Debranch-First Technique with Zone 0 Elephant Trunk for Redo Operation of Residual Type B Aortic Dissection: The Completion of Aortic Proximalization.

This article presents a straightforward hybrid arch technique for treating residual type B aortic dissecting aneurysms following type A repair (replacement of the ascending aorta) that employs a frozen elephant trunk (FET) straight vascular prosthesis. The debranch-first method involves only cutting and sewing the previous ascending graft, inserting the FET from zone 0, and debranching the arch vessels using a trifurcated graft. This technique is less invasive as it eliminates the need to manipulate the dissected distal arch aneurysm. We successfully applied this technique to 3 patients, with no instances of in-hospital death, stroke, or paraplegia. The debranch-first technique, combined with zone-0 FET insertion, simplifies the redo repair of residual type B aortic dissection.

A rare case of lethal Najuta endograft collapse.

BACKGROUND: The development of fenestrated endograft, Najuta endograft Kawasumi Laboratories, Inc, Tokyo, Japan) in thoracic endovascular aortic repair (TEVAR) has enabled the treatment of aortic arch aneurysms approaching zone 0 without the need of supra-aortic vessel branch reconstruction. However, the indications of Najuta remain controversial due to complications such as endograft collapse, which is rare and lethal. CASE PRESENTATION: We here report a 75-year-old male patient with arch saccular aneurysm. Because of his liver cirrhosis, 2 debranching TEVAR has chosen as a treatment using Najuta. After extrathoracic bypass was performed, a CTAG stent graft was implanted distal to the LSCA in order to deliver Najuta stent graft steadily. Najuta stent graft was successfully positioned in zone 0. However, he was suffered from stent-graft collapse. After additional TEVAR to salvage stent-graft collapse to zone 0, he complicated type A dissection, which was treated by ascending aorta replacement. After salvage operation complicated multiorgan failure and he died.

Echo-guided seldinger technique facilitates ascending aorta cannulation in type A aortic dissection.

BACKGROUND: The ascending aorta is the most simple and rapid arterial access for the establishment of antegrade systemic perfusion. In acute type A aortic dissection, prompt establishment of antegrade central perfusion, especially in unstable hemodynamic emergency operations, help to diminish organ malperfusion and to prevent retrograde embolism. The effectiveness as well as the safety of antegrade perfusion under ultrasonographic guidance through the dissected ascending aorta was evaluated for the repair of type A aortic dissection utilizing a new echo stabilizer. RESULTS: Ascending aortic cannulation was successfully performed in 64 consecutive patients, using the Seldinger technique, with the hands-free continuous-echo monitoring, utilizing a new stabilizer. Epiaortic 2-Dimensional and color Doppler imaging provided real-time monitoring for the placement and proper perfusion of ascending aorta cannulation. CONLUSIONS: Ascending aorta can routinely provide a rapid and reliable route of antegrade central systemic perfusion in type A acute aortic dissection. The echo-guided stabilizer-assisted cannulation method can safely provide a rapid and reliable route for antegrade central perfusion during in type A dissections repair.

Actual incidence of cerebral infarction after thoracic endovascular aortic repair: a magnetic resonance imaging study.

OBJECTIVES: The actual incidence of cerebral infarction (CI), including asymptomatic infarction, owing to thoracic endovascular aortic repair (TEVAR) has not been reported in detail. This study was performed to investigate the incidence of post-TEVAR CI by using diffusion-weighted magnetic resonance imaging (DW-MRI) and to determine the risk factors for both symptomatic and asymptomatic CI. METHODS: We examined 64 patients undergoing TEVAR at our institute between April 2017 and November 2020. Aortic atheroma was graded from 1 to 5 by preoperative computed tomography. Cerebral DW-MRIs were conducted 2 days after the procedure to diagnose postoperative CI. RESULTS: A total of 44 new foci were detected by post-interventional cerebral DW-MRI in 22 patients (34.4%). Only one patient developed a symptomatic stroke (1.6%), and TEVAR was successfully completed in all cases. Debranching of the aortic arch and left subclavian artery occlusion with a vascular plug was performed in 19 (29.7%) and 12 (18.8%) patients, respectively. The number of patients with proximal landing zones 0-2 was significantly higher in the CI group than in the non-CI group (68.2% vs 11.9%; P < 0.001). The following risk factors were identified for asymptomatic CI: aortic arch debranching (P < 0.001), left subclavian artery occlusion (P = 0.001) and grade 4/5 aortic arch atheroma (P = 0.048). CONCLUSIONS: Over one-third of the patients examined by cerebral DW-MRI after TEVAR were diagnosed with CI. High-grade atheroma and TEVAR landing in zone 0-2 were found to be positively associated with asymptomatic CI. CLINICAL TRIAL REGISTRATION: 02-014.

Free-floating thrombus of the aorta: 3 case reports.

BACKGROUND: Idiopathic free-floating thrombus (FFT) of the aorta is a rare occurrence, but it can lead to catastrophic consequences. The initial symptoms are typically cerebral or peripheral embolisms. Surgical thrombectomy and thrombolysis are two primary treatments for FFT. Here, we report three cases of patients with idiopathic FFT in the absence of coagulopathy who were treated successfully by surgery with no recurrent thrombi or relapse of symptoms. CASE PRESENTATION: Case 1 involved a 72-year-old male patient with a pedunculated thrombus in the distal aortic arch. Case 2 involved a 62-year-old female patient with a cylinder thrombus in the aortic arch and left common carotid artery. Case 3 involved a 65-year-old male patient with three pedunculated thrombi in the ascending aorta, aortic arch, and left subclavian artery. None of the patients had clinical signs of coagulopathy. Pedunculated or cylinder thrombi have a greater risk of breaking off, which can produce severe peripheral embolism in contrast with intramural thrombi (73% vs. 12%). Due to the high embolism risk for each patient, conservative medical treatment by heparinization was deemed inappropriate, so each patient underwent emergency surgical thrombus removal. After surgery, each of the three patients was treated with warfarin for secondary prevention of thromboembolism. At 7-month follow-up in outpatient practice, a computed tomography (CT) scan indicated that Patient 1 had no recurrent thrombus, and the patient has been symptom-free for 11 months. At 1-month follow-up in outpatient practice, a CT scan indicated that Patient 2 had no recurrent thrombus, and the patient has been symptom-free for 8 years. At 3-week follow-up in hospital, a CT scan indicated that Patient 3 had no recurrent thrombus, but he failed to follow-up after discharge, so his follow-up status is unknown. CONCLUSIONS: For a large pedunculated or cylinder thrombus located in the thoracic aorta, surgical thrombectomy should be performed. And, in surgical thrombectomy, the location of the cannulas and cross-clamp should be selected carefully according to the location of the thrombus. After surgery, anticoagulant is important to prevent recurrent idiopathic thrombi.

Successful Endovascular Repair of an Aortobronchial Fistula due to Takayasu Arteritis.

Endovascular approaches to treating a diseased ascending aorta are challenging. We report the use of an endovascular occlusion device for successful closure of a ruptured penetrating atherosclerotic ulcer of an ascending aorta. A 47-year-old female patient with Takayasu arteritis complained of a worsening hemoptysis. She had a history of Bentall procedure for a sinus of Valsalva aneurysm and redo surgery for a ruptured penetrating atherosclerotic ulcer close to the distal anastomosis. She developed methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after the second procedure and required negative pressure wound therapy. Computed tomographic angiography revealed recurrence of a ruptured penetrating aortic ulcer and an aortobronchial fistula. Because of the high risk of redo sternotomy after MRSA mediastinitis, we used an endovascular occlusion device to achieve successful percutaneous closure. The patient was discharged without any complications. Postoperative computed tomography scans showed that the endovascular device was positioned without migration and that complete thrombosis of the penetrating atherosclerotic ulcer was achieved. This is the first report on endovascular repair of a ruptured penetrating atherosclerotic ulcer of the ascending aorta in Takayasu arteritis.

Non-ischaemic intramyocardial dissection following total arch replacement.

Intramyocardial dissection (ID) is a rare left ventricular (LV) disorder characterized by myocardial fibre dissection and neocavitation. In this study, we present a rare case of a 66-year-old woman who had a history of sarcoidosis with non-ischaemic ID following total arch replacement. ID developed suddenly in the free wall of the LV and expanded rapidly to form an LV aneurysm. We successfully performed LV reconstructive surgery to prevent ID rupture.

Emergency surgery for left main disease: with and without cardioplegic arrest.

BACKGROUND: The aims of this study were to evaluate the on-pump beating-heart technique of coronary artery bypass in patients with acute myocardial infarction and left main disease, and to retrospectively compare the early postoperative results with those of conventional on-pump arrested-heart coronary surgery. METHODS: Eighty-five patients with acute myocardial infarction caused by left main disease, who underwent emergency surgery between January 1998 and April 2017 at Saiseikai Utsunomiya Hospital, were enrolled in this study. Of these patients, 56 were evaluated using propensity-matched analysis. The patients were divided into two groups according to the surgical procedure: group A ( n = 28) had on-pump surgery on the arrested heart, and group B ( n = 28) had on-pump surgery on the beating heart. Early postoperative results were compared between the two groups. RESULTS: Preoperative and intraoperative characteristics showed no significant differences between the two groups. The peak creatine kinase myocardial band level was significantly lower in group B (group A 151 vs. group B 91 IU·L-1, p = 0.01). The early mortality rate was higher in group A than group B, but the difference was not significant (group A 28.6% vs. group B 17.9%, p = 0.53). CONCLUSIONS: There was no significant advantage based on surgical procedure between on-pump beating-heart surgery and on-pump surgery on the arrested heart. On-pump beating-heart coronary artery bypass grafting significantly reduced the peak creatine kinase myocardial band level, but there were no significant differences in the early postoperative data, including the mortality rate and left ventricular function.

A Rare Solitary Fibrous Tumor Originating From the Distal Aortic Arch.

We report a 68-year-old man who presented with a well-circumscribed 6.9 × 6.5 × 3.6-cm tumor with a feeding vessel from the thyrocervical trunk in his left pleural cavity. The tumor was attached to the distal aortic arch, so he underwent a tumor resection with prosthetic graft replacement of the distal aortic arch. Pathological examination revealed a solitary fibrous tumor with potentially malignant features. To our knowledge, this is the first case of a solitary fibrous tumor arising from the aortic adventitia reported in the literature.

Aortic valve reconstruction using autologous pericardium (Ozaki procedure) for active infective endocarditis: a case report.

Approximately one-third of patients with infective endocarditis require surgical treatment, but the ideal procedure that prevents infection ensures long durability and maintains quality of life remains unclear. A 21-year-old man who was diagnosed with aortic active infective endocarditis was referred to our hospital for surgical treatment. Echocardiography showed bicuspid aortic valve, severe aortic regurgitation, a large vegetation, and a paravalvular abscess. We planned to perform elective surgical treatment after antibiotic therapy; however, progression to heart failure required urgent operation. Aortic valve reconstruction (AVr) using autologous pericardium was performed. Perioperative and postoperative courses were uneventful. No recurrence of infection or adverse events were observed 4 years postoperatively. Considering prosthetic valve infection and redo operation, AVr may be considered among young patients.

Open Conversion for Type A Ascending Aortic Dissection after Thoracic Endovascular Aortic Repair by the Chimney Graft Technique.

An 83-year-old man with aortic arch aneurysm underwent zone 0 thoracic endovascular aortic repair (TEVAR) by the chimney graft technique with two supra-aortic arch debranching grafts and developed subacute type A ascending aortic dissection. We performed emergency open conversion with circulatory arrest under deep hypothermia. The tip of the chimney graft (around the sino-tubular junction in the ascending aorta) was stiff, making it difficult to inspect the lumen and perform anastomosis. Deep hypothermic circulatory arrest and cutting the endograft stents to mobilize the graft were necessary for secure anastomosis.

Modified 'candy-plug' technique for chronic type B aortic dissection with aneurysmal dilatation: a case report.

BACKGROUND: The original 'candy-plug' technique has been reported to be beneficial for the treatment of residual perfused false lumen in patients with aortic dissection. However, this technique is also associated with several problems, such as narrowing of the true lumen and damage to the flap or vessel wall. Therefore, we modified the procedure to overcome these problems. Here we report a case in which the patient was successfully treated using the modified procedure. CASE PRESENTATION: A 59-year-old man presented with chronic type B aortic dissection with aneurysmal dilatation. The patient had undergone prosthetic graft replacement of the ascending aorta for acute type A aortic dissection 3 years previously and replacement of the descending aorta for residual type B aortic dissection with aneurysmal dilatation 1 year previously. After these procedures, the residual false lumen aneurysm of the distal descending aorta expanded to 57-mm in diameter. Endovascular stent grafting was successfully performed using the modified 'candy-plug' technique with relining of the true lumen and occlusion of the false lumen. The patient was discharged 10 days after the procedure. Follow-up imaging at 1 year showed a completely thrombosed false lumen aneurysm. CONCLUSION: The modified 'candy-plug' technique is useful for treatment of residual type B aortic dissection with aneurysmal dilatation.

Acute left atrial dissection during redo mitral valve replacement.

Left atrial (LA) dissection is an extremely rare and life-threatening complication which is most commonly associated with mitral valve surgery. We report a case of LA dissection after a redo mitral valve replacement and discuss its etiology and management.

Recurrent infarctions due to a dome-shaped pannus above the mitral valve prosthesis.

This report describes a unique case of a 56-year-old female who suffered from recurrent stroke after double mechanical valve replacement. During the four years after the surgery, she remained in normal sinus rhythm, received adequate anticoagulation therapy, and no apparent left atrial thrombus was detected. She underwent redo surgery to prevent further stroke after fourth instance of cerebral infarction. Intraoperative findings revealed a 'dome-shaped' pannus formation covering the sewing ring of the mitral prosthesis circumferentially, probably leading to clot formation and repeated infarctions. She has been stroke free for three years after pannus resection.

Natural history of the ascending aorta after aortic valve replacement: risk factor analysis for late aortic complications after aortic valve replacement.

BACKGROUND: The purpose of this study was to clarify the natural history of the ascending aorta and to identify risk factors for late ascending aortic events after first isolated aortic valve replacement (AVR). METHODS: A total of 287 patients undergoing AVR were enrolled. The patients were categorized into two groups based on the diameter of the ascending aorta at the time of AVR, as determined by computed tomography: Group A (n = 233) was defined as an ascending aortic diameter <40 mm, and Group B (n = 54) was defined as an ascending aortic diameter ≥40 mm. RESULTS: The mean follow-up period was 7.6 years. The baseline diameter of the ascending aorta was 31.4 ± 4.8 mm in Group A and 44.7 ± 4.2 mm in Group B. These values increased to 35.9 ± 7.4 mm in Group A and 50.1 ± 7.3 mm in Group B during the follow-up period (P < 0.001). Ten patients had acute type A aortic dissection (Group A: 1 patient vs. Group B: 9 patients; P < 0.001), and three patients had enlargement of the ascending aorta to ≥55 mm in diameter (Group A: 1 patient vs. Group B: 2 patients). Multivariate analysis revealed that the baseline ascending aortic diameter was the only significant risk factor for developing late ascending aortic events (P < 0.001). CONCLUSIONS: AVR alone may not prevent further enlargement of the ascending aorta. An ascending aorta ≥40 mm in diameter at the time of AVR increased the risk of late ascending aortic events.

Pseudo systolic anterior motion: potential for severe mitral regurgitation after aortic valve replacement.

A 68-year-old man with severe aortic stenosis (AS) and marked left ventricular hypertrophy (LVH), underwent aortic valve replacement (AVR). Preoperative echocardiography demonstrated contact between the anterior mitral leaflet and the interventricular septum during diastole without mitral regurgitation (MR), i. e., "pseudo systolic anterior motion (SAM). " After a mechanical prosthesis had been implanted, severe mitral regurgitation MR and pulmonary hypertension occurred due to "true" SAM of the mitral valve. Despite intensive management, it was difficult to control MR in the acute phase.In the chronic phase, echocardiography revealed the resolution of both SAM and MR. It is suggested that the dramatic reduction of afterload after alleviation of valvular stenosis by prosthetic replacement and increased flow velocity in the left ventricular outflow tract (LVOT) caused SAM with MR. The risk of SAM after AVR should be considered in AS patients with marked LVH, especially in the presence of "pseudo SAM. "