Stent-Graft Infection with Severe Pulmonary Adhesion Cured by Extra-Anatomical Bypass through the Anterior Position of the Pulmonary Hilum: a Case Report / 日本心臓血管外科学会雑誌

This is a case of an 81-year-old male who underwent stent-graft (SG) placement for type B aortic dissection at the age of 79. Two and a half years after the surgery, he was diagnosed with SG infection. Although he was scheduled for SG removal and the in-situ replacement of the descending aorta, he had difficulty maintaining oxygenation under single lung ventilation and detaching the severe adhesion of the aneurysm to the lung; therefore, only the aneurysm sac was opened, and abscess drainage was performed. The continuous irrigation and drainage of the aneurysm sac were performed, but the infection did not improve. On the 6th day after the surgery, the aortic aneurysm in the lung adhesion area was left untreated, and an extra-anatomical bypass was performed from the distal aortic arch to the anterior position of the pulmonary hilum, anastomosing with the abdominal aorta. All SGs were removed, the abscess and intima of the aortic aneurysm were extensively excised, and the remaining cavity was filled with omentum. The infection rapidly improved after the surgery, and he was discharged on the 52nd day after admission. Fortunately, the infection did not recur for 2 years since the surgery. This procedure is useful as an option for surgical reconstruction for stent graft infection for which in-situ descending aorta replacement is difficult.

Short-term outcome of ascending aorta replacement combined with total aortic arch fenestration technique for acute type A aortic dissection / 中国胸心血管外科临床杂志

@#Objective    To report our clinical experience and outcomes of thoracic endovascular aortic repair (TEVAR) for acute Stanford type A dissection using ascending aorta replacement combined with implantation of a fenestrated stent-graft of the entire aortic arch through a minimally invasive technique. Methods    From 2016 to 2020 in our hospital, 24 patients (17 males and 7 females, aged 45-72 years) with complicated Stanford type A aortic dissection, underwent replacement of the proximal ascending aorta with TEVAR. None of the patients with dissection involved the three branches of the superior arch, and all patients were replaced with artificial blood vessels of the ascending aorta under non-hypothermic cardiopulmonary bypass, preserving the arch and the three branches above the arch, and individualized stent graft fenestration. Results    Surgical technical success rate was 100.0%. There was no intraoperative complication or evidence of endo-leak in 1 month postoperatively. Hospital stay was 10±5 d. During postoperative follow-up, the stent was unobstructed without displacement, the preserved branch of the aortic arch was unobstructed, and the true lumen of the descending aorta was enlarged. Conclusion     This hybrid technique by using TEVAR with fenestrated treatment is a minimally invasive and effective method to treat high-risk patients with acute Stanford type A aortic dissection.

Temporal Hemostasis with Kampo Medicine for Bleeding Due to Enhanced Fibrinolytic Type of Chronic Disseminated Intravascular Coagulation : A Case Report / 日本東洋医学雑誌

A 74-year-old woman presented to our clinic with a history of vascular-and stent-graft insertion for aortic dissection developed a tendency to bleed from a palmar wound due to chronic disseminated intravascular coagulation (DIC). Initially, she sustained the palmar wound due to a fall. On the second day after the injury, she experienced continuous bleeding and consulted the orthopedic department of a general hospital, where her dressing was changed. On the third day after injury, she sought consultation at our clinic. The clot and wound remained intact even 12 days after the injury. Therefore, the clot was removed and the bleeding was stopped surgically. On the same day, 5 hours after the surgical treatment, the patient presented to our clinic because of continuous bleeding. She was then administered kyukikyogaito and kamikihito to stop the bleeding. Her laboratory findings revealed thrombocytopenia, and additional inspection was performed. The bleeding stopped on the next day. On the third day after administration, the bleeding remained controlled and an additional inspection revealed DIC. In the cardiology hospital, the cause of tendency to bleed of chronic DIC was pointed out as being due to a leakage at the end of the stent-graft. Kampo medicine was thought to be useful for temporal hemostasis for bleeding due to chronic DIC.

Stent graft infection after endovascular repair of abdominal aortic aneurysm: a case report and literature review

Aortic end graft (EVAR) infection isa challenging management problem in aortic surgery with 0.2% to 0.7% incidence, which is similar to aortic graft infection after open abdominal aortic aneurysm (AAA) repair. Although much attention has been given to the more common problem of endo leak management, yet only sporadic case reports have been reported about the late complication of endograft infection. We reported a case of elderly Saudi male, known to have multiple medical problems presented to our emergency department with severe progressive abdominal pain, vomiting, and fever over the last 7 days. He was evaluated and diagnosed as septic shock due to and infected stent graft following Endovascular Aneurysm Repair of abdominal aortic aneurysm, 4 years ago, with peritonitis. He underwent emergency laparotomy and a left paraaortic abscess was drained and a part of exposed metals of the stent graft found. Other intraperitoneal abcesses were drained and abdomen closed over drains. Patient remained under ICU care, but unfortunately deteriorated and died 3 days postoperatively.

Effects of Different Geometric Parameters on Flexibility of Z-Shaped Stent-Grafts / 医用生物力学

Objective To analyze the influence of different geometric parameters on flexibility of the commonly used Z-shaped stent-grafts for treating thoracic aortic aneurysm, as well as the primary and secondary order of such influence. Methods The three-dimensional models of the stent-grafts with different strut numbers, wire diameters, crest height, bending radius were established by SolidWorks and imported to ANSYS software for finite element analysis．The 60° rotation of X-axis was applied to the stent-grafts, and the flexibility of the stent-grafts was evaluated according to 3 evaluation parameters (Von Mises stress, reaction force and bending torque)． Results After bending of the stent-grafts, the maximum stress was concentrated on the inside of the bend；reducing the wire diameter, crest height and strut number of the stent-grafts, the flexibility of the stent-grafts would increase; increasing the bending radius， the flexibility of the stent grafts would increase; the effect of the wire diameter and strut number on flexibility of the stent-grafts was stronger than that from the bending radius and crest height． Conclusions The strut number, wire diameter, crest height, bending radius had a significant impact on flexibility of the stent-grafts. The research findings can provide theoretical references for the selection and optimal design of the stent-grafts in clinic, and have a positive influence on reducing the incidence rate of complications such as new entry.

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.

Different surgical procedures for Stanford type A aortic dissection: A case control study / 中国胸心血管外科临床杂志

@#Objective    To analyze the near-term clinical efficacy of two different surgical procedures (Sun's procedure and Debranching combined endovascular stent-graft procedure) to cure Stanford type A aortic dissection, and summarize the clinical experience to help better master the indications of the two surgical procedures. Methods     We retrospectively analyzed the clinical data of 46 patients with Stanford A aortic dissection in our hospital between September 2014 and September 2017. There were 39 males and 7 females at age of 20–74 (48.67±11.80) years. According to different surgical methods, the patients were divided into a Sun's procedure group (26 patients) and a debranching combined endovascular stent-graft procedure group (20 patients). The clinical effect of the two groups was compared. Results     The debranching combined endovascular stent-graft procedure group was significantly superior to the Sun's group in cardiopulmonary bypass (CPB) time, aortic cross clamp(ACC) time, intraoperative urine output, postoperative mechanical ventilation time, postoperative 24 h volumes of drain, CICU time, renal function recovery of postoperative 72 h and total hospital stay(P<0.05). The incidence of transient neurological damage after operation in the debranching combined endovascular stent-graft procedure group was significantly lower than that of the Sun's procedure group(P<0.05). The follow-up time ranged from 3 to 36 months. And the follow-up rate was 90.5%. One patient in the Sun's procedure group died of serious pulmonary infection postoperative 30 days. One patient in the debranching combined endovascular stent-graft group was found to have internal leakage in the early postoperative examination and   disappeared after 6 months. Sun's procedure group did not find endoleak. All patients during the follow-up time did not appear brain, coagulation disorders, stroke, paraplegia, upper limb ischemia and other complications. Conclusion     For Stanford type A aortic dissection, debranching combined surgery may have the risk of postoperative endoleak, but the overall effect is superior to Sun's operation. Therefore, debranching combined surgery should be preferred for the treatment of this type of dissection.

Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: A Comprehensive Review

Abdominal aortic aneurysm (AAA) can be defined as an abnormal, progressive dilatation of the abdominal aorta, carrying a substantial risk for fatal aneurysmal rupture. Endovascular aneurysmal repair (EVAR) for AAA is a minimally invasive endovascular procedure that involves the placement of a bifurcated or tubular stent-graft over the AAA to exclude the aneurysm from arterial circulation. In contrast to open surgical repair, EVAR only requires a stab incision, shorter procedure time, and early recovery. Although EVAR seems to be an attractive solution with many advantages for AAA repair, there are detailed requirements and many important aspects should be understood before the procedure. In this comprehensive review, fundamental information regarding AAA and EVAR is presented.

On table fenestrated stent graft in zone 0 and zone 1 for aortic arch diseases / 中华普通外科杂志

Objective To evaluate fenestrated thoracic endovascular aortic repair (f-TEVAR) using fenestrated stent graft on table in zone 0 and zone 1 for aortic arch diseases.Methods 13 patients undergoing f-TEVAR by using physician modified fenestrated stent grafts (PMSGs) on table in zone 0 and zone 1 for aortic arch diseases between Nov 2015 and Mar 2018 were retrospectively reviewed.Results The median age was 59 years(range,33-81 years).PMSGs were deployed from Z0 in 5 patients and Z1 in remaining 8 patients.All but 3 patients underwent elective procedure.The technical success rate was 92.3％.Overall mortality was 7.7％ (1/13).There were no perioperative neurologic complications and paraplegia.One patient suffering from acute left leg ischemia and renal failure recovered after openembolectomy and dialysis.Median length of stay was 9.0 days (range,4-35 days).12 patients were survival at a median follow-up of 11.5 months (range,1.0-19.0 months).Retrograde dissection occurred in one patient and resolved after open repair.During follow up,all target vessels remained patent,with no fenestration-related type Ⅰ or Ⅲ endoleaks.Conclusions f-TEVAR using modified fenestrated stent grafts on table in Z0 and Z1 is feasible for the treatment of aortic arch diseases.

Thoracic stent graft sizing for endovascular repair in Stanford type B aortic dissection / 中华外科杂志

Endovascular treatment for Stanford type B aortic dissection uses thoracic aortic stent-graft system, which consists of covered stent and delivery system. The system is different in the configuration of the stent, the delivery system and the mode of release. The principle of endovascular treatment for Stanford type B aortic dissection is different from aortic aneurysm, so there are differences in stent selection. On the basis of preoperative assessment and measurement, it is suggested that the proximal diameter oversize of the stent is 0 to 5%, at 160 to 200 millimeters in length. The distal end of the stent should pass through the bend of the descending aorta to accommodate the descending aorta blood flow, and the oversize is 0. The postoperative complications and mortality including reverse dissection of proximal part and intima rupture of distal part induced by the stent will be effectively reduced with familiarity with the characteristics of stent-graft, understanding of the possible side effects of stent-graft, combining with the actual conditions and mastering the above principles.

Endovascular Treatment of a Saccular Aneurysm in the Celiomesenteric Trunk: A Case Report and Review of Literature

To present a world-first case of a successful endovascular treatment of a celiomesenteric trunk (CMT) aneurysm. A 45-year-old man had an asymptomatic saccular aneurysm in a rare anomaly of CMT. Endovascular multiple micro-coil embolization of the common hepatic artery, splenic artery and the aneurysm was done, followed by a stent-graft deployment in the superior mesenteric artery covering the orifice to the aneurysm. Postoperative course was uneventful. Only 21 cases have been previously reported in the literature, and all were treated by open surgeries. Endovascular therapy can be safely done in selected cases of a CMT aneurysm with sufficient collaterals to the liver and spleen.

Fenestrated EVAR using physician-modified stent-grafts for thoraco-abdominal aortic lesions / 中华普通外科杂志

Objective To evaluate fenestrated endovascular aortic repair (FEVAR) using physician-modified stent-grafts (PMSGs) for thoraco-abdominal aortic lesions.Methods Seven cases of thoraco-abdominal aortic lesions (1 type Ⅲ thoraco-abdominal aortic aneurysm,1 type Ⅳ thoraco-abdominal aortic aneurysm,4 chronic thoraco-abdominal aortic dissection and 1 type Ⅰ endoleak after EVAR due to abdominal aortic aneurysm) were treated with FEVAR from Nov 2016 to Nov 2017.Results FEVAR was performed successfully in all cases.Type Ⅱ and Ⅲ endoleak occurred in 4 cases.One died of acute myocardial infarction 2 days postoperatively.Renal dysfunction deterioration occurred in one case of chronic dissection and improved after the medical treatment.Renal subcapsular hematoma was found in 2 cases postoperatively,and resolved after conservative therapy.Mean follow-up period was 7.2 months,target vessel patency was identified in 5 of the 6 cases.Conclusions FEVAR using PMSGs is a viable alternative to treat thoraco-abdominal aortic lesions.

A Case of Open Surgery for Endoleak after Thoracic Endovascular Aortic Repair of the Aortic Arch / 日本心臓血管外科学会雑誌

A 72-year-old woman underwent thoracic endovascular aortic repair (TEVAR) for an aortic arch aneurysm at a previous hospital. During follow-up, although the aneurysm was found to have become bigger, no further treatments were given, except for conservative follow-up. The patient sought a second opinion and thus visited our hospital. Enhanced computed tomography (CT) revealed a type I endoleak that required repair. Total arch replacement with removal of the partial stent-graft system was performed under deep hypothermic circulatory arrest. The patient made a steady progress postoperatively and was discharged without any complications. Endovascular repair is minimally invasive and frequently used in various medical facilities but carries a considerably high risk of reintervention. Treatment strategies for aortic aneurysm, including open surgery, should be carefully chosen.

Preventive effect of potassium citrate sustained-release tablets on formation of adherent stone in ureteral stent-graft after retrograde intrarenal surgery / 实用医学杂志

Objective To investigate the preventive effect of potassium citrate sustained-release tablets on the formation of adherent stone in ureteral stent-graft after retrograde intrarenal surgery. Methods Patients with upper urinary tract calculi after retrograde intrarenal surgery and without stasis confirmed by color ultrasound were randomly divided into test group and control group. Patients in test group were given potassium citrate sustained release tablets 3 times(1.08 grams each time)orally but those in the control group did not take the drug. Two groups of patients received conventional health education and diet guidance. The formation of adherent stone in ureteral stent-graft during surgical removal of ureteral stent and the adverse reactions during taking the medication 3,6 and 16 weeks after the surgery were compared. Results There were few cases of adherent stone formed 3 weeks after the operation,which can not be statistically analyzed. The incidence of adnexal calculus in the test group 6 and 16 weeks after the operation was significantly lower than that of the control group,which was statistically significant.No serious adverse reactions and complications occurred in the test group during the medication-taking. Conclusions Potassium citrate sustained-release tablet is safe and effective for preventing the formation of adher-ent stone in ureteral stent-graft after upper urinary tract calculi retrograde intrarenal surgery.

Safety and feasibility study of a novel stent-graft for thoracic endovascular aortic repair: a canine model experiment

Abstract Objective: To evaluate the safety and feasibility of a novel stent-graft for thoracic endovascular aortic repair (TEVAR) in a canine model, 9 adult hybrid dogs were used for the experiment. Methods: All animals were implanted with a novel thoracic aortic stent-graft via femoral artery. Blood sample was collected at pre-operation and 1, 2, 4, 8 and 12 weeks after implantation for hematological examination. Moreover, tissues from randomly selected 4 dogs were subjected to histopathological analysis with the optical microscope after stent-grafts were implanted for 3, 6, 9, and 12 months respectively. The experimental period lasted for more than 2 years. Results: A total of 9 stent-grafts were successfully implanted in the canine thoracic aortas and no migration or deformation occurred. Related indicators of blood routine, inflammatory factors, and immunology changes were not significantly (P>0.05), except the white blood cell (WBC) counts in the first week. Moreover, abnormal morphology was not found in all thoracic aortas via histopathological examination. Additionally, all stent-grafts were patent and did not migrate, and there was no thrombus in the lumens of stent-grafts. Conclusion: The novel thoracic aortic stent-graft made in China was safe and feasible for thoracic endovascular aortic repair in a canine model.

Iatrogenic dissection of the descending aorta: Conservative or endovascular treatment.

Transcatheter aortic valve implantation (TAVI) is without any doubt a standard technique and the treatment of choice of severe aortic valve stenosis (AVS) in very high‑operative risk patients. However, a number of complications may occur and has been described. Improper valve position, valve migration, paravalvular regurgitation, conduction disturbances, stroke and aortic dissection have been succeeded despite the perfection of the technique. For anyone of the complications above described, a solution may be invented. We present an interesting case of an 81‑year‑old woman with severe AVS treated through TAVI due to very high operative risk. This female, 12 days later presented with thoracic pain and shortness of breath and through the computed tomography of the chest performed was diagnosed a dissection of the descending aorta. She successfully underwent on thoracic endovascular aortic repair. In this report, we refer the bibliographic data and we discuss the treatment options in these cases.

Thoracic Endovascular Aortic Repair for Aortopulmonary Fistula Which Had Difficulty with Preoperative Diagnosis / 日本心臓血管外科学会雑誌

<p>Aortopulmonary fistula with an arch aortic aneurysm is a rare disease that is difficult to diagnose and often presents with sudden, life-threatening heart failure. Here we report a case of aortopulmonary fistula for which we performed a thoracic endovascular aortic repair (TEVAR) with favorable results. A 79-year-old man presented with slurring of speech and body malaise at a neighborhood clinic. A distal arch aortic aneurysm was detected on chest computed tomography (CT) scans, and the patient was referred to our hospital for further management. We identified a saccular aneurysm and the dilated pulmonary artery, with maximum vessel diameters of 80 and 38 mm, respectively, on preoperative chest CT scans. He was diagnosed with an impending aortic rupture and a TEVAR was performed after preparing for a cervical ramification bypass. Intraoperatively, the aortopulmonary fistula had invaded the pulmonary artery, and the shunt created by the invasion was responsible for the sudden exacerbation of heart failure symptoms in the patient. The diameter of the saccular lump did not increase in the postoperative CT and follow-up visits were scheduled for subsequent monitoring. In the absence of significant complications and with improvement of heart failure symptoms, the patient was discharged from our hospital on the 37th postoperative day. He was later transferred to a neighborhood clinic for rehabilitation and subsequently discharged for further recuperation at home in the fifth postoperative month.</p>

Endovascular Repair of Abdominal Aortic Diseases with Unibody Bifurcated Stent-graft / 中国微创外科杂志

Open surgery was the main treatment for abdominal aortic diseases in the past .However , with the development of endovascular instruments , endovascular repair technique has become the main option for abdominal aortic diseases .Unibody bifurcated stent-graft and modular bifurcated stent-graft are often used to treat abdominal aortic diseases .Unibody bifurcated stent-graft has its own features in endovascular repair of abdominal aortic diseases .We made a literature summary on application of unibody bifurcated stent-graft in abdominal aortic diseases .

EFFECTIVENESS EVALUATION OF THORACIC ENDOVASCULAR AORTIC REPAIR FOR BLUNT THORACIC AORTIC INJURY WITH HOSTILE STENT-GRAFT PROXIMAL LANDING ZONE / 中国修复重建外科杂志

OBJECTIVE: To explore the effectiveness of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) with hostile stent-graft proximal landing zone. METHODS: A retrospective analysis was made on the clinical data of 13 patients with BTAI with hostile stent-graft proximal landing zone treated by TEVAR between December 2007 and December 2014. There were 10 males and 3 females with the mean age of 44 years (range, 24-64 years). The imaging examination indicated Stanford type B aortic dissection in 7 cases, pseudoaneurysm in 3 cases, aneurysm in 1 case, and penetrating ulcer in 2 cases. According to the partition method of thoracic aortic lesion by Mitchell, 8 cases underwent stent-graft with left subclavian artery (LSA) coverage, 3 underwent chimney stents for LSA, and 2 for left common carotid artery (LCCA). In 2 cases receiving chimney TEVAR involving LCCA, one underwent steel coils at the proximal segment of LSA to avoid type II endoleak and the other underwent in situ fenestration for endovascular reconstruction of LSA. RESULTS: All TEVAR procedures were successfully performed. The mean operation time was 1.8 hours (range, 1-3 hours); the mean intraoperative blood loss was 120 mL (range, 30-200 mL); and the mean hospitalization time was 15 days (range, 7-37 days). No perioperative death and paraplegia occurred. The patients were followed up 3-30 months (mean, 18 months). Type I endoleak occurred in 1 case during operation and spontaneously healed within 6 months. Hematoma at brachial puncture site with median nerve compression symptoms occurred in 1 case at 3 weeks after operation; ultrasound examination showed brachial artery pseudoaneurysm and thrombosis, and satisfactory recovery was obtained after pseudoaneurysmectomy. No obvious chest pain, shortness of breath, left upper limbs weakness, numbness, and dizziness symptoms were observed. Imaging examination revealed that stentgraft and branched stent remained in stable condition. Meanwhile the blood flow was unobstructed. No lesions expanded and ruptured. No new death, bacterial infection, or other serious complications occurred. CONCLUSIONS: According to Mitchell method, individualized plan may be the key to a promising result. More patients and further follow-up need to be included, studied, and observed.

Preservation of Internal Iliac Artery after Endovascular Repair of Common Iliac Artery Dissection Using Modified Fenestrated Stent Graft

Standard endovascular repair of iliac/aortoiliac pathologies can lead to complications, such as buttock claudication, colon ischemia and erectile dysfunction. Branch grafts have been developed but require at least 6 weeks for customization and are not currently available in China; they are also quite expensive. To our knowledge, modified fenestrated stent grafts (MFSGs) are a safe and effective alternative for treating patients with juxtarenal aneurysms. Most MFSGs are used for the preservation of renal and left subclavian arteries. Few cases of MFSGs have been reported in the treatment of iliac pathologies. The use of an MFSG is decided on a case-by-case basis. This report presents our first clinical use of an MFSG for preservation of the internal iliac artery.