Varicose vein treatment reduces edema not only in the treated legs but also in the entire body.

OBJECTIVES: We explored the connection between varicose vein and edema, by investigating extracellular water ratio (E/T) using bioelectrical impedance analysis. METHODS: In a prospective cohort study 120 patients underwent varicose vein surgery with extracellular fluid to total body water ratio (E/T) and E/T postop divided by E/Tpreop (E/T ratio) measured using a body composition analyzer. Edema was defined as E/T ≥0.390. Seventy-nine patients received unilateral treatment, while 41 underwent bilateral. p < .05 is statistically significant. RESULTS: Preoperatively, patients exhibited edema (E/T) in the treated leg (0.394 ± 0.009), untreated leg (0.392 ± 0.009), trunk (0.390 ± 0.007), and whole body (0.391 ± 0.007). Postoperatively, E/T decreased across body (p < .05). The lowest E/T ratio was observed in the treated leg (0.991 ± 0.012), followed by the untreated leg (0.994 ± 0.012), the trunk (0.995 ± 0.009), and the whole body (0.994 ± 0.009). E/T ratio of bilateral group were lower than unilateral group (p < .05). CONCLUSION: Varicose vein contributes to generalized edema, and treatment alleviates edema in the treated leg and the entire body.

Thoracic Endovascular Aortic Repair Without Subclavian Revascularization of a Ruptured Kommerell Diverticulum.

A ruptured Kommerell diverticulum is extremely rare. This is the first report of thoracic endovascular aortic repair without subclavian revascularization of a ruptured Kommerell diverticulum with a right-sided aortic arch. However, decisions regarding subclavian revascularization should be individualized based on the patient's anatomy and clinical presentation.

[A Successful Surgical Treatment of Hemolytic Anemia Caused by Aortic Valve Perivalvular Leakage and Severely Kinked Elephant Trunk:Report of a Case].

Both perivalvular leakage and kinked prosthetic graft may cause hemolysis. A 72-year-old man was refereed to our hospital because of hemolytic anemia. He has past histories of total aortic arch replacement and repeat aortic valve replacement for aortic aneurysm and prosthetic valve endocarditis. Pre-operative examinations demonstrated aortic valve perivalvular leakage and severe graft kinking of the elephant trunk. Repeat aortic valve replacement and axillo-femoral bypass were performed successfully. Hemolysis got better after the operation and the patient discharged home in stable condition.

Strategy for acute DeBakey type I aortic dissection considering midterm results: a retrospective cohort study comparing ascending aortic replacement and total arch replacement with frozen elephant trunk technique.

BACKGROUND: Acute type A aortic dissection is treated with an emergency procedure that uses ascending aortic replacement (AAR). However, to avoid a residual dissected aorta with a false lumen, total arch replacement (TAR) is required. The frozen elephant trunk (FET) technique is a promising surgical approach that promotes false lumen obliteration in a single step. Therefore, this retrospective single-center study aimed to evaluate the operative outcomes of AAR and TAR with FET. METHODS: Between 2007 and 2021, 143 patients with acute DeBakey type I aortic dissection underwent a central repair using AAR (n = 95) or TAR with FET (n = 43). All perioperative variables, the duration of all-cause mortality, and aortic events defined as dilatation of the distal aorta > 5 cm, new occurrences of aortic dissection, distal aortic surgery, and distal aortic rupture were recorded. We compared these perioperative variables and mid-term results with an additional focus on distal aortic events. RESULTS: Patient background data did not differ between the two groups. Perioperative results for the TAR with FET group vs the AAR group showed similar operative times (306 vs 298 min, P = 0.862), but the TAR group had longer cardiopulmonary bypass times (154 vs 179 min, P < 0.001). The freedom from all-cause death for the TAR vs AAR groups using the Kaplan-Meier method was 81.9% vs 85.4% and 78.0% vs 85.4% (P = 0.407) at 1 and 3 years, respectively. Freedom from aorta-related events was 90.6% vs 97.6% and 69.3% vs 87.0% (P = 0.034) at 1 and 3 years, respectively. CONCLUSIONS: TAR with FET had comparable perioperative results to AAR in acute DeBakey type I aortic dissection and was considered a valuable method to avoid aorta-related events in the midterm.

Concomitant surgery of minimally invasive direct coronary artery bypass with left atrium appendage closure.

Surgical approaches of minimally invasive direct coronary artery bypass and left atrial appendage exclusion are different, and issues may arise in cases of concomitant surgery. Moreover, the safety of concomitant procedures has not been established. A man in his 80s with a history of stroke required minimally invasive coronary artery bypass grafting and left atrial appendage closure for the stenosis of the left anterior descending artery and atrial fibrillation. He suffered from bladder bleeding, which required early reduction of anticoagulant and antiplatelet medication. Therefore, he wished for surgical treatment. A lateral incision was necessary for left atrial appendage closure in minimally invasive surgery. We performed totally endoscopic harvest of the internal thoracic artery without a robotic system. This method allowed the incision to be made more laterally. Combining the endoscopic harvest of the internal mammary artery with left atrial appendage closure via lateral incision may be a reasonable technique.

Impact of quantitative flow ratio on graft function in patients undergoing coronary artery bypass grafting.

Recent studies showed that preoperative functional assessment with fractional flow reserve (FFR) could predict a long-term patency of arterial bypass grafts in patients with coronary artery bypass grafting (CABG). Quantitative flow ratio (QFR) is a novel angiography-based approach to estimate FFR. This study aimed to investigate whether preoperative QFR could discriminate arterial bypass function at 1 year after surgery. The PRIDE-METAL registry was a prospective, multicenter observational study that enrolled 54 patients with multivessel coronary artery disease. By protocol, left coronary stenoses were revascularized by CABG with arterial grafts, whereas right coronary stenoses were treated with coronary stenting. Follow-up angiography at 1 year after surgery was scheduled to assess arterial graft patency. QFR was performed using index angiography by certified analysts, blinded to bypass graft function. The primary end point of this sub-study was the discriminative ability of QFR for arterial graft function, as assessed by receiver-operating characteristic curve. Among 54 patients enrolled in the PRIDE-METAL registry, index and follow-up angiography was available in 41 patients with 97 anastomoses. QFR were analyzed in 35 patients (71 anastomoses) with an analyzability of 85.5% (71/83). Five bypass grafts were found to be non-functional at 1 year. The diagnostic performance of QFR was substantial (area under the curve: 0.89; 95% confidence interval: 0.83 to 0.96) with an optimal cutoff of 0.76 to predict functionality of bypass grafts. Preoperative QFR is highly discriminative for predicting postoperative arterial graft function.Trial registration: Clinical.gov reference: NCT02894255.

Revascularization for controlling hypertension and improving cardiorenal failure in Leriche syndrome.

Leriche syndrome usually occurs when atherosclerotic obstructions result in luminal narrowing of the abdominal aorta or iliac arteries and leads to thrombosis; it rarely causes heart or renal failure. We report the case of a 58-year-old Asian man with heart and renal failure as the dominant clinical manifestations of renovascular hypertension caused by Leriche syndrome. We performed an aorto-bifemoral bypass and unilateral renal artery stenting. Post-operative echocardiography showed improved cardiac function, with the left ventricular ejection fraction increasing from 30% before surgery to 54.2% after surgery. Moreover, his heart rate and blood pressure became stable, and his serum creatinine and brain natriuretic peptide levels decreased from 3.46 to 1.08 mg/dL and 685 to 4 pg/mL, respectively. Our case report shows that aorto-bifemoral bypass and unilateral renal artery stenting can effectively treat heart and renal failure resulting from renovascular hypertension caused by Leriche syndrome.

[Aortic Regurgitation due to Rupture of a Fibrous Strand in Fenestrated Aortic Valve:Report of a Case].

Fenestration of the aortic valve cusps rarely causes aortic regurgitation. A 54-year-old woman was diagnosed with aortic regurgitation secondary to a ruptured fibrous strand in a fenestrated aortic valve cusp. Diastolic murmur was pointed out during health checkup five months earlier, and transthoracic echocardiography revealed severe aortic valve regurgitation with a mobile mass attached to the aortic valve cusp. The patient underwent aortic valve replacement. Intraoperatively, we observed a ruptured fibrous strand attached to the non-coronary cusp and cusp laceration, both of which caused severe aortic regurgitation. Histopathological examination of the resected specimen showed myxomatous degeneration. The patient's postoperative course was uneventful, and she was discharged in a stable condition on postoperative day 14.

Prospective multicenter registry of hybrid coronary artery revascularization combined with non-saphenous vein graft surgical bypass and percutaneous coronary intervention using everolimus eluting metallic stents (PRIDE-METAL study).

The concept of hybrid coronary revascularization (HCR) combines the advantages of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) to improve the treatment of patients with complex multivessel disease. This study aimed to investigate a 1-year clinical follow-up of a prospective multicenter registry of HCR combined with non-saphenous vein graft surgical bypass and PCI using everolimus-eluting metallic stents (the PRIDE-METAL study). From June 2016 to June 2018, a total of 54 patients with multivessel coronary disease from six Japanese institutes were enrolled in this study. The primary endpoint of the study was the occurrence of major adverse cardiovascular event (MACE; all-cause death, myocardial infarction, stroke, and repeat revascularization) at 1 year. Three patients declined before complete HCR, and two patients were lost by the 1-year follow-up. All-cause mortality at 30 days and at 1 year was 0% and 4.1%, respectively. The rates of myocardial infarction, repeat revascularization, stroke, and MACE were 0% at 30 days, and 0%, 2.0%, 2.0%, and 8.2% at 1-year follow-up, respectively. No occlusion of arterial bypass graft at the 30-day follow-up was observed, and was observed in 1.7% at the 1-year follow-up. HCR was safe and feasible and associated with a low risk of MACE at the 1-year follow-up. Further validation in multicenter and randomized studies is needed.

Endoscopic Internal Thoracic Artery Harvesting with Changes in Scope Position.

Although minimally invasive direct coronary artery bypass (MIDCAB) is a less invasive procedure, internal thoracic artery (ITA) harvesting is difficult. A 65-year-old woman was advised to undergo MIDCAB for recurrent in-stent restenosis. We harvested the ITA using three-dimensional endoscopy without robotics and determined the scope position using enhanced computed tomography. We changed the camera installation between the wound and the camera port, according to the harvesting site with a harmonic scalpel using the skeletonized technique. We harvested the ITA from the subclavian vein level superiorly to the xyphoid process level inferiorly.

Results of off-pump coronary artery bypass grafting with off-pump first strategy in octogenarian.

BACKGROUND AND AIM: Ischemic heart disease is the leading cause of death around the world. Coronary artery bypass grafting offers efficient surgical revascularization for ischemic disease. Both on- or off-pump coronary artery bypass methods provide promising results to octogenarians, once complete vascularization is achieved. However, off-pump bypass requires a certain level of experience to achieve sufficient results. We have applied an off-pump coronary artery bypass-first strategy to all generations since 2008. This study investigated early and long-term results of surgical revascularization for octogenarians by a team with an off-pump-first strategy. METHODS: All cases of isolated coronary artery bypass grafting performed since 2008 were identified and divided into a young group (age < 80 years) and an old group (age ≥ 80 years). Peri-operative results were investigated retrospectively in both groups and long-term results for the old group were assessed. RESULTS: Among the 707 patients, 97% underwent off-pump bypass, and 94 cases were classified to the old group. Distal anastomoses and ventilator time were identical between groups (young vs. old: 3.3 vs. 3.2; 3.7 h vs. 3.7 h). In-hospital death rates were 0.5% and 0% in the young and old groups, respectively. With a mean follow-up of 1318 days, actual 1-, 3-, and 5-year survival rates for octogenarians were 92.1%, 81.2%, and 68.3%, respectively. Nearly half of the patients reached their nineties, which was close to the life expectancy of the national general octogenarian. CONCLUSIONS: An experienced team with an off-pump-first strategy could provide valid therapeutic options for octogenarians.

Surgical repair of thoracoabdominal aortic aneurysm accompanied by Leriche syndrome using a quadrifurcated graft without a distal anastomosis.

BACKGROUND: The coexistence of Leriche syndrome and thoracoabdominal aortic aneurysm is rare and challenging for surgeons especially if there are no distal anastomosis sites. CASE REPORT: A 56-year-old man with past medical histories of coronary artery bypass grafting and total arch replacement was planned to the surgery for thoracoabdominal aneurysm. His abdominal aorta was occluded just below the renal arteries and his terminal aorta, iliac and femoral arteries were hypoplastic. Right internal thoracic artery and visceral arteries provided collateral blood supply to the legs. The aneurysm was successfully repaired using a quadrifurcated graft without distal anastomoses. CONCLUSION: A quadrifurcated graft can be a therapeutic option for repair of thoracoabdominal aneurysm accompanied by Leriche syndrome without distal anastomosis sites.

Aortic Valve Replacement by a Transaxillary Anterior Minithoracotomy Approach.

A modified transaxillary approach for aortic valve disease to obtain the same exposure as the anterior minithoracotomy approach and to preserve the pectoralis major muscle is presented. When the patient's right shoulder is adducted horizontally, or the right arm is flexed anteriorly 90 degrees and adducted to the left, the right axilla comes close to the chest midline. That means that a right anterior thoracotomy can be made through the right axilla when the arm position is adjusted appropriately. The modified new approach is safe and faster than the conventional transaxillary approach, and it provides cosmetic advantages to the patient.

Clinical benefits of fast-track rehabilitation program for patients with uncomplicated type B acute aortic dissection.

OBJECTIVES: Uncomplicated type B acute aortic dissection (UTBAAD) has traditionally been treated medically. Although patients are treated based on the rehabilitation program established by the Japanese Circulation Society, we sometimes encounter patients with complications related to the long duration of bed rest. We performed novel fast-track rehabilitation for UTBAAD, which consisted of short-duration bed rest and the early initiation of walking under secure blood pressure control. METHODS AND RESULTS: From April 2009 to February 2017, there were 73 consecutive cases of UTBAAD. Conventional medical treatment was administered to 39 patients (group G) during the early period. From August 2013, 34 patients (group F) received our 'fast-track' rehabilitation program, which consisted of the following: oral intake and assuming a sitting position from day 1 after the onset, standing by the bed from day 2, walking in their room from day 4, and discharge from day 16 if all goes smoothly. Group F had a significantly earlier initiation of standing and walking, first defecation, and weaning from oxygen and intravenous antihypertensive agents than group G. The pneumonia complication rate was significantly lower in group F than in group G. The hospitalization duration was markedly shorter and the in-hospital expense lower in group F than in group G. There were no significant differences in the rate of late adverse aortic events within 12 months after onset. CONCLUSIONS: Our fast-track rehabilitation program for patients with UTBAAD resulted in a better in-hospital clinical course and lower expense than conventional medical treatment without any adverse aortic events.

Thoracic endovascular aneurysm repair to treat recurrent lower limb ischemia secondary to occlusion of axillofemoral bypass.

INTRODUCTION: A case of malperfusion in which the patient presented with aortic dissection is presented. PRESENTATION OF CASE: A 69-year-old man with an acute aortic dissection (Stanford type B) had lower limb ischemia. Axillary-femoral bypass was performed, and his lower limb ischemia improved. Eight months after the onset of acute aortic dissection, he again had lower limb ischemia. Contrast-enhanced computed tomography showed axillary-femoral bypass occlusion and true lumen collapse, compressed by the increased false lumen pressure in the aorta. Thoracic endovascular aortic repair (TEVAR) was performed for entry closure. His lower limb ischemia was improved by TEVAR. DISCUSSION: One of the complications of type B aortic dissection is malperfusion. Endovascular therapy is a first step in treating the malperfusion of type B aortic dissection. It is important to seal the entry for the treatment of malperfusion. CONCLUSION: If there is an entry, it is important to seal it for the treatment of malperfusion.

A Case of Collapsed Stent Graft, Severe Lower Limb Ischemia, and Ruptured Abdominal Aortic Aneurysm Due to Type B Acute Aortic Dissection 3 Years after Endovascular Aneurysm Repair.

We report a case of stent graft occlusion, severe lower extremity ischemia, and ruptured abdominal aortic aneurysm due to type B acute aortic dissection 3 years after endovascular aneurysm repair. He admitted our hospital because of abrupt back pain and dysesthesia of bilateral lower limb. Contrast-enhanced computed tomography (CT) scan showed type B acute aortic dissection and occlusion of the stent graft due to dynamic compression by the false lumen. Emergent right axillo-bifemoral bypass operation was done for his critical limb ischemia. Immediately after the successful operation, he fell into shock vital and dissecting abdominal aortic aneurysm rupture was revealed by CT scan. We performed the stump occlusion of the infrarenal abdominal aorta and the bilateral common iliac arteries by abdominal midline incision. Postoperative myonephropathicmetabolic syndrome due to the left ischemia resulted in amputation of his left lower leg for lifesaving. While EVAR cases are increasing, various its complications come to be reported. We consider that this case report might be cautious about the indication of EVAR for the younger generation. (This is a translation of Jpn J Vasc Surg 2019; 28: 367-371.).

Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery.

OBJECTIVES: To compare different configurations of the bilateral internal thoracic arteries for the left coronary system and examine early and late outcomes, including mid-term graft patency. METHODS: We reviewed 877 patients who underwent primary isolated coronary artery bypass grafting using in situ bilateral internal thoracic arteries [in situ right internal thoracic artery (RITA)-to-left anterior descending artery (LAD) grafting, n = 683; in situ left internal thoracic artery (LITA)-to-LAD grafting, n = 194]. We compared mid-term patency between the grafts. Propensity score matching was performed to investigate early and long-term outcomes. RESULTS: The 2-year patency rate for RITA-to-LAD and LITA-to-LAD grafts were similar. Multivariate analysis revealed that RITA-to-non-LAD anastomosis (P = 0.029), postoperative length of stay (P = 0.003) and chronic obstructive pulmonary disease (P = 0.005) were associated with graft failure. After statistical adjustment, 176 propensity-matched pairs were available for comparison. RITA-to-LAD grafting enabled a more distal anastomosis. Kaplan-Meier analysis revealed that the incidences of death, repeat revascularization and myocardial infarction were significantly higher in the LITA-to-LAD group among both the unmatched and matched samples (P = 0.045 and 0.029, respectively). CONCLUSIONS: The mid-term patency and outcomes of RITA-to-LAD grafting are good and reduces future cardiac event, in contrast to LITA-to-LAD grafting.