Stent implantation in a patient with non-hemorrhagic vertebral artery dissection associated with severe, continuously progressive stenosis in the posterior inferior cerebellar artery bifurcation region: A case report.

Generally, the prognosis of non-hemorrhagic vertebral artery dissection is good. Treatment should be considered when stenosis progresses or when an aneurysm is formed. However, no clear treatment policy has been established. The purpose of this case report was to describe the treatment policy for non-hemorrhagic onset vertebral artery dissection with severe stenosis around the posterior inferior cerebellar artery (PICA) bifurcation and aneurysm, where stent placement in the vertebral artery was difficult. This report describes healing without complications with stent implantation in the PICA performed to treat non-hemorrhagic vertebral artery dissection with associated severe, continuously progressive stenosis in the PICA bifurcation region. A 36-year-old woman was examined at the authors' hospital for persistent pain in the left posterior neck. Left vertebral arteriography revealed stenosis due to dissection around the PICA bifurcation and aneurysm formation at the distal position. Due to the progression of stenosis, there were concerns about PICA occlusion, and stent implantation in the vertebral artery was performed via the PICA. Neck pain ceased immediately after surgery, and 3 months later, cerebral angiography showed favorable patency of the PICA and decreased aneurysm size. This case suggests that stent implantation in the PICA might be a useful treatment option for non-hemorrhagic vertebral artery dissection with associated severe stenosis in the PICA bifurcation region.

Symptomatic Sinus Bradycardia in a Patient with Solitary Fibrous Tumor/Hemangiopericytoma Treated with Pazopanib.

Pazopanib, a multi-targeted tyrosine kinase inhibitor, is associated with cardiovascular adverse events, such as hypertension, cardiac dysfunction, and thromboembolism. However, symptomatic pazopanib-related bradycardia is uncommon. We herein report a case of symptomatic bradycardia of 35 beats per minute in a patient with solitary fibrous tumor/hemangiopericytoma (SFT/HPC) treated with pazopanib for 1 month. His heart rate recovered to a normal range soon after pazopanib cessation. He restarted pazopanib at a reduced dose, which was continued without SFT/HPC progression or bradycardia recurrence. This case highlights the possibility of bradycardia induced by pazopanib and the importance of monitoring the patient's heart rate.

Impaired mitochondrial oxidative phosphorylation capacity in epicardial adipose tissue is associated with decreased concentration of adiponectin and severity of coronary atherosclerosis.

Epicardial adipose tissue (EAT), a source of adipokines, is metabolically active, but the role of EAT mitochondria in coronary artery disease (CAD) has not been established. We investigated the association between EAT mitochondrial respiratory capacity, adiponectin concentration in the EAT, and coronary atherosclerosis. EAT samples were obtained from 25 patients who underwent elective cardiac surgery. Based on the coronary angiographycal findings, the patients were divided into two groups; coronary artery disease (CAD; n = 14) and non-CAD (n = 11) groups. The mitochondrial respiratory capacities including oxidative phosphorylation (OXPHOS) capacity with non-fatty acid (complex I and complex I + II-linked) substrates and fatty acids in the EAT were significantly lowered in CAD patients. The EAT mitochondrial OXPHOS capacities had a close and inverse correlation with the severity of coronary artery stenosis evaluated by the Gensini score. Intriguingly, the protein level of adiponectin, an anti-atherogenic adipokine, in the EAT was significantly reduced in CAD patients, and it was positively correlated with the mitochondrial OXPHOS capacities in the EAT and inversely correlated with the Gensini score. Our study showed that impaired mitochondrial OXPHOS capacity in the EAT was closely linked to decreased concentration of adiponectin in the EAT and severity of coronary atherosclerosis.

Postoperative initial 2-day blood pressure management facilitates the shrinkage of abdominal aortic aneurysm after endovascular aneurysm repair by reducing the incidence of type II endoleak.

OBJECTIVE: The aim of this study was to evaluate the effect of initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the incidence of subsequent type II endoleak (T2E) and shrinkage of abdominal aortic aneurysm (AAA) sac diameter. METHODS: We reviewed 136 patients who underwent EVAR for atherosclerotic AAA between July 2008 and July 2014 with one of three stent grafts (Excluder [W. L. Gore & Associates, Flagstaff, Ariz], Powerlink [Endologix Inc, Irvine, Calif], and Endurant [Medtronic Vascular, Santa Rosa, Calif]). Starting from 2013, the mean blood pressure of 76 participating patients (treatment group) was maintained at 75 to 90 mm Hg for the initial 48 hours after EVAR. The incidence of T2E at 7 days and AAA sac diameter 12 months after EVAR were evaluated using computed tomography scanning. The results so obtained were then compared with those of the control group composed of 60 consecutive patients who underwent EVAR before 2013. RESULTS: The incidence of T2E at 7 days was significantly lower in patients who received treatment (treatment group, 19.7%; control group, 40.0%; P = .013), and AAA sac diameter at 12 months in the treatment group had a mean decrease of 5.1 mm compared with the mean 2.2 mm in the control group (P = .004). In multivariate regression analysis, BPM was significantly related to the reduction of incidence of T2E at 7 days (odds ratio, 0.31; P = .007) and a decrease in AAA sac diameter at 12 months (P = .005). In addition, although the use of Endurant had less effect, the use of Excluder under controlled blood pressure conditions improved the incidence of T2E from 80% to 23% compared with those under normal postoperative management (P = .001). CONCLUSIONS: The initial 2-day postoperative BPM might have positive effects, such as lower incidence of T2E and facilitation of AAA sac shrinkage.

Preservation of Motor Function After Resection of Lower-Grade Glioma at the Precentral Gyrus and Prediction by Presurgical Functional Magnetic Resonance Imaging and Magnetoencephalography.

BACKGROUND: Intra-axial brain tumors located at anatomically eloquent areas are challenging conditions. On one hand, it is often difficult to pursue maximum extent of resection of tumor in these locations. On the other hand, neuroplasticity occurs in some patients with low-grade glioma, and the primary neural functions are known to sometimes shift from conventional "eloquent cortices." CASE DESCRIPTION: In a patient with a lower-grade glioma located at the precentral gyrus, shift of primary motor function from the precentral gyrus to the postcentral gyrus was detected on magnetoencephalography and functional magnetic resonance imaging. Aggressive removal of the pathologic precentral gyrus was accomplished via awake craniotomy without causing obvious motor function deficit. CONCLUSIONS: This case highlights the importance of preoperative multimodal neurophysiologic imaging in patients with low-grade gliomas in eloquent areas.

Voxel-Based Lesion Mapping of Cryptogenic Stroke in Patients with Advanced Cancer: A Detailed Magnetic Resonance Imaging Analysis of Distribution Pattern.

BACKGROUND: Ischemic stroke is one form of cancer-associated thrombosis that can greatly worsen a patient's performance status. The present investigation aimed to elucidate the characteristic distribution pattern(s) of cryptogenic stroke lesions using a voxel-based lesion-mapping technique and examine the differences in clinical manifestations between cryptogenic and conventional strokes in patients with advanced cancer. METHODS: Data from 43 patients with advanced cancer who developed acute ischemic stroke were retrospectively collected. Stroke etiology was grouped into either cryptogenic or conventional stroke etiology according to the ASCO stroke score. Clinical data were reviewed, and voxel-based lesion mapping using diffusion-weighted imaging (DWI) was performed to visualize the cross-patient spatial distribution of the lesions. RESULTS: Of the 43 patients, 25 were classified as having cryptogenic stroke etiology and 18 were classified as having conventional stroke etiology. Median survival time of patients from stroke onset was 96 days for cryptogenic stroke etiology and 570 days for conventional stroke etiology (P = .01). D-dimer of patients was significantly higher in cryptogenic stoke etiology than in conventional stroke etiology (P = .006). Voxel-based lesion mapping showed that DWI hyperintense lesions accumulated at cortical and internal watershed areas of the cerebrum and at the vascular border zone of the superior cerebellar and posterior inferior cerebellar arteries at the cerebellum. CONCLUSIONS: Voxel-based lesion mapping for cryptogenic stroke in patients with advanced cancer showed that lesions accumulated at vascular border zones within the brain both at the cerebrum and at the cerebellum, but not at perforating arterial territories.

Alternative Treatment for Residual Aortobronchial Fistula After Thoracic Endovascular Aortic Repair.

A patient with an aortobronchial fistula secondary to a thoracic endovascular aortic repair was successfully treated with a re-thoracic endovascular aortic repair with debranching technique. Five months postoperatively, the aneurysm had shrunk; however, computed tomography revealed air in the thrombo-excluded aortic aneurysmal sac without signs of infection. Because of worsening air finding at the eighth month, we performed a resection of the residual fistula and wrapped the stent graft in a pedicled muscle flap.

Outcomes of surgical aortic valve replacement using Carpentier-Edwards PERIMOUNT bioprosthesis series in elderly patients with severe aortic valve stenosis: a retrospective cohort study.

OBJECTIVE: We sought to compare the outcomes of Carpentier-Edwards PERIMOUNT (CEP), Magna and Magna Ease valves in Japanese elderly patients with severe aortic valve stenosis (AS). METHODS: We retrospectively identified 136 patients (mean age 76.61 ± 5.5 years old) who had undergone isolated surgical aortic valve replacement (SAVR) using CEP, Magna, and Magna Ease valves at a single institution, from January 2001 to December 2013. We compared the valves according to their survival rates, freedom from major adverse cardiovascular and cerebrovascular events (MACCE), and durability and hemodynamic performance by echocardiographic data. RESULTS: The thirty-day mortality after isolated SAVR in all the valve groups was "zero". The differences among the three groups in terms of survival rates, freedom from MACCE at 2 years, durability and hemodynamic performance of the valves by echocardiographic data was not statistically significant. CONCLUSION: All CEP, Magna and Magna Ease valves seemed to be similarly useful in Japanese elderly patients with severe AS. Our data did not clearly support the superiority of one valve over another. A longer follow-up period might be necessary to compare the durability and hemodynamic performance of these valves with more certainty.

A case report of primary cardiac myxofibrosarcoma presenting with severe congestive heart failure.

BACKGROUND: Primary cardiac sarcomas are extremely rare. Furthermore, the myxofibrosarcomas are one of the rarest forms of cardiac sarcomas, and its prognosis is known to be quite poor. CASE PRESENTATION: This is a case of a 23-year-old man who presented with acute severe congestive heart failure caused by almost complete obstruction of the mitral valve due to a large left atrial tumor. The patient required endotracheal intubation before his arrival to the hospital, and underwent an emergent surgical excision of the tumor. The tumor had a complex shape and originated from the orifice of the right upper pulmonary vein. Because the tumor seemed to extend over most of the surface of the left atrium, it seemed impossible to reconstruct the left atrium had we done a complete transmural resection. Instead, we carefully peeled the tumor leaving the outer layer of the left atrial wall. We applied cryoablation to the attached site, in order to prevent a recurrence of the tumor. The pathology report revealed that the tumor was a myxofibrosarcoma, and it seemed to originate from the heart. The patient received radiation therapy after the surgery and continues to be alive and well after 1-year, without apparent recurrence. CONCLUSIONS: Cardiac myxofibrosarcoma can cause acute, severe left-sided heart failure. Non-transmural atrial wall resection with cryoablation might be effective for patients with cardiac myxofibrosarcomas with extensive atrial attachment.

Bladder and rectal incontinence without paraplegia or paraparesis after endovascular aneurysm repair.

Spinal cord ischemia is a well-known potential complication of endovascular aneurysm repair (EVAR), and it is usually manifested by paraplegia or paraparesis. We describe a case in which spinal cord ischemia after EVAR presented by isolated bladder and rectal incontinence without other neurological deficits. A 63-year-old woman presented with intermittent claudication secondary to an infrarenal abdominal aortic aneurysm (AAA), and a left common iliac artery obstruction, for which she underwent EVAR using an aorto-uniiliac (AUI) device and ilio-femoral artery bypass. On postoperative day 3, she developed urinary and fecal incontinence without signs of paraplegia or paraparesis. Magnetic resonance imaging (MRI) showed a hyper-intense signal in the spinal cord. She received hyperbaric oxygen (HBO) therapy and was discharged after 18 days when her urinary and fecal incontinence were almost resolved. This report suggests that spinal cord ischemia after EVAR for aortoiliac occlusive disease might present as bladder and rectal incontinence without other neurological manifestations.

Thoracic Endovascular Aortic Repair for Challenging Aortic Arch Diseases Using Fenestrated Stent Grafts From Zone 0.

BACKGROUND: Although previous reports have described the repair of distal aortic arch aneurysms through debranching and chimney techniques, these methods invariably involve surgical management of the carotid artery. We report clinical results of thoracic endovascular aortic repair (TEVAR) using fenestrated stent grafts in the treatment of aortic arch aneurysms located less than 15 mm from the left common carotid artery. METHODS: A semi-custom-made fenestrated stent graft designed to fit aortic arch tortuosity and preserve blood flow at least into the brachiocephalic and left common carotid arteries was placed from zone 0. RESULTS: From 2007 through 2013, TEVAR from zone 0 was performed on 37 high-risk patients for open surgery (mean age 78.2 years). The mean length between the left common carotid artery and aortic aneurysm was 11.1 mm (range, 5 to 15 mm). The left subclavian artery was preserved for 26 patients (70.3%) through surgical reconstruction (n = 19) and graft fenestration (n = 7). The early mortality rate was 0%. Postoperative strokes and spinal cord ischemia occurred in 2 (5.4%) and 3 (8.1%) patients, respectively. Although type I endoleaks at discharge were noted in 12 (32.4%) patients, aneurysm enlargement was noted during follow-up in 6 (16.2%). Four patients (10.8%) underwent secondary interventions consisting of 3 coil embolization procedures; 2 re-TEVARs and 1 open conversion. There were no aorta-related late deaths. Survival and aorta-related event-free rates at 2 years were 86.3% and 88.8%, respectively. CONCLUSIONS: Thoracic endovascular aortic repair using fenestrated stent graft from zone 0 can be considered as one of therapeutic options for high-risk patients with aortic arch diseases.

[Ascending aorta cannulation in stanford type a acute aortic dissection].

Establishment of cardiopulmonary bypass for Stanford type A acute aortic dissection( type A AAD) should be quick and safe. The femoral artery, axillary artery, ascending aorta, and left ventricular apex are potential access points for cannulation. The most important reason for establishing cardiopulmonary bypass for type A AAD is to allow antegrade blood flow through the true lumen. Starting in 2007, Jakob et al, and Inoue et al. applied the technique of ascending aortic cannulation for type A AAD. From 2008, we applied this method of ascending aorta cannulation in 8 patients and compared preoperative, operative, and postoperative data with a control group, or the femoral artery cannulation group. Ascending aorta cannulation was done safely and easily with the use of the Seldinger technique under epiaortic color Doppler echography and transesophageal echography. No cerebral events or hypoperfusion-based complications occurred in the group of ascending aorta cannulation. Given that no cases of complication occurred using this method, it could be considered as an effective choice of cannulation for cardiopulmonary bypass.

Therapeutic strategies for patients with internal carotid or middle cerebral artery occlusion complicated by severe coronary artery disease.

BACKGROUND/OBJECTIVES: Ischemic stroke is one of major complications of cardiac surgery. Although a current American Heart Association (AHA) guideline states that carotid endarterectomy is probably recommended before or concomitant to coronary artery bypass grafting (CABG) for the carotid stenosis, there is no report that analyzed optimal strategies in cardiac surgery for patients with total occlusion of the internal carotid artery (ICA) or the middle cerebral artery (MCA). Therefore, this preliminary study was aimed to clarify whether preoperative blood flow measurements and prophylactic superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis could reduce the incidence of perioperative ischemic stroke during cardiac surgery in patients with total occlusion of the ICA or MCA. METHODS: This prospective study included eight patients who were admitted to undergo cardiac surgery including CABG. All of them had total ICA or MCA occlusion on preoperative magnetic resonance (MR) examinations. Preoperative cerebral blood flow and its reactivity to acetazolamide were quantitatively determined in all eight patients using single photon emission computed tomography or positron emission tomography. RESULTS: Preoperative blood flow measurements revealed that two (25%) of eight patients had normal cerebral hemodynamics because of well-developed collaterals. They safely underwent cardiac surgery. However, a marked impairment of cerebral perfusion reserve was identified in six (75%) of eight patients in the ipsilateral hemispheres. Of these, four patients underwent prophylactic STA-MCA anastomosis prior to CABG. Subsequently, they safely underwent CABG without perioperative ischemic stroke. CONCLUSION: This is the first report suggesting that preoperative identification of hemodynamic compromise and prophylactic STA-MCA anastomosis may reduce perioperative ischemic stroke during cardiac surgery in patients with ICA or MCA occlusion, although further studies are needed to assess the validity.

[Case with L5 radiculopathy caused by far-out syndrome and lumbar canal stenosis].

Far-out syndrome (FOS) is caused by L5 nerve root entrapment at the L5-S1 extraforaminal area surrounded by the sacral alar and the transverse process. Here, we report a case with right L5 radiculopathy caused by L4-5 lumbar canal stenosis (LCS) and FOS. A 57-year-old man suffered from progressing right sciatica and leg pain in the L5 nerve root distribution. MR images showed canal stenosis and a slight disc herniation at the L4-5 level. He underwent surgical decompression for LCS, but he only obtained partial pain relief. Multiplanner reformatted CT scans showed that the right L5 nerve root was entrapped by the sacral alar and lateral disc bulging at the L5-S1 level. Selective radiculograpy demonstrated L5 nerve root compression in the far-lateral area, and a nerve root block provided temporary pain relief. He received a second operation for decompression of the L5 nerve root in the far-lateral zone by partial removal of the sacral alar and the transverse process. He was relieved completely from pain after the operation. He left our hospital on the 9th postoperative day, and returned to work on the 16th day. Visual analogue scales of pain and numbness were 8.7 and 8.7 respectively at first examination. These scores decreased to 5.5 and 3.7 two months after the first operation for LCS, and to 0 and 0 one month after the second operation for FOS. We recommend that more attention be paid to FOS when patients with L5 radiculopathy are diagnosed.

Does intensive management of cerebral hemodynamics and atheromatous aorta reduce stroke after coronary artery surgery?

BACKGROUND: Atheromatous aorta and carotid artery disease are known predictors for stroke after coronary artery bypass grafting (CABG). The clinical significance of intracranial cerebral artery disease is not known. This study was designed to determine whether a therapeutic strategy based on perioperative detection of intracranial and extracranial occlusive cerebrovascular disease and atheromatous aorta could reduce perioperative stroke. METHODS: We studied 485 patients who underwent isolated CABG. The control group was 247 patients who underwent standard-protocol CABG. The 238 subjects in the intervention group underwent preoperative magnetic resonance angiography of the head and neck and intraoperative epiaortic scanning. Cerebral hemodynamics were evaluated by single photon emission computed tomography and acetazolamide tests in patients with significant occlusive cerebrovascular disease. Surgical outcomes were compared. RESULTS: In the intervention group, magnetic resonance angiography detected significant intracranial or extracranial occlusive cerebrovascular disease, or both, in 40 patients. Prophylactic cerebrovascular interventions were performed in 7 patients who had disturbed cerebral hemodynamics. Aorta no-touch off-pump coronary artery bypass (OPCAB) was chosen intraoperatively in 37 patients with moderate to severe atheromatous aorta. The in-hospital stroke rate was 0.42% in the intervention group vs 2.8% in the control group (p = .068). A multivariate analysis revealed that the perioperative interventional protocol was the most powerful predictor of reduced risk of perioperative stroke (odds ratio, 0.023; 95% confidence interval, 0.001 to 0.469). CONCLUSIONS: Prophylactic cerebrovascular interventions and the selective use of aorta no-touch OPCAB can significantly reduce the incidence of perioperative stroke. Careful vascular evaluation before and during CABG can improve surgical outcomes.

Efficacy of modified endoventricular circular patch plasty in ischemic cardiomyopathy--innovative delimitation technique using integrated myocardial management.

BACKGROUND: Optimal delimitation is one of the most important factors for successful endoventricular circular patch plasty (EVCPP). The aim of this study was to determine whether our modification as an application of integrated myocardial management enables reproducible delimitation and feasible myocardial protection, resulting in better clinical outcomes for ischemic cardiomyopathy (ICM) patients. METHODS: Between September 1998 and November 2001, 22 ICM patients underwent EVCPP with coronary artery bypass grafting (CABG) [group I, n = 14] or CABG only [group II, n = 8]. The majority had congestive cardiac failure, and NYHA in groups I and II were 2.9 +/- 0.5 and 2.7 +/- 0.8, respectively. After complete revascularization, delimitation was determined by palpation of the empty beating heart during antegrade warm blood perfusion without unclamping the aorta. The heart was then re-arrested for secure cryotherapy and suturing under single aortic clamping. RESULTS: There were no in-hospital deaths and no need for mechanical support. Preoperative angiograms in group I showed a lower EF (21.2 +/- 4.0 vs 26.8 +/- 2.6%, P < 0.01) and a more dilated ventricle (LVESVI: 115 +/- 39 vs 73 +/- 15 ml/m2,P < 0.01). In contrast, early postoperative results were comparable between the groups as far as EF (39 +/- 12 vs 43 +/- 9%) and LVESVI (55 +/- 26 vs 54 +/- 11 ml/m2). During follow-up (15 +/- 10 months), freedom from cardiac death was 100%, and 95% of patients were NYHA I or II. CONCLUSIONS: ICM patients with LV dilation could safely be treated by CABG and EVCPP with modified delimitation technique to regain reduced LV volume and function as good as patients without LV dilation undergoing CABG alone.