[Bentall Operation for Pregnant Women with Marfan's Syndrome].

A 35-years-old pregnant woman with Marfan's syndrome visited the emergent department. She had sudden severe back pain. She was at the 20th week of gestation. An emergent chest computed tomo-graphy scan showed Stanford type B acute aortic dissection. After admission, strict blood pressure control was started. According to aortic valve insufficiency and fluid retention with pregnancy, acute heart and respiratory failure was getting worse. It seemed risky for both mother and the fetus to continue pregnancy. After sincere and detailed discussion between the patient and our multidisciplinary medical team, the patient decided to continue pregnancy. An urgent Bentall operation was performed. A careful attention was paid for the fetus during and after the surgery. Strict blood pressure control was also continued. The mother and the 30-week-gestation newborn recovered uneventfully. During four years of follow-up, thoracic and thoraco-abdominal aortic replacement was performed. The patient survived all of these procedures without any complication.

[Hybrid Treatment for Thoracoabdominal Aortic Aneurysm by Combined Graft Replacement and Stent-graft].

Graft replacement for thoracoabdominal aortic aneurysm(TAAA) is still an important technique, yet it has high risks of mortality, spinal cord ischemia, and pulmonary complications. In our hospital, thoracoabdominal aneurysm repair with grafting and endovascular treatment (TARGET) method was performed in patients with severe chronic obstructive pulmonary disease( COPD), severe pulmonary adhesions after descending aortic replacement, or those considered high risk from general condition to undergo a wide range replacement. In this method, thoracoabdominal aortic replacement near the diaphragm was followed by stent graft treatment of the residual proximal or distal lesions. Here the usefulness of this technique was reported.

[Mediastinal Bronchial Artery Aneurysm Resected together with the Descending Aorta under the Partial Extracorporeal Circulation;Report of a Case].

Bronchial artery aneurysm(BAA) is quite rare, but its rupture is often lethal. Once it is found, treatments should be aggressively considered. A 67-year-old woman was diagnosed to have a 26 mm mediastinal BAA on computed tomography (CT) which was performed for screening. CT revealed a very short inflow vessel of the BAA and arteriovenous fistula at the outflow. Considering these features of the aneurysm, endovascular interventions deemed difficult and surgery was carried out. Because of the fragility, the aneurysm was resected together with the descending aorta and the graft replacement was performed under partial extracorporeal circulation. The patient has no untoward event for 1 year postoperatively. Although most recent reports advocate endovascular interventions, we think surgical treatment is a variable option in selected patients. Careful evaluation for each BAA case would be essential to determine the treatment strategy.

Compressed Amplatzer Vascular Plug II Embolization of the Left Subclavian Artery for Thoracic Endovascular Aortic Repair is Efficient and Safety Method Comparable to Conventional Coil Embolization.

BACKGROUND: Left subclavian artery (LSA) embolization is occasionally required to prevent type II endoleak in the thoracic endovascular aortic repair (TEVAR) procedure. This is a retrospective study comparing compressed Amplatzer Vascular Plug II embolization (CAE) and conventional coil embolization (CCE) in preventing retrograde flow into the aneurysmal sac through the LSA after TEVAR. METHODS: We retrospectively reviewed the records of patients who underwent CAE or CCE of the LSA during TEVAR from June 2013 to March 2016 in our hospital. The efficacy, safety and cost of each method were compared between two groups. RESULTS: Thirty patients underwent LSA embolization during TEVAR. Six CCEs in 6 patients were performed from June 2013 to November 2013, while twenty-four CAEs in 24 patients were performed from December 2013 to March 2016. Technical success was achieved in all patients in both groups. No embolization-related complications or type II endoleaks from LSA were recorded during the follow-up period in all patients. In both groups, all embolic materials were detected in the proximal portion of the LSA from the LSA orifice to the vertebral artery origin and no vertebral artery occlusions were detected. The mean compression ratio of AVP II was 58 ± 5.9% of predicted length of standard procedure. In the CAE group, one AVP II was sufficient to achieve complete LSA occlusion in all patients. On the other hand, multiple coils (10.2 ± 2.7) were used in the CCE group (P < .01), resulting in a significantly lower cost incurred in the CAE group (CAE: 129,000 JPY vs. CCE: 639,600 ± 140,060 JPY; P < .01). CONCLUSION: The CAE is a useful and cost-effective procedure for TEVAR-related LSA embolization.

[Hybrid Treatment for Aortic Arch Aneurysm Concomitant with Right Subclavian Artery Aneurysm].

A 78-year-old man was hospitalized for aortic arch aneurysm concomitant with right subclavian artery aneurysm. Maximum diameter of each aneurysm was 65 mm and 40 mm, respectively. Both aneurysms clearly needed to be treated. However, simultaneous surgery of total arch replacement (TAR) and right subclavian artery grafting carries both technical difficulty of surgical exposure and considerable risk of bilateral recurrent nerve palsy. Thus, to avoid these serious problems, we chose hybrid treatment. TAR was performed as the 1st procedure, followed by stent graft placement to right subclavian artery aneurysm. At the 1st procedure, an 8 mm graft was anastomosed to right common carotid artery in end to side fashion. This was used for cerebral perfusion, and after that, another end of this graft was anastomosed to a branch of quadrant graft which was anastomosed to brachiocephalic artery. Then, right common carotid artery was ligated at proximal portion to create a proximal landing zone. As the 2nd procedure, excluder leg was deployed via right axillary artery without difficulty. He was discharged with uneventful postoperative course.

Spinal cord protection during thoracoabdominal aortic replacement: spinal cord perfusion maintenance.

OBJECTIVES: Spinal cord protection during thoracoabdominal aortic surgery is challenging for surgeons. We performed thoracoabdominal replacement using a strategy for maintaining spinal cord perfusion pressure. Here, we report our experience with this procedure and the surgical outcomes. METHODS: Between January 2000 and December 2014, 130 patients [male: 91 (74.6%), female: 39 (25.4%); mean age: 66.6 ± 12.8 years] underwent thoracoabdominal replacement using cardiopulmonary bypass at Hiroshima Shimin Hospital, Japan. The surgical outcomes of these patients were analysed. RESULTS: The in-hospital mortality rate of all patients was 2.5%. The incidence of postoperative paraplegia was 3.8%. Aortic event-free survival rates at 1, 3 and 5 years were 98.2%, 93.9% and 80.7%, respectively. CONCLUSIONS: The present study suggests that our strategy for maintaining spinal cord perfusion pressure provides acceptable outcomes.

Innominate artery cannulation for arterial perfusion during aortic arch surgery.

OBJECTIVE: Antegrade cerebral perfusion during aortic arch surgery plays an important role in improving postoperative neurological outcomes. We report our experience using innominate artery cannulation for arterial perfusion during aortic arch surgery. METHODS: From January 2008 to December 2015, 159 patients underwent aortic arch surgery using innominate artery perfusion and were included in the study analysis (mean age, 71.4 ± 9.1 years; male, 120). RESULTS: Total arch replacement was performed in 84.1% of all patients. The incidence of postoperative stroke was 2.5%, with an overall in-hospital mortality rate of 2.5%. CONCLUSIONS: Innominate artery perfusionis a safe and useful technique for aortic arch surgery.

Operative results of the anterolateral thoracotomy with partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch.

Objectives: There are various treatment strategies for chronic-type B aortic dissection involving the aortic arch. Our aim was to review our surgical experience in the anterolateral thoracotomy with the partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch. Methods: From January 2000 to October 2015, 39 patients underwent the single-stage open surgery for chronic-type B aortic dissection involving the aortic arch using the anterolateral thoracotomy with partial sternotomy approach. Results: Among the 39 patients, 32 were men (82.1%; mean age at surgery, 61.3 ± 11.9 years), with a mean dissecting aortic aneurysm diameter of 50.21 ± 12.20 mm; 28 patients (71.8%) had patent false lumens of the descending aorta. The median interval from dissection occurrence until surgery was 34.05 ± 52.34 months. Twenty-one patients underwent descending aortic replacement plus total aortic arch replacement and 18 underwent descending aortic replacement (plus partial aortic arch replacement). Overall in-hospital mortality and postoperative stroke rates were 5.1% (2 patients) and 10.3% (4 patients), respectively. Survival rates at 1, 3 and 5 years were 94.7%, 94.7% and 90.2%, respectively. Aortic event-free rates at 1, 3 and 5 years were 90.9%, 90.9% and 80.2%, respectively. Conclusions: The anterolateral thoracotomy with partial sternotomy approach is a useful surgical procedure with acceptable outcomes for chronic-type B aortic dissection cases involving the aortic arch, when aortic remodelling using thoracic endovascular aortic repair cannot be performed.

Outcomes of Anterolateral Thoracotomy With or Without Partial Sternotomy for Kommerell Diverticulum.

BACKGROUND: Kommerell diverticulum is a rare aortic arch anomaly. The indications for operative intervention and surgical strategy are still controversial. The standard surgical procedure at our institution is total aortic arch plus descending aortic replacement using anterolateral thoracotomy with partial sternotomy. The aberrant subclavian artery is reconstructed anatomically or extraanatomically. METHODS: From 2002 to 2014, 6 patients (1 woman), aged 55 to 78 years, underwent graft replacement through an anterolateral thoracotomy or anterolateral thoracotomy with a partial sternotomy approach for Kommerell diverticulum. All patients underwent graft replacement of the descending aorta or total aortic arch plus descending aorta in addition to aberrant subclavian artery reconstruction. RESULTS: No hospital deaths or major complications occurred. Recurrent nerve injury developed at discharge in 1 patient. All patients were well during the follow-up period (range, 11 to 116 months). CONCLUSIONS: Kommerell diverticulum and its associated symptoms were surgically treated with acceptable outcomes.

Outlet strut fracture and leaflet escape of Bjork-Shiley convexo-concave valve.

Prosthetic valve fracture is a serious complication and may arise in patient post-valve replacement. We experienced an outlet strut fracture and leaflet escape of a Bjork-Shiley convexo-concave valve. We performed an emergency redo mitral valve replacement and successfully retrieved the fractured strut and escaped leaflet from superficial femoral artery and the abdominal aorta. The patient showed an uneventful postoperative recovery.

[Closure of Ascending Aortic Entry by Debranching Endovascular Management in an Elderly Patient with Acute Stanford Type A Dissection].

An 85-year-old woman was hospitalized by emergency for an acute Stanford type A aortic dissection. Computed tomography showed a primary entry on the ascending aorta and pericardial effusion. Although her hemodynamics was unstable due to cardiac shock, her family wished no open surgery considering her age and frailty. A couple of days later, her condition became stabilized with antihypertensive therapy. Since the dissection was limited within the ascending aorta, closure of the entry with the stentgraft was considered appropriate and much less invasive as compared with an open surgery. After obtaining informed consent with her family, thoracic endovascular aortic repair was performed with Gore C-TAG with 2-debranch. The procedure was completed without complications and the entry closure was confirmed by aortography. Her postoperative course was uneventful. Her physical activity restored to the preoperative level and she was discharged.

Aortogastric Fistula Caused by a Foreign Body in a Hiatal Hernia.

Foreign body ingestion is more common in children than in adults, and sharp foreign body ingestion is extremely rare. We report a 93-year-old woman who was unaware of foreign body ingestion and who presented with sudden hematemesis and circulatory collapse. Computed tomography showed a hiatus hernia and part of the stomach herniating in the posterior mediastinum. Additionally, a needle-shaped object was seen penetrating the aorta through the herniated gastric wall. Therefore, immediate endovascular repair of the aorta was performed. Subsequent endoscopy identified a bamboo stick. Therefore, emergent laparotomy and gastrotomy were performed to retrieve the stick, followed by repair of the hernia. The postoperative recovery was uneventful. Such cases are associated with high morbidity, mandating long-term follow-up.

Two cases of thoracic aortic aneurysm with right aortic arch: comparison of two operative strategies for hybrid thoracic endovascular repair.

Hybrid TEVAR was performed in 2 patients with right aortic arch accompanied by Kommerell's diverticulum and aortic aneurysm. In patient 1, total debranch + TEVAR was performed with 1-stage median sternotomy. In patient 2, total arch replacement and insertion of a peripheral elephant trunk were performed first, followed by TEVAR. No endoleaks or aortic events were observed in either case during the observation period, and both patients had good postoperative clinical courses. We report our experience with two such cases that were treated with two different methods of hybrid TEVAR, and discuss the merits and demerits of each treatment method.

Optimal timing of aortic valve replacement in elderly patients with severe aortic stenosis.

PURPOSE: The elderly population with severe aortic stenosis (AS) requiring aortic valve replacement (AVR) is increasing. The optimal timing of AVR in these patients has been under discussion. METHODS: We retrospectively reviewed the data from severe AS patients (n = 84) who underwent AVR with/without concomitant procedures from 2005 to 2010. The symptom status, preoperative data, operative outcome, late survival and freedom from cardiac events were compared between elderly patients (age ≥80 years [n = 31]) and younger patients (age <80 years [n = 53]). RESULTS: The operative mortality in elderly patients (3.2 %) and younger patients (3.8 %) was comparable. The symptoms in elderly patients were more severe and hospitalized heart failure (HF) was more frequently noted as the primary symptom (p = 0.017). Patients with and without hospitalized HF differed significantly in late survival and freedom from cardiac events (p = 0.001), but advanced age had no significant effect. The results of a Cox proportional hazards analysis revealed that hospitalized HF was a significant predictor for cardiac events after AVR, irrespective of age (hazard ratio 6.93, 95 % confidence interval 1.83-26.26, p < 0.004). CONCLUSIONS: In elderly patients with severe AS, surgery should be recommended even in the presence of minimal symptoms and should be performed before the onset of life-threatening HF.

Missing leaflet: a rare cause of structural deterioration of a bovine pericardial aortic bioprosthesis-report of a case.

We experienced a rare cause of aortic bioprosthesis deterioration in which one of the leaflets disappeared 8.7 years after primary aortic valve replacement (AVR) in a male octogenarian. Successful redo AVR with a 23-mm Magna EASE (Carpentier-Edwards, Irvine, CA) was performed. No embolic complications occurred. We were unable to identify the cause of this devastating complication. When heart failure symptoms develop in patients with bioprostheses, clinicians should therefore consider a diagnosis of acute progression of structural valve deterioration and follow the patient carefully with echocardiography.

Single-Stage Endovascular Treatment Performed on Multiple Aortic Aneurysms in a Patient with Behçet's Disease-Report of a Case.

A 50-year-old male diagnosed with Behçet's disease was referred to our department for stent graft treatment because of thoracic, abdominal, and right common iliac artery (CIA) aneurysms. He had a superior mesenteric artery aneurysm in 2005 that was treated with resection and bypass surgery through the radial artery. He later underwent four abdominal surgical procedures for conditions such as intestinal perforation and ileus. Stent graft treatment was performed. The postoperative course was uneventful; postoperative computed tomography (CT) showed no apparent endoleak, while that performed at 3 years post-discharge showed that the aneurysms had decreased in size.

Acute aortic dissection at 33 weeks of gestation with fetal distress syndrome.

The present report describes a female patient, 33 weeks pregnant, who demonstrated complicated abnormal placenta formation and fetal distress, and who presented with an acute type A aortic dissection. The patient underwent an immediate cesarean section and hysterectomy followed by a successful emergency surgical aortic repair, thereby obtaining a favorable outcome for both mother and baby.

Saphenous vein graft aneurysm after coronary artery bypass grafting.

Saphenous vein graft (SVG) aneurysms are an unusual but potentially fatal complication after coronary artery bypass grafting (CABG). We report a case of multiple SVG aneurysms 23 years following CABG. Although the patient was on dialysis and had a poor left ventricular function, the aneurysms were successfully excised, and the ascending aorta was uneventfully replaced to be possible for percutaneous coronary intervention in the near future.

[Mediastinal abdominal wall fistula due to ePTFE membrane].

A 78-year-old woman who had undergone double valve replacement 13 years before was referred to our department because of postoperative wound dehiscence and exudate. Although the result of exudate culture was negative, the wound was disinfected continuously for 4 weeks and showed a transient remission. However, the exudate was observed again 3 weeks later. By chest computed tomography (CT), a highly bright shadow was revealed in the mediastinum, which was suspected to be a foreign body and, therefore, the cause of the exudate. Considering the possibility of infection, the patient underwent an operation. Following incision of the epigastric region and the resection of the xiphoid process, ePTFE membrane with poor granulation tissue was found. The membrane was removed, the lesion was washed with warm saline, and then the wound was closed. The postoperative course was uneventful without recurrence. This complication was considered to be caused by biological reaction to a foreign body.

Chronic contained rupture of an abdominal aortic aneurysm with vertebral erosion: report of a case.

A 73-year-old man had lumbago of unknown cause for several months prior to presentation. At examination prior to surgery for gastric cancer, an abdominal aortic aneurysm (AAA) of 6 cm in maximum diameter, retroperitoneal hematoma and vertebral erosion were found on abdominal computed tomography (CT). Hematological examination revealed mild anemia and stable hemodynamics. A diagnosis of chronic contained rupture of an AAA was made and knitted Dacron bifurcated graft replacement was performed. When an intraluminal thrombosis at the posterior wall was removed, a punched-out defect (3 x 2 cm) was discovered. When the old hematoma was removed, a destroyed vertebral body was found. After surgery, the lumbago was alleviated. The patient was transferred to the Department of Surgery and a gastrectomy was performed. The patient's postoperative course was uneventful.