[Early to Long-term Results of Left Atrial Appendage Closure Using Clip Device in Patients with Atrial Fibrillation].

Oral anticoagulants for atrial fibrillation are the standard approach to prevent stroke in patients with atrial fibrillation. However, oral anticoagulant therapy carries the risk of cerebral infarction recurrence, not to mention hemorrhagic complications, even under appropriate drug therapy. Surgical treatments targeting the left atrial appendage include left atrial appendage closure( LAAO) and left atrial appendage resection (LAAR). Our hospital uses AtriClip (approved and available in Japan since 2018) as a device for LAAO, and we investigated the early and long-term results of LAAO using AtriClip in our hospital. As a result, stable early to long-term results were expected for left atrial appendage closure using AtriClip device, suggesting that it may be an option that can be considered as a method for preventing stroke in patients with atrial fibrillation. But further investigation is required in the future.

Incidence of Acute Thrombosis After Surgical Left Atrial Appendage Occlusion for Atrial Fibrillation.

BACKGROUND: The clinical implications of acute phase thrombosis after surgical left atrial appendage (LAA) closure remain unclear. This study sought to determine the frequency, prognosis, and factors involved in thrombogenesis after surgical LAA occlusion. METHODS: In this study, data from patients who underwent 2 types of standalone surgical LAA closure (either resection or clipping) between July 2014 and March 2020 at a single center were analyzed. RESULTS: A total of 239 consecutive patients with atrial fibrillation underwent minimally invasive standalone surgical LAA occlusion (184 resection cases and 55 clipping cases). On postoperative day 2, electrocardiogram synchronized contrast-enhanced computed tomography (CT) was performed in 223 cases (93.3%), and echocardiography follow-up was performed in 16 cases when CT was contraindicated. Acute postoperative thrombus on the closed stump was detected in 35 cases (14.7%), of which 29 cases (15.8%) belonged to the resection group and 6 cases (10.9%) belonged to the clipping group. No significant difference was detected between the groups, and no significant predictors of acute-phase thrombosis were found. Thromboembolism occurred in 4 patients before postoperative imaging follow-up, and there was no evidence of thrombi in these patients on postoperative day 2 CT. Three months after the first CT, thrombi were no longer detected in 34 of 35 patients (97.1%). CONCLUSIONS: Thrombosis can occur after surgical LAA occlusion. Although the clinical significance is yet unclear, it may be reasonable to continue anticoagulation therapy until a lack of thrombosis is confirmed, unless there are contraindications.

A comparison between stand-alone left atrial appendage occlusion and resection as a method of preventing cardiogenic thromboembolic stroke.

OBJECTIVE: The present study evaluated the differences between left atrial appendage occlusion (LAAO) and left atrial appendage resection (LAAR) in terms of the safety and efficacy. MATERIALS AND METHODS: From January 2018 to August 2022, 94 patients underwent a stand-alone LAAO, and 90 patients underwent stand-alone LAAR in our institution. All of these patients were included in this study. LAAO was performed via left mini-thoracotomy, and LAAR was performed via a left thoracoscopic approach. The patients' characteristics and perioperative and postoperative data were obtained by retrospectively reviewing their medical records. RESULTS: The mean age of the patients was 72.4 ± 10.2 (LAAO) and 66.2 ± 9.4 (LAAR) years old (P < 0.05). There were no marked differences in the mean duration of atrial fibrillation (AF) or the ratio of AF type between both groups. The average CHA2DS2-Vasc scores were 4.4 ± 1.6 (LAAO) and 2.7 ± 1.8 (LAAR) (P < 0.05), and the average HAS-BLED scores were 2.9 ± 1.0 (LAAO) and 2.2 ± 1.2 (LAAR) (P < 0.05). The mean operation time was 49 ± 20 min (LAAO) and 34 ± 15 min (LAAR) (P < 0.05). No substantial gaps were detected in preoperative echo-graphic findings between the groups. No significant differences were observed in the amount of intraoperative or postoperative bleeding or the rate of intraoperative massive bleeding events between the groups. Successful LAA closure was achieved in all cases in both groups. Approximately 50% of patients underwent concomitant left pulmonary vein isolation (LPVI) during surgery, indicating no significant differences between the groups (P = 0.872). The early mortality rate was 1.04% in the LAAO group and 0% in the LAAR group (P = 0.132). There was no significant difference in the rate of postoperative LAA stump thrombus between the groups (8.5% in the LAAO group and 6.7% in the LAAR group; P = 0.320). The mean follow-up period was 851 ± 500 (6-1618) days in the LAAO group and 1208 ± 357 (49-1694) days in the LAAR group. Postoperative stroke events were detected in 1 patient in each group (P = 0.432). There was no significant difference in the sinus rhythm recovery rate after LPVI between these groups (31.1% in the LAAO group and 28.6% in the LAAR group; P = 0.763). CONCLUSION: There were no significant differences between LAAO and LAAR in terms of the feasibility and the effectiveness as a method for stroke prophylaxis only to selected patients for both procedures, although further studies including the comparison between groups with the same backgrounds to confirm the authentic differences in the clinical results between these procedures.

Aortic Remodeling After Stepwise External Wrapping for Type A Acute Aortic Dissection.

BACKGROUND: The optimal repair technique for type A acute aortic dissection is graft replacement; however, the treatment approach in high-risk patients remains controversial or suboptimal. METHODS: We have retrospectively analyzed a cohort of high-risk patients who were admitted to our center for type A acute aortic dissection and who were treated by a new surgical approach using artificial grafts (stepwise external wrapping) between January 2016 and January 2020. The primary endpoints included inhospital mortality and survival during follow-up. Secondary endpoints included the assessment of aortic remodeling after ascending aorta wrapping. RESULTS: Among the 134 patients admitted for type A acute aortic dissection, 43 patients underwent stepwise external wrapping. The mean patient age was 79.1 ± 6.8 years. The new standard European System for Cardiac Operative Risk Evaluation score was 64% ± 12%. There was one hospital death (2.3%). There were two major complications of persistent cerebral disorder (4.6%). Minor complications included temporary neurologic disorder (2.3%) and renal failure (2.3%). The intensive care unit and hospital stays were 2.8 ± 1.0 days and 11.7 ± 2.5 days, respectively. The follow-up survival rate was 95.3% ± 6.2% and 91% ± 10.2% at 1 and 3 years, respectively, after surgery. There was no aortic-related death during follow-up. At 1 year after surgery, complete remodeling of the ascending aorta was obtained in 30 patients (85.7%), and 5 patients (14.3%) showed partial remodeling. CONCLUSIONS: Our stepwise external wrapping technique was associated with excellent outcomes for high-risk patients with type A acute aortic dissection.

Inverted Thoracic Stent Graft Technique for Separation of a Stent Graft and Bare Stent Caused by Aortic Elongation.

INTRODUCTION: Component separation (CS) of the Zenith Dissection Endovascular Graft and Stent have been reported with some causes. However, CS caused by aortic elongation has not yet been reported. A long treatment range with the sacrifice of some intercostal arteries (ICAs) is sometimes needed when repairing CS because of the large difference in the diameter between the proximal and distal landing zones with a reverse taper. CASE PRESENTATION: A 78-year-old man, who underwent thoracic endovascular aortic repair (TEVAR) using a Zenith Dissection Graft and stents for acute type B aortic dissection 3 years and 8 months previously was admitted to our hospital with severe back pain. Contrast-enhanced computed tomography (CT) showed separation of the SG and bare stent, and aortic elongation. As there was a large difference in the diameter of the proximal and distal landing zones with a reverse taper, a long treatment range with the sacrifice of two large ICAs was needed. Thus, TEVAR using an inverted thoracic SG technique was performed in order to shorten the treatment range to preserve a large ICA and reduce the risk of paraplegia. Completion angiography showed that the separation was repaired with preservation of the large ICA. The postoperative course was uneventful, and he was discharged on postoperative day 10 with relief of his severe pain. At 1 year after secondary TEVAR, CT showed that the diameter of the descending aorta had decreased with no separation of the SGs. CONCLUSION: Deployment of an inverted thoracic SG for the treatment of CS of the Zenith Dissection Endovascular Graft and Stent is a feasible and effective procedure to preserve ICAs. An overlapping range of >1.5 times the length of a bare stent within an SG is needed to prevent CS of the Zenith Dissection Endovascular Graft and Stent caused by aortic elongation.

Successful hybrid repair for ruptured abdominal aortic aneurysm caused by type IIIa endoleak resulting from a disconnected contralateral limb.

The occurrence of a type IIIa endoleak after endovascular aortic repair is a rare, but crucial, complication leading to rupture. Treatment of a ruptured abdominal aortic aneurysm caused by a type IIIa endoleak can sometimes be challenging. We have reported the case of a 78-year-old man who had presented with a ruptured abdominal aortic aneurysm caused by a type IIIa endoleak resulting from disconnection of a contralateral limb. The patient underwent hybrid repair using manual reconnection of the limbs with laparotomy and an endovascular technique, including balloon occlusion of the infrarenal aorta and new contralateral limb deployment. We found this hybrid repair to be an effective and minimally invasive procedure when total endovascular repair would have been difficult.

Early Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Increases the Success of Aortic Remodeling.

BACKGROUND: Type B aortic dissection (TBAD) is treated with thoracic endovascular aortic repair (TEVAR). However, the optimal timing of the surgical intervention remains unclear. We aimed to investigate whether the timing of TEVAR impacts aortic remodeling. METHODS: Forty-three patients with TBAD (31 men and 12 women) who had undergone surgical intervention with TEVAR between January 2014 and June 2021 were retrospectively evaluated. The relationship between the timing of TEVAR and success of aortic remodeling was assessed using linear regression analysis. Successful aortic remodeling was defined by a reduction of diametric ratio (false lumen/aorta) at 3 points (thoracic region, thoracoabdominal region, and abdominal region) and measured using computed tomography both pre- and post-operatively. The level of statistical significance was set at P < 0.05. RESULTS: The timing of TEVAR after symptom onset was defined as early (≤14 days, n = 27, group E) or late (≥15 days, n = 16, group L). The median duration from symptom onset to TEVAR in groups E and L were 3 days (interquartile range [IQR], 1.5-6 days) and 196 days (IQR, 89.8-252.3 days), respectively (P < 0.001). Patent type, rupture, malperfusion, and continuous pain were present preoperatively in 82%, 3.7%, 14.8%, and 33.3% of patients in group E, respectively, and in 37.5%, 0%, 6.3%, and 0% of patients in group L, respectively. In group E, thoracic aortic diameter and false luminal thickness were decreased significantly from pre- to post-operation (36.9 ± 12.4 vs. 35 ± 12.7 mm, P = 0.03; 13.6 ± 6.2 vs. 3.4 ± 4.5 mm, P < 0.001, respectively). Whereas, thoracic aortic diameter significantly increased, and false luminal thickness did not significantly change pre- and post-operation in group L (32.7 ± 9.5 vs. 37 ± 12.8 mm, P = 0.041; 9.1 ± 4.5 vs. 7.5 ± 9.5 mm, P = 0.4, respectively). CONCLUSIONS: Our results suggest that early intervention for TBAD with TEVAR increases the success of aortic remodeling.

Relationship of acute type A aortic dissection and disseminated intravascular coagulation.

OBJECTIVE: Acute type A aortic dissection (ATAAD) is a critical disease presenting with disseminated intravascular coagulation (DIC). However, the relationship between the degree of DIC and false lumen conditions remains unclear. In the present study, we evaluated the degree of preoperative DIC and the outcomes of ATAAD treatment. METHODS: A total of 124 patients with ATAAD (70 men and 54 women) treated from January 2012 to January 2020 were included in the present study. The correlation between the preoperative Japanese Association for Acute Medicine (JAAM) DIC score and the false lumen diameter and length, measured using preoperative computed tomography, was examined retrospectively. The correlations were calculated using liner regression analysis. The level of statistical significance was set at P < .05. RESULTS: The patients were divided into two groups: a low JAAM DIC score group and a high JAAM DIC score group. The preoperative JAAM DIC scores in the high- and low-score groups were 4.8 ± 1.2 and 1.7 ± 2.3, respectively (P < .001). The 5-year survival rates and aortic event-free rates in the low-score group were favorable compared with the high-score group; however, the differences were not statistically significant (80.8% vs 54.5%, P = .065; 63.9% vs 59.8%, P = .15, respectively). The false lumen diameter in the ascending aorta was greater in the high-score group than that in the low-score group (P < .05). The JAAM DIC score correlated significantly with the ascending false lumen diameter and the dissection length (r = 0.32 and P < .001; r = 0.29 and P = .001, respectively). A high JAAM DIC score was associated with communicating-type ATAAD (P < .05). CONCLUSIONS: Our results suggest that high preoperative JAAM DIC scores are associated with a large false lumen and communicating-type ATAAD.

Stepwise external wrapping procedure for type A intramural hematoma.

BACKGROUND: The optimal treatment for Stanford type A acute intramural hematoma remains controversial, especially in elderly or high-risk patients. METHODS: We have developed a new surgical approach using artificial grafts (stepwise external wrapping) for high-risk patients. The aim of this study is to report our results using the stepwise external wrapping procedure in the treatment of high-risk patients with type A intramural hematoma. Among the 129 patients admitted for type A intramural hematoma between January 2016 and January 2020, 49 patients underwent stepwise external wrapping. The mean patient age was 78 ± 7 years. The new standard European system for cardiac operative risk evaluation II was 54% ± 23%. The mean overall operation and cardiopulmonary bypass times were 96 ± 13 minutes and 35 ± 10 minutes, respectively. RESULTS: There were no hospital deaths. Two cases of temporary neurologic disorder, 1 case of renal failure, and 2 cases of wound infection occurred during the postoperative period. The intensive care unit and hospital stays were 2 ± 1 days and 10 ± 3 days, respectively. The thickness of intramural hematoma that had been the target of the stepwise external wrapping procedure decreased significantly from 18.0 ± 10.7 mm preoperatively to 5.2 ± 4.4 mm at 3 months after surgery (P < .05). The follow-up survival was 97.7% ± 4.4 % at 1 year after surgery and 89.8% ± 11.4% at 3 years after surgery. There was no aortic-related death during follow-up. CONCLUSIONS: Our stepwise external wrapping is a feasible alternative to conventional graft replacement for high-risk patients with type A intramural hematoma. The early and midterm outcomes of the procedure were satisfactory, but further careful follow-up is needed.

Use of coagulation-fibrinolysis markers for prognostication of Stanford type A acute aortic dissection.

PURPOSE: Coagulation-fibrinolysis markers are widely used for the diagnosis of Stanford type A acute aortic dissection (SAAAD). However, the role of these markers in estimating prognosis remains unclear. METHODS: A single-center retrospective study was conducted to identify the relationship between preoperative D-dimer and fibrinogen levels on SAAAD postoperative early prognosis. RESULTS: Of 238 SAAAD patients who underwent surgery between January 2012 and December 2018, 201 (84.5%) and 37 (15.5%) patients constituted the survival and non-survival groups, respectively, 30 days after surgery. D-dimer and fibrinogen levels in the survival and non-survival groups were 45.2 ± 74.3 vs. 91.5 ± 103.6 µg/mL (p = 0.014) and 224.3 ± 95.6 vs. 179.9 ± 96.7 µg/mL (p = 0.012), respectively. According to logistic predictor analysis of 30-day mortality, significant factors showed patent type (OR 10.89, 95% CI 1.66-20.31) and malperfusion (OR 4.63, 95% CI 1.74-12.32). Increasing D-dimer (per +10 µg/mL) and decreasing fibrinogen (per -10 µg/mL) were significantly associated with patent type and malperfusion. Receiver operating characteristic analysis was performed to distinguish between survival and non-survival. The cutoff value of D-dimer was 60 µg/mL (sensitivity 61.1%; specificity 82.5%; area under curve [AUC] 0.713 ± 0.083); fibrinogen was 150 mg/dL (sensitivity 44.4%; specificity 84.0%; AUC 0.647 ± 0.092). Kaplan-Meier survival curve analysis showed that patients with D-dimer levels > 60 µg/mL and fibrinogen levels < 150 mg/dL had significantly low survival rates at 30 days after surgery (60.0%, p < 0.001). CONCLUSION: Preoperative coagulation-fibrinolysis markers may be useful for predicting early prognosis in SAAAD.

[Less Invasive Surgical Closure of the Left Atrial Appendage for Cardiogenic Cerebral Embolism in a Patient with Dilated Cardiomyopathy].

Less invasive surgical closure of the left atrial appendage is recommended to prevent cardiogenic thromboembolism in patients with chronic non-valvular atrial fibrillation( Af) and other high-risk cardiac diseases such as dilated cardiomyopathy (DCM). We report a case of a 57-year-old man with Af and DCM. Catheter ablation for Af was contraindicated in this patient with a history of cardiogenic thromboembolism, and anticoagulation therapy was initiated. Despite anticoagulation therapy, the patient developed another ischemic stroke and we administered aggressive anticoagulation therapy resulting in successful resolution of the left atrial appendage thrombus. Less invasive surgical closure of the left atrial appendage was successfully performed, and thromboembolism has not recurred for one year postoperatively.

Custom-made iliac fenestrated endoprosthesis for the treatment of internal iliac artery aneurysm with preservation of the superior gluteal artery.

A 56-year-old man with huge bilateral internal iliac artery aneurysms (IIAAs) had emergently undergone right common iliac artery replacement. Intermittent claudication was induced by 8 minutes of walking on postoperative day 16. Endovascular repair using a custom-made iliac fenestrated endoprosthesis for the treatment of the left IIAA with preservation of the superior gluteal artery was performed on postoperative day 20 without discharging the patient. The patient had no ischemic complications. When an IIAA with a short length (<55 mm) and large diameter (>21 mm) of the common iliac artery is anatomically suitable, the placement of a custom-made iliac fenestrated endoprosthesis is a feasible and effective technique.

Hybrid stepwise external wrapping for type a acute aortic dissection with cerebral Malperfusion.

BACKGROUND: Acute aortic dissection (AAD) is a life-threatening condition which can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. Mortality of surgical treatment in high-risk or elderly patients with Type A AAD (TAAAD) still remains high, and treatment for such patients remains controversial. We report a successful treatment of TAAAD with a communicating false lumen in a 60-year-old man with acute hemi-cerebral malperfusion. CASE PRESENTATION: The ascending aorta was wrapped with stepwise external wrapping (SEW) procedure, and subsequent thoracic endovascular aortic repair (TEVAR) was successfully performed. The patient was discharged in good physical condition without any complications. CONCLUSIONS: Hybrid therapy with SEW and TEVAR with TAAAD associated with major cerebral malperfusion should be considered, especially in patients for whom open surgery is extremely risky.

Early and Middle-Term Results and Anticoagulation Strategy after Left Atrial Appendage Exclusion Using an Epicardial Clip Device.

OBJECTIVE: The present study aimed to evaluate short- and middle-term results and postoperative anticoagulation of left atrial appendage (LAA) exclusion with an epicardial clip device. MATERIALS AND METHODS: From September 2017 to August 2019, 102 patients at our institution underwent epicardial LAA exclusion using the AtriClip device. Anticoagulation therapy was resumed in the very early postoperative period and continued for at least three months after surgery. The patients' data were obtained by reviewing their medical records retrospectively. RESULTS: The mean and median durations of follow-up was 510 ± 184 days and 482 days (range, 216-938 days), respectively. Successful LAA exclusion was confirmed in all but one patient. No device-related complications occurred during surgery. Postoperative computed tomography (CT) findings revealed no migration or displacement of the clips in any patient; however, small clots were observed at the LAA stump in seven patients. Stroke-free rate during the follow-up period was 98.9%. CONCLUSION: LAA exclusion using the AtriClip device was a feasible treatment method in terms of its early and middle-term safety and efficacy. In addition, our postoperative anticoagulation strategy could be optimal for maximizing the procedure's merits, although further studies, involving a larger number of patients and longer duration of follow-up, are needed.

[Transthoracic Endovascular Aortic Repair for Malperfusion after Ascending Aortic Replacement for Stanford Type A Acute Aortic Dissection;Report of a Case].

A 53-year-old man was presented with Stanford type A acute aortic dissection. We first performed emergency ascending aortic replacement under selective cerebral perfusion with moderate hypothermia. He developed abdominal pain after the surgery. Six days after the 1st surgery, computed tomography revealed that the new entries were located in the distal anastomosis site and the distal aortic arch, and the true lumen of the aorta was obstructed by the false lumen and stenosis. Visceral malperfusion was diagnosed and emergent total debranching thoracic endovascular aortic repair (TEVAR) was planned. One proximal covered stentgraft and 2 distal bare stents were deployed.

Total debranching thoracic endovascular aortic repair with elephant trunk insertion technique.

We report successful total debranching thoracic endovascular aortic repair using the elephant trunk insertion technique without hypothermic circulatory arrest for a 56-year-old man who developed aortic arch dissection and ascending aortic aneurysm. In the first step, an elephant trunk graft was inserted into the ascending aorta under cardiopulmonary bypass, and a branched prosthetic graft was attached to the ascending aorta. The left common carotid artery and brachiocephalic artery were sequentially anastomosed to the branched graft. The second step was thoracic endovascular aortic repair covering the elephant trunk to the distal arch. Postprocedure digital subtraction angiography showed no endoleaks or false lumen.

Pelvic collateral pathway during endovascular aortoiliac aneurysm repair with internal iliac artery interruption: a retrospective observational study.

BACKGROUND: Ipsilateral branches of the deep femoral artery (DFA) are qualitatively identified as collateral arteries based on angiography after internal iliac artery (IIA) interruption. The purpose of this study was to quantitatively identify the major collateral pathway after unilateral IIA interruption during endovascular aortoiliac aneurysm repair to preserve the pelvic circulation and reduce the risk of ischemic complications. METHODS: The study population included 28 patients (mean age 76.3 years) with aortoiliac aneurysm who underwent endovascular aneurysm repair with unilateral IIA interruption from August 2012 to January 2020. The diameters of the bilateral preoperative and postoperative DFA, lateral femoral circumflex artery (LFCA), medial femoral circumflex artery (MFCA) and obturator artery (ObA) were measured on contrast-enhanced computed tomography using a 3-dimensional image analysis system. The measured values were evaluated and analyzed with a repeated measures two-way analysis of variance and Dunnett's test. RESULTS: The postoperative diameters of the MFCA (P = 0.051) and ObA (P = 0.016) were observed to be larger than the preoperative diameters. Such increases in the MFCA (P < 0.001) and ObA (P < 0.001) diameters were only found to be significant on the unilateral side of the IIA interruption, and the diameter of the ipsilateral LFCA (P < 0.001) was also found to have significantly increased in size. However, no significant arterial extension was found on the contralateral side. CONCLUSIONS: The ipsilateral MFCA-ObA pathway might therefore be a major collateral pathway arising from the DFA to preserve pelvic circulation after unilateral IIA interruption.

A 103 Year Old Man With a Ruptured Abdominal Aortic Aneurysm.

INTRODUCTION: With wider use of stent grafts, treating nonagenarians with abdominal aortic aneurysm has become more common in Japan. This is the report of a 103 year old patient with a ruptured abdominal aortic aneurysm who successfully underwent emergency endovascular aortic repair. To the present authors' knowledge, this report describes the oldest patient treated for a ruptured abdominal aortic aneurysm with a successful outcome. REPORT: A 103 year old man with ruptured abdominal aortic aneurysm was successfully treated by endovascular aortic repair. The post-operative course was uneventful, and he was discharged from the hospital on post-operative day 11. Two months later, in the outpatient clinic, the patient was doing well. CONCLUSION: It is important that decisions concerning the operative indications for a ruptured abdominal aortic aneurysm in elderly patients are based not only on age, but also on a comprehensive pre-operative assessment, including consideration of the patient's activity of daily life and personal wishes, as well as the desires of family members.

Single-stage total endovascular therapy for an aberrant right subclavian aneurysm.

A 34-year-old woman who demonstrated an aberrant right subclavian artery aneurysm was referred to our hospital. Single-stage total endovascular therapy with preservation of the right vertebral artery using a surgeon-modified fenestrated stent graft was performed. Contrast-enhanced computed tomography on postoperative day 4 revealed the patency of the right vertebral artery with no evidence of endoleaks. The patient was discharged on postoperative day 6. Three years later, the patient had no adverse events. When an aberrant right subclavian artery aneurysm is anatomically suitable, single-stage total endovascular therapy for such an aneurysm is considered to be a feasible and appropriate minimally invasive treatment.