Long-Term Outcomes of Endovascular Aneurysm Repair in Patients Aged ≤70 Years.

Objectives: The efficacy of endovascular aneurysm repair (EVAR) against abdominal aortic aneurysm (AAA) in younger patients remains unknown. Hence, the current study aimed to investigate whether the aneurysm-related mortality rate of EVAR is acceptable among patients aged ≤70 years. Methods: Among 644 patients, 148 underwent EVAR (EVAR group), and 496 received open surgical repair (OSR group). The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events after AAA repair were evaluated using the cumulative incidence function in the presence of competing risks. Results: The EVAR group had higher prevalences of several comorbidities, and overall survival for the EVAR group was significantly inferior to that of the OSR group. The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events at 5 years were 1.5%, 11.7%, and 6.4% in the EVAR group and 1.3%, 5.3%, and 5.9% in the OSR group, respectively. EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. However, it was an independent poor prognostic factor of any intervention. Conclusion: EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. Therefore, it demonstrated acceptable procedure-related long-term outcomes, at least in high-risk young patients.

[Minimally Invasive Cardiac Surgery-Coronary Artery Bypass Grafting by Left Small Intercostal Thoracotomy for Very Elderly Patients:Report of Two Cases].

The increase in the age of patients undergoing operations has become more prominent in recent years. We report our experience of minimally invasive cardiac surgery-coronary artery bypass grafting (MICS-CABG) by left small intercostal thoracotomy for very elderly patients. Case 1:The patient was a 91-year-old woman with a history of percutaneous coronary intervention (PCI) for left anterior descending artery (LAD) and right coronary arteries at different timings. Due to her contrast media allergy, we performed MICS-CABG to treat 75% stenosis of LAD. Blood transfusion was not required. She was discharged on the 13th day. Case 2:The patient was a 92-year-old man. We performed MICS-CABG for 75% stenosis of the left main trunk and 90~99% stenosis of the LAD with severe calcification. Blood transfusion was not required. He was discharged on the 21th day. MICS-CABG can be performed with less invasiveness in comparison to the conventional method and therefore seems to be an effective method of surgery for very elderly patients.

Debranching thoracic endovascular aortic repair for distal aortic arch aneurysm in elderly patients aged over 75 years old.

BACKGROUND: We examined the outcome of debranching thoracic endovascular aortic repair (d-TEVAR) without sternotomy for distal aortic arch aneurysm in patients aged ≥75 years. METHODS: Patients who underwent d-TEVAR or TAR for aortic arch aneurysm between 2008 and 2015 at our hospital and aged ≥75 years were included. Age, sex, left ventricular ejection fraction, preoperative creatinine level, diabetes, cerebrovascular disease, and chronic obstructive pulmonary disease were matched using PS. RESULTS: Among 74 patients (d-TEVAR: 51, TAR: 23), 17 patients in each group were matched. No difference in surgical outcome was detected between the d-TEVAR and TAR groups, including 30-day death (0% vs. 0%), hospital death (5.8% vs. 0%: p = 0.31) and incidence of cerebral infarction (5.8% vs. 7.6%: p = 0.27) as well as the long-term outcomes of 5-year survival (92.8% vs. 74.8%: p = 0.30) and 5-year aorta-related event-free rate (88.2% vs. 100%: p = 0.15). Average duration of ICU stay (1.3 ± 1.1 days vs. 5.6 ± 1.3 days: p = 0.025) and hospital stay (16.5 ± 5.2 days vs. 37.7 ± 19.6 days: p = 0.017) were significantly shorter in the d-TEVAR group. CONCLUSION: Our results indicated that d-TEVAR is less invasive without affecting long-term outcome up to 5 years. Although the number of the patients included in the study was small, debranching TEVAR could be one of the treatments of the choice in the elderly, especially with comorbidities.

Successful Surgical Remodeling of a Giant Venous Aneurysm Formed in an Autogenous Arteriovenous Fistula: A Case Report.

One complication of an autogenous arteriovenous fistula (AVF) for hemodialysis is the formation of a venous aneurysm. The treatment of a massive aneurysmal AVF generally involves ligation or resection with the use of prosthetic interposition. We present the case of a 46-year-old man in whom an AVF aneurysm was successfully treated by placating the excess free wall of the aneurysm with sutures. This method is a simple and effective intervention for managing aneurysm-associated complications. In addition, this approach helps to maintain the benefits of autogenous access while conserving future dialysis sites.

Feasibility of three-dimensional fusion imaging with multimodality roadmap system during endovascular aortic repair.

OBJECTIVE: Endovascular procedures for aortic aneurysm repair have become widely accepted as safe and effective surgical options. We investigated the efficacy of the multimodality roadmap (MMR) system with biplane fluoroscopy to attempt to reduce the use of contrast medium and exposure to radiation during surgery. METHODS: We retrospectively reviewed 263 consecutive cases with elective endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR). Patients were categorized into two groups, with and without introduction of the MMR system, which was applied in 164 patients (62.4%). The MMR- group included 62 EVAR and 37 TEVAR cases, and the MMR+ group consisted of 81 EVAR and 83 TEVAR cases. Radiation dose, contrast medium use, and complications were compared between the MMR- and MMR+ groups in the respective EVAR and TEVAR groups. RESULTS: There was a significantly lower amount of contrast medium use in the MMR+ group compared with the MMR- group in EVAR (32.9 ± 10.6 g and 28.2 ± 10.2 g; P = .009) and TEVAR (31.7 ± 11.5 g and 26.9 ± 7.8 g; P = .009). In addition, significantly lower radiation exposure was observed in the MMR+ group of TEVAR (872 ± 623 mGy vs 638 ± 463 mGy; P = .033). The operative time of the MMR+ group was significantly shorter for patients with TEVAR compared with the MMR- group (96.4 ± 27.0 minutes vs 86.2 ± 23.9 minutes; P = .023). The incidence of access injury and other complications was similar in both EVAR and TEVAR groups. CONCLUSIONS: The MMR system with three-dimensional fusion imaging can reduce the contrast medium dose in EVAR and the exposure to contrast medium and radiation in TEVAR.

Smooth muscle cell sheet transplantation preserve cardiac function and minimize cardiac remodeling in a rat myocardial infarction model.

BACKGROUND: We examined whether a vascular smooth muscle cell (SMC) sheet is effective in the treatment of a rat myocardial infarction (MI) model. METHODS: We examined the effect of SMC sheet on the cardiac function and cardiac remodeling in a rat MI model in comparison with their effect of dermal fibroblast (DFB) sheet in vivo. Furthermore, we estimated the apoptosis and secretion of angiogenic factor of SMC under hypoxic condition in comparison with DFB. Seven days after MI, monolayer cell sheets were transplanted on the infarcted area (SMC transplantation group, SMC-Tx; DFB transplantation group, DFB-Tx; no cell sheet transplantation group, Untreated; neither MI nor cell sheet transplantation group, Sham). We evaluated cardiac function by echocardiogram, degree of cardiac remodeling by histological examination, and secretion of angiogenic growth factor by enzyme immunoassay. RESULTS: Twenty-eight days after transplantation, SMC-Tx showed the following characteristics compared with the other groups: 1) significantly greater fractional area shortening (SMC-Tx, 32.3 ± 2.1 %; DFB-Tx, 23.3 ± 2.1 %; untreated, 25.1 ± 2.6 %), 2) suppressed left ventricular dilation, smaller scar expansion, and preserved wall thickness of the area at risk and the posterior wall, 3) decreased fibrosis, preserved myocardium in the scar area, and greater number of arterioles in border-zone, 4) tight attachment of SMC sheets on the scarred myocardium, and less apoptotic cell death. In in vitro experiments, SMCs secreted higher amounts of basic fibroblast growth factor (SMC, 157.7 ± 6.4 pg/ml; DFB, 3.1 ± 1.0 pg/ml), and showed less apoptotic cell death under hypoxia. CONCLUSIONS: Our results illustrate that transplantation of SMC sheets inhibited the progression of cardiac remodeling and improve cardiac function. These beneficial effects may be due to superior SMC survival.

Missing leaflet: a rare cause of structural deterioration of a bovine pericardial aortic bioprosthesis-report of a case.

We experienced a rare cause of aortic bioprosthesis deterioration in which one of the leaflets disappeared 8.7 years after primary aortic valve replacement (AVR) in a male octogenarian. Successful redo AVR with a 23-mm Magna EASE (Carpentier-Edwards, Irvine, CA) was performed. No embolic complications occurred. We were unable to identify the cause of this devastating complication. When heart failure symptoms develop in patients with bioprostheses, clinicians should therefore consider a diagnosis of acute progression of structural valve deterioration and follow the patient carefully with echocardiography.

Inhibition of development of experimental aortic abdominal aneurysm in rat model by atorvastatin through inhibition of macrophage migration.

Recently, atherosclerosis has been considered to be the result of inflammation. Interestingly, hydroxymethylglutaryl-coenzyme (HMG-Co) A inhibitors (statins), which are clinically used as lipid-lowering agents, have been reported to have various anti-inflammatory effects. As abdominal aortic aneurysm (AAA) is a common degenerative condition associated with atherosclerosis, this study was designed to investigate the inhibitory effect of a statin, atorvastatin, on aneurysm formation apart from its lipid-lowering effect. We employed an elastase-induced rat AAA model, as statins do not lower cholesterol in rats. Mean aneurysm diameter was significantly smaller in the atorvastatin treatment group as compared to control at 4 weeks after surgery (P<0.05). Interestingly, atorvastatin inhibited the expression of ICAM and MCP-1, followed by the suppression of macrophage recruitment into the aortic wall at 1 week after operation. A significant reduction in MMP-12, but not MMP-2, -3 and -9, expression was also observed by treatment with atorvastatin at 1 week after surgery. In addition, synthesis of collagen and elastin in the vascular wall were significantly increased by atorvastatin. Here, the present study demonstrated a direct effect of atorvastatin to inhibit the progression of aortic aneurysm, independent of its lipid-lowering effect. This study suggests new therapeutic aspects of statins to inhibit the progression of aneurysms.

Inhibition of experimental abdominal aortic aneurysm in a rat model by the angiotensin receptor blocker valsartan.

Angiotensin (Ang) II exerts direct effects on the arterial wall to influence atherosclerosis and aneurysm development with the induction of vascular inflammation. Therefore, we examined the hypothesis that the inhibition of Ang II would decrease the expansion of abdominal aortic aneurysm (AAA) in a rat model. We used the Ang II receptor blocker (ARB) valsartan to inhibit the effect of Ang II. Additionally, we employed a dosage of valsartan (1 mg/ kg/day) that does not affect blood pressure, to avoid the effect of blood pressure lowering. Notably, progression of elastase-induced AAA was inhibited in rats treated with valsartan (P< or =0.05). To clarify the mechanism, we focused on matrix metalloproteases (MMPs) and inflammatory related factors. Western blot analysis demonstrated that the expression of MMPs was significantly decreased in an AAA model treated with continuous ARB infusion compared to an AAA model treated with vehicle (P< or =0.05), through suppression of nuclear factor kappaB activation (P< or =0.05). Consistently, valsartan significantly inhibited infiltration of macrophages into the aortic wall, accompanied by a reduction of protein expression of intercellular adhesion molecule-1. Importantly, the inhibitory effect of valsartan on MMP-2 and MMP-9 expression was also confirmed using isolated peritoneal macrophages from a rat AAA model. Moreover, treatment with valsartan protected against the destruction of elastic fibers. Overall, the present study demonstrated that treatment with valsartan, significantly prevented the progression of experimental AAA in a rat model. These data suggest that blockade of Ang II has an inhibitory effect on the development of AAA, independent of its antihypertensive effect.

Left ventricular-free wall rupture after successful coronary intervention: report of a case.

We experienced the case of a left ventricular-free wall rupture (LVFWR) following successful coronary intervention for acute myocardial infarction (AMI). A 73-year-old woman was hospitalized because of chest oppression that had been continuing for 8 days. She was diagnosed to have AMI, and percutaneous coronary intervention (PCI) was performed. PCI was successful. However, immediately following PCI, she developed electromechanical dissociation secondary to tamponade because of blow-out-type LVFWR. The perforation tear was initially closed by a direct suture, followed by reinforcement using bovine pericardium patches sealed with GRF glue. The patient died of irreversible brain damage on postoperative day 3, but no re-bleeding or aneurysmal dilatation was detected at autopsy.

Improvement of survival of skin flaps by combined gene transfer of hepatocyte growth factor and prostacyclin synthase.

BACKGROUND: Increasing the local blood flow is a critical factor for long-term survival of skin flaps. Thus, a molecular therapy to increase the blood flow by means of an angiogenic factor is considered to be a useful strategy to improve skin flap survival. We focused on a combined strategy to stimulate not only angiogenesis, but also vasodilation of local microvessels, using co-transfection of the hepatocyte growth factor (HGF) and prostacyclin synthase (PGIS) genes to enhance the survival of random-pattern skin flaps. METHODS AND RESULTS: A 2 x 8 cm full thickness cranial pedicled random-pattern flap was made on the back of each 12-week-old male rat. At 3 days before operation, 400 microg of human HGF and PGIS naked plasmid DNA or control plasmid was transfected into the flaps by needle-less injection using a Shima Jet, resulting in successful expression of human HGF and PGIS in the skin flaps. Transfection of both genes into the distal half of skin flaps at 3 days prior to operation significantly increased the survival rate of skin flaps, while transfection all over the flaps did not. In addition, transfection prior to operation was more effective than simultaneous treatment. Moreover, co-transfection of these genes improved the survival area of skin flaps, accompanied by an increase in blood flow of skin flaps, even in a diabetic model. CONCLUSIONS: Overall, these results indicate that combination treatment with HGF and PGIS genes by Shima Jet could be an effective strategy to improve skin flap survival.

Hypertension accelerated experimental abdominal aortic aneurysm through upregulation of nuclear factor kappaB and Ets.

In this study, we focused on the effect of hypertension on the transcription factors nuclear factor kappaB (NFkappaB) and ets in the mechanisms of abdominal aortic aneurysm (AAA), and we investigated how hypertension affects the progression of AAA. AAA was produced by elastase perfusion in hypertensive rats and normotensive rats. The size of AAA rapidly increased in hypertensive rats as compared with normotensive rats. Western blot analysis demonstrated that the expression of matrix metalloproteinase (MMP)-2, -3 , -9, and -12, as well as intercellular adhesion molecule, was increased in hypertensive AAA rats, accompanied by upregulation of NFkappaB and ets. Moreover, in situ zymography showed that the activity of MMPs was increased in the aorta of a hypertensive AAA model as compared with that in a normotensive AAA model. Interestingly, transfection of chimeric decoy oligodeoxynucleotide (ODN) resulted in significant inhibition of aortic dilatation both in normotensive and hypertensive rats at 4 weeks after transfection. Destruction of elastic fibers was also significantly inhibited by transfection of chimeric decoy ODN in both hypertensive rats and normotensive rats. The expression of MMP-2, -3, -9, and -12, as well as intercellular adhesion molecule, was significantly attenuated by the chimeric decoy ODN, accompanied by inhibition of the migration of macrophages. Also, the effect of chimeric decoy ODN was confirmed in an organ culture. The present study demonstrated that hypertension accelerated the progression of experimental AAA through upregulation of NFkappaB and ets. Inhibition of NFkappaB and ets could be a novel therapeutic strategy to treat AAA in hypertensive patients.

Inhibitory effects of NFkappaB decoy oligodeoxynucleotides on neointimal hyperplasia in a rabbit vein graft model.

Autologous vein remains the commonly used conduit for bypass grafts; however, neointimal hyperplasia is known to be one of the major disease processes in vein graft failure. In this study, we focused on the important role of NFkappaB which controls the expression of numerous genes for various cytokines and adhesion molecules in the mechanism of graft failure. Thus, we investigated the inhibitory effect of NFkappaB decoy oligodeoxynucleotides (ODN) on vein graft failure in a rabbit hypercholesterolemic model. Jugular vein to carotid artery interposition grafts in rabbits were transfected intraoperatively with NFkappaB decoy ODN (40 micromol/l) by ex-vivo pressure-mediated transfection (300 mm Hg, 10 min). Treatment with NFkappaB decoy ODN significantly suppressed intimal hyperplasia 4 weeks after vein implantation as compared to scrambled decoy ODN, and increased medial thickness, leading to a significant reduction in intima-to-media ratio. Treatment with NFkappaB decoy ODN significantly inhibited the recruitment of macrophages and the proliferation of vascular smooth muscle cells (VSMC), while apoptosis in VSMC was significantly increased by NFkappaB decoy ODN. In addition, a study of vascular reactivity demonstrated that transfection of grafts with NFkappaB decoy ODN significantly improved endothelium-mediated vasorelaxation as compared to scrambled decoy ODN. Here, we demonstrated that inhibition of NFkappaB activation using decoy ODN inhibited the development of neointimal hyperplasia, followed by suppression of inflammatory changes and accumulation of VSMC in the neointima of rabbit vein grafts. The present study raises the possibility of a novel strategy for prevention of graft failure.