of T2EL. As a possible adverse event associated with nBCA injection, 2 cases of transient lower-limb motor dysfunction (1.9%) were observed. Propensity score analysis revealed that the treatment group had a significantly lower incidence of T2EL than that in the control group (P = .0002) even though there was no difference in the incidence of inferior mesenteric artery coil embolization between the groups. The survival rate without aneurysm sac enlargement (100.0% vs 69.8%; P = .014) and the reintervention-free rate (100.0% vs 63.1%; P = .034) in the treatment group were significantly higher than those in the control group. CONCLUSIONS: Concomitant nBCA injection can provide durable EVAR without T2EL, as supported by the avoidance of reintervention associated with aneurysm sac enlargement.

Initial two-day blood pressure management after endovascular aneurysm repair improves midterm outcomes by reducing the incidence of early type II endoleak.

OBJECTIVE: The aim of this study was to evaluate midterm outcomes of our novel strategy of postoperative initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the prevention of subsequent type II endoleak (T2EL) in a single-center series. METHODS: Between 2008 and 2014, 137 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from 2013, the mean blood pressure was maintained between 75 and 90 mmHg for the initial 24 hours after EVAR followed by systolic pressure controlled below 120 mmHg during the next 24 hours in the treatment group (n = 76). The incidence of T2EL detected at 7 days, reintervention, and AAA sac diameter up to 5 years after EVAR were compared with those of the control group comprising of 60 consecutive patients who underwent standard EVAR without BPM prior to 2013. RESULTS: Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL at 7 days (19.7% vs 40.0%; P = .009), a mean decrease of AAA sac diameter at 1-year (-5.1 ± 4.9 vs -2.2 ± 6.7 mm; P = .013) and 2-year (-5.4 ± 7.7 vs -1.7 ± 10.8 mm; P = .045). In addition, there was a significant decrease in the incidence of T2EL detected at 7 days with the use of the Gore Excluder with 22.7% in the treatment group vs 80.0% in the control group (P < .001), which resulted in a significant decrease in the aneurysm sac diameter up to 4 years after EVAR. Survival rate without AAA sac enlargement at 5 years after EVAR (83.0% vs 70.0%; P = .021) in the treatment group was significantly higher than that of the control group, whereas no significant differences were observed in the freedom rates of reintervention, T2EL-related reintervention, and all-cause mortality between the groups. CONCLUSIONS: Postoperative initial 2-day BPM had a preventive effect on AAA sac enlargement until midterm periods, by reducing the incidence of T2EL at 7 days after EVAR. The usage of Gore Excluder under BPM was especially associated with sustained positive effects until the midterm follow-up.

Thoracic Endovascular Aortic Repair on Zone 2 Landing for Uncomplicated Type B Aortic Dissection with Measurement of Intra-False Lumen Pressure.

BACKGROUND: This study aimed to evaluate the midterm results of zone 2 thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (TBAD) by measuring the intra-false lumen pressure (IFLP) during TEVAR. METHODS: Fifteen patients (9 men; mean age, 57 years) who underwent zone 2 TEVAR for uncomplicated TBAD were reviewed. Delta systolic pressure (defined as the difference between systemic pressure and IFLP) was measured before and after primary entry closure, and aortic remodeling and thrombo-occlusion of the false lumen (FL) were evaluated 12 months after TEVAR at 5 different levels of the aorta. RESULTS: Median duration from onset to TEVAR was 34 days. The left subclavian artery was preserved in 13 patients (87%) by using stent graft fenestration. Although 1 patient (6%) had a transient cerebral infarction, there were no severe TEVAR-related complications. Entry closure significantly reduced delta systolic pressure (mm Hg) compared to preoperative pressure at all levels (distal arch: -22.2 ± 10.8 vs. -5.2 ± 9.6; Th8: -20.1 ± 12.4 vs. -6.9 ± 7.2; Th10: -14.3 ± 14.6 vs. -4.7 ± 7.5; Th12: -14.4 ± 14.5 vs. -4.9 ± 7.8; L2: -14.5 ± 14.2 vs. -3.4 ± 6.9). The percentages of aortic remodeling with expansion of the true lumen (distal arch: 82%; Th8: 80%; Th10: 54%; Th12: 45%; L2: 50%) and complete false lumen thrombosis (distal arch: 100%; Th8: 100%; Th10: 67%; Th12: 11%; L2: 0%) were approximately consistent with the change in delta systolic pressure. During a follow-up of 41 months, distal stent-induced new entry occurred in 2 patients (13%) requiring secondary intervention; however, there were no cases of FL enlargement or aorta-related mortality. CONCLUSIONS: Zone 2 TEVAR for uncomplicated TBAD may prevent TEVAR-related complications. Measuring IFLP could be a new predictive marker for assessing the extent of aortic remodeling.

Early- and Mid-Term Results of Abdominal Endovascular Aneurysm Repair Using an Aortic Cuff Prior to the Main Body to Prevent Type II Endoleaks.

PURPOSE: Postoperatively persistent type II endoleaks (T2ELs) in abdominal endovascular aneurysm repair (EVAR) are known risk factors for long-term aneurysm enlargement. Therefore, various measures have been proposed to prevent T2ELs. Notably, the Kilt technique, which can be used in patients with dumbbell-shaped morphology, employs an aortic cuff deployed in the distal seal zone before the main body. Although previous studies have successfully applied this technique for preventing T2ELs, the mid- and long-term outcomes remain unclear. This study aimed to report the early- to mid-term outcomes in cases where an aortic cuff technique was used to prevent T2ELs. MATERIALS AND METHODS: This retrospective single-center study analyzed 9 patients (mean age, 79 years; range, 69-88 years; 8 men) with abdominal aortic aneurysms. All patients underwent EVAR using an aortic cuff to prevent T2ELs. The primary end points were technical success (successful deployment) and clinical success (no T2ELs). Secondary end points included morbidity, reintervention, and aortic remodeling during follow-up. RESULTS: The technical success rate was 100%. There were no intraprocedural or postoperative complications. No deaths or reinterventions occurred. Postoperative computed tomography showed no endoleaks in 6 patients, while T2ELs from the lumbar artery outside the aortic cuff deployment range were noted in 3 patients. However, no T2ELs were observed in the artery in the aortic cuff deployment range in any patient. The average number of successfully occluded arteries was 4.2 (range, 2-8). All patients had follow-up >6 (mean, 18.6; range, 6-36) months. Aneurysm sac shrinkage occurred in 5 patients during the follow-up period, whereas aneurysm size was stable in 3 patients. In contrast, only 1 patient showed transient dilation of the aneurysm sac enlargement; however, this dilation remained unchanged even after 1.5 years. CONCLUSION: The aortic cuff technique is a favorable endovascular method for preventing T2ELs in EVAR. The present study showed that a single aortic cuff could easily and reliably occlude arteries branched from the aneurysm sac.

Scattered Media Elastic Fibers from the Aortic Root to the Ascending Aorta in a 30-Year-Old Marfan Syndrome Patient.

We present a case report of a 30-year-old Marfan syndrome patient who underwent a David procedure for severe aortic valve insufficiency and Valsalva aneurysm. Harvested aortic walls were examined by pathologists. Although the tunica media of the ascending aorta contained aligned elastic fibers, the aortic root media lacked aligned elastic fibers.

Estimation Model for Hypothermic Circulatory Arrest Time to Predict Risk in Total Arch Replacement.

BACKGROUND: We created an estimation model for hypothermic circulatory arrest time and analyzed the risk factors for major adverse outcomes in total arch replacement. METHODS: This study involved 272 patients who underwent total arch replacement. The estimation model for hypothermic circulatory arrest time was established using multiple linear regression analysis, and the predicted hypothermic circulatory arrest time from this model was analyzed to detect risk factors. RESULTS: Atrial fibrillation, rupture, malperfusion, saccular aneurysm, cardiopulmonary bypass time, and hypothermic circulatory arrest time were identified as independent risk factors associated with major adverse outcomes. The estimation model for hypothermic circulatory arrest time was established as follows: hypothermic circulatory arrest time = 99.3 - 0.19 × age + 0.65 × body mass index + 6.19 × previous cardiac operation + 11.7 × acute dissection + 8.9 × rupture + 0.19 × aortic angulation + 0.15 × length to the distal anastomosis site - 6.17 × total arch replacement surgeon case volume - 3.06 × surgery year. The predicted hypothermic circulatory arrest time calculated by this estimation model was evaluated using multivariate logistic analysis, which identified atrial fibrillation, rupture, malperfusion, saccular aneurysm, and predicted hypothermic circulatory arrest time as risk factors. CONCLUSIONS: As with the actual hypothermic circulatory arrest time, the predicted hypothermic circulatory arrest time using our model detected significant factors associated with major adverse outcomes. These results indicated that this prediction model for hypothermic circulatory arrest time may be effective.

Physician-modified stent graft with inner branches for treating ruptured thoracoabdominal aortic aneurysm.

Thoracoabdominal aortic aneurysm (TAAA) repair remains challenging in patients with high surgical risk. We report a case of TAAA in an 84-year-old woman with type Ib endoleak after thoracic endovascular aortic repair with coeliac artery coverage due to impending ruptured TAAA. A stent graft was assembled to create 3 fenestrations and sew 3 inner grafts for the superior mesenteric artery (SMA) and bilateral renal arteries. This stent graft system was inserted into the thoraco-abdominal aorta and partially unsheathed until the first inner branch endograft fully expanded. The wire was used to catheterize the stent graft, inner branch, and SMA from the left upper limb, and a bridge stent was deployed from the inner branch to the SMA. A similar procedure was performed for bilateral renal arteries. The stent graft system was fully unsheathed. Postoperative computed tomography angiography revealed no endoleak and good flow of the visceral artery. The use of the physician-modified inner branched endograft system described is feasible and can make TAAA endovascular repair simpler and safer.

Descending thoracic aorta-abdominal aortic bypass and bilateral renal arterial blood circulation reconstruction are effective in atypical coarctation of the aorta with heart failure: a case report.

BACKGROUND: There are a lot of reports of the renal failure and heart failure due to coarctation of the aorta. However, there are no case reports in which revascularization dramatically improved left ventricular function in patients with progressive decline in left ventricular function. Herein, we present a rare case in which the left ventricular function was dramatically improved by surgical treatment for progressive left ventricular dysfunction due to atypical coarctation of the aorta. CASE PRESENTATION: A 58-year-old man underwent left axillary artery-bilateral femoral artery bypass at another hospital for atypical coarctation of the aorta due to Takayasu's arteritis. Approximately 10 years later, he was re-hospitalized for heart failure, and the left ventricular ejection fraction gradually decreased to 28%. Computed tomography showed severe calcification and stenosis at the same site from the peripheral thoracic descending aorta to the lower abdominal aorta of the renal artery, and aortography showed delayed bilateral renal artery blood flow. An increase in plasma renin activity was also observed. Despite the administration of multiple antihypertensive drugs, blood pressure control was insufficient. We decided to perform surgical treatment to improve progressive cardiac dysfunction due to increased afterload and activated plasma renin activity. Descending thoracic aorta-abdominal aorta bypass and revascularization of the bilateral renal arteries via the great saphenous vein grafts were performed. Postoperative blood pressure control was improved, and the dose of antihypertensive drugs could be reduced. Plasma renin activity decreased, and transthoracic echocardiography 1.5 years later showed an improvement in contractility with a left ventricular ejection fraction of 58%. CONCLUSION: In atypical coarctation of the aorta in patients with decreased bilateral renal blood flow, heart failure due to renal hypertension, and progressive decrease in left ventricular contractility, descending thoracic aorta-abdominal aortic bypass and bilateral renal artery recirculation can be extremely effective.

A case of a giant pulmonary artery aneurysm due to an atrial septal defect with left main coronary artery occlusion.

Cases of coronary artery occlusion due to the exclusion of pulmonary artery aneurysm are extremely rare, and there are few reports of surgical treatment. A 60-year-old woman with pulmonary hypertension due to an atrial septal defect and obstruction of the left main coronary trunk due to the exclusion of a giant pulmonary artery aneurysm underwent surgery. The surgery included atrial septal defect closure, tricuspid annulus plasty, pulmonary artery aneurysmorrhaphy, and coronary artery bypass grafting. One and a half years after the surgery, no re-expansion of the pulmonary artery was observed, and the symptoms of heart failure had improved. There are no reports of improvement in pulmonary valve regurgitation by aneurysmorrhaphy in pulmonary artery aneurysm. Surgery for pulmonary artery aneurysm with the exclusion of other organs was effective, and aneurysmorrhaphy for pulmonary artery aneurysm was acceptable.

Antiatherosclerotic Phenotype of Perivascular Adipose Tissue Surrounding the Saphenous Vein in Coronary Artery Bypass Grafting.

Background Perivascular adipose tissue (PVAT) is associated with metabolically driven chronic inflammation called metaflammation, which contributes to vascular function and the pathogenesis of vascular disease. The saphenous vein (SV) is commonly used as an essential conduit in coronary artery bypass grafting, but the long-term patency of SV grafts is a crucial issue. The use of the novel "no-touch" technique of SV harvesting together with its surrounding tissue has been reported to result in good long­term graft patency of SV grafts. Herein, we investigated whether PVAT surrounding the SV (SV-PVAT) has distinct phenotypes compared with other PVATs of vessels. Methods and Results Fat pads were sampled from 48 patients (male/female, 32/16; age, 72±8 years) with coronary artery disease who underwent elective coronary artery bypass grafting. Adipocyte size in SV-PVAT was significantly larger than the sizes in PVATs surrounding the internal thoracic artery, coronary artery, and aorta. SV-PVAT and PVAT surrounding the internal thoracic artery had smaller extents of fibrosis, decreased gene expression levels of fibrosis-related markers, and less metaflammation, as indicated by a significantly smaller extent of cluster of differentiation 11c-positive M1 macrophage infiltration, higher gene expression level of adiponectin, and lower gene expression levels of inflammatory cytokines, than did PVATs surrounding the coronary artery and aorta. Expression patterns of adipocyte developmental and pattern-forming genes were totally different among the PVATs of the vessels. Conclusions The phenotype of SV-PVAT, which may result from inherent differences in adipocytes, is closer to that of PVAT surrounding the internal thoracic artery than that of PVAT surrounding the coronary artery or that of PVAT surrounding the aorta. SV-PVAT has less metaflammation and consecutive adipose tissue remodeling, which may contribute to high long-term patency of grafting when the no-touch technique of SV harvesting is used.

Successful Endovascular Repair of an Abdominal Aortic Aneurysm in a Patient with a Horseshoe Kidney and Accessory Renal Arteries Using an Aortic Cuff to Prevent Type II Endoleak.

A 78-year-old man presented with an abdominal aortic aneurysm (AAA) and a horseshoe kidney coexisting with accessory renal arteries. We performed surgical treatment with endovascular aneurysm repair, sacrificing the accessory renal arteries. We used an aortic cuff to prevent a type II endoleak from the inferior mesenteric and accessory renal arteries. Decreased renal function was transient, and postoperative computed tomography showed no endoleak. This case report supports the feasibility of endovascular surgery for treating AAA in patients with a horseshoe kidney.

A rare case of pseudoaneurysm at the site of untreated coarctation of the aorta in an adult patient.

Here we report a rare case of pseudoaneurysm at the site of aortic coarctation. Aortic coarctation and a saccular aortic aneurysm protruding from the site of this coarctation were detected in a 50-year-old woman. Owing to the shape of the aneurysm and high risk of rupture, an open surgical repair was performed. The pathological findings of the removed aneurysm revealed a pseudoaneurysm consisting of only a thin adventitial wall. Adult uncorrected aortic coarctation has a poor prognosis. One of its causes may be the formation of such a pseudoaneurysm.

Long-Term Clinical Outcomes of Thoracic Endovascular Aortic Repair for Arch Aneurysms with the Najuta Thoracic Stent-Graft System.

Objective: The treatment for arch aneurysms by endovascular repair is often difficult. This study evaluated the long-term outcomes of thoracic endovascular aortic repair for aortic arch aneurysms treated with the Najuta stent-graft system. Materials and Methods: From January 2009 to December 2019, 37 patients underwent treatment for aortic aneurysms with the Najuta stent graft system at two institutes, including our hospital. We retrospectively analyzed the short- and long-term clinical outcomes. Results: Of all 37 cases, the technical success rate was 97.3% (36 of 37). The mean proximal neck length was 20.1±5.3 mm. The postoperative results revealed 10 patients with type Ia endoleaks (27.8%), 6 with stroke (16.7%), and one with paraplegia (2.8%). In the chronic phase, the overall survival rates and the rates of freedom from aorta-related events at 7 years were 71.3% and 50.7%, respectively. Between two groups divided based on the proximal neck diameter of 20 mm, the <20-mm group had significantly higher rates of aorta-related events in terms of freedom from aortic events (P=0.046). Conclusion: The fenestrated stent graft can be a less invasive option for the treatment of high-risk patients with aortic aneurysms.

Surgical Treatment of a Left Axillary Arterial Aneurysm with Marfan Syndrome by Combining Two Skin Incisions.

An axillary arterial aneurysm is a rare disorder, with few surgical cases reported to date. Here we report the case of a left axillary arterial aneurysm associated with Marfan syndrome. A 44-year-old female with Marfan syndrome presented with numbness of the left upper limb and a pulsatile mass on the left chest. A computed tomography scan revealed a highly enlarged and tortuous left axillary arterial aneurysm. We performed a graft replacement and resection of the aneurysm with two skin incisions. After the surgery, the blood flow to the patient's left upper limb was confirmed, and the neurological symptoms improved significantly.

[Left Ventricular Patch Plasty for Post-infarct Ventricular True Aneurysm with Ventricular Septal Perforation;Report of a Case].

We experienced a rare case of post-infarct left ventricular aneurysm (LVA) and ventricular septal perforation (VSP). An 83-year-old woman was treated for acute cardiac insufficiency. Three weeks later after hospitalization, she had sudden cardiorespiratory failure and was diagnosed with VSP and LVA. She underwent emergency heart surgery. After establishing extracorporeal circulation, the LVA was excised longitudinally from the left side of the left anterior descending branch. Endoventricular patch plasty (Dor procedure) was performed to exclude the ventricular aneurysm, and the VSP was closed using Dacron patch. After surgery, echocardiography found no residual shunts and exclusion of the LVA. The patient underwent successful surgical treatment of VSP and LVA.