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.
We present a successful case of the management of a 46-year-old woman with an abnormal aortic valve formed by four cusps (three equal large cusps and one smaller cusp; type B according to the Hurwitz ...and Roberts classification) with a marked loss of coaptation that caused a severe aortic insufficiency (AI). The patient underwent an aortic valvuloplasty of the defect using the glutaraldehyde (GA)-pretreated autologous pericardium, restoring the subnormal function and competency of the aortic valve. The postoperative course was unremarkable. The early follow-up showed a trivial AI and a significant reduction of regurgitant volume was identified in a cardiac magnetic resonance imaging (MRI) when compared to the preoperative state (27.2 vs. 2.1 ml). The follow-up transthoracic echocardiography 1 year after the surgery showed mild AI.
A woman in her childbearing age with a large pelvic mass was referred to our department. Contrasted computed tomography revealed an oval pelvic arteriovenous malformation (PAVM) with the longest ...diameter of 60 mm. The PAVM had a sole tortuous arterial feeder branching from the fifth lumbar artery, and a venous outlet to the left common iliac vein (LCIV). Because of the acute branch separation angle of the lumbar artery and the distal tortuosity, the tip of the catheter could not be stabilized at the appropriate positions for embolization through the right common femoral arterial access. From the right brachial arterial (RBA) access, the X-ray opaque tip of a 0.014 inch guidewire was able to be advanced partially into the PAVM. However, the stabilization was not robust enough to support the tracking of a microcatheter or delivery sheath through the angulation before the arterial pedicle. In contrast, from the left common femoral venous (LCFV) access, the guidewire could be easily advanced into the PAVM but not into the arterial gate of the PAVM. The tip of the guidewire from the RBA was snared, and brought out through the LCFV access sheath, creating an RBA–LCFV stabilizing wire. The tip of a 6 Fr sheath could then be advanced and stabilized in the arterial pedicle sufficiently. Three self-expandable nitinol mesh devices were used to embolize the arterial pedicle and the fifth lumbar artery. After the arterial inflow embolization, the PAVM was packed coil-embolized. The final angiography confirmed the complete obliteration of PAVM, with no occurrence of post-procedural complications. The patient was discharged on the second postoperative day. She had an uneventful course of pregnancy and bore a child 18 months after the procedure. Two years after the embolization, computed tomography revealed a volume reduction of PAVM with the maximum diameter decreased to 32 mm.
Various treatment options are currently available for spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) including conservative management, anticoagulation therapy, ...endovascular stenting, and surgical repair. We report an experience with retrograde open mesenteric stenting for SIDSMA. A 45-year-old man presented to the emergency department with acute onset of severe abdominal and back pain. Computed tomography angiography revealed a long occlusion of the SMA trunk. Initially, an endovascular solution was attempted, but this was unsuccessful as the guidewire failed to cross the lesion. Four hours after the onset of symptoms, because of aggravation of abdominal pain, the patient underwent an exploratory laparotomy under general anesthesia. The small intestine looked pale, and the arterial pulsation was not recognized in the mesentery. A 5-cm mesenteric portion of the SMA trunk was exposed. The SIDSMA diagnosis was confirmed after arteriotomy because a freshly formed thrombus and a severely stenosed true lumen (TL) were detected beneath the adventitia. From the proximal stump of the TL, a 6-French sheath introducer was inserted in a retrograde fashion. The occlusion was traversed with a 0.035-in guidewire. After predilatation, self-expandable stents were placed inside the occluded SMA. The patient was discharged from the hospital 3 weeks after the operation. Stent patency has been confirmed for 6 months. Retrograde stenting performed under laparotomy could be a rescue procedure after the failure of percutaneous stenting for SIDSMA.
We report a case of a 56-year-old woman. She had a history of emergent ascending aorta replacement due to type A dissection. Seven years later, aortic arch enlargement (55 mm) was detected on CT ...scan, and indicated secondary repair. Because of the existence of the aberrant right subclavian artery (ARSA), the safer surgical management needed to be discussed. Total arch replacement with the use of open stent-grafting technique and extra-anatomical reconstruction of ARSA was chosen for the treatment. In the operation, straight woven grafts (7 mm in diameter) were firstly anastomosed to the bilateral axillary arteries. Deep hypothermic circulatory arrest with antegrade cerebral perfusion through median sternotomy was established. The aortic arch was transected between the right and left subclavian arteries. The left subclavian artery was ligated at its origin, and an aortic open stent graft was inserted distally. An aortic reconstruction was performed between the left common carotid artery and the left subclavian artery with a 4 branched J-graft. The left carotid artery was reconstructed anatomically, and the tube grafts anastomosed to the bilateral axillary arteries were reconstructed in an extra-anatomical fashion. On the 11th postoperative days, coil-embolization of the ARSA was performed to complete the treatment. The patient had an uneventful post-operative recovery. Total arch replacement using an open stent-grafting technique was a feasible treatment option for the aortic arch aneurysm with ARSA.
The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE; W. L. Gore and Associates, Flagstaff, AZ, USA) applicability is limited by the aorto-iliac length (AOL). The shortage may be a major exclusion ...criterion. An 85-year-old male presented with an abdominal aortic and left common iliac arterial aneurysm. The left-side AOL was 146-mm, which was deemed 19-mm too short for IBE usage. To increase implantation length, the contra-lateral connection stent graft was deployed along the implantation line, wound half-circumferentially around the ipsilateral limb. Any form of endoleak, limb occlusion, and device migration has not been observed for twelve months.
The medical uses of three-dimensional (3D) printing are evolving at a rapid pace. The current roles and the future outlooks of this technology for physician-modified endovascular graft (PMEG) in ...patients with juxtarenal aneurysm are discussed. Fenestrations of PMEG are designed taking into account the geometry of the stent graft. Designing of such stent grafts is extremely complicated, especially when PMEG is planned for the angulated portion of the aorta. A 3D model enables the designing of branch fenestrations, with consideration for the geometrical adaptation of the stent graft in a complex aortic anatomy. With the aid of 3D-printing technology, patients with juxtarenal aortic pathologies can be treated using fenestrated stent grafts, preserving the vital organ circulation and securing a robust length of proximal sealing zone.
Injury to the right coronary artery (RCA) is a rare complication of tricuspid annuloplasty. We report a patient who developed right ventricular (RV) infarction, because of tricuspid annuloplasty, and ...review management options.
Purpose
Although the outcomes of aortic arch surgery have improved, stroke remains one of the most devastating complications. Therefore, identification of true risk factors and understanding the ...pathogenesis of intraoperative stroke are necessary to decrease its occurrence.
Methods
From January 2002 to December 2010, a total of 251 consecutive patients underwent aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion in our hospital. Hemiarch replacement cases were excluded. Of the remaining patients, 190 elective cases that could be reviewed with full perioperative clinical data were analyzed. Strokes were classified into three subtypes according to their distribution on imaging studies: multiple-embolism type, hypoperfusion type, and solitary-embolism type.
Results
Operative death occurred in 1.1% of patients (2/190), and aortic arch surgery-related in-hospital death occurred in 5.3%. Among the 188 survivors, intraoperative strokes occurred in 5.9%. Multiple-embolism, hypoperfusion type, and solitary-embolism stroke occurred in 2.7%, 2.1%, and 1.6%, respectively. Multivariate analysis revealed that the risk factor for multiple-embolism stroke was high-grade atheroma in the ascending aorta
P
< 0.001, odds ratio (OR) 118.0, and that for hypoperfusion type stroke was prolonged brain ischemia time over 120 min (
P
= 0.004, OR 31.5). No significant risk factor was found for solitary-embolism stroke.
Conclusion
Intraoperative strokes during elective aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion are strongly influenced by the presence of a high-grade atheroma in the ascending aorta and prolonged brain ischemia time. The results suggest that these are key issues to reduce stroke in aortic arch surgery.
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