Right Carotid Artery Origin Compression Caused by Endovascular Repair for Kommerell Diverticulum Associated with a Right-Sided Aortic Arch.

Owing to the unique anatomical features, the endovascular repair for Kommerell diverticulum poses a surgical challenge. An 80-year-old, asymptomatic female with Kommerell diverticulum and associated right-sided aortic arch underwent an endovascular repair, consisting of an aortic arch endografting with a proximal extension, axillo-axillary crossover bypass, and right subclavian parallel endografting. An additional stent was promptly placed retrogradely at the right carotid artery origin as the completion aortography revealed an ostial occlusion. During the 6th month follow-up, she remained well without any neurological deficits. This report elucidated the disease-specific and procedure-related causes leading to right carotid artery ostium occlusion.

Impact of Recovery from Acute Kidney Injury After Aortic Arch Repair.

BACKGROUND: The impact of recovery from acute kidney injury (AKI) after open thoracic aortic surgery on follow-up outcomes is unclear. METHODS: This retrospective study included 214 patients who underwent aortic arch surgery requiring hypothermic circulatory arrest between 2007 and 2019. Patients who required preoperative renal replacement therapy and patients who died within 7 postoperative days were excluded. The incidence of recovery from AKI was examined. Renal outcomes were compared among patients with no AKI (Group N), recovery from AKI (Group R), and persistent AKI (Group P). RESULTS: Preoperative kidney function was similar among the 3 groups. Among the 115 patients who developed postoperative AKI, 80.9% recovered from AKI at discharge. The 5-year cumulative mortality rate was 18.0%, 24.5%, and 68.4% in Group N, R, and P, respectively (P < .001, Group R vs Group P). The 5-year cumulative incidence of renal replacement therapy dependency was 0.0%, 5.4%, and 22.7%, respectively (P = .04, Group N vs Group R; P = .01, Group R vs Group P). The medians (interquartile range) of estimated glomerular filtration rate (mL/min/1.73 m2) 2 years after surgery were 65.2 (50.4-80.2), 54.3 (41.4-65.9), and 56.9 (40.2-67.5), respectively (P = .03, Group N vs Group R). CONCLUSIONS: The majority of patients recovered from AKI after thoracic aortic repair by discharge. However, the prolonged impact of AKI recovery on kidney function was observed during the follow-up period. Diligent follow-up after discharge is warranted for early identification of patients at high risk of kidney disease progression.

A Rabbit Venous Interposition Model Mimicking Revascularization Surgery using Vein Grafts to Assess Intimal Hyperplasia under Arterial Blood Pressure.

Although vein grafts have been commonly used as autologous grafts in revascularization surgeries for ischemic diseases, the long-term patency remains poor because of the acceleration of intimal hyperplasia due to the exposure to arterial blood pressure. The present protocol is designed for the establishment of experimental venous intimal hyperplasia by interposing rabbit jugular veins to the ipsilateral carotid arteries. The protocol does not require surgical procedures deep in the body trunk and the extent of the incision is limited, which is less invasive for the animals, allowing long-term observation after implantation. This simple procedure enables researchers to investigate strategies to attenuate the progression of intimal hyperplasia of the implanted vein grafts. Using this protocol, we reported the effects transduction of microRNA-145 (miR-145), which is known to control the phenotype of vascular smooth muscle cells (VSMCs) from the proliferative to the contractile state, into harvested vein grafts. We confirmed the attenuation of intimal hyperplasia of vein grafts by transducing miR-145 before implantation surgery through the phenotype change of the VSMCs. Here we report a less invasive experimental platform to investigate the strategies that can be used to attenuate intimal hyperplasia of vein grafts in revascularization surgeries.

MicroRNA-145-loaded poly(lactic-co-glycolic acid) nanoparticles attenuate venous intimal hyperplasia in a rabbit model.

BACKGROUND: MicroRNA-145 (miR-145) reportedly alters the phenotype of vascular smooth muscle cells (VSMCs) from a proliferative to a contractile state. So far, viral or plasmid vectors have been experimentally used to transduce microRNAs into VSMCs. We hypothesized that a simple ex vivo microRNA delivery system using miR-145-loaded poly(lactic-co-glycolic acid) (PLGA) nanoparticles (PLGA NPs) could control the VSMC phenotype and prevent intimal hyperplasia. METHODS: Jugular vein grafts of male Japanese white rabbits were soaked in phosphate-buffered saline, control microRNA (cont-miR)-loaded PLGA NP solution or miR-145-loaded PLGA NP solution for 30 minutes (n = 8 for each). Vein grafts were implanted in the ipsilateral carotid artery and assessed 2 weeks after the implantation. RESULTS: Quantitative polymerase chain reaction analysis showed significantly higher miR-145 expression in the miR-145-treated group. The neointimal area was significantly smaller in the miR-145-treated group (phosphate-buffered saline-treated vs cont-miR-treated vs miR-145-treated group; 1.63 ± 0.52 mm2 vs 1.67 ± 0.49 mm2 vs 0.88 ± 0.34 mm2, respectively; P < .01 for the miR-145-treated vs the cont-miR-treated group). In the miR-145-treated group, Ki-67-positive cells were significantly fewer, indicating lower VSMC proliferation. An inflammation-related molecule, CD40 expression was significantly reduced by miR-145-loaded PLGA NP treatment. CONCLUSIONS: Local and sustained release of miR-145 by PLGA NPs attenuated intimal hyperplasia in the rabbit model by maintaining VSMCs in a contractile state. This simple ex vivo miR-145 delivery system would be promising toward broader clinical application.

Transcutaneous oxygen pressure as a surrogate index of lower limb amputation.

INTRODUCTION: A large number of clinical trials of therapeutic angiogenesis in patients with critical limb ischemia have been conducted in recent years. However, limb amputation, which is used as a primary endpoint in such studies, is not often required in Japan, which can make it difficult to carry out related clinical trials. Transcutaneous oxygen pressure (TcPO2) is widely used to evaluate the severity of limb ischemia, to decide the level of amputation, and to predict wound healing after limb amputation. The aim of the present study was to elucidate whether TcPO2 can be a surrogate index of limb ischemia, and to define an appropriate cutoff value for wound healing after limb amputation using meta-analysis. EVIDENCE ACQUISITION: A computer search was performed to identify studies describing the association between TcPO2 and limb ischemic events. From these, studies focused on wound healing after limb amputation were combined and analyzed. EVIDENCE SYNTHESIS: Eleven studies were identified for inclusion in this analysis. The analysis demonstrated that TcPO2 20 mmHg was a valid cutoff value for limb amputation and TcPO2 30 mmHg would be an appropriate value for wound healing after limb amputation. CONCLUSIONS: TcPO2 of 20 and 30 mmHg were considered appropriate cutoff values for limb amputation and wound healing after amputation, respectively.

[Perioperative management of two patients with renal malignant tumor involving the vena cava].

Two patients underwent resection of renal malignant tumors involving vena cava. Such tumors occasionally extend to the inferior vena cava with tumor thrombus and invasion to the lymph nodes and adjacent organs. Perioperative management of patients with these tumors is difficult because of the risk of pulmonary embolism and massive bleeding, and requires appropriate cooperation among the surgical team. In case 1, a 56-year-old man, renal cell carcinoma with tumor thrombus had extended into the intrahepatic vena cava. It was resected after isolating the liver from vena cava and incising the cross-clamped inferior vena cava without extracorporeal circulation or blood transfusion. A prosthetic graft replaced the inferior vena cava. In case 2, a 64-year-old woman, renal pelvis cancer adhered to the inferior vena cava and the mesentery with enlarged lymph nodes. It was separated from the inferior vena cava and removed with the ascending colon. The patient received a blood transfusion of approximately 2,000ml. Cardiomyopathy associated with a left ventricular outflow tract pressure gradient of 100mmHg required perioperative management. After surgery, both patients underwent controlled ventilation in the intensive care unit. After recovery, they were discharged without complications. We discuss perioperative management, with regard to the level of the tumor extension and perioperative complications.

[Successful treatment of a saphenous vein graft aneurysm detected 15 years after coronary bypass grafting (CABG)].

A 72-year-old female with a history of hypertension, dyslipidemia, and coronary artery bypass grafting (CABG) 16 years before was admitted because of chest discomfort. Enhanced computed tomography (CT) revealed a mass lesion, with a diameter of 40 mm and an enhanced area in its inner part. Coronary arteriography showed saphenous vein graft dilatation, and the diagnosis of saphenous vein graft aneurysm was made. Because of the risks of aneurysmal rupture, embolization, and myocardial infarction, surgery was performed. Revascularization of the coronary artery distal to the aneurysm and aneurysmectomy were performed with the beating heart under cardiopulmonary bypass to prevent myocardial infarction. The patient's postoperative course was uneventful.

[Transmitral left ventricular thrombectomy using an endoscope in a patient with left ventricular non-compaction].

We report a case of isolated left ventricular non-compaction(LVNC) associated with poor left ventricular function, multiple cerebral infarctions, and a mobile and pedunculated thrombus in the left ventricular apex. LVNC is a rare congenital cardiomyopathy resulting from an arrest in normal endomyocardial embryogenesis. The thrombus and some other small thrombi in the left ventricle were successfully removed through the mitral valve using an endoscope without making a left ventricular incision to preserve cardiac function. Mitral annuloplasty, the maze procedure, and left atrial thrombectomy were also performed. The patient's postoperative course was uneventful. By using an endoscope, details of the left ventricular cavity could be observed, and left ventricular function could be preserved by avoiding ventriculotomy.

[Prosthetic valve endocarditis associated with paravalvular aortic and mitral abscesses].

A 63-year-old female, who had undergone aortic and mitral valve replacement 16 years ago, was admitted because of urinary tract infection. The patient developed cerebral hemorrhage. Methicillinresistant Staphylococcus aureus was isolated from her blood culture. Transesophageal echocardiography revealed paravalvular aortic and mitral abscesses, and the diagnosis of prosthetic valve endocarditis was established. A redo double valve replacement was performed. Both paravalvular abscess cavities were debrided and closed with fresh autologous pericardial patches, and mechanical valves were implanted. The patient's postoperative course was uneventful, and she had no sign of recurrent infection 3 years postoperatively.