Influence of Type 2 Endoleaks on Long-Term Outcomes after Endovascular Repair for Abdominal Aortic Aneurysms: A National Hospital Organization Network Study for Abdominal Aortic Aneurysms in Japan.

BACKGROUND: Although endovascular repair (EVAR) is the first-line treatment for abdominal aortic aneurysm, type 2 endoleak (EL), which is associated with late sac enlargement or rupture, remains a concern. The present study aimed to assess the influence of type 2 EL on long-term outcomes after EVAR. METHODS: Among 550 patients who underwent EVAR between 2007 and 2013 at 14 Japanese national hospitals, 135 patients had type 2 EL diagnosed on follow-up computed tomography (CT) within 12 months after EVAR (EL2[+] group) and 415 patients did not have EL within 12 months (EL2[-] group). The cumulative incidences of sac enlargement, late intervention, and aneurysm-related death after EVAR were estimated using the cumulative incidence function method, and prognostic factors were investigated using the Fine-Gray hazard model. RESULTS: The median follow-up period was 5 years, and the 5-year cumulative incidence rates of sac enlargement, late intervention, and aneurysm-related death were 30.7% ± 4.4%, 25.3% ± 4.1%, and 2.6% ± 1.4%, respectively, in the EL2(+) group, and 8.7% ± 1.6%, 7.6% ± 1.4%, and 0.3% ± 0.3%, respectively, in the EL2(-) group. The cumulative incidence rates of sac enlargement (P = 0.002), late intervention (P < 0.001), and aneurysm-related death (P = 0.015) were significantly different between the 2 groups. As the first-line treatment for sac enlargement with type 2 EL, transcatheter coil embolization was performed in 30 patients. Information about sac behavior on CT after coil embolization was available in 20 of the 30 patients. Among these patients, no patients experienced sac shrinkage, and the aneurysmal sac dilated after coil embolization in 18 patients. CONCLUSIONS: Type 2 EL affects the long-term outcomes after EVAR. It is not recommended to observe large aneurysmal sacs conservatively as they tend to dilate in the presence of type 2 EL.

Impact of introducing endovascular aneurysm repair on treatment strategy for repair of abdominal aortic aneurysm--National Hospital Organization network study in Japan.

BACKGROUND: The objective of the present study was to assess the hypothesis that the introduction of endovascular aneurysm repair (EVAR) into Japan has expanded the indication of abdominal aortic aneurysm (AAA) repair without increasing surgical mortality. METHODS AND RESULTS: From 10 national hospitals, we registered a total of 2,154 consecutive patients (Open surgery [OS]: n=1,577, EVAR: n=577) over 8 years, divided into 4 time periods: Group I (2005-2006: n=522), Group II (2007-2008: n=475), Group III (2009-2010: n=551), Group IV, (2011-2012: n=606). Mean age increased over the 4 time periods (P<0.0001). The incidences of COPD, smoking history, history of abdominal surgery and concomitant malignancy significantly increased as well, while the numbers of patients with preoperative shock or high ASA status reduced over time. The proportion of EVAR in AAA repair increased from: 0% in Group I, 11.6% in Group II, 41.0% in Group III, to 48.8% in Group IV (P<0.0001). Early mortality was 0.8% in the EVAR and 3.4% in the OS (P<0.001) groups. Survival rates among the 4 groups free of all-cause death and aneurysm-related death at 1 year were 92.1-96.3% (P=0.1555) and 95.5-96.8% (P=0.9891), respectively. Multiple logistic regression analysis for surgical death failed to demonstrate survival advantage of EVAR over OS. CONCLUSIONS: Introduction of EVAR expanded the indication of AAA repair without increasing mortality, while high risk for anesthesia and emergency cases reduced over time. UMIN-CTR (UMIN000008345).

Long-Term Outcomes of Endovascular Aneurysm Repair in Patients Aged ≤70 Years.

Objectives: The efficacy of endovascular aneurysm repair (EVAR) against abdominal aortic aneurysm (AAA) in younger patients remains unknown. Hence, the current study aimed to investigate whether the aneurysm-related mortality rate of EVAR is acceptable among patients aged ≤70 years. Methods: Among 644 patients, 148 underwent EVAR (EVAR group), and 496 received open surgical repair (OSR group). The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events after AAA repair were evaluated using the cumulative incidence function in the presence of competing risks. Results: The EVAR group had higher prevalences of several comorbidities, and overall survival for the EVAR group was significantly inferior to that of the OSR group. The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events at 5 years were 1.5%, 11.7%, and 6.4% in the EVAR group and 1.3%, 5.3%, and 5.9% in the OSR group, respectively. EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. However, it was an independent poor prognostic factor of any intervention. Conclusion: EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. Therefore, it demonstrated acceptable procedure-related long-term outcomes, at least in high-risk young patients.

Relationship between cardiac output and onset of succinylcholine chloride action in electroconvulsive therapy patients.

BACKGROUND: Succinylcholine chloride (Sch) is ideal for electroconvulsive therapy (ECT). However, the appropriate interval between Sch administration and electrical stimulation has not been reported. Cardiac output at the time of drug administration seems to be the major contributing factor for variability in onset time. The present study therefore investigated relationships between cardiac output before Sch administration and the onset of Sch action. METHODS: Cardiac output and cardiac index (CI) were continuously monitored in 24 patients using a noninvasive impedance cardiac output monitor. Anesthesia was induced using intravenous propofol at 1 mg kg(-1). After loss of consciousness, dorsiflexion of the hallux was monitored as single-twitch stimulations using a peripheral nerve stimulator equipped with an acceleration sensor. A 1 mg kg(-1) dose of Sch was administered, and patients were assisted by mask ventilation with 100% oxygen. A bilateral ECT was performed after single-twitch response reached zero. We measured the intervals between Sch administration and the appearance of the first fasciculation (int-F), and between Sch administration and the loss of the single twitch response (int-S0) as time of Sch onset. To determine the effective duration of Sch action, we measured the intervals between the first fasciculation and the single-twitch response above zero (int-A) and between loss of the single-twitch response and recovery above zero (int-R). RESULTS: The alteration in CI during ECT was biphasic. The CI before Sch administration (pre-CI) varied from 2.01 to 5.94 L min(-1) m(-2) (4.23 +/- 1.20 L min(-1) m(-2)). The int-F was 40 +/- 5 seconds (range, 31-49 seconds) and int-S0 was 90 +/- 17 seconds (range, 58-124 seconds). The correlations were significantly inverse between int-F and pre-CI (n = 10, R2 = 0.504, P = 0.0189), and between int-S0 and pre-CI (n = 17, R2 = 0.339, P = 0.0127). The int-A was 236 +/- 95 seconds (range, 119-391 seconds) and int-R was 184 +/- 106 seconds (range, 60-369 seconds). We also found correlations between int-A and pre-CI (n = 10, R2 = 0.413, P = 0.0438) and between int-R and pre-CI (n = 17, R2 = 0.405, P = 0.0466). CONCLUSIONS: The onset of muscle relaxation varies among patients receiving ECT and is related to CI before Sch administration. In patients for whom fasciculation is difficult to determine, the effects of a muscle relaxant should be objectively confirmed before electrical stimulation of the brain.

Predictors of surgical indications for acute type B aortic dissection based on enlargement of aortic diameter during the chronic phase.

OBJECTIVES: Patients with Stanford type B dissection who have been treated successfully with medical hypotensive therapy during the acute phase (< 14 days) have the risk of surgery during the chronic phase because of enlargement of the dissected aorta. The objective of this retrospective analysis is to determine the predictors of surgical indications for acute type B aortic dissection by studying chronic-phase enlargements of aortic dissection in patients treated successfully with medical hypotensive therapy. METHODS: Altogether, 131 patients with type B aortic dissection were treated medically during the acute phase between 1987 and 2004. Multivariate factor analyses were performed to determine the predictors of chronic-phase enlargement (> or = 55 mm, as defined for our surgical criteria) of the dissected aorta. RESULTS: Overall dissection-related mortality was 17.6%. Patency of the false lumen was an independent risk factor for dissection-related death (P = 0.0238, hazard ratio 2.594, confidence interval 1.009-6.122) and for dissection-related events (P = 0.0157, hazard ratio 1.870, confidence interval 1.116-3.133). The incidence of patients treated surgically during the chronic phase was 32.8%. The predictors for aortic enlargement during the chronic phase were the condition of maximum aortic diameter > or = 45 mm with a patent false lumen during the acute phase. The rates of freedom from aortic enlargement (> or = 55 mm) for patients with maximum diameter (> or = 45 mm) with a patent false lumen during the acute phase at 1, 5, and 10 years were 72.6%, 66.0%, and 42.8%, respectively, whereas in patients with a maximum aortic diameter of < 45 mm with a thrombosed false lumen the values were 100%, 94.7%, and 89.2%, respectively (P < 0.005). CONCLUSIONS: These data suggest that patients with acute type B dissection with a patent false lumen or a diameter > or = 45 mm (or both) during the acute phase are at risk for enlargement of the dissecting aorta. The patients with dissecting aortas > or = 45 mm or a patent false lumen (or both) therefore require close follow-up to detect enlargement of the dissecting aorta, whereas patients with a maximum aortic diameter of < 45 mm with a thrombosed false lumen can stay on conservative therapy.

Late Sac Behavior after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm.

BACKGROUND: Sac behavior after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) is considered as a surrogate for the risk of late rupture. The purpose of the study is to assess the sac behavior of AAAs after EVAR. METHODS AND RESULTS: Late sac enlargement (LSE) (≥5 mm) and late sac shrinkage (LSS) (≥5 mm) were analyzed in 589 consecutive patients who were registered at 14 national centers in Japan. The proportions of patients who had LSE at 1, 3 and 5 years were 2.6% ± 0.7%, 10.0% ± 1.6% and 19.0% ± 2.9%. The proportions of patients who had LSS at 1, 3 and 5 years were 50.1% ± 0.7%, 59.2% ± 2.3% and 61.7% ± 2.7%. Multiple logistic regression analysis identified two variables as a risk factor for LSE; persistent endoleak (Odds ratio 9.56 (4.84-19.49), P <0.001) and low platelet count (Odds ratio 0.92 (0.86-0.99), P = 0.0224). The leading cause of endoleak in patients with LSE was type II. CONCLUSIONS: The incidence of LSE is not negligible over 5 year period. Patients with persistent endoleak and/or low platelet count should carefully be observed for LSE. CLINICAL TRIAL REGISTRATION: UMIN-CTR (UMIN000008345).

Successful surgical repair of an ilio-iliac arteriovenous fistula associated with a ruptured common iliac artery aneurysm.

INTRODUCTION: We describe the case of an 86-year-old man with an ilio-iliac arteriovenous fistula (AVF) resulting from a ruptured aneurysm. This condition rarely occurs, has a high mortality rate, and was successfully treated via surgery. PRESENTATION OF CASE: The patient presented with a temporary loss of consciousness and left leg edema. A pulsatile abdominal mass with vascular murmur and thrill was detected. Enhanced computed tomography showed abdominal aortic and iliac aneurysms with left common iliac vein occlusion, and the left external iliac vein was easily seen through the AVF. We directly sutured the AVF and performed aneurysmectomy and prosthetic graft replacement. During surgery, placement of occlusive balloon catheters through the AVF minimized intraoperative bleeding. The patient recovered uneventfully, and swelling of the left leg was immediately reduced after surgery. DISCUSSION: Although rare, AVFs can be life-threatening, and urgent treatment and intensive care are occasionally needed. Surgical management of AVF requires a definitive preoperative diagnosis and control of venous bleeding during surgery. Fulfilling these major requirements can potentially reduce morbidity and mortality in patients with AVFs. Interestingly, there was no sign of high-output heart failure throughout the treatment course due to compression of the aneurysm and consequent blood flow failure to the left iliac vein. CONCLUSION: Using the balloon occlusion technique, we were able to minimize blood loss during open repair. Use of multiple imaging modalities facilitates correct preoperative diagnosis and consequently improves surgical outcome.

Real-time cerebral monitoring using multichannel near-infrared spectroscopy in total arch replacement.

Multichannel near-infrared spectroscopy (NIRS) could detect change in the regional cerebral oxygenation by following animated pictures of oxy-hemoglobin (OxyHb), deoxy-hemoglobin (DeoxyHb) and total hemoglobin in operations for three surgical cases of thoracic aortic aneurysm with selective cerebral perfusion (SCP). Simultaneously measured jugular venous oxygen saturation (SjO2) showed no change in parallel to OxyHb or DeoxyHb of NIRS. It was concluded that SjO2 represented the entire rather than the local findings of the cerebral oxidative metabolism. Assessment of the intra cranial oxidative metabolism using a multichannel NIRS provided real-time information about the efficacy of SCP, while SjO2 had a comprehensive limited value. The animation enabled the detection of regional hypoperfusion visually and instantly during SCP. This multichannel NIRS was a new real-time monitoring method and was useful to prevent cerebral neurological complication due to hypoperfusion during SCP.

Is conservative therapy acceptable for thrombosed type A acute aortic dissection?

OBJECTIVES: The surgical treatment for thrombosed type A dissection is controversial because it has a better prognosis than with conservative therapy. We discuss the validity of conservative therapy for thrombosed type A dissection and examine the relationship between the morphology of the dissecting aorta and its operative indications. METHODS: Subjects were 28 patients with acute type A aortic dissection in which the false lumen was totally thrombosed who were transferred to our hospital in the acute phase between 1990 and 2002. We performed medical therapy on all of them at first. We calculated the ratio of the false lumen and the true lumen (F/T) by enhanced computed tomography scan at the onset. The maximum aneurysmal size was measured approximately every week. RESULTS: Fifteen of them needed surgical repair; six in the acute phase and nine in chronic. One-year and 5-year survival rate for the operative and the non-operative group are 93.3, 80.0 and 92.3, 92.3% respectively. The mean F/T was 30% in the operative group and 50% in the non-operative group (p = 0.04). There was almost no reduction in size in the operative group during the follow up (-0.5 +/- 1.2 mm). CONCLUSIONS: Conservative therapy with frequent imaging follow-up can be a rational option for thrombosed type A acute aortic dissection. A low ratio of the false lumen and the true lumen at the onset and no reduction in the aneurysmal size are the predictive factors by which we should consider surgical repair.

Risk factors affecting survival after surgical repair of ruptured abdominal aortic aneurysm.

PURPOSE: The purpose of this study is to identify the risk factors affecting the high mortality rates associated with the treatment of ruptured abdominal aortic aneurysm (AAA). METHODS: In this retrospective study, the subjects consisted of 105 patients who underwent repair of ruptured AAA at our institution from December 1984 to March 2012. We compared the patients of ruptured AAA in survival group with those in death group to evaluate the clinical factors in ruptured AAA mortality. RESULTS: The operative and in-hospital mortality of ruptured AAA patients was 22.9% compared with 1.9% for that of non-ruptured AAA patients. The mean hemoglobin level was significantly lower in death group than in survival group. Intraoperative bleeding volume was significantly higher in death group than in survival group. Cox proportional hazard analysis showed that level 3 or 4 according to the Rutherford classification, preoperative hemoglobin level of less than 9.0 g/dl, intraoperative blood loss volume of more than 3000 ml, postoperative bowel ischemia and class 3 or 4 according to the Fitzgerald classification were significantly associated with high mortality. CONCLUSION: These findings showed that every effort to maintain preoperative hemodynamic stability reduce volumes of blood loss in operation, and to minimize postoperative deterioration of organ functions would be essential to improve patient survival.

Surgical treatment for acute type A aortic dissection during pregnancy (16 weeks) with Loeys-Dietz syndrome.

A 32-year-old woman at 16 weeks of pregnancy was diagnosed with acute type A aortic dissection and severe aortic regurgitation. Aortic valve and aortic arch replacement was successfully performed under circulatory arrest with deep hypothermia. After the operation, she was diagnosed with Loeys-Dietz syndrome. At 36 weeks of gestation, the patient underwent a cesarean section and delivered a healthy baby.

Early outcomes of open abdominal repair versus endovascular repair for abdominal aortic aneurysm: report from national hospital organization network study in Japan.

OBJECTIVE: Early outcomes of open abdominal repair (OS) versus endovascular repair (EVAR) for abdominal aortic aneurysm were retrospectively analyzed, after commercialized devices for EVAR had become available in Japan. PATIENTS AND METHODS: A total of 781 consecutive patients (OS, n = 522; EVAR, n = 259) were treated at ten medical centers between January 2008 and September 2010. The OS group comprised patients with preoperative shock (SOS, n = 34) and without shock (NOS, n = 488). RESULTS: Patients in the EVAR group were 3 years older than those in the NOS group. There was greater prevalence of hostile abdomen, on dialysis, chronic obstructive pulmonary disease on inhaled drug, and cerebrovascular disease in the EVAR group than in the NOS group. Surgical mortality was 16 cases (2.0% in all patients, EVAR: 0.8%, NOS: 1.4%, SOS: 21%). Hospital stay >30 days was documented in 52 (11%) with NOS, 11 (33%) with SOS, and 8 (3%) with EVAR. Thirty late deaths included 6 aneurysm related death and 14 cardiovascular causes at a mean follow up of 1.0 year. The survival rates freedom from all cause death at one year, were 95 ± 1% in NOS and 94 ± 2% in EVAR respectively. CONCLUSION: Though significant differences in patient characteristics among three groups were noted, early results were satisfactory.

Perforation of the esophagus by a fish bone leading to an infected pseudoaneurysm of the thoracic aorta.

A 79-year-old woman was urgently referred to a district hospital with dull central chest pain after swallowing a fish bone. The bone was removed by esophagoscopy. Eleven days later she presented because of hematemesis. Computed tomography and aortic arch angiography confirmed a diagnosis of esophageal perforation leading to mediastinitis and the presence of an infected pseudoaneurysm. The infected pseudoaneurysm was completely resected, followed by direct aorto-aorta anastomosis and omental coverage in a one-stage operation. She improved and was discharged 2 months later.

Early and mid-term results after thoracic aortic surgery in patients aged over 70: survival and effect of the age factor.

OBJECTIVES: The increase in the life span of the Japanese population over the past decade has resulted in a significant increase in elderly patients in cardiac and aortic surgery. This study describes the early and mid-term survival after thoracic aortic surgery, and the influence of age on the operative mortality. METHODS: A total of 85 consecutive patients aged over 70 years underwent a thoracic aortic operation at our institution from January 1995 to June 2005. Their mean age was 76.2 +/- 4.6 years. Their preoperative risk scores were classified into 5 groups (good, fair, poor, high, extremely high) based on the Parsonnet method. RESULTS: There were 10 operative and hospital deaths (11.8%). The survival rates for all patients were 77.8%, 69.4%, and 58.2% at 1, 3, and 5 years, respectively. The major complication was respiratory failure. According to the Parsonnet model, the observed mortality was lower than the predicted mortality. When the age score was excluded in the Parsonnet model, the observed mortality became almost equal to the predicted mortality except in the high-risk group. CONCLUSION: Patients aged over 70 years will undergo thoracic aortic surgery with a reasonable chance of recovery unless there are major preoperative complications. We should consider whether elective surgery can be performed on elderly patients before a rupture develops.