Type 1a Endoleak after Fenestrated Frozen Elephant Trunk Technique.

The patient was a 48-year-old man who had undergone fenestrated frozen elephant trunk (FET) technique for acute type A aortic dissection. Postoperative enhanced computed tomography (CT) imaging revealed a type 1a endoleak from the fenestration. Nevertheless, the stented portion of the FET exhibited circular expansion. However, 2 months after surgery, enhanced CT imaging revealed the flattening of the FET due to the persistent endoleak and we performed an urgent zone 2 thoracic endovascular aortic repair (TEVAR). When type 1a endoleak from the fenestration is observed, the FET can be flattened, as in this patient, additional intervention should be considered.

Descending thoracic aortic repair outcomes for chronic aortic dissection: a single-centre experience.

OBJECTIVES: Thoracic endovascular aortic repair is a widely accepted treatment for chronic aortic dissection because of good early results compared to open surgical repair. We provide early and long-term results of descending thoracic aortic repair for chronic aortic dissection. METHODS: Patients who underwent descending thoracic aortic repair for chronic aortic dissection between January 2012 and December 2020 at Kawasaki Aortic Centre were included in this analysis. RESULTS: Four hundred ninety-two patients (median age, 64 years; interquartile range, 52-75 years) were included. The median duration of follow-up was 3.2 years (interquartile range, 1.5-5.2 years). The early mortality rate was 2.0% (n = 10); strokes occurred in 17 patients (3.5%); and spinal cord injuries occurred in 30 patients (6.1%). Early major adverse events including early death, stroke, spinal cord injury, tracheostomy and haemodialysis at the time of discharge occurred in 62 patients. Multivariable analysis indicated that age > 70 years and non-elective surgery were predictors of early major adverse events. Among patients without both risk factors (i.e. low-risk patients), 1 early death (0.4%), 3 strokes (1.5%) and 1 spinal cord injury (0.4%) were observed, 2 tracheostomies were performed (0.8%) and no patients required haemodialysis at the time of hospital discharge. The 5-year survival rate was 87.2%. The cumulative incidence of chronic aortic dissection-related aortic reintervention at 5 years was 7.9%. CONCLUSIONS: Descending thoracic aortic repair for chronic aortic dissection resulted in good early and long-term results, and it can serve as the gold standard for low-risk patients.

Mid-Term Results of Frozen Elephant Trunk Technique for Chronic Aortic Dissection.

Objective: In this study, we report our experience using the frozen elephant trunk (FET) technique for chronic aortic dissection. Methods: Between January 2011 and December 2017, 15 patients underwent total arch replacement (TAR) with the FET technique for chronic aortic dissection (CAD). Results: Hospital mortality was 6.7% (n=1). No patients experienced spinal cord injury. Distal stent-induced new entry (dSINE) occurred in the early postoperative period in one patient. There were four unplanned additional operations to manage dSINE. Five patients suffered from dSINE, and aortoesophageal fistula developed in three of them. Short insertion length of the FET and large angle between the distal edge of the FET and the descending aorta were significantly more common in the dSINE group than in the non-dSINE group. The cumulative survival rates at 1, 3, and 5 years were 93.3%, 93.3%, and 66.4%, respectively. The cumulative aortic event-free rates at 1, 2, and 3 years were 85.7%, 77.1%, and 52.9%, respectively. Conclusion: The FET technique for CAD provided good early results. Short insertion length of the FET, however, can induce dSINE, which requires an additional operation at mid-term. Thus, surgical indication of the FET technique for CAD must be discussed.

A Ruptured Mediastinal Bronchial Artery Aneurysm Treated with Urgent Thoracic Endovascular Aortic Repair.

Bronchial artery aneurysms (BAA) are a rare but potentially life-threatening complications because of the massive hemothorax or hemoptysis that occurs with ruptures. A 79-year-old woman was transferred to our hospital because of the sudden onset of back pain, syncope, and subsequent hypotension. Computed tomography showed a left BAA with bilateral hemothorax and hemomediastinum. Transcatheter bronchial artery embolization failed because of the anatomical location, and she went into cardiopulmonary arrest. Cardiopulmonary resuscitation was performed with successful revival. Urgent thoracic endovascular aortic repair to cover the root of the left bronchial artery was successful, and she survived without any neurological deficits.

Association between false lumen segmental arteries and spinal cord ischemia in type A acute aortic dissection.

BACKGROUND: Spinal cord ischemia (SCI) and paraplegia are complications of surgery for type A acute aortic dissection (TAAAD). Since the segmental arteries play a key role in SCI, this study evaluated the association between SCI and false lumen segmental arteries (FLSAs: segmental arteries originating from the false lumen). METHODS: The study included 101 consecutive TAAAD patients (mean age, 66±13; range, 34-89 years) who underwent surgery from January 2011 to April 2017. The diagnosis of TAAAD and the number of FSLAs were determined by preoperative computed tomography (CT). Patients were divided into two groups according to the number of FLSAs at the Th9-L2 level: Group A (N.=13), ≥8 FLSAs; and group B (N.=88), ≤7 FLSAs. Preoperative, perioperative, and postoperative findings were compared between the groups, and risk factors for SCI were evaluated. RESULTS: The frequency of preoperative paralysis was significantly higher in Group A than Group B (P=.0070). The overall incidence of postoperative SCI was 8% (8/101) and significantly higher in Group A than Group B (5/13 [45%] vs. 3/88 (4%), P<0.0001). Hospital mortality was 8% (8/101) and significantly higher in Group A than Group B (3/13 [23%] vs. 5/88 [6%], P=.0302). Multivariate analysis showed that the independent risk factors for SCI were ≥8 FLSAs at Th9-L2 (odds ratio [OR], 20.4; 95% confidence interval [95% CI], 3.34-124.9, P=0.0011) and diabetes mellitus (OR, 22.3; 95% CI, 1.69-294.5; P=0.0184). CONCLUSIONS: In patients who underwent surgery for TAAAD, ≥8 FLSAs at the Th9-L2 levels on preoperative CT was a risk factor for SCI.

Aorto-Esophageal Fistula Caused by Distal Stent Graft-Induced New Entry after Frozen Elephant Trunk Technique for Chronic Aortic Dissection.

We present a case of aorto-esophageal fistula (AEF) caused by distal stent graft-induced new entry (dSINE) after the frozen elephant trunk (FET) technique for chronic aortic dissection. We propose that the combination of the spring-back force and the radial force of the FET may play a role in the occurrence of dSINE, leading to AEF. In this case, we successfully performed a three-stage surgery, including esophagectomy, descending aortic replacement, and esophageal reconstruction. To prevent this critical complication, additional endovascular aortic repair should be performed if the FET is not positioned at the straight portion of the descending aorta.

Single-Stage Surgical Repair of Kommerell Diverticulum with Annuloaortic Ectasia via a Median Sternotomy: Frozen Elephant Trunk Technique with an Antler-Like Shape Reconstruction of Arch Branches.

We present here a case of Kommerell diverticulum (KD) with annuloaortic ectasia, in which single-stage surgical repair was performed via a median sternotomy using frozen elephant trunk (FET) technique. We used this technique for the following reasons: firstly, we could perform surgery only via a median sternotomy without thoracotomy; secondly, we were able to deliver the FET using a guidewire through the severely angulated aortic arch. We here investigate this technique as it could potentially be a good treatment option of KD.

Hybrid Repair for Ruptured Thoracic Aortic Aneurysm: Frozen Elephant Trunk Technique with Thoracic Endovascular Aortic Repair.

We present a case of ruptured thoracic aortic aneurysm (TAA) with type B aortic dissection in which hybrid repair, namely, the frozen elephant trunk (FET) technique with thoracic endovascular aortic repair (TEVAR), was performed. The TAA extended to the proximal descending aorta at the level of the pulmonary trunk bifurcation. We thus employed the FET technique to control the blood flow into the TAA. After performing the FET technique, intraoperative catheter aortography revealed slight type 1B endoleak. We therefore performed additional TEVAR to control the blood flow into the TAA. The patient's postoperative course was uneventful.

Endovascular repair for three-channelled aortic dissection.

Surgical repair of extensive thoracic aortic disease induced by repeated aortic dissection is challenging due to its invasive nature in some cases. We report a rare case of successful endovascular repair of a dissected 3-channelled thoracic aortic aneurysm using the PETTICOAT (provisional extension to induce complete attachment) technique and false-lumen embolization (the candy-plug technique). The PETTICOAT technique improved visceral flow, and the false lumen of the aneurysm was completely thrombosed by the candy-plug technique. This minimally invasive combination technique might be a good option for the treatment of complex dissected thoracic aorta.

Stented balloon fenestration before entry repair using the frozen elephant trunk technique for chronic aortic dissection.

Endovascular fenestration on the abdominal aorta is effective for preventing visceral malperfusion in aortic dissection. We report a case of stented balloon fenestration before residual entry repair using the frozen elephant trunk technique for chronic aneurysmal dissection after ascending aortic replacement for DeBakey I aortic dissection. We recognized poor communication between the true lumen and false lumen in the abdominal aorta, and visceral perfusion depended almost entirely on the proximal large entry. Therefore, we scheduled catheter angioplasty on the small re-entry before upstream entry closure. After balloon angioplasty using a PTA catheter, a 10-mm × 4-cm self-expandable stent was deployed at the re-entry. We performed open surgery 5 days after angioplasty. Computed tomography after entry repair showed complete thrombosis of the false lumen on the descending aorta, and the celiac and superior mesenteric arteries were supplied via the abdominal re-entry stent. Stented balloon fenestration before entry repair using frozen elephant trunk with chronic aortic dissection was effective for preventing visceral malperfusion.

Early- and mid-term aortic remodelling after the frozen elephant trunk technique for retrograde type A acute aortic dissection using the new Japanese J Graft open stent graft.

OBJECTIVES: We previously performed the frozen elephant trunk (FET) technique for acute type A aortic dissection to try to improve the long-term prognosis. In this study, we report the mid-term results of the FET technique for treating retrograde type A acute aortic dissection using a new device, the J Graft open stent graft (JOSG). METHODS: Between January 2008 and December 2015, 24 patients (mean age: 59.3 ± 13.9 years) underwent total arch replacement with the FET technique using the JOSG for retrograde type A acute aortic dissection. All patients had at least 1 year of follow-up imaging. RESULTS: The average outer diameter of the JOSG was 28 ± 2.8 mm (range: 25-35 mm). The average position of the distal edge of the JOSG was Th 6.6 ± 1.1. The cumulative survival rate at 1 year was 91.6%. Postoperative computed tomography 1 year after surgery showed that complete thrombosis was present in all patients at the level of the distal edge of the stent graft and the aortic valve. At the diaphragmatic level, complete thrombosis was seen in 14 (70%) patients, the false lumen was patent in most patients (90%) at the superior mesenteric artery level. CONCLUSIONS: The use of the FET technique with the JOSG for retrograde type A acute aortic dissection provides good outcomes. With the proper use of the JOSG, it is possible to expand the true lumen and eliminate antegrade false-lumen flow, resulting in good aortic remodelling. Furthermore, there should be obliteration of the false lumen from the stent graft to the aortic valve, and this might reduce long-term complications.

Management of cerebral malperfusion in surgical repair of acute type A aortic dissection.

OBJECTIVES: Cerebral malperfusion for patients with acute type A aortic dissection (AAAD) remains an unsolved problem. The present study aimed to evaluate our management of cerebral perfusion and identify predictors of perioperative cerebral malperfusion in patients undergoing surgical repair of AAAD. METHODS: Between January 2004 and December 2015, 137 consecutive patients with AAAD underwent aortic replacement at Tsuchiya General Hospital. The status of the dissected supra-aortic branch vessels (SABVs) was classified as patent or thrombosis by preoperative computed tomographic angiography. Intraoperative cerebral perfusion was monitored by transcutaneous carotid echo and regional oxygen saturation. In cases with neurological symptoms or cerebral malperfusion, quick cerebral perfusion was immediately started using a quick cutdown technique. We assessed clinical outcomes, including mortality and complications, and analysed predictors of early mortality and cerebral malperfusion. RESULTS: The early mortality rate was 8.0%. Postoperative cerebral injury was observed in 4 patients (2.9%). Nineteen patients had perioperative cerebral malperfusion. There were no postoperative cerebral injuries in the patients in whom intraoperative cerebral malperfusion was corrected. Multivariable analysis revealed that preoperative shock (odds ratio [OR] 22.60, P < 0.0001) and extension of dissection to the abdominal aorta (OR 9.31, P = 0.0064) were significant risk factors for early mortality. Preoperative neurological symptoms (OR 12.40, P = 0.0006) and partial or complete thrombosis of the SABV (OR 64.10, P < 0.0001) were identified as independent predictors of perioperative cerebral malperfusion. CONCLUSIONS: Perioperative cerebral perfusion should be carefully managed, especially in the patients with preoperative neurological symptoms or partial or complete thrombosis of the SABV.

Impact of the size mismatch between saphenous vein graft and coronary artery on graft patency.

BACKGROUND: The saphenous vein graft (SVG) is widely used in coronary artery bypass grafting because of its availability and ease of use. However, the patency rate of the SVG grafted to the right coronary artery (RCA) is poor. Diameter mismatch between the coronary artery and SVG is an important cause of graft occlusion. In this study, we assessed how the degree of diameter mismatch affects SVG patency. METHODS: We reviewed the records of 123 patients who underwent aorto-right coronary artery bypass grafting with an SVG. The patency rate of the SVG, SVG diameter, RCA diameter and SVG-RCA diameter ratio (SR ratio) was assessed based on angiography and CT. RESULTS: The mean SVG diameter was 3.61 ± 0.72 mm, the mean RCA diameter was 1.57 ± 0.32 mm and the mean SR ratio was 2.37 ± 0.57. Cumulative patency rate of the SVG was 95.5 % at the early phase, 85.2 % at 1 year, and 70.2 % at 5 years. Multivariate analysis showed that the SR ratio was an independent predictor of SVG occlusion. The cutoff value of the SR ratio was 2.8, calculated from the point of maximal specificity (81.2 %) and sensitivity (64.7 %), and the area under the ROC curve was 0.734. When the SR ratio was ≤2.8, the 3-year patency rate was 86.1 %. CONCLUSIONS: A mismatch between SVG diameter and RCA diameter has an impact on the patency rate of the SVG. Evaluation of the saphenous vein before surgery and selection of a graft to minimize mismatch should improve SVG patency.

A pitfall of false lumen embolization in chronic aortic dissection: intimal injury caused by the embolization device edge.

We report a case of intimal injury caused by the occluder device in the false lumen (FL) after treatment of refractory chronic aortic dissection with FL embolization. We speculate that the intimal injury was due to the disproportionate stress from the FL. We covered the new entry by an additional stent graft in the true lumen. The deployment of a stent device in both lumens at the level of embolization might be indispensable for FL embolization.

Endovascular Repair by Graft-to-Graft Bridging in a Patient with Marfan Syndrome.

We report a case of chronic aortic dissection in a patient with Marfan syndrome in which we performed thoracic endovascular repair after aortic root replacement, total arch replacement with open stent grafting and thoracoabdominal aortic repair. We consider that endovascular repair of the dissected descending aorta in a patient with Marfan syndrome can be effective when graft-to-graft bridging is performed as the "finishing procedure".

Right Atrial Calcified Ball Thrombus Mimicking a Myxoma.

An 80-year-old woman was admitted to our hospital because of congestive heart failure. Transthoracic echocardiography revealed severe aortic valve stenosis, and a mobile calcified mass was attached to the interatrial septum in the right atrium. We suspected that the mass was cardiac myxoma. We urgently performed aortic valve replacement and resection of the mass. The histological diagnosis of the mass was thrombus, and her post-operative course was uneventful. Although the mechanism of right atrial thrombus formation in our case was unclear, it is important to continue anticoagulation therapy after surgery to avoid recurrence. Furthermore, strict follow-up in this patient is needed.

Patch Repair for a Subepicardial Aneurysm With an Approach From Inside the Heart.

We present a case of subepicardial aneurysm that developed as a complication of acute myocardial infarction. Although the patient had stable hemodynamics, the diameter of the aneurysm tended to increase over time; thus, an operation was performed. We thought that approaching the aneurysm from outside the heart would injure the papillary muscle or distort the left ventricle and exacerbate mitral regurgitation. Therefore, we performed patch repair using bovine pericardium and approached the aneurysm from inside the heart. This is the first case report of a subepicardial aneurysm that was approached and repaired from inside the heart.

Single-Stage Repair of Thoracic Aortic Aneurysm through a Median Sternotomy in a Patient with Pseudocoarctation of the Aorta and Severe Aortic Valve Stenosis.

Pseudocoarctation of the aorta is a rare anomaly and considered a benign condition. Pseudocoarctation of the aorta has been associated with aneurysm formation in the thoracic aorta, which may cause sudden rupture or dissection. Thus, the presence of an aneurysm in combination with pseudocoarctation of the aorta is thought to be an indication for surgery. We present a case of pseudocoarctation of the aorta associated with thoracic aortic aneurysm and severe aortic valve stenosis with a bicuspid aortic valve. In our case, single-stage repair was performed through a median sternotomy using our "pleural-window approach."