The usefulness of chest drain and epicardial pacing wire culture for diagnosing mediastinitis after open-heart surgery.

PURPOSE: Culture of extracted drains or epicardial pacing wires is an easy and noninvasive method for detecting mediastinitis after open-heart surgery, although studies on its sensitivity and specificity are limited. We, therefore, investigated the usefulness of this approach for diagnosing mediastinitis. METHODS: We retrospectively studied the culture results of drains and epicardial pacing wires extracted from 3308 patients. Prediction models of mediastinitis with and without culture results added to clinical risk factors identified by a logistic regression analysis were compared. RESULTS: The incidence of mediastinitis requiring surgery was 1.89% (n = 64). Staphylococcus was the causative bacterium in 64.0% of cases. The sensitivity, specificity, and positive and negative predictive values of positive culture results were 50.8%, 91.8%, 10.7%, and 99.0%, respectively. Methicillin-resistant Staphylococcus aureus had the highest positive predictive value (61.5%). A multivariate analysis identified preoperative hemodialysis (OR 5.40 [2.54-11.5], p < 0.01), long operative duration (p < 0.01), postoperative hemodialysis (OR 2.25 [1.01-4.98], p < 0.05), and positive culture result (OR 10.2 [5.88-17.7], p < 0.01) as independent risk factors. The addition of culture results to pre- and postoperative hemodialysis and a lengthy operative time improved the prediction of mediastinitis. CONCLUSIONS: A culture survey using extracted drains and epicardial pacing wires may provide useful information for diagnosing mediastinitis.

Clinical Outcomes and Factors Associated With Aortic Shrinkage After Thoracic Endovascular Aortic Repair for Aneurysmal Chronic Aortic Dissection.

PURPOSE: The effectiveness of thoracic endovascular aortic repair (TEVAR) for chronic aortic dissection (AD) with aneurysmal degeneration remains controversial. We retrospectively investigated clinical outcomes and assessed predictors of aortic shrinkage after TEVAR for chronic aneurysmal AD. MATERIALS AND METHODS: Between January 2010 and December 2021, 70 patients with double-barrel-type chronic AD were enrolled. Major intimal tears in thoracic aorta were covered by stent graft. Early and late clinical outcomes, and diameter change of downstream aorta during follow-up period were reviewed. Subsequently, factors associated with aortic shrinkage were assessed by logistic regression analysis. RESULTS: Mean age was 63 (interquartile range [IQR]: 54-68) years, 54 (80%) men, median duration from AD onset was 4 (IQR: 1-10) years, and maximum aortic diameter was 53 (IQR: 49-58) mm. Supra-aortic debranching procedure was required in 57 (81%) patients. Early aorta-related death occurred in 2 (3%) patients. Both stroke and spinal cord ischemia occurred in 1 (2%) patient. Five-year freedom rates from aorta-related death and reintervention were 96% and 51%, respectively. Sixty-four patients underwent follow-up computed tomography (84%) 1 year after TEVAR, with 33 (52%) achieving aortic shrinkage. In multivariable analysis, duration from AD onset (per year) (odds ratio [OR]: 0.82, 0.70-0.97; p=0.017) and maximum aortic-diameter ratio between aortic arch and descending aorta (per 0.1) (morphologic index; OR: 1.34, 1.04-1.74; p=0.023) were independent aortic shrinkage predictors. CONCLUSIONS: Thoracic endovascular aortic repair for chronic AD with aneurysmal degeneration achieved satisfactory survival outcomes, but with a considerable reintervention rate. Duration from AD onset and preoperative aortic morphology could affect post-TEVAR aortic shrinkage. Earlier intervention could lead to better aortic shrinkage. CLINICAL IMPACT: Thoracic endovascular aortic repair for chronic aortic dissection with aneurysmal degeneration showed low incidence of early and late aorta-related death. By contrast, aortic shrinkage rate was low with high incidence of reintervention to the residual downstream aorta. According to the assessment of preoperative variables, chronicity and aortic morphology could predict postoperative aortic shrinkage.

Impact of Patent Lumbar Arteries on Aneurysm Sac Enlargement with Type II Endoleak after Endovascular Aneurysm Repair.

OBJECTIVE: This study aimed to investigate the impact of the number of patent lumbar arteries (LAs) on sac enlargement after endovascular aneurysm repair (EVAR). METHODS: This was a retrospective cohort single centre registry study. Between January 2006 and December 2019, 336 EVARs were reviewed using a commercially available device excluding type I or type III endoleaks during a follow up of ≥ 12 months. Patients were divided into four groups based on the pre-operative patency of the inferior mesenteric artery (IMA) and high (≥ 4) or low (≤ 3) number of patent LAs: Group 1, patent IMA and high number of patent LAs; Group 2, patent IMA and low number of patent LAs; Group 3, occluded IMA and a high number of patent LAs; Group 4, occluded IMA and low number of patent LAs. RESULTS: Groups 1, 2, 3, and 4 included 124, 104, 45, and 63 patients, respectively. The median follow up duration was 65.1 months. Significant differences in the incidence of overall type II endoleak (T2EL) at discharge between Group 1 and Group 2 (59.7% vs. 36.5%, p < .001) and between Group 3 and Group 4 (33.3% vs. 4.8%, p < .001) were observed. In patients with a pre-operatively patent IMA, the rate of freedom from aneurysm sac enlargement was significantly lower in Group 1 than in Group 2 (69.0% vs. 81.7% five years after EVAR, p < .001). In patients with a pre-operatively occluded IMA, the freedom rate from aneurysm sac enlargement was not significantly different between Groups 3 and Group 4 (95.0% vs. 100% five years after EVAR, p = .075). CONCLUSION: A high number of patent LAs seemed to have a significant role in sac enlargement with T2EL when the IMA was patent pre-operatively, whereas a high number of patent LAs seemed to have limited influence on sac enlargement when the IMA was occluded pre-operatively.

Successful surgery for secondary aortoduodenal fistula based on 18F-fluorodeoxyglucose positron emission tomography/computed tomography findings.

Secondary aortoduodenal fistula (sADF) is a critical late complication of abdominal aortic repair, requiring complete excision of the infected prosthesis. However, this is a highly invasive procedure for the elderly. We describe a case of sADF repair in a 76-year-old woman. Through 18F (fluorine-18)-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography mapping, focal high FDG uptake at the sADF site, right medial limb, and ligated left lateral limb of the prosthesis was detected. The duodenal and prosthetic grafts were partially resected. The proximal and distal anastomotic segments, with no FDG uptake, were retained. The abdominal aorta was reconstructed using a bovine pericardium roll and femorofemoral bypass. Thus, FDG positron emission tomography/computed tomography mapping of the infection site could help in such cases.

The technique of balloon occlusion-assisted repair of a pseudoaneurysm originated from the side branch of an ascending aortic prosthetic graft via mini-thoracotomy.

A 69-year-old woman underwent aortic root reimplantation and graft replacement of the ascending aorta 12 years ago. A pseudoaneurysm (2.5 cm × 3 cm) arising from the side branch of the ascending aortic prosthetic graft was incidentally detected on contrast-enhanced computed tomography. After endovascular balloon occlusion of the side branch through the left subclavian artery, the side branch was exposed via right mini-thoracotomy in the third intercostal space. After circumferential dissection, the side branch was ligated uneventfully. The patient was discharged home on postoperative day 7 without any complications.

Endovascular treatment of perigraft seroma in patient with prior hybrid thoracoabdominal repair using visceral bypass to relieve duodenal obstruction.

Perigraft seroma (PS) is a postoperative complication occurring after prosthesis placement. A 48-year-old man who had previously undergone visceral debranching bypass surgery as a part of hybrid thoracoabdominal aortic repair was referred to our hospital because of vomiting. Contrast-enhanced computed tomography revealed a duodenal obstruction resulting from compression by a PS located around the bypass graft and extending to the right renal artery. Endovascular relining of the visceral bypass graft using a covered stent was performed, resulting in immediate resolution of the duodenal obstruction and shrinkage of the PS. Endovascular repair can be considered as an effective option for treating a PS.

Challenging endovascular treatment of a thoracic saccular aneurysm in extensive coral reef aorta.

Coral reef aorta (CRA) is characterized by heavily calcified obstructive lesions in the aorta. Thoracic endovascular aortic repair (TEVAR) is an established, less invasive procedure for aortic diseases; however, aortic occlusive diseases are commonly treated with conventional open surgery, and there are no reports of TEVAR in patients with a saccular aneurysm in CRA. We present a 72-year-old frail woman with a descending thoracic saccular aneurysm in CRA; therefore, we performed TEVAR. Although we had difficulty in advancing the stent graft system because it was caught in the severely calcified aorta, we finally succeeded in excluding the aneurysm.

Impact of the Patency of Inferior Mesenteric Artery on 7-Year Outcomes After Endovascular Aneurysm Repair.

PURPOSE: The impact of preoperative patent inferior mesenteric artery (IMA) on late outcomes following endovascular aneurysm repair (EVAR) remains unclear. This study aimed to investigate the specific influence of IMA patency on 7-year outcomes after EVAR. MATERIALS AND METHODS: In this retrospective cohort study, 556 EVARs performed for true abdominal aortic aneurysm cases between January 2006 and December 2019 at our institution were reviewed. Endovascular aneurysm repairs performed using a commercially available device with no type I or type III endoleak (EL) during follow-up and with follow-up ≥12 months were included. A total of 336 patients were enrolled in this study. The cohort was divided into the patent IMA group and the occluded IMA group according to preoperative IMA status. The late outcomes, including aneurysm sac enlargement, reintervention, and mortality rates, were compared between both groups using propensity-score-matched data. RESULTS: After propensity score matching, 86 patients were included in each group. The median follow-up period was 56 months (interquartile range: 32-94 months). The incidence of type II EL at discharge was 50% in the patent IMA group and 19% in the occluded IMA group (p<0.001). The type II EL from IMA and lumbar arteries was significantly higher in the patent IMA group than in the occluded IMA group (p<0.001 and p=0.002). The rate of freedom from aneurysm sac enlargement with type II EL was significantly higher in the occluded IMA group than in the patent IMA group (94% vs 69% at 7 years; p<0.001). The rate of freedom from reintervention was significantly higher in the occluded IMA group than in the patent IMA group (90% vs 74% at 7 years; p=0.007). Abdominal aortic aneurysm-related death and all-cause mortality did not significantly differ between groups (p=0.32 and p=0.34). CONCLUSIONS: Inferior mesenteric artery patency could affect late reintervention and aneurysm sac enlargement but did not have a significant impact on mortality. Preoperative assessment and embolization of IMA might be an important factor for improvement in late EVAR outcomes. CLINICAL IMPACT: The preoperative patency of the inferior mesenteric artery was significantly associated with a higher incidence of sac enlargement and reintervention with type II endoleak following endovascular aneurysm repair, even after adjustment for patient background. Preoperative assessment and embolization of inferior mesenteric artery might be an important factor for improvement in late EVAR outcomes.

Acute posteromedial papillary muscle rupture secondary to aortic valve endocarditis: a case report.

Background: Acute papillary muscle (PM) rupture due to infective involvement has been recognized as a complication of infective endocarditis. However, there is very limited literature describing the rupture of the posteromedial PM in primary aortic valve endocarditis without aortic root abscess. This report highlights the aetiology of the PM rupture in the setting of primary aortic valve endocarditis and the importance of a multidisciplinary approach. Case summary: An 81-year-old man without any heart failure symptoms presented with fever and loss of vision in his left eye. Initial echocardiography revealed moderate aortic valve regurgitation due to a perforated right coronary cusp without aortic root abscess, and his blood cultures were positive for Group G Streptococci. During adequate antibiotic therapy, he developed acute severe mitral regurgitation secondary to posteromedial PM rupture. Following emergent aortic and mitral valve replacement using bioprosthetic valves, he made excellent progress on a 6-week course of intravenous antibiotics. Discussion: The echocardiography and the histological findings suggested that the main cause of PM rupture was most likely a metastatic focus of infection from the aortic valve via a regurgitant jet. Successful treatment of this fatal complication includes early diagnosis and prompt surgical intervention by a multidisciplinary approach.

Effectiveness of Proximal Landing Zones 0, 1, and 2 Hybrid Thoracic Endovascular Aortic Repair: A Single Centre 12 Year Experience.

OBJECTIVE: Hybrid thoracic endovascular aortic repair (TEVAR) is being accepted increasingly as a first line treatment for arch repair at the present authors' institution. This study aimed to clarify the effectiveness of zones 0, 1, and 2 landing hybrid TEVAR. METHODS: This was a retrospective single centre case series. From April 2008 to March 2020, 348 patients (median age 72 years; interquartile range [IQR] 65, 77 years) were enrolled, with a median follow up period of 5.6 years (IQR 2.6, 8.7 years). The procedures included zone 0 in 135 patients (38.8%), zone 1 in 82 patients (23.6%), and zone 2 proximal landing zone (LZ) hybrid TEVAR in 131 patients (37.6%). The pathologies consisted of dissecting aortic aneurysms in 123 (35.3%) patients. Emergency procedures were performed in 39 (11.2%) patients. RESULTS: The 30 day mortality (n = 2, 0.6%) and hospital deaths (n = 6, 1.7%) were registered. The stroke rate was 1.1% (n = 4), while early and late endoleak rates were 4.8% (n = 17) and 1.7% (n = 6), respectively. Type 1a endoleak and retrograde type A dissection occurred in seven (2.0%) and three (0.9%) patients, respectively. The cumulative survival, freedom from aorta related deaths, and freedom from aortic events in 10 years were 75.0%, 97.2%, and 84.1%, respectively. The freedom from aortic events in each landing zone in 10 years was 82.3%, 81.4%, and 87.9% for zones 0, 1, and 2, respectively. The 10 year survival rates were 82.5% and 73.6%; the 10 year aorta related death free rates were 94.9% and 98.6%, and the 10 year aortic event free rates were 82.3% and 85.5% in the zone 0 and zone 1 and 2 TEVAR, respectively. CONCLUSION: Satisfactory early and long term results of hybrid arch repair at zones 0, 1, and 2 were achieved. To avoid complications and aortic events, the treatment strategy of hybrid arch repair for aortic arch pathologies should be tailored using accurate pre-operative assessment of the ascending aorta and the aortic arch.

Comparison of the Outcomes of Total Endovascular Aortic Arch Repair Between Branched Endograft and Chimney Endograft Technique in Zone 0 Landing.

PURPOSE: Zone 0 landing in thoracic endovascular aortic repair (TEVAR) has recently gained increasing attention for the treatment of high-risk patients. The aim of this study was to compare the outcomes of total endovascular aortic arch repair between branched TEVAR (bTEVAR) and chimney TEVAR (cTEVAR) in the landing zone (LZ) 0. MATERIALS AND METHODS: This was a single-center, retrospective, and observational cohort study. From January 2010 to March 2020, 40 patients (bTEVAR, n=25; cTEVAR, n=15; median age: 79 years) were enrolled in this study, with a median follow-up period of 4.1 years. These patients were considered unsuitable for open surgical treatment. RESULTS: All procedures were successful and no cases of conversion to open repair were noted during the 30-day postoperative period. The 30-day mortality was 2.5% (n=1; bTEVAR [0 of 25, 0%] vs cTEVAR [1 of 15, 6.7%]; p=0.375), the perioperative stroke rate was 10.0% (n=4; bTEVAR [4 of 25, 16.0%] vs cTEVAR [0 of 15, 0%], p=0.278), and type 1a endoleak rate was 15.0% (n=6; bTEVAR [0 of 25, 0%] vs cTEVAR [6 of 15, 40.0%], p=0.001). The risk factor for stroke was atheroma grade of ≥2 in the brachiocephalic artery (p<0.001). The risk factor for type 1a endoleak was cTEVAR (p=0.001). The 8-year survival rate was 49.9%. The aorta-related death-free rate and aortic event-free rate at 8 years were 94.4% (bTEVAR: 95.5% vs cTEVAR: 93.3%, p=0.504) and 60.7% (bTEVAR: 70.7% vs cTEVAR: 40.0%, p=0.048), respectively. CONCLUSIONS: Total endovascular aortic arch repair using bTEVAR and cTEVAR is feasible for the treatment of aortic arch diseases in high-risk patients who are unsuitable for open surgery. However, as the rate of stroke is high, strict preoperative evaluation to prevent stroke is needed. No rupture of the aneurysm was observed in cTEVAR, but patients should be selected carefully because of the high incidence of type 1a endoleak.

Impact of radiation to the eye of operators during endo-cardiovascular surgery and the importance of protection.

OBJECTIVE: To verify the amount of radiation exposure to the eye of operators during endocardiovascular surgery (ECVS) in hybrid operating room (HOR), which increases the risk of cataracts in surgeons. METHODS: Fifty cases of ECVS (including 36 transcatheter aortic valve implantation and 14 thoracic endovascular repair) using the transfemoral approach performed from February 2020 to July 2020 were included. A measurement device was attached to the left side of the head of the operators and their assistants to measure the cumulative dose (CD) of intraoperative radiation exposure. The subjects were divided into the control group (Group C, n = 26), received conventional protection using the protective curtain in HOR and the protected group (Group R, n = 24), received conventional protection and protection sheet. The normalized CD by dose area product (CD/DAP) was evaluated. RESULTS: The CD/DAP of the surgeons was significantly decreased in Group R, averaging at 5.97 µSV/Gy cm2 in Group C group and 4.40 µSV/Gy cm2 in Group R (p < 0.01). Moreover, CD/DAP of the assistant was significantly reduced in the Group R, with an average of 1.87 µSV/Gy cm2 in the Group C and 1.01 µSV/Gy cm2 in Group R (p < 0.01). CONCLUSIONS: The radiation exposure to the surgeon's eye could be significantly reduced by protection sheet.

Open anatomical repair for primary coarctation of the aorta in adults.

OBJECTIVES: Although endovascular repair has become an alternative treatment for coarctation of the aorta (CoA) in adults, open repair provides concomitant repair of other cardiac complications, including post-stenotic aneurysm, ascending aortic aneurysm, and intracardiac diseases. We evaluated open anatomical repair for CoA repair in adults. METHODS: Eleven patients (6 men, age range 21-63 years) underwent primary CoA repair. Complicating conditions included post-stenotic aortic aneurysm in the descending aorta in 5 patients (45.5%) and ascending aortic aneurysm in 3 (27.3%). Two patients (18.2%) had a bicuspid aortic valve, and one (9.1%) had a quadricuspid aortic valve. Ventricular septal defect was detected in 1 patient (9.1%). Eight patients (72.7%) underwent descending aorta replacement through a left thoracotomy, comprising partial cardiopulmonary bypass in 4 and deep hypothermic circulatory arrest in 4. Of those, the left subclavian artery was reconstructed in 4 patients. The remaining 3 patients (27.3%) underwent total arch replacement, through a median sternotomy in 1 and using a combination of median sternotomy and thoracotomy in 2. RESULTS: No in-hospital mortality was observed. No spinal cord ischemia or neurological events were encountered, but 1 patient (9.1%) who underwent CoA repair via median sternotomy and thoracotomy required prolonged ventilatory support for more than 48 h. During the follow-up of 90 months (interquartile range 65-124 months), no patient died or required reintervention for the repaired segment. CONCLUSIONS: CoA in adults could be anatomically repaired with graft replacement both through the median sternotomy, the left thoracotomy, and the combination of both approaches, according to the complicated aortic or intracardiac lesions.

The impact of vascularized tissue flap coverage on aortic graft infection with and without infected graft excision.

OBJECTIVES: Aortic graft infection (AGI) is a serious condition associated with a high mortality rate. However, optimal surgical options have not been identified. Therefore, we retrospectively reviewed AGI cases, including those in the thoracic and abdominal regions, with or without fistula formation, to investigate the various options for better outcomes. METHODS: We reviewed 50 patients who underwent surgical interventions for AGI out of 97 patients with arterial infective disease. The mean patient age was 67 ± 17 years. Fourteen patients (28%) had a fistula with the gastrointestinal tract or lung. A combination of graft excision and vascularized tissue flap coverage was performed in 25 cases (50%). Tissue flap alone, graft excision alone and cleansing alone were performed in 9 (18%), 10 (20%), and 6 cases (12%), respectively. RESULTS: Total in-hospital mortality rate was 32% (n = 16). In-hospital mortalities in patients with and without fistulas were 43% (6/14) and 28% (10/36), respectively (P = 0.33). Subgroup analysis among patients without fistula demonstrated that the in-hospital mortality rate of the patients with vascularized tissue flap (3/21, 14%) was significantly lower than that of the patients without vascularized tissue flap (7/14, 50%, P = 0.026). Overall 1- and 5-year survival rates were 66% and 46%, respectively. In multivariable analysis, an independent factor associated with in-hospital mortality was vascularized tissue flap (odds ratio 0.20, P = 0.024). CONCLUSIONS: Vascularized tissue flaps could provide better outcomes for AGI. Graft preservation with vascularized tissue flaps could be a useful option for AGI without fistula.

Severe intraluminal atheroma and iliac artery access affect spinal cord ischemia after thoracic endovascular aortic repair for degenerative descending aortic aneurysm.

OBJECTIVES: This study aimed to reveal additional factors potentially contributing to the multifactorial ethiopathogenesis of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (TAA). METHODS: The medical records of 293 patients who underwent TEVAR without debranching procedures for descending TAA between 2011 and 2018 were retrospectively reviewed. We excluded the following cases from the study: 72 patients with aortic dissection; 15 with rupture; 14 with anastomotic pseudoaneurysm; 22 with re-TEVAR; 34 without evaluation of the artery of Adamkiewicz (AKA). Sufficient data were available for 136 patients (79% men; mean age of 76 ± 7.4 years). We conducted univariable and multivariable analyzes using the logistic regression analysis to assess the relationship between pre-/intraoperative factors and postoperative SCI. RESULTS: SCI was observed in nine patients (6.8%). Severe intraluminal atheroma [odds ratio (OR), 6.23; p = 0.014] and iliac artery access (OR 4.65; p = 0.043) were identified as the positive predictors of SCI by univariable analysis. Risk factors of SCI were determined additionally as follows: coverage of the intercostal artery branching AKA (ICA-AKA) (OR 4.89; p = 0.054); coverage of the ICA-AKA combined with iliac access (OR 10.1; p = 0.002); that combined with severe intraluminal atheroma (OR 13.7; p = 0.001). CONCLUSION: Severe intraluminal atheroma and iliac artery access were the independent predicting factors of SCI after TEVAR for degenerative descending TAA. In patients with complicated aortoiliofemoral access route, coverage of the ICA-AKA is associated with the risk of SCI.

Surgical outcomes of acute type A aortic dissection in patients undergoing cardiopulmonary resuscitation.

OBJECTIVES: The surgical indications for acute type A aortic dissection (AAAD) in patients in cardiopulmonary arrest remain controversial. Outcomes of AAAD for patients who underwent cardiopulmonary resuscitation (CPR) were evaluated. METHODS: Between 2004 and 2018, of the 519 patients who underwent AAAD repair, 34 (6.6%) required CPR before or on starting AAAD repair. The patients were divided into 2 groups, survivors (n = 13) and nonsurvivors (n = 21), to compare the early operative outcomes, including mortality and neurological events. RESULTS: The major cause of cardiovascular collapse requiring CPR was aortic rupture/cardiac tamponade (n = 21 [61.8%]), followed by coronary malperfusion (n = 12 [35.3%]) and acute aortic valve regurgitation (n = 3 [8.8%]). There were 3 (23.1%) patients in the survivors group and 11 (52.4%) in the nonsurvivors group who required ongoing CPR at the beginning of AAAD repair (P = .039). Of these patients, 1 survivor and 6 nonsurvivors could not achieve return of spontaneous circulation after pericardiotomy (P = .045). Although the duration from onset or arrival to the operating room was similar (P = .35 and P = .49, respectively), overall duration of CPR was shorter in survivors (10 minutes [range, 7.5-16 minutes] vs 16.5 minutes [range, 15-20 minutes]; P = .044). All survivors without any neurological deficits showed return of spontaneous circulation after pericardiotomy. Multivariate regression modeling showed that CPR duration >15 minutes was a significant risk factor for in-hospital mortality (P = .0040). CONCLUSIONS: CPR duration beyond 15 minutes may be a contraindication for AAAD repair. Moreover, we should reconsider surgery for patients who cannot achieve return of spontaneous circulation after pericardiotomy.

Preoperative renal function affects outcomes of surgery for aortic arch aneurysm in the elderly.

OBJECTIVES: This study aimed to determine the optimal surgical procedure for arch aneurysm in the elderly based on preoperative comorbidities, especially focusing on renal function. METHODS: The medical records of 374 patients who experienced arch surgery between 2008 and 2019 were reviewed. Among the 374 patients, 92 who underwent total arch replacement (TAR) were assigned to the TAR group and the remaining 152 who underwent debranching thoracic endovascular aortic repair (DTEVAR) were assigned to the DTEVAR group. RESULTS: Chronic kidney disease (CKD) was an independent risk factor of mortality (hazard ratio, 2.85; p = 0.029) in the TAR group but not in the DTEVAR. In the Grade I/II category CKD (estimated glomerular filtration rate (eGFR) > 60 mL/min), freedom from all-cause mortality was significantly higher in the TAR group than in the DTEVAR group (p = 0.0155, log-rank). Freedom from all-cause mortality was comparable between the two groups in the Grade IIIa CKD (eGFR, 45-60) (p = 0.584, log-lank), Grade IIIb (eGFR, 30-45) (p = 0.822), and Grade IV/V (eGFR < 30) (p = 0.548). CONCLUSION: In elderly patients who underwent TAR, CKD was the independent risk factor of the mortality, but not in the patients who underwent debranching TEVAR. Conversion of surgical strategy from TAR to debranching TEVAR in the treatment of aortic arch aneurysms in the elderly with CKD below Grade IIIa is acceptable considering that less-invasiveness. While, in the elderly with Grade I/II CKD, TAR still remains as a primary choice for the arch repair for better mid-term survival.

Efficacy of entry exclusion strategy for DeBakey type III retrograde Stanford type A acute aortic dissection.

OBJECTIVES: Resection of a primary entry tear is essential for the treatment of Stanford type A acute aortic dissection (AAAD). In DeBakey type III retrograde AAAD (DBIII-RAAAD), resection of the primary entry tear in the descending aorta is sometimes difficult. The frozen elephant trunk technique and thoracic endovascular aortic repair (TEVAR) enable the closure of the primary entry in the descending aorta. The aim of this study was to investigate the efficacy of resection or closure of primary entry, i.e. entry exclusion, in patients with DeBakey type III retrograde-AAAD. METHODS: The medical records of 654 patients with AAAD who underwent emergency surgery between January 2000 and March 2019 were retrospectively reviewed, and 80 eligible patients with DeBakey type III retrograde-AAAD were divided into the excluded (n = 50; age, 62 ± 12 years) and residual (n = 30; age, 66 ± 14 years) groups according to postoperative computed tomography angiographic data of the false lumen around the primary entry. The excluded group was defined as having a postoperative false lumen at the level of the elephant trunk or thrombosis of the endograft including primary entry. Patients with early false lumen enhancement around the elephant trunk or an unresected primary entry tear after isolated hemiarch replacement were included in the residual group. The early and long-term surgical outcomes were compared between the groups. RESULTS: The in-hospital mortality rate was 8% (6/80), with no significant difference observed between the excluded and the residual groups (10% and 7%, respectively; P > 0.99). Ninety-five percentage of the patients (20/21) achieved entry exclusion with stent grafts including the frozen elephant trunk procedure and TEVAR. Spinal cord ischaemia was not observed in either group. The cumulative overall survival at 5 years was comparable between the 2 groups (76% and 81% in the excluded and residual groups, respectively; P = 0.93). The 5-year freedom from distal aortic reoperation rate was significantly higher in the excluded group (97%) than in the residual group (97% vs 66%; P = 0.008). CONCLUSIONS: Not only resection but also closure using the entry exclusion approach for DeBakey type III retrograde-AAAD utilizing new technologies including the frozen elephant trunk technique and TEVAR might mitigate dissection-related reoperations.

Extrathoracic collaterals to critical segmental arteries after endovascular thoraco-abdominal aneurysm repair.

OBJECTIVES: The risk of spinal cord injury after thoraco-abdominal aortic aneurysm repair increases when the segmental arteries (SAs) in the critical segment are sacrificed. Such critical SAs cannot be reconstructed when performing thoracic endovascular aortic repair (TEVAR). We aimed to elucidate extrathoracic collaterals to the critical SAs (T9-L1) that develop after TEVAR. METHODS: Between 2006 and 2018, the critical SAs (T9-L1) of 38 patients were sacrificed during TEVAR. Nineteen of these patients who underwent multidetector row computed tomography 6 months after surgery were included (mean age 60 ± 13 years; 10 male; Crawford extent II:III, 14:5). We retrospectively assessed extrathoracic collaterals to the sacrificed critical SAs. RESULTS: Ninety-four collaterals to the critical SAs were observed, originating from the subclavian (26/94), external iliac (50/94) and internal iliac (18/94) arteries. Twenty-five of the 26 (96%) collaterals from the subclavian artery were from its lateral descending branch, and 19 of the 26 (73%) collaterals fed into T9. Forty-three of the 50 (86%) collaterals from the external iliac artery were from its lateral ascending branch, and 25 of the 50 (50%) collaterals communicated with T11. Patients with a history of left thoracotomy (no collaterals in 6 patients) had fewer collaterals via the lateral descending branch of the left subclavian artery in comparison with the patients without (10 collaterals in 13 patients) (P = 0.009). CONCLUSIONS: After critical SAs were sacrificed, extrathoracic collaterals developed with certain regularity. Previous left thoracotomy could influence the development of extrathoracic collaterals from the left subclavian artery.