Mid-term outcomes of physician-modified endograft therapy for complex aortic aneurysms.

OBJECTIVES: Our goal was to evaluate early and mid-term outcomes of physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms from 10 Japanese aortic centres. METHODS: From January 2012 to March 2022, a total of 121 consecutive adult patients who underwent physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms were enrolled. We analysed early and mid-term postoperative outcomes, including postoperative complications and mortality. RESULTS: The pararenal and thoraco-abdominal aortic aneurysm groups included 62 (51.2%) and 59 (48.8%) patients, respectively. The overall in-hospital mortality rate was 5.8% (n = 7), with mortality rates of 3.2% (n = 2) and 8.5% (n = 5) in pararenal and thoraco-abdominal aortic aneurysm groups, respectively (P = 0.225). Type IIIc endoleaks occurred postoperatively in 18 patients (14.9%), with a significantly higher incidence (P = 0.033) in the thoraco-abdominal aortic aneurysm group (22.0%, n = 13) than in the other group (8.1%, n = 5). Major adverse events occurred in 7 (11.3%) and 14 (23.7%) patients in pararenal and thoraco-abdominal aortic aneurysm groups (P = 0.074), respectively. The mean follow-up period was 24.2 months. At the 3-year mark, both groups differed significantly in freedom from all-cause mortality (83.3% and 54.1%, P = 0.004), target aneurysm-related mortality (96.8% and 82.7%, P = 0.013) and any reintervention (89.3% and 65.6%, P = 0.002). Univariate and multivariate regression analyses demonstrated that ruptures, thoraco-abdominal aortic aneurysms and postoperative type IIIc endoleaks were associated with an increased risk of all-cause mortality. CONCLUSIONS: The mid-term outcomes of physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms were clinically acceptable and comparable with those in other recently published studies. Notably, pararenal and thoraco-abdominal aortic aneurysms represent distinct pathological entities with different postoperative outcomes.

[Staged Fenestrated Endovascular Repair of Thoracoabdominal Aneurysm].

Fenestrated endovascular repair (FEVAR) can be a treatment option for thoraco-abdominal aneurysm( TAAA), especially in the cases with high surgical risks. Spinal cord ischemic injury( SCI) continues to be the most devastating complication, that has multifactorial etiologies including embolic events and coverage of Adamkiewicz's artery (AKA). Recently, we experienced a case of Crawford III TAAA. The 77 year-old male had multiple comorbidities including recent myocardial infarction, chronic heart failure with reduced ejection fraction, and an end-stage renal disease. A colostomy was located on the left side of the abdomen after the surgical resection of rectal cancer. The AKA was originated from the intercostal artery at the level of the tenth thoracic vertebra( THV), which was intended to be covered by a stent-graft. To reduce the risk of SCI, FEVAR was scheduled in a staged fashion, with the proximal coverage up to the tenth THV and a branch-typed endovascular reconstruction of the celiac artery performed as the first stage treatment. The completion repair was achieved in 4 weeks, with the remaining superior mesenteric and renal arteries successfully stented. Neither SCI nor endoleak was detected periprocedurally.

Physician-modified endograft using three-dimensional model-assisted planning.

Objective: Case-specific and true-to-scale three-dimensional (3D) models have become increasingly useful tools for physician-modified endovascular grafting. This study aimed to validate the use of 3D model-assisted planning for fenestration design. Methods: Thirty-two consecutive patients (2019-2021) presenting with pararenal or juxtarenal abdominal aortic aneurysm (n = 16), paravisceral abdominal and Crawford's extent IV thoracoabdominal aortic aneurysm (n = 12), and type I endoleak after endovascular repair (n = 4) were analyzed retrospectively. All cases were planned manually with a standard method using curved planar reconstruction stretch images and multiplanar images perpendicular to the centerlines. The design was finalized by intraoperative 3D model-assisted planning. Intermethod agreements were assessed for geometrical relationships (separation heights and angles) between the superior mesenteric and renal arteries. The datasets from 55 double measurements of the entire cohort in this series were used to assess measurement discrepancies (≥3 mm separation height or ≥15° angle difference) and fenestration mismatches (≥3 mm separation between the manually planned and 3D model-assisted-planned renal arterial centers on the device surface) between manual and 3D model-assisted planning. Statistical analyses were performed to test the impact of anatomical factors on the discrepancies and mismatches. The imposition accuracy of 3D model-assisted planning and short-term clinical results of the 32 cases were also evaluated. Results: Fourteen fenestration measurement discrepancies were detected. The size of the stent graft (P = .0381), the aortic angle (P = .0008), and the prior existence of stent graft (P = .0123) were found to have a statistically significant impact on the measurement discrepancy, using single logistic and Fisher's exact tests. Twelve fenestration mismatches were observed and found to be significantly affected (P = .0039) by aortic angle. A cutoff value for fenestration mismatch was found to be 36.5°, with a sensitivity and specificity of 69.2% and 80.5%, respectively, using receiver operating characteristic analysis (area under the curve, 0.782 ± 0.081; P = .0023). A high level of branch preservation (100%) was achieved. During the observation period (1.3 years on average; range, 0.5-2.5 years), no patient experienced complications related to fenestration. Conclusions: The differences between the planning methods were non-negligible. However, 3D model-assisted planning increased the precision of the fenestration design when the conformation of the stent graft to the aortic anatomy is taken into account.

Intermittent endoleak via an aneurysm-iliac venous fistula after endovascular aneurysm repair.

We have reported the rare case of an intermittent endoleak via an aneurysm-venous fistula (AVF). An 89-year-old woman had experienced postoperative sac expansion 6 years after she had undergone endovascular aneurysm repair. During aneurysmorrhaphy, we detected a small AVF, which was the source of the endoleak responsible for the aneurysmal sac expansion. This AVF had a check valve-like mechanism that allowed the inflow of blood from the iliac vein to the sac when the venous pressure exceeded the endotension. Our case has demonstrated the occurrence of an AVF after endovascular aneurysm repair that had resulted in an endoleak that was invisible on imaging studies and the presence of endotension.

Case of an octogenarian with an asymptomatic double aortic arch undergoing CABG.

Double aortic arch is a rare congenital anomaly of the aortic arch system where a complete vascular ring is formed around the trachea and esophagus. Case reports of elderly patients are extremely rare. We report a case of coronary bypass grafting in an elderly patient with right-dominant DAA.

[Cardiac Surgery for Mitral Regurgitation Associated with Essential Thrombocythemia].

An 80-year-old woman with essential thrombocythemia was diagnosed with severe mitral regurgitation and moderate tricuspid regurgitation. Preoperatively, she had been treated with hydroxycarbamide and low-dose aspirin since her platelet count was high( 96.2×104/µl). After the platelet count was reduced to 46.2×104/µl, she underwent mitral valve repair and tricuspid valve annuloplasty. Atypical heparin resistance was noted intraoperatively. After initial heparin infusion, the activated clotting time(ACT) increased as expected. However, it decreased after initiation of cardiopulmonary bypass, despite additional heparin infusion and heparin concentration maintenance. A correlation between platelet factor 4 and heparin resistance was suggested. On discharge, she had no complications. We should consider the possibility of heparin resistance in essential thrombocythemia even when platelet count is adequately controlled.

Quadricuspid aortic valve repair by neo-cuspidization of an accessory cusp using autologous pericardium.

We present a successful case of the management of a 46-year-old woman with an abnormal aortic valve formed by four cusps (three equal large cusps and one smaller cusp; type B according to the Hurwitz and Roberts classification) with a marked loss of coaptation that caused a severe aortic insufficiency (AI). The patient underwent an aortic valvuloplasty of the defect using the glutaraldehyde (GA)-pretreated autologous pericardium, restoring the subnormal function and competency of the aortic valve. The postoperative course was unremarkable. The early follow-up showed a trivial AI and a significant reduction of regurgitant volume was identified in a cardiac magnetic resonance imaging (MRI) when compared to the preoperative state (27.2 vs. 2.1 ml). The follow-up transthoracic echocardiography 1 year after the surgery showed mild AI.

Importance of Distal Sealing during Endovascular Aneurysm Repair Using Aneurysmal Common Iliac Artery as Landing Zone.

BACKGROUND: Although the use of aneurysmal common iliac artery (CIA) as the landing zone during endovascular aortic aneurysm repair EVAR remains an essential procedure, this procedure may increase the risk of late complications such as ongoing CIA dilatation and type Ib endoleak (CIA-related complications). We hypothesized that incomplete sealing of the aneurysmal CIA segment during EVAR could increase the incidence of CIA-related complications. In this study, we evaluated the midterm results of EVAR with aneurysmal CIA used as the landing zone and assessed the importance of distal sealing in this procedure. METHODS: We retrospectively reviewed all cases of endovascular aneurysm repair using CIA as landing zone between 2007 and 2015 that had at least 3 years' follow-up. We defined aneurysmal CIA as maximum diameter ≥18 mm. The main outcome was the incidence of CIA-related complications. We compared midterm results between normal CIA and aneurysmal CIA. Next, we analyzed risk factors for CIA-related complications in aneurysmal CIA. RESULTS: Four complications occurred in normal CIA (mean follow-up, 66.5 ± 22.1 months); 21 occurred in aneurysmal CIA (mean follow-up, 62.2 ± 20.5 months). The 5-year portion of freedom from CIA-related complications was 97.3% in normal CIA and 69.4% in aneurysmal CIA (P < 0.001). Multivariable analysis in aneurysmal CIA showed that unsealed CIA segment length was only risk factor for CIA-related complications. Given the receiver operating characteristic curve results, we defined the unsealed CIA segment ≥10 mm as incomplete sealing. The hazard ratio for incomplete sealing associated with CIA-related complications was 3.92 (95% confidence interval 1.62-9.46, P = 0.02). CONCLUSIONS: Use of aneurysmal CIA as landing zone increases the risk of CIA-related complications. However, maximum sealing of the aneurysmal CIA segment could prevent these complications.

Effect of Atheromatous Aorta on Thromboembolic Complications after Endovascular Aortic Aneurysm.

Objective: The purpose of this study was to evaluate the effect of atheromatous aorta on thromboembolic complications after endovascular aortic aneurysm repair (EVAR) and to assess the risk factors for these complications. Materials and Methods: This retrospective study included patients who underwent EVAR for an abdominal aortic aneurysm at the Shizuoka Red Cross Hospital from 2007 to 2018. We defined atheromatous aorta as a thoracic shaggy aorta or abdominal aorta with neck thrombus. The main outcome was renal dysfunction and peripheral embolization (thromboembolic complications). We compared the incidence of thromboembolic complications between patients with normal aorta and atheromatous aorta. Moreover, we assessed the risk factors associated with thromboembolic complications in patients with atheromatous aorta. Results: Patients with atheromatous aorta had significantly more thromboembolic complications, such as renal dysfunction (24.5% vs. 3.9%; P<0.001) and peripheral embolization (12.3% vs. 0.0%; P<0.001) than those with normal aorta, respectively. We identified no risk factors associated with thromboembolic complications in patients with atheromatous aorta. Conclusion: Atheromatous aorta increases the risk of thromboembolic complications after EVAR. However, there is no established therapy for these thromboembolic complications. Further studies are necessary to determine the appropriate therapy, including appropriate preoperative medication, to prevent these complications.

Preliminary Experience of Viabahn Stent Graft Inside the Occluded Prosthetic Bypass Graft for the Treatment of Above Knee Femoropopliteal Bypass Occlusion.

PURPOSE: To describe a multi-center preliminary experience of treating prosthetic above knee femoropopliteal (AKFP) bypass occlusion by placing a Viabahn stent graft inside the occluded prosthetic bypass graft. MATERIALS AND METHODS: Retrospective analysis of consecutive 14 patients (mean age 73.2 ± 10.2, 78.6% male) receiving Viabahn stent graft inside the occluded prosthetic bypass graft for the treatment of prosthetic AKFP bypass occlusion in the collaborating hospitals from November 2016 to June 2019 was performed. RESULTS: Technical success was achieved in all patients. Mean lesion length was 34.0 ± 3.5 cm, concomitant thrombectomy or thrombus aspiration was performed in 11 patients (78.6%), and average of 1.57 ± 0.65 Viabahn stent grafts were used. Mean ankle-brachial index improved from 0.24 ± 0.23 to 0.98 ± 0.14 after the treatment. All patients had preoperative ischemic symptoms with 9 patients (64.3%) having Rutherford class > 4 symptoms; however, all preoperative symptoms resolved after the treatment. During the mean follow-up of 450.9 ± 234.7 days, there were two target lesion revascularizations, leading to a primary patency rate of 92.9% and a secondary patency of 100.0% at 1 year. CONCLUSION: Placing a Viabahn stent graft inside the occluded prosthetic bypass graft for the treatment of prosthetic AKFP bypass occlusion appears to be effective from our preliminary experience. Even though sample size is limited in our study, it may be considered as a potential treatment option before surgical reintervention.

Preoperative Planning for Physician-Modified Endografts Using a Three-Dimensional Printer.

The medical uses of three-dimensional (3D) printing are evolving at a rapid pace. The current roles and the future outlooks of this technology for physician-modified endovascular graft (PMEG) in patients with juxtarenal aneurysm are discussed. Fenestrations of PMEG are designed taking into account the geometry of the stent graft. Designing of such stent grafts is extremely complicated, especially when PMEG is planned for the angulated portion of the aorta. A 3D model enables the designing of branch fenestrations, with consideration for the geometrical adaptation of the stent graft in a complex aortic anatomy. With the aid of 3D-printing technology, patients with juxtarenal aortic pathologies can be treated using fenestrated stent grafts, preserving the vital organ circulation and securing a robust length of proximal sealing zone.

One Technique to Modulate a Device Implantation Path in a Short Treatment Length Using the Gore IBE Device.

The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE; W. L. Gore and Associates, Flagstaff, AZ, USA) applicability is limited by the aorto-iliac length (AOL). The shortage may be a major exclusion criterion. An 85-year-old male presented with an abdominal aortic and left common iliac arterial aneurysm. The left-side AOL was 146-mm, which was deemed 19-mm too short for IBE usage. To increase implantation length, the contra-lateral connection stent graft was deployed along the implantation line, wound half-circumferentially around the ipsilateral limb. Any form of endoleak, limb occlusion, and device migration has not been observed for twelve months.

[Aortic Valve-preserving Root Remodeling in a Patient with Bicuspid Aortic Valve and Severe Annulo-aortic Ectasia].

A 48-year-old man underwent aortic root remodeling for a giant aneurysm of sinus of Valsalva, 98 mm in diameter, as well as a bicuspid aortic valve. The aortic valve was defined as type 0(L-R) according to Sievers classification and the aortic annulus was highly dilated up to 35 mm. Geometric height of the left and right cusps were 22 mm and 32 mm in diameter, respectively. Dacron straight graft of 24 mm was chosen and each tongue was then created in a 180°fashion. After completion of root reconstruction, external circular suture annuloplasty using CV-0 expanded polytetrafluoroethylene (ePTFE) was made to adjust the annulus down to 22 mm in diameter. The free margin of both cusps were centrally plicated to raise the effective height to 9 mm. Postoperative echocardiography at 2 year showed trivial aortic regurgitation but no root re-dilatation. Remodeling with external circular suture annuloplasty is a reproducible and reliable method to stabilize the root, even for the patient with a giant aneurysm of sinus of Valsalva.

Retrograde Stent Placement for Symptomatic Spontaneous Isolated Dissection of the Superior Mesenteric Artery.

Various treatment options are currently available for spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) including conservative management, anticoagulation therapy, endovascular stenting, and surgical repair. We report an experience with retrograde open mesenteric stenting for SIDSMA. A 45-year-old man presented to the emergency department with acute onset of severe abdominal and back pain. Computed tomography angiography revealed a long occlusion of the SMA trunk. Initially, an endovascular solution was attempted, but this was unsuccessful as the guidewire failed to cross the lesion. Four hours after the onset of symptoms, because of aggravation of abdominal pain, the patient underwent an exploratory laparotomy under general anesthesia. The small intestine looked pale, and the arterial pulsation was not recognized in the mesentery. A 5-cm mesenteric portion of the SMA trunk was exposed. The SIDSMA diagnosis was confirmed after arteriotomy because a freshly formed thrombus and a severely stenosed true lumen (TL) were detected beneath the adventitia. From the proximal stump of the TL, a 6-French sheath introducer was inserted in a retrograde fashion. The occlusion was traversed with a 0.035-in guidewire. After predilatation, self-expandable stents were placed inside the occluded SMA. The patient was discharged from the hospital 3 weeks after the operation. Stent patency has been confirmed for 6 months. Retrograde stenting performed under laparotomy could be a rescue procedure after the failure of percutaneous stenting for SIDSMA.

[Myocardial Ischemia in Acute Type A Aortic Dissection; Coronary Artery Dissection and Functional Ischemia].

Myocardial ischemia due to acute type A dissection is a fatal complication. This study was undertaken to evaluate the surgical results of acute type A aortic dissection with myocardial ischemia. Between 1986 and 2014, 364 patients were treated for acute type A dissection in our hospital. Twenty-four patients were underwent myocardial revascularization. Preoperative coronary artery stent placement was involved in 2, coronary-artery bypass grafting (CABG) 18 (right 12, left 4, both 2), reCABG 2, and Carrel patch with coronary orifice restoration 2. Seven of CABG group had no symptom of myocardial ischemia, but right coronary artery was circumferentially detached from the intimal ostia. Hospital mortality was 20.1% in patients who underwent CABG. Sixteen patients with significant electrocardiogram ischemic change were not undertaken with CABG, because coronary artery was not involved by dissection. In these cases, acute aortic valve regurgitation, loss of backward pressure from distal aorta, or valve formation by intimal tear in ascending aorta might decrease diastolic pressure at aortic root and make myocardial ischemia.

Endovascular Aneurysm Repair of Acute Occlusion of Abdominal Aortic Aneurysm with Intra-Aneurysmal Dissection.

BACKGROUND: To report a rare case of acute abdominal aortic aneurysm (AAA) occlusion successfully treated by endovascular aneurysm repair (EVAR). CASE REPORT: An 89-year-old man complained of severe back pain and weakness in the bilateral lower extremities. Although there were neither acute ischemic signs on the brain computed tomography (CT) nor critical leg ischemia, the patient presented progressing weakness in the bilateral lower extremities and decreased sensation in the perianal and saddle area. Contrast-enhanced CT demonstrated an infrarenal AAA, the formation of an ulcer-like lesion in the aneurysmal wall, and the complete occlusion of distal AAA because of the caudal extension of intramural hematoma. Both common iliac arteries were patent because of the development of collateral vessels. The neurologic symptoms were considered to be caused by the occlusion of lumbar radicular arteries. EVAR seemed anatomically feasible, if the occlusion could be crossed by guidewires from both side of the common femoral artery. Wires easily traversed the occlusion, and the stent graft could be smoothly unwrapped and opened. The patient could recover decent iliac arterial flow. The neurovascular deficits recovered within 4 days after the procedure. CONCLUSIONS: Although our experience may not be reproduced in all case of AAA occlusion, EVAR warrants consideration to reduce the high mortality rate associated with the classical treatments.

Refractory primary hepatic actinomycosis with direct infiltration to the diaphragm and thorax: the usefulness of contrast-enhanced ultrasonography.

An 80-year-old man was admitted to our hospital with a diagnosis of primary hepatic actinomycosis determined based on a percutaneous aspiration biopsy. The abscesses and state of liquefaction were easily and effectively visualized on contrast-enhanced ultrasonography. Ampicillin/sulbactam was administered; however, lesions of hepatic actinomycosis suddenly infiltrated the diaphragm and right thorax six months later. A drainage tube was inserted into the right thoracic space, and the pleural effusion gradually decreased. The patient received continuous antibiotic therapy for nearly two years and remained free of hepatic actinomycosis on follow-up more than one year later.

Stepwise angioplasty and catheter directed thrombolysis for budd-Chiari syndrome complicated with floating thrombus in inferior vena cava.

Recently, we experienced a rare case of Budd-Chiari Syndrome. The case was a 57-year-old female patient. Venous return had been severely disturbed by the membranous occlusion of the IVC and a giant floating thrombus. After catheter directed thrombolysis combined with stepwise percutaneous angioplasty, the IVC was recanalized sufficiently and the thrombus was completely resolved.

Initial experience with proximal ligation for profunda femoris artery aneurysms: report of three cases.

Profunda femoris artery aneurysms (PFAAs) are rare and difficult to diagnose in the early stage. They are often found due to the presence of complicated conditions, such as rapid expansion, rupture, or acute lower limb ischemia. Surgical procedures such as aneurysmectomy and endoaneurysmorrhaphy tend to be technically challenging because of the patient status and the extent of the aneurysm. We experienced three cases of PFAAs that were treated by proximal ligation (PL) without complete control of the distal branches. The exclusion of PFAAs was confirmed by duplex ultrasound or angiography at the end of the operation. There was no mortality in the perioperative period. During a 12-month follow-up, all cases exhibited complete exclusion of aneurysms with marked size reduction. Based on these findings, we propose that PL, with a careful follow-up for PFAA exclusion and distal limb circulation, could be an alternative treatment for complicated PFAAs.