Endovascular Aneurysm Repair Using Physician-Modified Fenestrated Endurant Contralateral Limb for Internal Iliac Artery Preservation.

CLINICAL IMPACT: We developed a novel Endovascular aortic repair technique for internal iliac artery preservation using a physician modified Endurant contralateral limb. This procedure was safe and reliable for preserving internal iliac artery flow in 24 patients with common and internal iliac artery aneurysms. We believe that our technique has the potential to expand the anatomic indications for internal iliac artery preserving procedures.

Successful Endovascular Repair of a Ruptured Common Iliac Artery Aneurysm Associated with an Ileal Pouch Neobladder Fistula.

A spontaneous fistula between a ruptured common iliac artery aneurysm and the ileal pouch neobladder is quite rare. We present the case of a 74-year-old man presenting with intense abdominal pain and massive hematuria. Computed tomography angiography revealed a ruptured common iliac artery aneurysm-ileal pouch neobladder fistula. His hemodynamics was unstable; emergent endovascular aortic repair was performed successfully. Infection and dysfunction of the neobladder were avoided owing to appropriate management.

[Pericardiocentesis and Pericardial Drainage].

Peicardiocentesis and surgical pericardial drainage are essential treatment and diagnostic modality for pericardial effusion. Though it theoretically is a simple therapeutic method, accurate diagnosis, correct decision, and safe procedure are not always easy. Thoracic and cardiovascular surgeons are required to have high level of expertise in pericardial drainage as surgeons who specialize this anatomical part of the body. The presence of pericardial effusion does not always require drainage. Accurate diagnosis is essential to determine correct indication. Echocardiography and computed tomography are useful tools for accurate diagnosis. The percutaneous drainage has become much safer in these 2 decades with the aid of imaging technology, especially echocardiography and fluoroscopy. Surgical pericardial window still has its role and is considered one of the standard treatment methods with minimal chance to require repeat procedure compared to percutaneous drainage.

[Prosthetic Valve].

In valvular disease treatment, it is extremely important to ensure good hemodynamics, to avoid thromboembolism and hemorrhagic complications, and to avoid reoperation. Due to the development of prosthetic valves, remarkable improvement in these results has been obtained. In recent years, the using rate of bioprosthetic valve has increased with the improvement of the durability of the bioprosthetic valve. Furthermore, a new bioprosthetic valve has also been developed, and it seems possible that the treatment strategy for valve disease such as valve selection of prosthetic valve and reoperation at the remote phase will change dramatically in the near future.

Outcomes of prosthetic valve replacement in women of child-bearing age.

PURPOSE: The outcomes of pregnancy are more favorable for women with bioprostheses than for those with mechanical prostheses. However, bioprostheses are associated with a high reoperation rate in young women and it remains unclear whether these young women can give birth without any complications. We analyzed the outcomes of prosthetic valve replacement and investigated the effectiveness and problems associated with bioprostheses in women of child-bearing age in Japan. METHODS: The subjects of this study were six consecutive young adult women aged under 40 years, who underwent prosthetic valve replacement between January 2007 and April 2016. RESULTS: Bioprostheses were selected for four of these six women in consideration of their child-bearing age. Mechanical valves were selected for the other two women who underwent the Konno procedure and double valve replacement (AVR, MVR) in view of their high risk for reoperation. The cardiac operations, although without mortality or morbidity, were complex and some involved multi-time procedures. Three of the women with bioprostheses had uneventful term pregnancies. CONCLUSIONS: These young women with bioprostheses were able to give birth safely; however, as multiple operations are often required, and bioprostheses may not be ideal for young women. Prosthetic valve selection for young women of child-bearing age requires adequate pregnancy counseling and long-term planning.

Identification of Coronary Artery Orifice to Prevent Coronary Complications in Bioprosthetic and Transcatheter Aortic Valve Replacement.

BACKGROUND: The aim of this study was to identify anatomical variations in coronary artery orifices among high-risk patients with a small aortic root undergoing bioprosthetic aortic valve replacement (BAVR) and transcatheter aortic valve replacement (TAVR) in order to prevent coronary orifice obstruction perioperatively. METHODS AND RESULTS: Coronary orifice and root structure were identified in 400 patients using aortic multidetector-row computed tomography (MDCT). We measured the aortic root diameter; intercommissural distances; and distance from coronary orifice to valve annulus, commissure, and sinotubular junction. We examined positional relationships between the coronary orifice and stent post, or sewing cuff of the bioprosthetic valve and leaflet of the transcatheter aortic valve. Most left coronary artery orifices were distributed near the center of the non-left and left-right commissures; right ones were relatively distributed on the non-right commissural side. Thirty-four patients (8.5%) with BAVR (coronary orifice near the commissure: 31, 7.8%; low takeoff: 5, 1.3%; and both: 2) and 39 (9.8%) with TAVR were at risk for coronary orifice obstruction. During BAVR, one-stitch rotation of the stent and one-stitch rotation with intra-annular implantation were used in near-commissure and low takeoff cases, respectively. During TAVR, percutaneous coronary intervention may be required in the height of the coronary orifice was ≤10 mm from the base of the ventricle aortic junction. CONCLUSIONS: Potential coronary complications during BAVR and TAVR in high-risk patients for coronary obstruction were identified using preoperative aortic MDCT. Choice of appropriate surgical technique or valve is essential.

Postoperative hyperglycemia and atrial fibrillation after coronary artery bypass graft surgery.

BACKGROUND: Postoperative atrial fibrillation (AF) is a common complication following coronary artery bypass grafting (CABG). We investigated the risk factors for postoperative AF and analyzed the relationship between blood sugar concentration (BS) and AF after CABG. METHODS AND RESULTS: A total of 199 consecutive patients who underwent isolated CABG were retrospectively examined and classified according to the presence (n=95) or absence (n=104) of postoperative AF. On univariate analysis mean postoperative BS (P<0.001), postoperative drainage volume (P<0.001), age (P=0.034), presence of diabetes mellitus (DM; P=0.004), and postoperative estimated glomerular filtration rate (P=0.032) were significant risk factors for postoperative AF. On multivariate analysis mean postoperative BS (OR, 1.041; 95% CI: 1.008-1.079; P<0.001), postoperative drainage volume (OR, 1.003; 95% CI: 1.001-1.006; P=0.001), and age (OR, 1.040; 95% CI: 1.002-1.083; P=0.041) were significant risk factors for postoperative AF. Postoperative AF often occurred in patients with high postoperative BS, irrespective of DM. The BS cut-off that predicted postoperative AF occurrence was 180 mg/dl. A strong positive correlation existed between the time of the maximum postoperative BS and AF onset time (ρ=0.746). CONCLUSIONS: Mean postoperative BS and postoperative drainage volume are risk factors for AF after CABG. AF was strongly associated with maximum postoperative BS. Intensive glycemic control could reduce AF occurrence after CABG.

Purulent pericardial effusion and mycotic pseudoaneurysm following insertion of a bare metal stent.

A 65-year-old male was diagnosed with purulent pericarditis, caused by Staphylococcus aureus five weeks after bare metal stenting for a 90% stenosis of the right coronary artery ostium. Subsequently, he developed a pseudoaneurysm in the right coronary sinus of Valsalva (CSV) requiring surgical intervention during the treatment of the pericarditis. Bacteremia after percutaneous coronary intervention (PCI) occurs in < 1% of patients and usually has insignificant clinical sequelae. We present an infected coronary bare metal stent of the proximal right coronary artery after PCI that resulted in a purulent pericardial effusion and mycotic pseudoaneurysm of the right coronary sinus of Valsalva (CSV). The patient successfully underwent surgical treatment.

[Ascending-descending Aortic Bypass and Aortic Valve Replacement for Aortic Coarctation with Bicuspid Aortic Valve and an Aberrant Right Subclavian Artery;Report of a Case].

A 53-year-old woman was developed congestive heart failure. She was diagnosed as having aortic coarctation, incompetent bicuspid aortic valve and an aberrant right subclavian artery by using echocardiography and enhanced computed tomography. Ankle brachial pressure index(ABI)in the right was 0.71 and 0.69 in the left. Blood pressure of the right arm was 60 mmHg lower than that of the left arm. To avoid perioperative adverse cardiac events due to a 2-staged operation, we performed ascending-descending aortic bypass and aortic valve replacement simultaneously through a median sternotomy. The heart was retracted cranially, and a vascular prosthesis was anastomosed to the descending aorta just above the diaphragm in an end-to-side manner. Then the graft was placed curvilinearly around the right atrium and was anastomosed to the ascending aorta. After the operation, the right and left ABI increased to 0.90 and 0.98 respectively. There was no pressure difference between the arms. The postoperative course was uneventful.

[Valve Replacement for Tricuspid Valve Regurgitation due to Pacemaker Lead Adherence;Report of Two Cases].

We experienced tricuspid valve regurgitation (TR) due to pacemaker lead adherence in an 81-year-old woman and in a 68-year-old woman, who both had right heart failure. The cause of TR was deformation of the tricuspid valve by pacemaker leads. Because of strong adherence between the lead and the leaflet or the tendinous cord, lead extraction and valve replacement were performed. The living lead was preserved by fixation at the septum wall outside the valve cuff in 1 patient. In the other patient, the epicardial lead was used for implantation because it was easier compared to intravenous lead implantation. The heart failure and TR improved after the operation in both patients.

[Graft replacement under percutaneous cardiopulmonary system for traumatic aortic rupture with multiple injuries].

We report a case of traumatic aortic rupture with multiple injuries. A 20-year-old man was transferred to our hospital. He was suffering from traumatic thoracic aortic rupture with multiple injuries (femoral fracture, pelvis fracture and so 4th) due to a traffic accident. Enhanced computed tomography revealed leakage from the aortic isthmus and hematoma in the surrounding area. Emergency operation was performed. The left 4th intercostal thoracotomy was performed and a lacerated foramen was observed across the lesser curvature of the aortic isthmus. The affected site was replaced by a prosthetic graft under percutaneous cardiopulmonary system. He was treated with open fixation of the right femur 11 days after the 1st operation. The postoperative recovery was generally uneventful and he was discharged on the 51st hospital day.

Impact of Accessory Renal Artery Embolization on Renal Deterioration Under Endovascular Aortic Repair.

OBJECTIVE: The optimal management strategy for patients with accessory renal arteries undergoing endovascular aortic repair is unclear. This study aimed to investigate the impact of accessory renal artery (aRA) embolization on postoperative renal deterioration and to identify the predictors of postoperative renal deterioration in patients who underwent endovascular aortic repair (EVAR). METHODS: A retrospective single-centre observational study was conducted at our hospital. Of 331 consecutive patients who underwent endovascular aortic repair between April 2011 and February 2021, 29 patients with an aRA were included in this study. Spearman's rank correlation coefficients of decrease in estimated glomerular filtration rate (eGFR), renal volume reduction rate, infarcted renal volume, and quantity of contrast use for postoperative renal deterioration were analyzed. The correlation coefficients of the correlations between infarcted renal volume, renal volume reduction rate, and decrease in eGFR and the rate of aRA diameter were also analyzed. Multivariable nominal logistic regression analyses were conducted to evaluate the odds of postoperative renal deterioration. RESULTS: The renal volume reduction rate and infarcted renal volume had a significant positive correlation with the decrease in eGFR. Body surface area and preoperative renal volume were significantly but negatively correlated with the decrease in eGFR. The infarcted renal volume, renal volume reduction rate, and decrease in eGFR were significantly and positively correlated with the aRA diameter. The odds ratio for decreased eGFR rate in preoperative renal volume was .96 (95% CI 0.930‒.996, P = .009). CONCLUSIONS: EVAR with aRA embolization impacts postoperative renal deterioration in patients with preoperative low renal volume, and the diameter of the embolized aRA might be a predictor of postoperative renal deterioration.

Reversed L-shaped incision for resection of a large azygos vein aneurysm: a case report.

BACKGROUND: Azygos vein aneurysms are rare and asymptomatic in many cases. The management for these aneurysms is controversial, and there is no clear guideline or evidence-based threshold for surgical or interventional therapy. CASE PRESENTATION: Herein, we report the case of a giant azygos vein aneurysm in a 78-year-old man that was treated with a reversed L-shaped incision. A 56 × 77 mm saccular azygos vein aneurysm was incidentally detected on computed tomography. Subsequently, surgical resection with interventional radiology and reversed L-shaped thoracotomy was performed. First, we performed coil embolization of the azygos vein aneurysm inflow. Next, a cardiopulmonary bypass was established through a reversed L-shaped sternotomy, and the aneurysm was excised. CONCLUSIONS: In this case, surgical resection via reversed L incision was effective.

Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm.

PURPOSE: To achieve early recovery and early discharge from the hospital by applying an enhanced recovery after surgery (ERAS) protocol, which is mainly used with colonic surgery, for the perioperative management of open AAA surgery. METHOD: One hundred twenty-seven open AAA surgery cases successfully carried out between 2003 and 2011 were included in this study. The ERAS protocol was used for the cases from April 2008 onward, and we performed a comparison of the conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs. RESULTS: The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n = 52) compared to the conventionally managed group (n = 75); with values of 59 ± 15 and 93 ± 25 h (p = 0.021), 9 ± 3 and 16 ± 5 days (p = 0.001), respectively. The medical costs for the ERAS group were 92 % of the costs of the conventionally managed group. CONCLUSION: Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.

[Thoracic endovascular stent graft for late pseudoaneurysm formation after patch aortoplasty; report of a case].

We report a case of a 51-year-old man presenting with pseudoaneurysm associated with a knitted Dacron patch used to repair coarctation of the aorta. At the age of 15 years, he underwent patch angioplasty for coarctation of the aorta. However the computed tomography( CT) scan, taken after 36 years, demonstrated pseudoaneurysm of the thoracic aorta at the anastmotic site. He was treated by endovascular stent graft using Gore-TAG 3115. His postoperative course was uneventful. Follow-up CT scan demonstrated no recurrence of pseudoaneurysm.

Coronary artery bypass grafting in a patient with situs inversus totalis: a case report.

BACKGROUND: Coronary artery bypass grafting in situs inversus totalis patients has been seldom reported in the literature. CASE PRESENTATION: A 76-year-old woman visited our hospital for chest pain and dyspnea that had started about 5 years earlier. Coronary angiography revealed triple-vessel disease, and computed tomography showed situs inversus totalis. Coronary artery bypass grafting was performed. In this case, the main operating surgeon stood on the right side of the patient until cardiopulmonary bypass was established and then switched positions to the left side of the patient for anastomosis. CONCLUSION: CABG was successfully completed in a patient with situs inversus totalis. The position shift helped improve the safety and ease of the surgery.

Postoperative outcomes of valve reoperation are associated with the number of previous cardiac operations.

OBJECTIVE: This study compared operative mortality and morbidity based on the number of previous cardiac operations to identify whether this was a risk factor for outcomes after valve reoperation. METHODS: Among valve surgery patients in the Japan Cardiovascular Surgery Database (2013‒2015), 4436 patients who underwent valve reoperation with a previous cardiac surgery were included. Patients were divided into three groups based on the number of previous cardiac operations (NPO1, NPO2, and NPO3+). Multivariable logistic regression analyses were conducted, adjusting for patient- and surgery-related factors to estimate the association of the NPO with the clinical outcomes of valve reoperation. RESULTS: Postoperative mortality was 8.6% in the NPO1, 11.2% in the NPO2, and 14.4% in the NPO3 + group, and the corresponding postoperative morbidity rates were 40.0, 46.2, and 59.2%, respectively. On multivariable logistic regression analysis, the odds of operative death were 1.36 (95% confidence interval [CI] 0.98‒1.87, p = 0.06) times higher for the NPO2 and 1.61 (95% CI 0.89‒2.90, p = 0.11) times higher for the NPO3+ group than for the NPO1 group. The odds ratios for postoperative complications were 1.31 (95% CI 1.08‒1.59, p < 0.01) for the NPO2 and 2.49 (95% CI 1.66‒3.74, p < 0.01) for the NPO3+ relative to the NPO1 group. CONCLUSION: The number of previous cardiac operations is associated with postoperative outcomes in patients undergoing valve reoperations. Considering the risk of repeat cardiac surgery, we recommend careful selection of operative procedures to avoid reoperation in patients requiring primary valve surgery.

Incidence and outcomes of surgical site infection after cardiovascular surgery (complete republication).

OBJECTIVES: Surgical site infection in cardiovascular surgery had a great effect on postoperative outcomes. This study examined the current status of surgical site infection and postoperative outcomes used the registered data of the Japan Cardiovascular Surgery Database. METHODS: From the registry, we extracted 53,186 cases of thoracic cardiovascular surgery performed under median sternotomy in 2018. According to Japanese Healthcare Associated Infections Surveillance (JHAIS), patients were divided into three groups: coronary artery bypass graft (CABG) with saphenous vein graft (SVG) (SVG+ ; n = 14,246), CABG without SVG (SVG-; n = 5535), and operations other than CABG (no CABG; n = 33,405). The incidence of deep sternal wound infection, leg wound infection, hospital death, and hospitalization more than 90 days was examined. RESULTS: The incidence of deep sternal wound infection is 1.4% in all cases and 1.7% in SVG+ , 1.2% in SVG-, and 1.4% in no CABG. In deep sternal wound infection cases, incidence of hospital death was 24.7% and was higher than no infection cases. Especially, in no CABG group, incidence of hospital death was 30.1%. The long-term hospitalization rate and readmission rate within 30 days of patients with deep sternal wound infection were also high. CONCLUSIONS: The incidence of deep sternal wound infection was low, but it has not decreased. Postoperative outcomes in patients with surgical site infection were still bad.

Hemolytic anemia caused by kinked graft 6 months after aortic dissection repair.

BACKGROUND: Clinically insignificant hemolytic anemia is occasionally a complication of prosthetic valve replacement. However, hemolysis related to kinked grafts is a very rare complication after central repair for acute aortic dissection. CASE PRESENTATION: A 42-year-old man had undergone replacement of the ascending aorta and a root repair for type A aortic dissection 6 months previously. Laboratory data showed mild hemolysis 5 months later, and he began to complain of fatigue on exertion. The serum hemoglobin level reduced to 8.6 g/dL, and lactate dehydrogenase levels increased to 3071 IU/L with gross change in urine color, indicating hemoglobinuria. We diagnosed mechanical hemolytic anemia caused by a kinked graft and planned a repeat operation. The kinked graft was resected and graft-graft anastomosis was performed. Postoperatively, the clinical course was uneventful, and the hemolytic anemia completely resolved. CONCLUSION: We herein report a case of hemolytic anemia caused by kinking of the graft 6 months after acute aortic dissection repair. The diagnosis was swiftly made, and the patient was successfully managed with redo surgery.