Recurrent left ventricular thrombus due to essential thrombocythemia complicated by COVID-19.

Essential thrombocythemia is a risk factor for thrombosis and hemorrhage. During the perioperative period of cardiac surgery, the risk of thrombosis and hemorrhage increases. Coronavirus disease 2019 (COVID-19) is also associated with thrombosis. We present the case of a 69-year-old man with essential thrombocythemia complicated by COVID-19 who developed a left ventricular thrombus. We performed thrombectomy, but the patient developed recurrent left ventricular thrombus 8 days after surgery. Emergency redo thrombectomy was performed followed by aggressive blood-thinning therapy. The postoperative course was complicated by cardiac tamponade requiring surgical drainage 8 days after the second surgery. The patient was discharged home 25 days after the second operation without any complications. Learning objective: Left ventricular thrombus is a rare but fatal complication associated with essential thrombocythemia. COVID-19 has also been reported to cause coagulopathy. This case suggested that after surgery for left ventricular thrombus complicated by multiple risk factors including essential thrombocythemia and COVID-19, aggressive blood-thinning therapy with combination of anticoagulation, antiplatelet, and metabolic antagonist may help prevent recurrent thrombosis.

Coil-in-Plug Method for Left Subclavian Artery Embolization in Thoracic Endovascular Aortic Repair with Arch Vessel Debranching.

Objectives: Since 2018, we have routinely placed an Amplatzer vascular plug (AVP) in the proximal left subclavian artery (LSCA) to prevent embolic events during thoracic endovascular aortic repair with arch vessel debranching (d-TEVAR). Type II endoleaks of LSCA origin were observed in two patients (20%), and the coil-in-plug (CIP) method, i.e., microcatheter insertion through the plug and addition of coil embolization, which has been used since August 2019, was performed. This study aims to evaluate the effectiveness of the CIP method for LSCA embolization. Methods: A total of 26 patients who underwent d-TEVAR for an aortic arch aneurysm between 2018 and 2022 were retrospectively reviewed. Ten patients who underwent d-TEVAR with a simple AVP placement (the control group) and 16 patients who underwent d-TEVAR with the CIP method (the CIP group) were compared. Results: Two patients had type II endoleaks in the control group, whereas none had them in the CIP group. LSCA length was significantly shorter in patients with endoleaks than in those without endoleaks (24.5 vs. 50.3 mm; p<0.01). No perioperative deaths or cerebral infarctions occurred in either group. Conclusions: AVP placement in the LSCA during d-TEVAR effectively prevented perioperative cerebral infarction. d-TEVAR with CIP was especially useful in patients with a short LSCA.

Acute Kidney Injury after High-Flow Regional Cerebral Perfusion in Neonatal and Infant Aortic Arch Repair.

OBJECTIVES: We applied high-flow regional cerebral perfusion (HFRCP) for aortic arch reconstruction in neonates and infants by monitoring regional oxygen saturation of the thigh (rSO2T) using near-infrared spectroscopy to maintain peripheral perfusion. This study was designed to investigate the optimal perfusion flow of HFRCP for renal protection. METHODS: From 2009 to 2021, 28 consecutive neonates and infants who underwent aortic arch reconstruction with HFRCP were enrolled. The median age of the patients was 27 days; the median body weight was 3.0 kg. In HFRCP, perfusion flow was targeted at approximately 80-100 mL/kg/min and then lowered corresponding to brain rSO2 levels and blood gas data. Isosorbide dinitrate and chlorpromazine were administered to enhance peripheral perfusion flow. Regional oxygen saturation of the forehead and thighs were monitored. The stage of acute kidney injury (AKI) was classified based on the Kidney Disease Improving Global Outcomes criteria. RESULTS: No patients had neurological events and peritoneal dialysis after surgery. The incidence of AKI was 39.3% with only three patients having greater than stage 2 AKI. The maximum postoperative serum creatinine concentration was negatively associated with the lowest rSO2T during HFRCP. The rSO2T during HFRCP was a predictive factor for postoperative creatinine increase of ≧0.3 mg/dL. The area under receiver operating characteristic curve was 0.78 with the cutoff value of 48% for rSO2T. CONCLUSIONS: The rSO2T during HFRCP is a potential predictor of postoperative renal function. To prevent AKI, the rSO2T should be preserved more than 48% by increasing HFRCP flow.

Outcomes after Rivaroxaban Treatment of Extensive Deep Vein Thrombosis.

BACKGROUND: Regression of thrombus in response to treatment with direct oral anticoagulants (DOACs) in patients with extensive deep vein thrombosis (DVT) has not been fully evaluated. This study aimed to determine the therapeutic efficacy of rivaroxaban in the treatment of extensive DVT. METHODS: We retrospectively evaluated 76 patients treated with rivaroxaban among 728 new DVT patients, at our hospital from January 2018 to March 2021. Extensive DVT was defined as thrombus connecting to 2 or more segments of the inferior vena cava (IVC), iliac vein, femoral vein, or popliteal vein. Localized DVT was defined as a thrombus confined to 1 segment of the inferior vena cava (IVC), iliac vein, femoral vein, or popliteal vein. We compared the changes in thrombus between the extensive DVT group (36 patients) and the localized DVT group (40 patients). RESULTS: In the localized DVT group, 14 (37%) had total recanalization within 3 weeks after DOAC initiation, and 30 (79%) had total recanalization within 3 months. In the extensive DVT group, only 3 (9%) had total recanalization within 3 weeks after starting DOAC, and even after 3 months, only 5 (15%) had total recanalization. Symptoms (P = 0.01) and extensive DVT (P < 0.01) were significantly associated with the risk for failure of total recanalization. CONCLUSIONS: Rivaroxaban was highly effective for total recanalization of localized DVT but not for symptomatic or extensive DVT. In patients with symptomatic extensive DVT, catheter-based thrombolysis may be considered in selected cases.

Gluteal Blood Flow Monitoring in Endovascular Aneurysm Repair With Internal Iliac Artery Embolization.

BACKGROUND: When an internal iliac artery (IIA) has to be embolized during endovascular aneurysm repair (EVAR), buttock claudication sometimes poses problems. However, there is no established method to evaluate intraoperative blood flow to the gluteal muscles.Methods and Results:Gluteal regional oxygen saturation (rSO2) was monitored using near-infrared spectroscopy (NIRS) during surgery, and changes in rSO2were compared with treatment results. Twenty-seven patients who underwent EVAR and IIA embolization at our institution between April 2019 and May 2020 were included in this study. The association between intraoperative changes in rSO2and postoperative incidence of buttock claudication was analyzed. Furthermore, the presence or absence of communication between the superior and inferior gluteal arteries and the intraoperative changes in rSO2were compared to ascertain whether rSO2reflects blood flow change. Postoperative buttock claudication occurred in 4 of 19 patients (21%) with unilateral occlusion of IIA and in 4 of 8 patients (50%) with bilateral occlusion of IIAs. rSO2was found to decrease significantly further in patients with buttock claudication than in patients without buttock claudication (-15±12% vs. -4±16%, P<0.05). In addition, rSO2was predominantly lower in patients without the communication between the superior and inferior gluteal arteries than in those with the communication. CONCLUSIONS: Gluteal rSO2is useful as an indicator of intraoperative gluteal blood flow.

Risk Factors for Progression of Distal Deep Vein Thrombosis.

BACKGROUND: There is insufficient evidence regarding the optimal treatment method for distal deep vein thrombosis (DVT), including indications for anticoagulation therapy. Treatment results of patients with distal DVT were evaluated to clarify the risk factors that result in extension of distal DVT to the proximal vein and indications for anticoagulation therapy.Methods and Results:Among 430 patients with DVT between January 2018 and December 2019, 253 were diagnosed with distal DVT; 41 patients who had already started anticoagulation therapy were excluded, and the remaining 212 were included as study subjects. Anticoagulation therapy was not started immediately; conservative treatment with compression stockings was performed. Ultrasonography after 2 weeks revealed thrombus disappearance in 39 patients (21%), and thrombus reduction in 38 patients (20%). In contrast, extension of thrombus to the proximal vein was noted in 12 patients (6.3%) and anticoagulation therapy was commenced. After 3 months, the thrombus had disappeared in 75 patients (52%). No patient developed pulmonary thromboembolism during follow-up. With respect to the risk factors for extension to proximal vein during conservative treatment, active cancer (P=0.03), prolonged bed rest (P<0.01), and D-dimer level >8µg/mL (P=0.01) were identified. CONCLUSIONS: It is reasonable to consider anticoagulation therapy in distal DVT patients with active cancer, prolonged bed rest or high D-dimer level.

Watch-and-wait strategy for type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta: a Japanese single-centre experience.

OBJECTIVES: In this study, we investigated the early and midterm outcomes of initial watch-and-wait strategy for Stanford type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta in patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection in the ascending aorta. METHODS: Inpatient and outpatient records were retrospectively reviewed. RESULTS: Of the 81 patients with type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta between April 2011 and April 2019, a watch-and-wait strategy was selected in 46 patients. The mean age of the patients was 68 years, and 22 (48%) patients were female. Ten patients underwent emergency pericardial drainage for cardiac tamponade at the time of presentation and 8 patients underwent aortic repair during hospitalization for new ulcer-like projection, re-dissection or rupture. In-hospital mortality occurred in 2 (4%) patients. During follow-up, survival at 1 and 2 years was 95% and 92%, respectively. There was no significant difference in survival or aortic events between patients in whom the watch-and-wait strategy and emergency surgical treatment were indicated. CONCLUSIONS: The early and midterm outcomes of the initial watch-and-wait strategy were favourable for type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta in Japanese patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection. Further study is required to show the safety of this strategy.

Endovascular Therapy for Chronic Type B Aortic Dissection.

Objectives: Endovascular repair of the thoracic aorta (TEVAR) represents a therapeutic option for type B aortic dissection. However, the optimal timing for TEVAR is controversial. We examined the outcomes of TEVAR for chronic type B dissection and reviewed aortic morphology using pre- and postoperative CT scan images. Methods: Between 2012 and 2017, 12 patients underwent TEVAR for chronic type B dissection at our institution. We retrospectively reviewed the clinical and operative data including CT scan images, comparing the values between early group (5 cases, 3 months to 1 year from initial dissection) and late group (7 cases, more than 1 year from initial dissection). Results: There were no paraplegia, stroke, and death in our cohort. There was no difference in degree of the aortic remodeling between two groups. Conclusions: Outcomes after TEVAR for chronic type B aortic dissection were favorable. Aortic remodeling could be obtained in selected patients by closing an entry with TEVAR procedure. (This is a translation of Jpn J Vasc Surg 2018; 27: 281-287.).

Outcomes of Extended Endovascular Aortic Repair for Aorto-Iliac Aneurysm with Internal Iliac Artery Occlusion.

Objective: Patients of aorto-iliac aneurysms who undergo endovascular aortic repair (EVAR) require internal iliac artery (IIA) occlusion with coil embolization and its coverage with the stent graft to prevent type II endoleak after extending the endograft into the external iliac artery. However, it has become well recognized that IIA occlusion cause buttock claudication and other various sequelae due to pelvic ischemia. We retrospectively analyzed IIA occlusion outcomes. Methods: From October 2008 to February 2015, 71 patients with aorto-iliac aneurysms underwent IIA occlusion prior to EVAR. The relationship between pelvic circulation and symptom of pelvic ischemia was studied. Results: Buttock claudication occurred in 17 patients (22.9%) of all. Eight patients (14.8%) in unilateral IIA occlusion group (54 patients) and nine patients (52.9%) in bilateral IIA group (17 patients) had sequelae of claudication. The sacrifice of the communication of superior gluteal artery (SGA) and inferior gluteal artery (IGA) led to buttock claudication in 18 (64.3%) of 28 limbs. Instead, only 4 of 60 limbs had buttock claudication, when we preserved the communication between SGA and IGA. In all patients, staged treatment of aorto-iliac aneurysms with IIA occlusion and EVAR were done successfully without pelvic ischemic complications except for buttock claudication, and postoperative CT scanning showed no endoleakage. Conclusion: IIA occlusion prior to EVAR is recognized as a safe and reasonable strategy. It is emphasized that preservation of the communication of SGA and IGA is important to prevent buttock claudication. (This is a translation of Jpn J Vasc Surg 2016; 25: 240-245.).

Open Surgery of a Descending Thoracic Aortic Aneurysm Impending Rupture with a Compression of Left Main Bronchus.

We describe the successful surgical treatment of an impending rupture of a saccular descending thoracic aortic aneurysm and accompanying compression of the left main bronchus. A 69-year-old man presented with a history of tingling chest pain lasting for a few hours. His left lung cannot be auscultated, and he was rapid progression of dyspnea. Computed tomography (CT) showed a saccular aneurysm compressing the left main bronchus. The patient was treated with conventional open surgery. The compression was immediately released. No additional surgical intervention was needed and his postoperative course was uneventful. After 6 months of surgery, he remains well.

Comparison of direct effects of clinically available vasodilators; nitroglycerin, nifedipine, cilnidipine and diltiazem, on human skeletonized internal mammary harvested with ultrasonic scalpel.

Direct vasodilator effects of nitroglycerin, nifedipine, cilnidipine and diltiazem on human skeletonized internal mammary artery graft harvested with ultrasonic scalpel were assessed in the presence of 0.1 or 0.2 µM of noradrenaline. Ring preparations were made of distal end section of the bypass grafts, and those dilated by acetylcholine were used for assessment. Each drug dilated the artery in a concentration-related manner (0.01-10 µM, n = 6 for each drug) with a potency of nitroglycerin > nifedipine = cilnidipine > diltiazem. These results indicate that nitroglycerin can be useful for treating internal mammary artery spasm, that clinical utility of diltiazem may not depend on its vasodilator effect on the bypass graft, and that cilnidipine as well as nifedipine will have anti-spastic action which is in the middle between those of nitroglycerine and diltiazem.

Relationship between arteriosclerosis obliterans and the ratio of serum eicosapentaenoic acid to arachidonic acid.

PURPOSE: A low ratio of serum eicosapentaenoic acid to arachidonic acid (EPA/AA) has been associated with coronary artery disease. We retrospectively examined serum concentrations of polyunsaturated fatty acids in patients with arteriosclerosis obliterans (ASO) and in non-atherosclerotic patients. METHODS: From April 2011 to March 2012, serum EPA/AA was retrospectively examined in 33 consecutive outpatients with ASO complicated by intermittent claudication and 21 outpatients with hypercholesterolemia without ASO as controls. The Student's t-test was used for continuous variables and Chi-square test for categorical variables, with analysis of covariance adjusting for age, sex, body mass index, smoking, alcohol, and diabetes. RESULTS: The ASO group were significantly different with regard to mean age (71.5 vs. 63.9 year-old, p = 0.03), body mass index (21.3 vs. 24.1 kg/m(2), p = 0.002) and morbidity of diabetes mellitus (51.5 vs. 4.8%, p = 0.0004). Serum EPA/AA was significantly decreased in ASO (0.36 vs. 0.61, p = 0.03), when adjusted for age, sex, body mass index, smoking status and alcohol drinking, but was not statistically significant when adjusted for diabetes. CONCLUSION: Patients with ASO were more likely to have a low EPA/AA ratio and non- diabetic patients with ASO had a significantly reduced EPA/AA.