Extensive Aortic Stent Graft Coverage for Thoracoabdominal Aortic Aneurysm is Associated With Hemorrhagic Complications Induced by Disseminated Intravascular Coagulation.

BACKGROUND: Hybrid endovascular repair for thoracoabdominal aortic aneurysm (TAAA) is a less invasive alternative treatment than conventional open repair. However, disseminated intravascular coagulation (DIC) and hemorrhagic complications can occur postoperatively. We investigated risk factors for hemorrhagic complications after hybrid endovascular TAAA repair. METHODS: Sixty-one patients who underwent elective hybrid endovascular TAAA repair between 2007 and 2020 were included. Laboratory data before and after placing stent graft were collected, and DIC was diagnosed using a scoring system established by the Japanese Association for Acute Medicine. The length of the stent graft used to cover the aorta was defined as the aortic coverage length, which was measured using the first postoperative computed tomography image. Predictors of unexpected hemorrhagic complications were evaluated. RESULTS: Postoperative thrombocytopenia was observed in 57 (93%) patients, and their platelet count decreased significantly after stent graft placement (14.3 [9.5-18.0] vs. 8.2 [5.4-10.9] × 104/µL, P < 0.001). Fifteen (25%) and 45 patients (74%) were diagnosed with DIC before and after stent graft placement, respectively. Hemorrhagic complications were observed in 21 patients (34%). Multivariate logistic regression analysis revealed that aortic coverage length was an independent risk factor for hemorrhagic complications (odds ratio 1.441/50 mm increase; 95% confidence interval, 1.041-1.994, P = 0.027). The cutoff value for aortic coverage length obtained from the receiver operating characteristic curve (area under the curve = 0.72) was 304.4 mm (sensitivity 0.76, specificity 0.70). CONCLUSION: Aortic coverage length is a risk factor for hemorrhagic complications. Patients undergoing extensive aortic coverage greater than 304 mm should be closely monitored.

True Aneurysm of the Left Main Trunk in a Marfan Syndrome Patient at Remote Period after Bentall Operation and Total Arch Replacement: A Case Report.

In 2002, a 37-year-old male with Marfan syndrome underwent the Bentall operation, total arch replacement, and aortobifemoral bypass for DeBakey type IIIb chronic aortic dissection, annuloaortic ectasia, and aortic regurgitation. In 2007, mild mitral regurgitation (MR) caused by mitral valve prolapse was identified. In April 2017, echocardiography revealed the worsening of MR and moderate tricuspid regurgitation (TR). Moreover, coronary angiography (CAG) revealed a coronary artery aneurysm in the left main trunk (LMT). In August 2017, the patient underwent mitral valve replacement (MVR), tricuspid annuloplasty (TAP), and coronary artery reconstruction. We reconstructed the LMT aneurysm using an artificial graft. True aneurysm of the coronary artery complicated with Marfan syndrome is a rare complication that has seldom been reported. This case highlights that it is essential to carefully follow-up patients with Marfan syndrome after the Bentall operation.

A case of ruptured aneurysm of coronary-pulmonary artery fistula diagnosed after emergency thoracotomy.

BACKGROUND: Coronary fistulae are occasionally detected using echocardiography or coronary angiography. We report a patient with cardiac tamponade because of a ruptured aneurysm of a coronary artery fistula. CASE PRESENTATION: A 60-year-old man was referred to our hospital with sudden onset of chest pain and unconsciousness. He was initially diagnosed with cardiac tamponade for type A acute aortic dissection, and an emergency operation was performed. A large amount of bleeding was seen in the pericardium, but aortic dissection around the arch was not observed. Instead, a ruptured aneurysm of a coronary-pulmonary fistula was identified on the pulmonary artery root. The aneurysm was resected, and the fistula was closed by ligation. The patient's postoperative progress was good, and he was discharged on postoperative day 12 without any abnormalities on the coronary arteriogram. CONCLUSIONS: Preoperative diagnosis of the rupture of the small coronary artery aneurysm is difficult in such an emergency case, and this possibility should be considered in differential diagnosis when the CT image does not show typical aortic dissection.

Difficult preoperative diagnosis in a case of rapidly progressive carcinomatous pericarditis.

A 54-year-old woman initially diagnosed with stage IIIb squamous cell carcinoma of the uterine cervix was treated with chemotherapy and radiation therapy. After 8 months, she developed dyspnea, leg edema, pleural effusion, pericardial effusion, and liver congestion. Her cardiac ejection fraction was normal and cardiomegaly was not evident. Metastatic carcinomatous pericarditis or pleurisy was suspected, but laboratory findings, including tumor markers, were normal. She was transferred to our hospital for the repair a cardiac injury caused by a pericardial drainage procedure. Emergency surgery was performed for the misplaced drainage catheter in the right atrium and for an abnormal mass in her right and left atria. The clinical diagnosis of carcinomatous pericarditis was made; however, her condition rapidly deteriorated, and she died 6 days postoperatively. At autopsy, metastasis was identified in a large area of the pericardium and myocardium.

Extended observation of the nasal cycle using a portable rhinoflowmeter.

OBJECTIVE: Nasal patency varies owing to the effects of humidity, temperature, and exercise. In addition, periodic cycles of congestion and decongestion that alternate between the right and the left side of the nose, which are termed the "nasal cycle," have been observed. The physiologic mechanisms underlying this cycle are not clear. Sympathetic nerves that supply the nose are regulated by the hypothalamus and the vasomotor areas of the brainstem. It is possible that the nasal cycle could be involved in protection against respiratory infection or allergies. Conventional methods of studying the nasal cycle, including rhinomanometry and acoustic rhinometry, impose limitations on the location and timing of evaluation. We studied the nasal cycle using a new portable device for relatively long-term rhinoflowmetry. METHODS: Twenty normal subjects aged 24 to 77 years were fitted with the portable rhinoflowmeter (Rhinocycle, Rhinometrics, Lynge, Denmark) to continuously measure nasal air flow via each nostril over 12 daytime hours. RESULTS: No subject complained of discomfort owing to the device, and 14 of them showed a detectable nasal cycle. The mean nasal cycle duration was 110 minutes, although variation was considerable, even in a single subject. CONCLUSIONS: The portable device proved useful for observing the nasal cycle, and it should be valuable for the general investigation of nasal physiology.

[Changes in the nasal NO level, nasal resistance, and nasal patency before and after exercise in normal subjects].

The nasal mucosa plays an important role in human disease resistance by repeatedly constricting and expanding. The nasal membrane also shrinks after exercise and thereafter recovers gradually. We studied exercise-induced changes in nasal NO, nasal resistance, and a minimal cross-sectional area in normal subjects and discuss the role of nasal NO. Subjects were 11 healthy adults (5 men and 6 women 24-52 years of age). They underwent a 6-minute fixed-load treadmill exercise, walking about 6 km/hr for 6 minutes. The nasal NO level, nasal resistance, and minimal cross-sectional area were measured consecutively before exercise, immediately after exercise, and at 5, 10, 15, 20, 25, and 30 minutes after exercise. Nasal resistance is known to decrease immediately after exercise and thereafter gradually increases until it reaches baseline levels. The minimal cross-sectional area increases immediately after exercise, but returns to baseline levels thereafter. The nasal NO level decreases immediately after exercise, but does not show changes parallel to nasal resistance or minimal cross-sectional area. The nasal NO level increases gradually, but then suddenly decreases at around 20 or 25 minutes after exercise. Its level thus shows 2 dips. This pattern is caused by a depletion of the NO substrate. As a result, NO is required by the various exercise-induced changes in many parts of the body. These findings suggest that NO production is related to the maintenance of homeostasis.