Staged hybrid repair for a patient with chronic type B aortic dissection.

Vascular prosthesis replacement and thoracic endovascular repair (TEVAR) are used to treat patients with enlarged chronic type B aortic dissection. A case in which thrombosis of the false lumen was achieved by the staged combination of these two methods is presented. A 41-year-old woman with a thoracoabdominal aortic aneurysm (maximum short diameter 44 mm) identified 5 years earlier was being monitored as an outpatient in our department when she presented with back pain. Computed tomography (CT) showed acute type B aortic dissection (DeBakey type IIIa), which was managed conservatively. When CT showed an aortic dissection with a patent false lumen immediately below the left subclavian artery bifurcation, one-debranching TEVAR was performed to close the entry, along with right axillary artery to left axillary artery bypass surgery. Outpatient CT at 3 months postoperatively showed rapid enlargement in the vicinity of the celiac artery. Thoracoabdominal aortic replacement to prevent rupture was performed, and the patient was then monitored as an outpatient. CT at age 43 years showed enlargement of the residual false lumen. Additional TEVAR was successfully performed. Thus, three-stage treatment was conducted to enlarge the residual false lumen, causing successful thrombosis of the false lumen.

Ratio of the false lumen to the true lumen is associated with long-term prognosis after surgical repair of acute type A aortic dissection.

Objectives: The aim of this study was to assess potential predictors of aortic events after an emergency surgery for acute type A aortic dissection, especially paying attention to the findings of computed tomography (CT) performed immediately after the surgery. Methods: Between January 2001 and December 2015, 72 patients, who were diagnosed as having Stanford type A acute aortic dissection with a patent false lumen in the descending thoracic aorta, survived the emergency operation, and had postoperative CT scan data, were included in this study (mean follow-up, 8.2 ± 3.8 years; range 0.8-17.4 years). From the CT scan data, the diameter of the false lumen (FL-D) and true lumen (TL-D) were measured, and the FL-D:TL-D ratio was calculated. Long-term outcomes of the FL-D > TL-D group (n = 30) and the FL-D < TL-D group (n = 42) were compared. Results: In the late follow-up, 17 aortic events in the downstream aorta were observed. The FL-D:TL-D ratio (P = .01) was an adjusted risk of aortic events in multivariable analysis. The rates of freedom from aortic events at 5 and 9 years were superior in the FL-D < TL-D group than in the FL-D > TL-D group (92.0% and 88.6% vs 81% and 60.7%; log rank P < .05). Conclusions: Our results suggest that the false lumen:true lumen ratio predicts long-term prognosis after surgical repair of acute type A aortic dissection.

Long-term results of modified bentall procedures: 18-year experience of the flanged technique.

OBJECTIVES: To evaluate the early and late outcomes of the modified Bentall procedure with the flanged technique. METHODS: We reviewed the medical records of 63 patients who had undergone root replacement by the modified Bentall procedure at our institute between January 2001 and December 2018. In most cases, we adopted a composite graft constructed with a mechanical valve or bioprosthesis and a Dacron graft by the flanged technique. Since 2011, we have used Valsalva grafts. RESULTS: Mean age 57 ± 16 years, range 16-80, male 43 cases. The mean follow-up was 75 ± 56 months (range 0-216). Through April 1, 2020, we could follow up on 61 cases (97%) within a six-month period. Hospital mortality was 7.9% (4.8% in elective cases). In late follow-up, eight deaths were observed. In the bio-Bentall group (n=26), no deaths or major adverse valve-related events (MARVEs) occurred. In the mechanical Bentall group (n=37), seven cases of MARVEs, including two cerebral hemorrhages and one cerebral embolism, were observed. All patients were free from MARVEs at 5 years post procedure in the bio-Bentall group, and 93.8% and 76.8% were event-free at 5 years and 10 years, respectively, in the mechanical Bentall group. CONCLUSIONS: The 18-year results of the modified Bentall procedure were acceptable, providing excellent outcomes in the bio-Bentall group. The flanged technique enabled the use of a larger prosthesis, which may have resulted in good durability with the bio-Bentall procedure.

Impending rupture of abdominal aortic aneurysm due to spontaneous obstruction of aortocaval fistula after endovascular abdominal aortic aneurysm repair.

Endovascular aortic aneurysm repair (EVAR) is a valid treatment for patients with abdominal aortic aneurysm with aortocaval fistula. However, an endoleak can be caused by persistent communication between the aneurysm and the inferior vena cava. We present a case of impending rupture due to spontaneous obstruction of an aortocaval fistula after EVAR. Spontaneous obstruction of an aortocaval fistula is rare; however, when occurs, it will cause an endoleak, followed by dilatation or impending rupture of the abdominal aortic aneurysm. EVAR alone for aortocaval fistula will sometimes not be adequate if the type II endoleak is patent.

The results of an entry-oriented strategy for acute type A aortic dissection in octogenarians: an 18-year experience.

OBJECTIVES: The aim of this study was to evaluate the 18-year results of emergency operations for acute type A aortic dissection, especially in octogenarians. METHODS: We reviewed 199 patients who underwent surgical aortic repair of an acute type A aortic dissection from January 2001 to December 2018. If the primary entry existed in the ascending aorta, we limited the extent of the replacement to within the ascending aorta. We analysed the early and late outcomes and identified the predictive factors for in-hospital death and difficulty of direct discharge to home. RESULTS: The hospital mortality was 16%. The causes of death were postoperative bleeding (n = 8, 4%), intestinal ischaemia (n = 6, 3%), respiratory failure (n = 5, 3%), systemic inflammatory response syndrome (n = 4, 2%), low output syndrome (n = 3, 2%), sudden death (n = 3, 2%), myonephrotic metabolic syndrome (n = 2, 1%) and stroke (n = 1, 1%). Multivariable analysis revealed that an estimated glomerular filtration rate <30 (P = 0.006), malperfusion (P = 0.001), rupture (P < 0.001) and cross-clamping time (P = 0.003) were independent predictive factors of in-hospital death. Age was not a significant factor for predicting in-hospital death. Ascending aorta replacement (P = 0.013), advanced age (P = 0.002) and prolonged extracorporeal circulation time (P = 0.009) were independent predictive factors of difficulty in direct discharge to home. In the late follow-up period, the 5-year survival and aortic event-free rates were 62.2% and 88.9% in octogenarians, respectively. CONCLUSIONS: From the perspective of saving lives, the results of emergency surgery for octogenarians were acceptable. Avoiding the postoperative decline in activities of daily living in octogenarians is a consideration going forward.

Late Gadolinium Enhancement Predicts Improvement in Global Longitudinal Strain after Aortic Valve Replacement in Aortic Stenosis.

Myocardial fibrosis, as detected by late gadolinium enhancement (LGE) magnetic resonance imaging (MRI), is related to mortality after aortic valve replacement (AVR). This study aimed to determine whether LGEMRI predicts improvement in global longitudinal strain (GLS) after AVR in patients with severe aortic stenosis (AS). Twenty-nine patients with severe AS who were scheduled to undergo AVR were enrolled. Two-dimensional echocardiography and contrast-enhanced MRI were performed before AVR. GLS and LGEcore (g: > 5 SD of normal area), LGEgray (g: 2-5 SD), and LGEcore+gray (g) were measured. One year after AVR, GLS were examined by echocardiography to assess improvement in LV function. Preoperatively, GLS correlated with LGEcore (g) (r2 = 0.14, p < 0.05), LGEgray (g) (r2 = 0.32, p < 0.01) and LGEcore+gray (g) (r2 = 0.36, p < 0.01). LGEcore was significantly lower in patients with improved GLS after AVR (GLS1year ≥ -19.9%) compared to those with no improvement (1.34 g vs. 4.70 g, p < 0.01). LGE predicts improvement in LV systolic function after AVR.

Long-Term Outcomes of Spontaneous Isolated Superior Mesenteric Artery Dissection.

Spontaneous isolated dissection of the superior mesenteric artery (SMAD) is not still well known. We retrospectively analyzed our 30 patients with SMAD to elucidate the treatment strategy and long-term follow-up outcomes. Due to severe abdominal symptom we performed a stents deployment and surgical reconstructive surgery for each one case. Anerysmectomy and bypass surgery was performed for a patient with aneurysmal change. Other 27 patients were managed conservatively. SMAD patients had only two vascular events (renal infarction and graft occlusion), and showed good prognosis for 6-146 (mean 69) months follow-up. We found that there is a few SMAD patients necessary of invasive management at acute phase and that most patients are safely conservatively treated with good prognosis. (This is a translation of J Jpn Coll Angiol 2018; 58: 195-199.).

Tricuspid and Mitral Valve Regurgitation with Bi-fascicular Block Following a Horse Kick.

A 40-year-old man was transferred to our hospital following an isolated horse kick injury to the anterior chest wall. The case showed bi-fascicular block, severe tricuspid valve regurgitation due to ruptured chordae tendineae of the anterior leaflet, moderate mitral valve regurgitation due to prolapse of mitral anterior leaflet, and hypokinetic motion of the inferior septal wall. Both tricuspid and mitral insufficiency were completely repaired by a surgical operation. Fortunately, these injuries were not fatal in this case, but the comprehensive assessment of cardiac damage and careful observation are important for managing patients with cardiac injury.

Inferior Mesenteric Artery Aneurysm Complicated With Occluded Celiac and Superior Mesenteric Artery After Replacement of Thoracoabdominal Aorta for Chronic Dissected Thoracoabdominal Aortic Aneurysm.

We report a case of inferior mesenteric artery aneurysm (IMAA) after the replacement of the thoracoabdominal aorta for a chronic dissected thoracoabdominal aortic aneurysm in which the celiac artery and superior mesenteric artery were occluded. We performed the resection of the IMAA and the revascularization of the superior mesenteric artery, inferior mesenteric artery, and meandering artery. The patient's postoperative course was uneventful, without bowel ischemia. From the findings of intraoperative flow measurement of the visceral arteries, revascularization of the superior mesenteric artery was judged to be appropriate in this situation.

Prevention of Embolization in Concomitant Endovascular Therapy for Thoracic and Abdominal Aneurysms with Severely Atheromatous Aorta.

A 74-year-old man with multiple aortic aneurysms and shaggy aorta was simultaneously treated by conventional open repair for an abdominal aortic aneurysm and endoluminal stent grafting for a thoracic aortic aneurysm. We performed intermittent clamping of the visceral and carotid arteries under an extracorporeal circulation circuit without a blood flow pump, which lead to the avoidance of embolization in spite of the disadvantage of endoluminal stent grafting for atheromatous aorta.

Video-assisted endoscopic resection of left ventricular papillary fibroelastoma through the aortic valve.

Papillary fibroelastoma is a rare, benign cardiac tumor. Surgical resection is indicated to prevent embolization. We herein report a case of a 78-year-old asymptomatic man who was found to have a mobile left ventricular papillary fibroelastoma anchoring deep in the left ventricle by incidental transthoracic echocardiography. The tumor was resected under visualization by a video-assisted rigid endoscope with a flexible head inserted through the aortic valve into the left ventricle. Intraoperative frozen section analysis provided a pathological diagnosis of papillary fibroelastoma. The postoperative course was uneventful. This technique is recommended for the observation and resection of a tumor anchoring deep in the left ventricle and is helpful for avoiding the adverse effects of left ventriculotomy.

[Efficacy of Early Surgical Strategy for Active Infective Endocarditis].

UNLABELLED: The aim of study was to analyze the outcome of aggressive, early surgical intervention to active infective endocarditis (IE) complicated by acute congestive heart failure, uncontrollable infection and large, mobile vegetation and to evaluate the validity of current therapeutic strategy on it's long-term outcome. PATIENTS AND METHODS: We retrospectively investigated surgical outcome of 51 patients who underwent surgical intervention to eradicate intra-cardiac infection and to reconstruct subsequent structural destruction due to active IE performed between 2002 and 2013. Patient's mean age was 56 ± 17 (14~83) years and 36 males, 2 prior cardiac surgery-performed and 2 hemodialysis-dependent renal failure patients were included. All patients were followed on long-term basis. Mean follow up duration was 61 ± 46 (1~164) months. We classified patients into 2 groups according to urgency of surgical intervention:early surgical (ES) group who underwent surgery within 2 weeks from diagnosis of IE and conservative surgical (CS) group who underwent after 2 weeks more from the diagnosis. RESULTS: Two patients died during hospitalization due to low cardiac output syndrome (LOS) for ischemic myopathy after old myocardial infarction and postoperative ischemic colitis (preoperative hemodialysis-dependent patient). Two cerebral infarctions and 1 hemorrhagic transformation of cerebral infarction occurred postoperatively. There was no mediastinal infection and recurrent intracardiac infection postoperatively. On long-term follow up, cumulative survival was 90/79/68% in 1/5/10 years. on ES group and 100/89/79% in 1/5/10 years. on CS group, respectively. Freedom from cardiac death were 100/100/100% in 1/5/10 years. on ES group and 100/100/100% in 1/5/10 years. on CS group, respectively. There were 1 cardiac death(125 months after operation) and 8 non-cardiac deaths on long-term survival. CONCLUSION: Early surgical strategy for active infective endocarditis to prevent IE-related preoperative adverse complications seems to be acceptable.

[Coronary Artery Bypass Surgery in Acute Coronary Syndrome].

Acute coronary syndrome (ACS) is a critical situation. Early reperfusion is important to improve not only infarction size but also survival expectation rate. Percutaneous coronary intervention is in the 1st line in emergency situation to achieve earl perfusion. In this situation, urgent coronary artery bypass grafting (CABG) in ACS is indicated in patient with coronary anatomy not amenable to percutaneous transluminal coronary angioplasty (PCI) who have ongoing or recurrent ischemia, cardiogenic shock, severe heart failure, or other high-risk feature. When the patient does not require urgent treatment, CABG would be indicated according to the guideline for the management of stable angina as CABG is superior to PCI in regarding long-term survival and free from re-intervention. Even in any situations, decision making in heart team is important, especially in case of complicated and difficult situations.

Management strategy of isolated spontaneous dissection of the superior mesenteric artery.

OBJECTIVE: Isolated spontaneous dissection of the superior mesenteric artery (SMA) is very rare among of the visceral artery dissection and its treatment is not established. In this paper we present our experiences and consider the treatment of isolated SMA dissection. METHODS: A retrospective review of our cases from 2005 was performed. Clinical symptoms, radiologic findings and results were evaluated. There were 14 cases of visceral artery dissection, in which all cases were with SMA dissection. There were 12 males and 2 females with a mean age of 57 years (range 41-78 years). RESULTS: We categorized SMA dissection into the six types according to the Sakamoto's and Zerbib's classification. One patient with type VI underwent emergent endovascular surgery with stent. One patient with type VI received thrombectomy and intimectomy with open surgery. One patient with type II underwent aneurysmectomy due to enlarged dissected SMA 3 months later from onset. The other eleven patients were managed conservatively. At follow-up, the diameter of SMA did not enlarged and the length of the dissection significantly decreased to 20.7 ± 15.7 mm from 38.0 ± 15.1 mm at onset (p <0.01). After treatment, imaging indicated the following changes in classification: type I, one patient; type II, 4 patients; type IV, 4 patients; complete remodeling, one patient, all without any event during the follow-up period of 5-82 months. CONCLUSION: Most patients with isolated visceral artery dissection occurred in superior mesenteric artery and can be treated conservatively; however, endovascular or surgical procedures including laparotomy are indicated when there is suspicion of severe mesenteric ischemia. Because the dissection configuration will change, long term follow-up is necessary. (English translation of Jpn J Vasc Surg 2013; 22: 695-701).

Effects of phenylephrine and noradrenaline on coronary artery motion in an open-chest porcine beating heart model.

PURPOSE: During off-pump coronary artery bypass (OPCAB), surgeons are required to perform a precise anastomosis on the beating heart. The hypotension caused by vertical displacement of the heart during OPCAB is usually treated with vasopressors, such as noradrenaline and phenylephrine. However, the effects of these agents on coronary artery motion are unknown. The present study analyzed the motion of the target coronary arteries during noradrenaline or phenylephrine infusion using three-dimensional motion capture and reconstruction technology. METHODS: The left anterior descending (LAD) artery, left circumflex (LCX) artery and right coronary artery (RCA) of 12 female landrace pigs (weight 50 ± 1 kg) were stabilized using a tissue stabilizer. The motions in the regions were captured before and during noradrenaline (n = 5) and phenylephrine (n = 7) infusion. RESULTS: Noradrenaline (0.15 µg/kg/min) and phenylephrine (1.1 µg/kg/min) significantly increased the blood pressure. Noradrenaline significantly increased the motion parameters, such as the distance moved, maximum velocity, acceleration and deceleration at the LAD (4.2 vs. 7.9 mm, P = 0.025; 95.7 vs. 215.5 mm/s, P = 0.0074; 35.3 vs. 83.6 m/s(2), P = 0.0096 and -35.6 vs. -83.6 m/s(2), P = 0.005, respectively). The values during phenylephrine infusion did not change except for the distance moved at the LAD (3.8 vs. 7.7 mm, P = 0.042). The motion parameters at the LCX and RCA during noradrenaline and phenylephrine infusion did not change significantly. CONCLUSIONS: The effect of phenylephrine on the coronary artery motion was less dramatic than that of noradrenaline.

Intraoperative thrombectomy for occluded carotid arteries in patients with acute aortic dissection: report of two cases.

The present study describes two cases in which intraoperative thrombectomy was performed for occluded or severely stenosed carotid arteries in patients with acute aortic dissection complicated by cerebral malperfusion. A Fogarty catheter was inserted into the true lumen of the occluded branch under hypothermic circulatory arrest, and thrombi within the false lumen were removed. The arch vessels were patent on subsequent computed tomographic imaging, and no neurological complications were found postoperatively. In these cases, the choice of appropriate management strategies took into consideration the brain ischemic time and the presence or absence of cerebral infarction. This technique represents a useful option for the management of this clinical scenario.

Thoracic endovascular aortic repair with visceral arteries intermittent clamp technique for descending thoracic aortic aneurysm with shaggy aorta.

Aortic repair for severely atheromatous aneurysm remains a challenge. We used an intermittent clamp technique for all visceral arteries during thoracic endovascular aortic repair (TEVAR) for a thoracic aortic aneurysm with a "shaggy aorta" to prevent systemic thromboembolism. In addition, we applied an extracorporeal circulation circuit to trap the thrombi during the endovascular repair. Postoperatively, no embolic complications were seen, and microscopic examination showed trapped plaques on the filter. We conclude that this technique is an option for preventing thromboembolism in aortic aneurysm repair in the context of a shaggy aorta when substantial concern of distal diffuse atheromatous emboli is raised based on clinical history or clear evidence on imaging.

Left ventricular noncompaction complicated by mitral valve prolapse: report of a case.

A 31-year-old male was diagnosed with congestive heart failure due to left ventricular noncompaction and coarctation of the aorta by echocardiography and computed tomography. He also developed mitral valve prolapse of the posteromedial commissural leaflet due to rupture of chordae tendineae. Segmental leaflet resection was performed with ring annuloplasty. Aorto-bifemoral bypass was carried out simultaneously to attenuate the ventricular afterload. His postoperative course was uneventful.

Open-stent grafting with a GORE TAG thoracic endoprosthesis for an extended severely atheromatous thoracic aortic aneurysm: report of a case.

An 82-year-old man with asthma and chronic obstructive pulmonary disease experienced sudden back pain. Chest computed tomography (CT) showed a thoracic aortic aneurysm (TAA) 63 mm in maximum diameter, with severe atheromas, representing "shaggy aorta", extending down to the level of the ninth thoracic vertebra. Emergency surgery was necessitated by the impending rupture of the aneurysm. The patient underwent successful total arch replacement with open-stent grafting using a GORE(®) TAG(®) thoracic endoprosthesis. His postoperative course was uneventful and there were no neurological complications. We discuss the advantages and disadvantages of using the GORE TAG system for an open-stent graft.