In Situ Replacement for a Mycotic Aneurysm on the Porcelain Aorta Using the Superficial Femoral Artery as a Vascular Graft / 日本心臓血管外科学会雑誌

Infected thoracic aortic aneurysms are rare. Standard treatment methods have not yet been established for medical treatment, timing of surgery, or surgical techniques. In this study, we report a case in which an ascending aortic reconstruction using an autologous superficial femoral artery was successfully performed for an infected pseudoaneurysm of the thoracic aorta without the use of artificial materials. The patient was a 78-year-old man with bacteremia caused by Staphylococcus aureus and an infected pseudoaneurysm of the thoracic aorta. The patient underwent replacement of the ascending aorta and coronary artery bypass grafting. The patient was discharged from the hospital with no recurrence of infection and no abnormality of the reconstructed aorta.

Utility of Noncontrast Magnetic Resonance Angiography for Aneurysm Follow-Up and Detection of Endoleaks after Endovascular Aortic Repair

Objective@#To assess the noncontrast two-dimensional single-shot balanced turbo-field-echo magnetic resonance angiography (b-TFE MRA) features of the abdominal aortic aneurysm (AAA) status following endovascular aneurysm repair (EVAR) and evaluate to detect endoleaks (ELs). @*Materials and Methods@#We examined four aortic stent-grafts in a phantom study to assess the degree of metallic artifacts. We enrolled 46 EVAR-treated patients with AAA and/or common iliac artery aneurysm who underwent both computed tomography angiography (CTA) and b-TFE MRA after EVAR. Vascular measurements on CTA and b-TFE MRA were compared, and signal intensity ratios (SIRs) of the aneurysmal sac were correlated with the size changes in the AAA after EVAR (AAA prognoses). Furthermore, we examined six feasible b-TFE MRA features for the assessment of ELs. @*Results@#There were robust intermodality (r = 0.92–0.99) correlations and interobserver (intraclass correlation coefficient = 0.97–0.99) agreement. No significant differences were noted between SIRs and aneurysm prognoses. Moreover, “mottled high-intensity” and “creeping high-intensity with the low-band rim” were recognized as significant imaging findings suspicious for the presence of ELs (p < 0.001), whereas “no signal black spot” and “layered high-intensity area” were determined as significant for the absence of ELs (p < 0.03). Based on the two positive features, sensitivity, specificity, and accuracy for the detection of ELs were 77.3%, 91.7%, and 84.8%, respectively. Furthermore, the k values (0.40–0.88) displayed moderate-toalmost perfect agreement. @*Conclusion@#Noncontrast MRA could be a promising imaging modality for ascertaining patient follow-up after EVAR.

Utility of Noncontrast Magnetic Resonance Angiography for Aneurysm Follow-Up and Detection of Endoleaks after Endovascular Aortic Repair

Objective@#To assess the noncontrast two-dimensional single-shot balanced turbo-field-echo magnetic resonance angiography (b-TFE MRA) features of the abdominal aortic aneurysm (AAA) status following endovascular aneurysm repair (EVAR) and evaluate to detect endoleaks (ELs). @*Materials and Methods@#We examined four aortic stent-grafts in a phantom study to assess the degree of metallic artifacts. We enrolled 46 EVAR-treated patients with AAA and/or common iliac artery aneurysm who underwent both computed tomography angiography (CTA) and b-TFE MRA after EVAR. Vascular measurements on CTA and b-TFE MRA were compared, and signal intensity ratios (SIRs) of the aneurysmal sac were correlated with the size changes in the AAA after EVAR (AAA prognoses). Furthermore, we examined six feasible b-TFE MRA features for the assessment of ELs. @*Results@#There were robust intermodality (r = 0.92–0.99) correlations and interobserver (intraclass correlation coefficient = 0.97–0.99) agreement. No significant differences were noted between SIRs and aneurysm prognoses. Moreover, “mottled high-intensity” and “creeping high-intensity with the low-band rim” were recognized as significant imaging findings suspicious for the presence of ELs (p < 0.001), whereas “no signal black spot” and “layered high-intensity area” were determined as significant for the absence of ELs (p < 0.03). Based on the two positive features, sensitivity, specificity, and accuracy for the detection of ELs were 77.3%, 91.7%, and 84.8%, respectively. Furthermore, the k values (0.40–0.88) displayed moderate-toalmost perfect agreement. @*Conclusion@#Noncontrast MRA could be a promising imaging modality for ascertaining patient follow-up after EVAR.

Ascending Aorta and Total Arch Replacement in a Stanford Type A Aortic Dissection with Island Reconstruction for an Isolated Left Vertebral Artery / 日本心臓血管外科学会雑誌

The ascending aorta and aortic arch were replaced in a 72-year-old woman with Stanford type A aortic dissection. Preoperative three-dimensional computed tomography (3D-CT) revealed that the anatomy of an isolated left vertebral artery was abnormal. After hypothermic circulatory arrest, a 12-mm sealed graft was connected to the island-shaped arch under retrograde cerebral perfusion, followed by antegrade cerebral perfusion via a branch of the graft. The main graft was distally anastomosed, and the graft of the cerebral arteries was subsequently anastomosed on the main graft under continuous cerebral and systemic perfusion. The patient tolerated all procedures well without cerebral or bleeding complications, and was discharged 18 days after surgery. This technique was useful for island reconstruction, even with abnormal cerebral arteries and bleeding control of this anastomosis was simple compared to the conventional island technique.

Unsuccessful LITA Harvest due to Sternocostoclavicular Hyperostosis / 日本心臓血管外科学会雑誌

A 78-year-old man presented at the emergency department with anterior chest pain. Coronary angiography (CAG) revealed three-vessel disease and percutaneous transluminal coronary angioplasty (PTCA) was performed on the right coronary artery. A preoperative plain chest computed tomography (CT) scan revealed hyperostosis of the sternum and clavicle. The patient underwent elective coronary artery bypass surgery 49 days later. During surgery, the thickness of the sternum caused difficulties with implementing median sternotomy. The pleura was also thicker than usual and even pulsation of the left internal thoracic artery (LITA) could not be determined due to severe adhesion. We harvested the right internal thoracic artery (RITA) instead of the LITA. The RITA was in a similar condition, but a 5 cm proximal portion could be prepared. The saphenous vein graft was anastomosed to the left anterior descending coronary artery after proximal anastomosis to the ascending aorta with the heartstring device because of the calcified aorta. The RITA-saphenous vein composite graft was anastomosed sequentially to the distal right coronary and circumflex artery. The patient's postoperative course was uneventful but he complained of numbness and lassitude of both upper extremities for one month. A postoperative contrast-enhanced CT scan revealed a patent LITA surrounded by thick tissue, indicating inflammatory disorders. The CT findings indicated a diagnosis of sternocostoclavicular hyperostosis. The postoperative CAG findings indicated that all bypass grafts were patent and the patient was discharged 32 days after surgery. Sternocostoclavicular hyperostosis is an inflammatory disease that might require surgeons to carefully reconsider graft selection.

Coarctation of the Aorta in an Adult Diagnosed by the Presence of Complete AV Block and Heart Failure / 日本心臓血管外科学会雑誌

A 51-year-old woman, who had been undergoing regular treatment and follow-up for hypertension since the age of 17, was diagnosed to have a patent ductus arteriosus (PDA) 6 months previously. On experiencing dyspnea, she visited the emergency room, where she was found to have a complete Atrioventricular (AV) Block and therefore was immediately admitted. The next day, she experienced acute heart failure requiring intubation. A DDD pacemaker was then implanted and the patient recovered thereafter. After recovery, a screening contrast-enhanced CT scan revealed coarctation of the thoracic aorta. The arterial pressure gradient between the arms and legs was about 70mmHg. The division of the PDA and the replacement of the coarcted aortic segment were performed under femoro-femoral cardiopulmonary bypass through a left posterolateral thoracotomy. The patient's postoperative course was good, however, she complained of abdominal pain on the 6th postoperative day. An abdominal CT scan showed hemorrhage in the left rectus abdominus and right iliopsoas muscles. This improved after rest. No arterial pressure gradient was observed between the arms and the legs postoperatively. She was discharged on postoperative day 20.Because the average life expectancy of patients with untreated coarctation of the aorta has been reported to be about 34 years, it is recommended that surgical repair be performed as soon as possible. Patients with childhood-onset hypertension should therefore be evaluated to determine the primary disease whenever possible, such as coarctation of the aorta as in this case.

Implantation Technique of a Left Ventricular Assist System through a Small Right Parasternal Incision / 日本心臓血管外科学会雑誌

A 62-year-old man was transferred to our institution with ventricular fibrillation. Percutaneous cardiopulmonary support (PCPS) was established and he underwent successful percutaneous transluminal coronary angioplasty. Since his left ventricular function did not recover, he was placed on a left ventricular assist system (LVAS). Under general anesthesia, a 10-cm longitudinal incision was made on the right parasternum. The third and fourth cartilages were completely resected. The pericardium was incised longitudinally. At first, an inflow cannula was insected to the right side of the left atrium. The ascending aorta was then partially excluded and an outflow cannula with a 10mm Gore-Tex prosthesis was anastomosed end-to-side to the aorta with a continuous Gore-Tex suture. After the pump was established, PCPS was gradually discontinued. During 9 days of support, his left ventricular function recovered and subsequently he was weaned from LVAS. Unfortunately, he died two days after LVAS removal. We think this procedure is useful because it is easy to perform, reduces the bleeding, shortens the operating time.

Redo Coronary Artery Bypass Grafting via a Small Thoracotomy without Cardiopulmonary Bypass / 日本心臓血管外科学会雑誌

We report two cases the first was a 74-year-old woman who had received coronary artery bypass grafting [SVG-to-LAD, SVG-to-Cx, SVG-to-RCA, the left internal thoracic artery (LITA) was mobilized but was unsuitable for the graft] two years previously. Postoperative angiography revealed graft occlusion. Since repeated catheter intervention was not successful, reoperation was performed. A MIDCAB procedure with radial artery graft and proximal anastomosis was performed on the left axillary artery. The operation was successful and there were no complications. Two weeks after the operation, the graft patency was confirmed and she was discharged. The second case was a 64-year-old man who received coronary artery grafting (LITA-to-LAD, SVG-to-Cx and SVG-to-RCA). Two months after the operation, recurrent chest pain was caused by severe stenosis of the LITA anastomotic site. Percutaneous transluminal coronary angioplasty was performed but was unsuccessful. He received redo CABG in the same manner using the saphenous vein. The postoperative course was uneventful and he was discharged 6 days after the operation. This procedure is useful for the patients whose left internal thoracic artery has been used on a previous operation. Good early results were obtained in both patients.