Examination of Treatment for Complications of the Downstream Aorta after a Frozen Elephant Trunk Procedure during the Follow-up Period / 日本心臓血管外科学会雑誌

Objective: We examined complications of the downstream aorta after the frozen elephant trunk (FET) procedure. Methods: Complications were diagnosed in eight patients: true aneurysm alone in five patients; type A aortic dissection in two patients; and both true aneurysm and type B aortic dissection in one patient. Results: Elective surgery was performed in seven patients. Five patients received a Matsui-Kitamura stent graft (MKS) and three patients received a J Graft Open Stent Graft (JGOSG). The FET procedure was successfully applied in all cases. Over the long term, dilatation of the descending thoracic aorta (dTA) alone was identified in two patients and dilatation of the dTA and migration was identified in three patients using the MKS. Complications of graft kinking and migration were seen in one patient and distal stent graft-induced new entry in two patients using the JGOSG. Thoracic aortic stent graft repair was successfully performed for complications in seven patients. Conclusion: For the improvement of clinical results, FET devices need to offer flexibility and appropriate radial force.

Three Cases of Extensive Aortoiliac Occlusive Disease (AIOD) with Aorto-Uni-Iliac (AUI) Stent-Grafting with Femoro-Femoral Crossover Bypass / 日本心臓血管外科学会雑誌

Aortoiliac occlusive disease (AIOD) can be difficult to treat. We performed aorto-uni-iliac (AUI) stent-grafting with external-iliac artery crossover bypass in 3 cases of extensive AIOD (mean age 69 years). Lesions were TASC II type D in 2 and D+A in 1. Mean ankle-brachial index of diseased side was 0.52. Bare stent placement for iliac stenosis was also done in 2 cases. All cases were a technical success with no complications. Mean operation time was 123 min and mean hospital stay was 11 days. We have been keeping good patency. We consider it an effective treatment option for AIOD.

Hybrid Technique for Extensive Aortic Arch Aneurysm after Thoracoabdominal Aortic Aneurysm Repair / 日本心臓血管外科学会雑誌

We report a case of operations using a hybrid technique for repeated extensive aortic aneurysm. A 71-year-old man had extensives aneurysms of the aortic arch and descending aorta. In the first operation, he had undergone thoracoabdominal aortic replacement with island repair for thoracoabdominal aortic aneurysm (Crawford type 3) at age 64. Six years later, computed tomography showed an aortic aneurysm around the region of the island repair and penetrating atherosclerotic ulcer (PAU). Therefore, he underwent abdominal debranching and thoracic endovascular aortic repair (TEVAR) at 70 years old. At the same time, he had an extensive aortic arch aneurysm. Considering the complicated surgical history and the affected region, we judged that conventional graft replacement was difficult. So, in the third operation, we performed TEVAR for the descending aorta at 71 years old. One month later, total arch replacement (TAR) with a frozen elephant trunk (FET) was performed (4th operation). The patient was discharged home 22 days after the 4th operation. This strategy of operations using hybrid techniques for extensive aortic aneurysm may be useful in high risk cases of surgical procedures and postoperative complications.

Distal Perfusion in Open Stent-Grafting / 日本心臓血管外科学会雑誌

<p><b>Objective</b> : We examined the utility of distal perfusion (DP) in open stent grafting (OSG) for the treatment of thoracic aortic aneurysm. <b>Methods</b> : Fifty patients who underwent OSG were categorized into two groups (the Non-DP group and the DP group) based on the presence or absence of distal perfusion in OSG. There was no statistically significant difference between the two groups with regard to patient characteristics. <b>Results</b> : There was no statistically significant difference between the two groups with regard to operation time, but, cardiopulmonary bypass time (178±22 min vs. 193±18 min ; <i>p</i> <0.01) and aortic cross clamp time (84±23 min vs. 106±19 min ; <i>p</i><0.01) were significantly longer in the DP group. Lower-body circulatory arrest time (46±11 min vs. 20±5 min ; <i>p</i><0.001) was significantly longer in the Non-DP group. Postoperative paraplegia and paraparesis occurred in one case each in the Non-DP group, whereas permanent spinal cord ischemia did not occur in the DP group. Postoperative intubation time (72.6±40.1 h vs. 40.1±34.7 h ; <i>p</i><0.05) was significantly longer in the Non-DP group. There were two in-hospital deaths due to stroke and respiratory failure in the Non-DP group, and one in-hospital death due to respiratory failure in the DP group. The postoperative maximum value of BUN (38.5±15.6 mg/dl vs. 30.8±9.8 mg/dl ; <i>p</i><0.05) and s-Cr (1.9±1.0 mg/dl vs. 1.3±0.4 mg/dl ; <i>p</i><0.01) were significantly higher in the Non-DP group. <b>Conclusion</b> : DP in OSG was an effective method for prevention of spinal cord ischemia, and for protection of respiratory and renal function.</p>

Recurrent of Aortic Coarctation in Extra-anatomical Bypass Surgery / 日本心臓血管外科学会雑誌

Recoarctation, systemic hypertension, aortic aneurysm and intracranial aneurysm are generally observed within a certain period after the surgical procedure for aortic coarctation, which is known as a systemic diseases caused by not only morphological abnormalities but also arterial functional abnormalities of artery. Here, we report a case who showed complications of recoarctation, hypertension and subarachnoid hemorrhage after surgery for aortic coarctation. A 17-year-old boy originally presented to our hospital with upper extremity systemic hypertension. Recoarctation after surgery for aortic coarctation was diagnosed in his childhood, following which hypertension was followed while he received continuous treatment with anti-hypertensive drugs. He was hospitalized with sudden headache and loss of consciousness. Since subarachnoid hemorrhage was diagnosed by computed tomography, clipping of intracranial aneurysms was performed. After the clipping procedure, he underwent percutaneous intravascular stenting angioplasty. However, the pressure gradient remained and sufficient dilatation was not obtained because of the hypoplastic anatomical distal aortic arch (from the left internal carotid artery to the site of recoarctation) due to the development of collateral circulation with rib notch. At age 21, extra-anatomical bypass (from the ascending aorta to the descending aorta) was performed because of persistent upper extremity systemic hypertension. However, systemic hypertension continued to require antihypertensive medication.

Initial and Mid-term Results of Thoracic Endovascular Repair (TEVAR)—Management of Left Subclavian Artery (LSA) during Zone 2 (Z2) Coverage— / 日本心臓血管外科学会雑誌

Between August 2008 and June 2012, 17 TEVAR procedures for thoracic aortic aneurysms (TAA) requiring Z2 coverage were performed at our institution. Patient age ranged from 46 to 82 years old (mean 69.4), 16 were male. Criteria for LSA revascularization at our institution are defined as either : 1) dominant left vertebral artery (VA), 2) absent or diminutive or occluded right VA, 3) no communication of bilateral VA, 4) bilateral carotid artery disease, 5) patent LIMA-coronary bypass, 6) if a long length of the thoracic aorta is covered. Devices utilized were Gore TAG (<i>n</i>=12) and TX2 (<i>n</i>=5). Deployment of the stent-graft (SG) was successful in 17 cases (100%) and complete thrombosis of the aneurysm or complete entry closure was achieved in 16 cases (94.1%). Axillo-axillar cross over bypass (Ax-Ax B) was performed in 5 cases (29.4%). There was no instance of cerebrospinal ischemia or hospital death and the mean follow-up was 22.9 month (range 5 to 46). One case was converted to open surgery due to secondary type 1 endoleak. There was no instance of Ax-Ax B graft occlusion or aneurysmal rupture. The initial and mid-term results of TEVAR requiring Z2 coverage were satisfactory, and we believe that our criteria for LSA revascularization played an important role in providing the satisfactory results.

Initial Results of Open Stent-Grafting Applied with a Matsui-Kitamura Stent in the Treatment of Thoracic Aortic Aneurysm / 日本心臓血管外科学会雑誌

We reporte the initial results of open stent-grafting (OSG) applied with a Matsui-Kitamura (MK) stent in the treatment of thoracic aortic aneurysm (TAA). From August 2005 to March 2011, OSG for TAA was applied in 35 cases (male/female, 29/6, 58∼86 years old, mean age 71). During deep hypothermic circulatory arrest with antegrade selective cerebral perfusion, the stent graft was delivered through the transected proximal aortic arch, followed by arch replacement with a 4-branched prosthesis. Concomitant procedures included 1 coronary artery bypass graft, 1 mitral valve replacement and 2 pacemaker implantations. Operative mortality within 30 days was 5.7% (respiratory failure in 1 and ischemic enteritis in 1). There was 1 in-hospital death due to brain stem infarction. Perioperative morbidity included 2 (5.7%) stroke, 5 (14.3%) spinal cord injuries (paraplegia in 1, paraparesis in 1 and transient paraparesis in 3) , and 1 (2.9%) temporary hemodialysis. Ten patients (28.6%) were intubated for more than 72 h. There was no complication with the graft-related incident. These initial results suggested the OSG method applied with a MK stent is a useful surgical procedure for the treatment of TAA.

Initial Results of Thoracic Endovascular Repair with the Gore TAG Device Evaluated by the Japan SCORE System / 日本心臓血管外科学会雑誌

We report the initial results of thoracic endovascular repair using the Gore TAG device (TAG) used in treatment of thoracic aortic aneurysms (TAA), and evaluate initial outcome based on the Japan SCORE (JS) system. From August 2008 to July 2009, thoracic aortic endovascular repair (TEVAR) for TAA was applied in 27 cases (men/women, 22/5, 53-88 years old, mean age 70.5). Locations included the distal arch in 7 cases, proximal descending TAA (dTAA) in 12 cases and middle or distal dTAA in 8 cases. Deployment of a stent-graft (SG) was successful in 27 cases (100%) and complete thrombosis of the aneurysm or complete entry closure was achieved in 26 cases (96.3%). There was 1 type 2 endoleak (3.7%), 2 iliac arterial injuries (7.4%) and 2 cases of temporary hemodialysis (7.4%). There was no occurrence of paraplegia or hospital death. The 30-day mortality rate and major complication rate examined by the Japan SCORE (JS) system did not show any statistical differences between the TEVAR group and the open repair (OR) group, however the data were higher in the TEVAR group, although not statisfically in the OR group. The OR group had a high complication incidence in comparison with the TEVAR group. Based on evaluation by the JS system, the initial results suggest that TAG for the treatment of TAA is superior to conventional open surgery.

Successfully Treated Secondary Aorto or Iliac Arterial-Enteric Fistula / 日本心臓血管外科学会雑誌

We here report two cases of successfully treated secondary aorto or iliac arterial-enteric fistula after graft replacement for abdominal aortic aneurysm. Case 1: A 80-year-old man who complained massive anal bleeding had undergone Y-shaped graft replacement for abdominal aortic aneurysm 22 years previously. Computed tomography demonstrated an aneurysm and hematoma formation at the anastomosis of the right graft limb and the right common iliac artery. Preoperative angiography showed no leak of contrast medium at the distal anastomosis of the right graft limb. A presumptive diagnosis of secondary iliac arterial enteric fistula was made, therefore, we performed an emergency operation. Extra-anatomic bypass preceded the removal of the right graft limb, partial resection and direct reconstruction of the ileum by the retroperitoneal approach. His postoperative course was uneventful and he was discharged on the 19th postoperative day. Case 2: A 77-year-old man who had received Y-shaped graft replacement of an abdominal aortic aneurysm 9 years previously was transferred to our hospital because of sudden onset epigastralgia and massive hematemesis. Gastroduodenoscopy revealed a fresh blood clot in the third portion of the duodenum where it was compressed by for surrounding pulsatile environment. An emergency computed tomography showed aneurysm formation without extravasation of contrast medium in the duodenum at the proximal anastomosis of the prosthetic graft. A secondary aortoenteric fistula was highly suspected and emergency operation was performed. Extra-anatomic bypass preceded the removal of the graft body, infrarenal aortic stump closure, duodenal closure and the greater omentum was used to fill defects. He underwent successful staged abdominal wall closure due to bowel edema making primary closure impossible. His postoperative course was uneventful and he was discharged on the 26th postoperative day.

A Successfully Treated Case of Primary Aortoenteric Fistula / 日本心臓血管外科学会雑誌

A 79-year-old man was transferred to our hospital because of massive hematemesis. Contrast-enhanced CT scan demonstrated extravasation of contrast medium into the jejunum. Therefore, we diagnosed primary aortoenteric fistula and performed an emergency operation. At surgical exploration, the jejunum was closely adherent to the normal-sized aorta. The fistula was present between the anterior wall of the aorta and the jejunum. Operative reconstruction was performed with <i>in-situ</i> grafting and a pedicled omentum flap was placed around the graft. The postoperative course was uneventful, and there has been no evidence of infection during the follow-up period of 1 year.

Detection of Late Presentation of Poststernotomy Mediastinitis in an Infant by Positron Emission Tomography / 日本心臓血管外科学会雑誌

Positron emission tomography (PET) is an established imaging tool in oncology that has also been used in infectious and inflammatory diseases. PET combined with computed tomography (PET/CT) can be used to visualize metabolic activity with precise localization. We report an infant with late presentation of poststernotomy mediastinitis, the diagnosis and localization of which was confirmed by PET/CT. An 8-month old infant, who had undergone the Jatene procedure and right ventricle outflow reconstruction 6 months prior, was admitted for inflammation surrounding the superior aspect of the healed scar. Cultures from the wound grew methicillin-resistant <i>Staphylococcus aureus</i> (MRSA). Although the only symptom was discharge from the wound, and there were no other signs or symptoms suggestive of severe general infection, substernal abscess was suspected by magnetic resonance imaging. Since PET/CT revealed high accumulation of 18-fluorodeoxyglucose at the substernal region, the diagnosis of MRSA mediastinitis was made, which was confirmed by subsequent surgical treatment.

A Case of Endovascular Aortic Repair of Traumatic Thoracic Aortic Rupture / 日本心臓血管外科学会雑誌

A 54-year-old man, involved in a motor vehicle collision, was transferred to our hospital. He was hemodynamically stable. A CT scan of the chest demonstrated traumatic aortic dissection and a mediastinal hematoma with hemothorax of left side. Endovascular aortic repair using a homemade device was immediately performed, and a completion angiogram revealed complete exclusion of the aortic injury, with no extravasation. A postoperative CT scan revealed satisfactory placement of the endograft, with no extravasation. The patient was discharged on the 13th postoperative day. Endovascular aortic repair was useful and minimally invasive therapy in this case for the treatment of traumatic thoracic aortic rupture.

A Case of Buerger's Disease Associated with Angina Pectoris and Carotid Stenosis / 日本心臓血管外科学会雑誌

A 60-year-old male who had a history of Buerger's disease was admitted due to chest pain on exertion. Coronary angiography showed severe double vessel disease (the left anterior descending artery and the right coronary artery). Carotid angiography showed severe stenosis of the left internal carotid artery associated with brain ischemia. In addition, angiography of the lower extremities showed segmental occlusion and collateral arteries resembly a “corkscrew” appearance. We implanted a stent in the carotid artery followed by revascularization surgery of the left lower leg and simultaneous coronary artery bypass surgery. The postoperative course was excellent.

Simultaneous Surgery for Angina Pectoris and Abdominal Aortic Aneurysm with Bilateral Iliac Artery Occlusion in a Chronic Hemodialysis Patient / 日本心臓血管外科学会雑誌

A 74-year-old man with renal failure had been treated with maintenance hemodialysis for 1.5 years at another hospital. The patient had an abdominal aortic aneurysm, bilateral iliac artery occlusion and coronary artery stenosis with a lesion in the left main trunk, but had been under observation because of the high risk of surgery. The patient elected to have surgery and was admitted to our hospital. We performed simultaneous surgery for severe coronary artery stenosis and abdominal aortic aneurysm with a maximum diameter of 85mm. The postoperative course was generally uneventful, but the patient required treatment of arrhythmia. We conclude that simultaneous surgery for angina pectoris and abdominal aortic aneurysm is feasible even in hemodialysis patients. It is important to pay attention to arrhythmia in the management of such patients, especially those with decreased cardiac function.