Background Although previous reports have described the repair of distal aortic arch aneurysms through debranching and chimney techniques, these methods invariably involve surgical management of the ...carotid artery. We report clinical results of thoracic endovascular aortic repair (TEVAR) using fenestrated stent grafts in the treatment of aortic arch aneurysms located less than 15 mm from the left common carotid artery. Methods A semi-custom-made fenestrated stent graft designed to fit aortic arch tortuosity and preserve blood flow at least into the brachiocephalic and left common carotid arteries was placed from zone 0. Results From 2007 through 2013, TEVAR from zone 0 was performed on 37 high-risk patients for open surgery (mean age 78.2 years). The mean length between the left common carotid artery and aortic aneurysm was 11.1 mm (range, 5 to 15 mm). The left subclavian artery was preserved for 26 patients (70.3%) through surgical reconstruction (n = 19) and graft fenestration (n = 7). The early mortality rate was 0%. Postoperative strokes and spinal cord ischemia occurred in 2 (5.4%) and 3 (8.1%) patients, respectively. Although type I endoleaks at discharge were noted in 12 (32.4%) patients, aneurysm enlargement was noted during follow-up in 6 (16.2%). Four patients (10.8%) underwent secondary interventions consisting of 3 coil embolization procedures; 2 re-TEVARs and 1 open conversion. There were no aorta-related late deaths. Survival and aorta-related event-free rates at 2 years were 86.3% and 88.8%, respectively. Conclusions Thoracic endovascular aortic repair using fenestrated stent graft from zone 0 can be considered as one of therapeutic options for high-risk patients with aortic arch diseases.
Objective: The treatment for arch aneurysms by endovascular repair is often difficult. This study evaluated the long-term outcomes of thoracic endovascular aortic repair for aortic arch aneurysms ...treated with the Najuta stent-graft system.Materials and Methods: From January 2009 to December 2019, 37 patients underwent treatment for aortic aneurysms with the Najuta stent graft system at two institutes, including our hospital. We retrospectively analyzed the short- and long-term clinical outcomes.Results: Of all 37 cases, the technical success rate was 97.3% (36 of 37). The mean proximal neck length was 20.1±5.3 mm. The postoperative results revealed 10 patients with type Ia endoleaks (27.8%), 6 with stroke (16.7%), and one with paraplegia (2.8%). In the chronic phase, the overall survival rates and the rates of freedom from aorta-related events at 7 years were 71.3% and 50.7%, respectively. Between two groups divided based on the proximal neck diameter of 20 mm, the <20-mm group had significantly higher rates of aorta-related events in terms of freedom from aortic events (P=0.046).Conclusion: The fenestrated stent graft can be a less invasive option for the treatment of high-risk patients with aortic aneurysms.
The aim of this study was to evaluate the effect of initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the incidence of subsequent type II endoleak (T2E) and ...shrinkage of abdominal aortic aneurysm (AAA) sac diameter.
We reviewed 136 patients who underwent EVAR for atherosclerotic AAA between July 2008 and July 2014 with one of three stent grafts (Excluder W. L. Gore & Associates, Flagstaff, Ariz, Powerlink Endologix Inc, Irvine, Calif, and Endurant Medtronic Vascular, Santa Rosa, Calif). Starting from 2013, the mean blood pressure of 76 participating patients (treatment group) was maintained at 75 to 90 mm Hg for the initial 48 hours after EVAR. The incidence of T2E at 7 days and AAA sac diameter 12 months after EVAR were evaluated using computed tomography scanning. The results so obtained were then compared with those of the control group composed of 60 consecutive patients who underwent EVAR before 2013.
The incidence of T2E at 7 days was significantly lower in patients who received treatment (treatment group, 19.7%; control group, 40.0%; P = .013), and AAA sac diameter at 12 months in the treatment group had a mean decrease of 5.1 mm compared with the mean 2.2 mm in the control group (P = .004). In multivariate regression analysis, BPM was significantly related to the reduction of incidence of T2E at 7 days (odds ratio, 0.31; P = .007) and a decrease in AAA sac diameter at 12 months (P = .005). In addition, although the use of Endurant had less effect, the use of Excluder under controlled blood pressure conditions improved the incidence of T2E from 80% to 23% compared with those under normal postoperative management (P = .001).
The initial 2-day postoperative BPM might have positive effects, such as lower incidence of T2E and facilitation of AAA sac shrinkage.
BackgroundAortic valve (AV) repair is a challenging procedure due to its complexity, lower reproducibility, and steep learning curve. To examine its durability and validity, we investigated mid-term ...outcomes following AV repair without aortic root replacement.MethodsBetween March 2007 and May 2018, we retrospectively identified 14 patients who underwent AV repair without aortic root replacement at our institution. We investigated their baseline characteristics and postoperative outcomes, including the reoperation rate due to aortic regurgitation (AR) recurrence. Furthermore, we divided them into two groups: those who required reoperation due to AR recurrence (Group R) and those who did not require reoperation (Group F), and statistically compared them.ResultsThe median age was 52.5 years (IQR: 42.0-60.8), with 11 male patients (78.6%). Eight patients (57.1%) had a bicuspid AV. Five cases (35.7%) underwent reoperation due to AR recurrence during a median follow-up period of 5.5 years. There were no significant differences in baseline characteristics between Group R (n=5, 35.7%) and Group F (n=9, 64.3%), including AR etiology, AV repair procedure, and intraoperative AR grade after the final declamp. All cases in Group R had at least mild to moderate AR on the echocardiogram before discharge. Regarding the AR grade before discharge, Group R had a significantly higher grade than Group F (p = 0.013).ConclusionsThe indication for AV repair for AR might need to be reassessed due to the considerable mid-term reoperation rate. Cases of AV repair with more than mild AR at discharge should be carefully monitored, as they are likely to require future reoperation for AR.
Objective
Postoperative acute mesenteric ischemia (AMI) in the long-term hemodialysis (HD) patients could be a disastrous complication leading to high mortality. The objective is to evaluate the ...association between the presence of superior mesenteric artery calcification (SMAC) and early and late outcomes after aortic valve replacement (AVR) in HD patients.
Methods
Between April 2003 and December 2018, the enrolled 46 HD patients (19 women; mean age 72 years) who underwent AVR for severe aortic valve stenosis were retrospectively reviewed. 25 patients (54.3%) who had severe calcifications of superior mesenteric artery (SMA) were defined as the SMAC group, and the calcification extent of SMA was evaluated on preoperative non-contrast CT using Agaston calcium score calcification area (cm
2
) × max CT value (HU). The operative outcomes were compared with those of the non-SMAC group comprising 21 patients (45.7%).
Results
The following factors in SMAC group were statistically higher compared with those of the non-SMAC group: age (73.6 ± 7.2 vs 69.3 ± 7.1 years;
p
= 0.04), celiac artery calcification (76.4% vs 17.6%;
p
< 0.001), calcium score of SMA (692.3 ± 300.0 vs 123.5 ± 180.7;
p
< 0.001), the incidence of AMI (24.0% vs 4.7%;
p
= 0.001), and hospital mortality (16.0% vs 0%;
p
= 0.02). In multivariate analysis, the presence of SMAC was significantly associated with AMI (OR 3.8,
p
= 0.05) and hospital mortality (OR 2.4,
p
= 0.02). Calcium score of SMA in patients complicated with AMI was significantly higher than those without AMI (815.7 ± 300.5 vs 366.9 ± 351.2;
p
< 0.01).
Conclusion
Quantitative evaluation of SMAC could be a predictive marker of incidence of AMI after AVR in HD patients.
Purpose
To investigate the relationships between indications for thoracic endovascular aortic repair for acute/subacute complicated Stanford type B aortic dissection and clinical outcomes, and ...complications specific to thoracic endovascular aortic repair.
Material and methods
The J-predictive study retrospectively collected data of patients treated with thoracic endovascular aortic repair for complicated Stanford type B aortic dissection at 20 institutions from January 2012 to March 2017. From the database, those treated for acute/subacute complicated Stanford type B aortic dissection were extracted (
n
= 118; 96 men; average age, 66.1 years; standard deviation, ± 13) and classified into groups 1, 2, and 3 according to thoracic endovascular aortic repair indications (rupture, superior mesenteric artery malperfusion, and renal or lower extremity malperfusion, respectively). Primary and secondary measures were mortality (overall and aortic-related) and complications related to thoracic endovascular aortic repair, respectively. For each outcome, the risks of being in groups 1 and 2 were statistically compared with that of being in group 3 as a control using Fisher’s exact test.
Results
Mortality rate (odds ratio, 5.22; 95% confidence interval CI, 1.33–20.53) and prevalence of paraparesis/paraplegia (odds ratio, 30.46; confidence interval, 1.71–541.77) were higher in group 1 than in group 3. Compared to group 3, group 2 showed no statistically significant differences in mortality or complications related to thoracic endovascular aortic repair.
Conclusions
Rupture as an indication for thoracic endovascular aortic repair for type B aortic dissection was more likely to result in worse mortality and high prevalence of spinal cord ischemia.
Level of Evidence
Level 4, Case series.
Surgical indication and treatment for patients with Kommerell diverticulum and aberrant subclavian artery are still not well established. A patient with esophageal and tracheal compression resulting ...from these anatomical abnormalities was successfully treated with a hybrid approach of total arch replacement, frozen elephant trunk technique, aberrant left subclavian artery transection, and left subclavian artery reconstruction through median sternotomy. Compressive symptoms were relieved without resecting the enlarged diverticulum. In this case, the importance of preoperative investigation for the main cause of compressive symptoms is illustrated and a novel treatment strategy is outlined.
Background
Cardiac metastasis from renal cell carcinoma is an exceptional event, particularly when there is lack of inferior vena cava involvement. Only a few cases have been reported worldwide so ...far.
Case presentation
We presented a case of a 58-year-old man diagnosed with isolated right ventricular metastasis of renal cell carcinoma in the absence of direct inferior vena cava extension, who underwent surgical tumor resection using cardiopulmonary bypass.
Conclusions
Surgical resection of the cardiac mass with an understanding of the pathology is needed to prevent sudden death from acute heart failure or tumor embolism and improve the patient’s quality of life.
Objectives: Abdominal aorto-enteric fistula (AEF) has many problems to be resolved such as bleeding and infection, and a treatment strategy has not been established. We have experienced successful ...treatment of several AEF cases and we report our treatment strategy. Methods: The important points as a treatment strategy of AEF are 1) rapid control of bleeding, 2) fistula treatment, and 3) infection control. First, bleeding is controlled with an endovascular aneurysm repair (EVAR), and after confirmation of no endoleaks, intestinal tract repair and omentopexy are performed by laparotomy. The stent graft is not removed due to the priority of minimal invasion. The most suitable antibiotics are selected from the results of intraoperative culture and administered for a sufficiently long period. Results: We experienced five cases of AEF from 2016 to 2020. Three cases were primary AEF (abdominal aortic aneurysm-duodenal fistula) and two cases were secondary AEF. Of the two cases, one was after EVAR (abdominal aortic aneurysm-duodenal fistula) and one was after traditional open repair (pseudoaneurysm of proximal anastomosis-small intestinal fistula). Bleeding was controlled by immediate EVAR except for one patient with a history of EVAR. After that, intestinal repair by laparotomy was performed in all cases. Omentopexy was performed in four cases and remaining one case was used mesentery because the omentum was absent due to total gastrectomy. As for antibiotics, penicillins or cephalosporins were administered intravenously for about 4 weeks and transferred to oral administration. Although one patient died of postoperative pneumonia, four patients were discharged from the hospital. An average of 17.8 months (2.1 to 53.8 months) has passed after surgery, and there are no signs of infection due to AEF. Conclusion: A treatment strategy for AEF focusing on rapid bleeding control, fistula treatment, and infection control has good results.
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