[Heparin Resistance After Administration of Andexanet Alfa:Report of a Case].

The management of patients on direct oral anticoagulants (DOACs) who require an emergency cardiac surgery has been disputed in Japan. Recently, the use of andexanet alfa as an antidote for apixaban and rivaroxaban, is approved in the setting of life-threating or uncontrollable major bleeding. However, the efficacy and safety of andexanet alfa have been investigated. We report a case of 72-year-old man taking rivaroxaban who required the emergency coronary artery bypass grafting. He received andexanet alfa prior to the operation. Heparin resistance was noted before starting cardiopulmonary bypass. Consideration should be given to the use of andexanet alfa before or during cardiopulmonary bypass.

Combined resection of lung cancer and thoracic aortic wall with simultaneous thoracic aortic endografting: a case report.

BACKGROUND: Combined resection of lung cancer and the thoracic aortic wall with thoracic aortic endografting has been reported. However, whether the resection and endografting should be performed simultaneously or in two steps remains controversial. CASE PRESENTATION: A 68-year-old man was referred to our hospital because of left chest pain. Chest contrast-enhanced computed tomography revealed a huge tumor of the left lower lung lobe, and invasion to the aortic wall was suspected. Bronchoscopic examination was performed, revealing squamous cell carcinoma with a programmed death ligand 1 expression level of 90%. The clinical stage was T4N0M0 stage 3A. After neoadjuvant chemotherapy and radiotherapy, we performed one-stage surgery with the patient in the right lateral decubitus position and the left inguinal region exposed for femoral vessel isolation. Posterolateral thoracotomy was performed with making a latissimus dorsi muscle flap. The pulmonary artery, vein, and left lower bronchus were cut with a stapler. After hilar isolation, we evaluated the involvement of the descending aorta and marked the area of the involved aortic wall by a surgical clip. Using the left femoral artery approach, a GORE TAG conformable thoracic stent graft was delivered to the descending aorta. After thoracic aortic endografting, the involved aortic wall was resected and the left lower lobe of the lung and resected aortic wall were resected en bloc. The adventitial defect was covered by the latissimus dorsi muscle flap. The operating time was 474 min, and the blood loss volume was 330 mL. The postoperative pathological diagnosis was adenocarcinoma with an epidermal growth factor receptor mutation of exon 19 deletion. The residual viable tumor was 7 mm in diameter and close to the resected aortic wall. The patient's postoperative course was uneventful. Five days after surgery, chest contrast-enhanced computed tomography revealed no endoleak or stent migration. Three months after surgery, he was alive with neither recurrence nor stent graft-related complications. CONCLUSIONS: One-stage surgery involving combined resection of lung cancer and the thoracic aortic wall with simultaneous thoracic aortic endografting in the right lateral decubitus position with the left inguinal region exposed is safe and acceptable.

[Dysphagia and Aspiration Pneumonia Caused by Kommerell's Diverticulum and the Vascular Ring Associated with Right-sided Aortic Arch:Report of a Case].

We report a case of an 80-year-old man complaining of dysphagia followed by aspiration pneumonia. Computed tomography of the chest revealed Kommerell's diverticulum associated with the right-sided aortic arch and the vascular ring which was formed by the aortic arch, the left subclavian artery, the ductus arteriosus, and the pulmonary artery around the esophagus and the trachea. Enlargement of the diverticulum was considered to be the cause of dysphagia. The surgery was performed at 20 ℃ under deep hypothermic circulatory arrest. We performed resection of the Kommerell's diverticulum, reconstruction of the left subclavian artery, and transection of the ductus arteriosus to relieve the compression by the esophagus and the trachea. The postoperative course was uneventful and dysphagia disappeared.

Successful endovascular repair of a ruptured isolated iliac artery aneurysm: A case report.

While isolated iliac artery aneurysm is rare, its rupture can lead to complete circulatory collapse and possibly death. Herein, we report a case of rupture of a large isolated aneurysm of the right common iliac artery that led to circulatory collapse and rapid endovascular repair saved the patient's life.

[Surgery for Flail Chest with Titanium Plates after Cardiopulmonary Resuscitation;Report of a Case].

A 74-year-old woman was admitted for the management of nausea with hyponatremia. On the 19th day of hospitalization, the patient developed cardiac arrest and needed cardiopulmonary resuscitation (CPR). CPR was successful but the patient developed multiple rib fractures with flail chest by CPR. Because of persistent dyspnea, surgery for fixing of the fractured ribs was performed using 4 titanium plates, with prompt improvement of the flail chest after the operation.

[Surgical Treatment of Acute Infective Endocarditis after Transcatheter Aortic Valve Replacement].

Infective endocarditis (IE) after transcatheter aortic valve replacement (TAVR) is a rare complication, but has a high mortality. An 86-year-old female with symptomatic severe aortic stenosis underwent TAVR at our hospital and she was discharged without complication after 10 days. She was readmitted with high fever and acute heart failure 1 month later. Blood culture revealed Staphylococcus, and echocardiography showed vegetation on the septal cusp of the tricuspid valve and perforation at the membranous ventricular septum. We decided to perform emergency operation due to active infection and intracardiac complication despite appropriate antibiotic treatment. The infected valve was replaced with a bioprosthetic valve and the right ventricular (RV)-left ventricular (LV) communication was closed with a bovine pericardial patch. The patient received the antibiotics for 6 week and was transferred to the previous facility.

Predictive Factors for Abdominal Aortic Aneurysm Shrinkage One Year after Successful Endovascular Aneurysm Repair.

BACKGROUND: Often, we experience cases of aneurysm shrinkage and no aneurysm shrinkage after successful endovascular aortic aneurysm repair, without postoperative endoleaks. We studied these cases to ascertain the predictive factors for aneurysm shrinkage. METHODS: From 2007 to 2014, we selected 255 cases that comprised aneurysm shrinkage (>4 mm) and no-shrinkage cases (shrinkage from 0 to 4 mm). Excluding 36 cases of endoleaks, 43 cases without 1-year follow-up computed tomography scan, and 3 cases of aortic dissection, we assessed 93 cases of aneurysm shrinkage (S group) and 80 cases of no aneurysm shrinkage (N group) at 1-year follow-up. RESULTS: No significant differences were found in sex, comorbidities (diabetes mellitus, chronic kidney disease, hemodialysis, and malignancy), and medications (antiplatelet drugs, anticoagulant drugs, steroids, and statins). Advanced age was a strong negative predictive factor for aneurysm shrinkage (N: 75.0 ± 1.0 vs. S: 72.1 ± 0.9 years; P = 0.023), and intraoperative endoleaks were more frequent in the N group (N: 31.3 vs. S: 9.7%; P = 0.001). Neck thrombus was more likely in the N group (N: 17.5 vs. S: 7.5%; P = 0.045), but it had a strong correlation with intraoperative endoleaks (P = 0.008). In the multivariate analysis, patient age and intraoperative endoleaks were predictive factors for aneurysm shrinkage. CONCLUSIONS: Advanced age and intraoperative endoleaks were negative predictive factors for aneurysm shrinkage at 1-year follow-up after successful endovascular treatment without postoperative endoleaks.

Anatomical repair for Kommerell diverticulum with deep site in-situ fenestration.

An 83-year-old woman with a Kommerell diverticulum was treated by anatomical endovascular repair with a deep site in-situ fenestration instead of complex debranching techniques. The main component of the thoracic stent-graft was deployed just distal to the third cervical branch to completely exclude the Kommerell diverticulum. A deep site in-situ fenestration was made on the main component using a radiofrequency needle through the left subclavian artery, and a stent-graft was deployed to bridge the main component to the left subclavian artery. Six months postoperatively, the Kommerell diverticulum was completely excluded with excellent left subclavian artery patency.

[Infectious Endocarditis due to Methicillin-sensitive Bovine Staphylococcus aureus;Report of a Case].

A 19-year-old male patient was admitted to our hospital after developing infectious endocarditis associated with methicillin-sensitive bovine Staphylococcus aureus septicemia. Brain magnetic resonance imaging confirmed occipital lobe cerebral bleeding. An echocardiogram showed severe mitral regurgitation with vegetation on the posterior mitral leaflet. We performed mitral valve replacement. However, a hepatic artery aneurysm and a ruptured splenic artery aneurysm was found on the 5th postoperative day and coil embolization was accordingly performed. The patient suffered repeated cerebral bleeding and received external decompression. He was discharged on the 92nd day after the valve replacement. Our case is rare in that methicillin-sensitive bovine Staphylococcus aureus isolated from human is extremely unusual especially complicated by multiple peripheral aneurysms. This is the 1st reported case of methicillin-sensitive bovine Staphylococcus aureus isolated from human in the Japanese literature.

Physician-Modified Thoracic Stent-Grafts for the Treatment of Aortic Arch Lesions.

PURPOSE: To evaluate outcomes of physician-modified thoracic stent-grafts for the treatment of aortic arch aneurysms. METHODS: A retrospective dual-center analysis was performed involving 36 patients (mean age 74.7±9 years, range 58-91; 27 men) with an aortic arch lesion who were treated between November 2013 and June 2016 using physician-modified thoracic stent-grafts. Half of the patients had a degenerative aneurysm; the remainder had type B dissection (n=9), traumatic transection (n=3), type Ia endoleak after previous endografting (n=5), or aortoesophageal fistula (n=1). All patients were considered to be at high surgical risk. Patients were treated using an aortic arch stent-graft with a single fenestration (n=24) or a proximal scallop (n=12); zone 0 was involved in 16 patients, zone 1 in 9, and zone 2 in 11. The modified thoracic stent-graft was deployed after supra-aortic branch revascularization in 24 (67%) patients. RESULTS: Mean time required for stent-graft modifications was 18 minutes (range 14-21). Technical success was obtained in all cases with no type I endoleak. One (3%) patient had a stroke without permanent sequelae. The 30-day mortality was 6%. During a mean follow-up of 11.4±6 months (range 2-36), there were no conversions to open repair. The overall mortality was 14%; aorta-related mortality was 6%. CONCLUSION: Our experience suggests that physician-modified thoracic stent-grafts are feasible for aortic arch lesions and provide encouraging results in the short term. Durability concerns will need to be assessed.

[Echographic Examination for Leg Vein Thromboembolism in Thoracic Surgery].

Echographic examination for leg vein thromboembolism was carried out in 123 patients scheduled for thoracic surgery. Preventive measures for thromboembolism were conducted after the risk assessment. Echography was done after surgery in 72 cases, most of which were cases of lung malignant tumors, and thromboembolism was detected in 4 cases. Thus, the incidence rate of venous thromboembolism was 5.6%( 4/72). There was no patients who developed pulmonary thromboembolism during the examination period, suggesting reasonable risk assessment and preventive measures in our procedure.

[Examination of the postoperative change of pedicled pericardial fat pad for reinforcement of bronchial sutures by computed tomography].

A pedicled pericardial fat pad (PPFP) is often used in pulmonary resection to reinforce bronchial sutures. Here, we assessed the significance of PPFP by serial chest computed tomography (CT). Ten cases in which bronchial stump were covered with a PPFP in the past 6 years were reviewed. The procedures were pneumonectomy (3), lobectomy (6), and a segmentectomy. According to the CT value evaluated serially PPFP was recognized as fat tissue until 1~2 postoperative months. No cases of bronchopleural fistulae was encountered in this series. The coverage of the sutures with the PPFP was thought to contribute to the prevention of bronchial fistula by staying around bronchial stump for at least 1 to 2 months.

[Total debranching through mini-sternotomy].

Aneurysms of the aortic arch are technically challenging to repair with thoracic endovascular aneurysm repair (TEVAR). Various optional techniques such as debranching or hybrid TEVAR enable landing zones to extend, however, there is still room for improvement. We have performed total debranching to facilitate TEVAR with adequate central neck length more than 2.5 cm. In summary our procedure has 3 features:mini-thoracotomy to minimize its surgical stress which might cause post-operative respiratory failure, side-to-side anastomosis of trifurcated graft with ascending aorta to avoid its kinking after chest closure, and the usage of Pruitt-Inahara shunt tube during anastomoses of the carotid artery.

[Simultaneous operation for ischemic heart disease combined with Leriche syndrome].

A 63-year-old male patient was admitted to the hospital complaining of chest pain. He had undergone aorto-bifemoral bypass and percutaneous coronary intervention due to Leriche syndrome and ischemic heart disease. Radiological examination revealed complete obstruction of the right coronary artery(#2) as well as the bypass graft. He was successfully treated with the simultaneous operation of coronary artery bypass grafting( CABG) and ascending aorta to bifemoral artery bypass.

Example of evoked potential monitoring for a neurogenic tumor positioned high in the mediastinum.

Excision of a neurogenic tumor of the brachial plexus positioned high in the mediastinal space could potentially result in a functional disorder of the arm. We report on a case in which we performed evoked potential monitoring on a tumor located high in the mediastinum. We found large potential changes in the median and ulnar nerve areas and had a concern that the excision might injure the brachial plexus. We did a biopsy and intraoperative rapid histological diagnosis, which promptly revealed that the tumor was not malignant. Thus, we decided not to excise the tumor because the procedure could possibly injure nerves in the arm.

[Infected left atrial myxoma; report of a case].

We report a rare case of infected left atrial myxoma. A 69-year-old male was admitted to our hospital due to cerebral infarction accompanied by lower limb ischemia. Transesophageal echocardiography showed a mobile left atrial tumor. On the 16th hospital day, he sufferd from high fever and Klebsiella pneumoniae was positive by blood culture. We excised the left atrial tumor, preventing systemic embolism and progression of sepsis. Histological examination showed a typical myxoma and organized thrombus with Gram-positive bacterial colonies, which disagreed with those in blood culture. After he recovered from sepsis, the 3rd toe of the right foot was amputated and then right femoro-popliteal bypass was done because of failure of wound healing. He was discharged from the hospital on the 74th postoperative day in good condition.

Examination of intercostal arteries with transthoracic Doppler sonography.

OBJECTIVE: There has been no study on the measurement of blood flow of the intercostal artery (ICA) or lumbar artery (LA) with the use of transthoracic Doppler sonography. Here, the method of the ICA depiction and flow measurement were described, and we suggested the clinical usage of this method. METHODS: Twelve healthy subjects were examined. The performance of transthoracic Doppler sonography was approached from the back on lateral decubitus position. The intercostal artery was depicted by two-dimension mode with color flow, and the inner diameter was measured. Peak systolic velocity (PSV), end-diastolic velocity (EDV), velocity-time integral (VTI), and heart rate (HR) were measured with pulsed Doppler, and the blood flow was calculated. RESULTS: Bilateral ICAs and LAs from Th4 to L4 were measurable with this method. The PSV of Lt Th9 was the fastest at 43.3 +/- 10.1 cm/sec and the PSV of the ICAs gradually decreased as distance from Th9 increased. As for the flow volume, the left Th11 was the greatest at 99.7 mL/min, and the flow volume of the ICA gradually decreased as distance from Th11 increased. The velocity and blood flow of right ICA tended to be lower than the left in the same spinal level. CONCLUSIONS: Evaluation technique of serial ICAs and LAs was shown. We think that it may be a clinically useful method in the study of spinal cord circulation in the repair of cases of descending thoracic or thoracoabdominal aortic aneurysm.

Fenestrated stent-graft facilitates emergency endovascular therapy for blunt aortic injury.

BACKGROUND: Endovascular stent-grafting with intentional coverage of the left subclavian artery may be used to treat aortic isthmus injury, but this procedure may have serious neurologic sequelae and may not provide an adequate proximal landing zone. In 2005, in an effort to mitigate these problems, we began to use fenestrated stent-grafts for emergency repair of blunt aortic injury (BAI). METHODS: Between 2005 and 2007, all patients in our practice with a BAI with mediastinal hematoma (except young patients without an associated critical injury) were treated with immediate endovascular stent-grafting, if anatomically possible. A fenestrated stent-graft was placed from the aortic arch, if the BAI was less than 20-mm distal of the left subclavian artery. The records of the 13 patients in the series were reviewed retrospectively. RESULTS: The BAI treatment was successful in all 13 patients. Eight patients (61.5%) were given a fenestrated stent-graft, placed distal to either the ascending aorta (n = 2), brachio-cephalic artery (n = 4), or left common carotid artery (n = 2), without concomitant bypass grafting or transposition of the head vessels. Two patients died of an associated critical brain injury (hospital mortality rate, 15.4%). There were no perioperative complications related to stent-graft usage and no unintentional occlusions of the head vessels by a fenestrated device. One patient underwent open repair of a newly developed type Ia endoleak 7 months after placement of a nonfenestrated stent-graft. CONCLUSION: Fenestrated stent-grafts can be used to treat BAI, without any concomitant procedures to provide an adequate proximal landing zone.

Less-invasive management of left subclavian artery in stent-grafting for distal aortic arch disease.

Simple coverage of the left subclavian artery (LSA) in thoracic endovascular aortic repair (TEVAR) is still a controversial procedure. We present our modified strategy dealing with LSA in TEVAR. Hand-made stent grafts were placed more proximal beyond the LSA for 104 patients. In elective 76, preoperative LSA occlusion test was performed on 31 patients, and preoperative computed tomographic angiography (CTA) of the vertebro-basilar artery was performed on the remaining 45. Head vessels were planned to be kept patent using fenestrated stent grafts, if possible. Stent grafts were placed from zone 0 in 23, zone 1 in 39, and zone 2 in 42. The LSA occlusion tests revealed harmful effects, such as loss of consciousness and vertigo in two out of 31 patients (6.5%). Vertebro-basilar arterial CTA revealed possible risks, if LSA covered, in three out of 45 patients (6.7%). Fenestrated stent grafts could successfully preserve 131 head vessels, except for one unintentional occlusion of the left carotid artery (0.75%). There was no LSA-related complication in any of the cases. A combination of preoperative vertebro-basilar arterial CTA and fenestrated stent grafts is useful to avoid possible LSA-related complications in TEVAR.

Repair of ventricular septal perforation with asymmetrical conical patch exclusion.

We report a case of repair of the postinfarction ventricular septal perforation (VSP), using an equine pericardium tailored in an asymmetrical conical shape for exclusion (modified sack technique) and an additional direct patch closure of VSP. An asymmetrical conical patch is easily sutured to the normal septum away from the VSP edge by using the longer part of the cone border. The postoperative left ventriculogram 1.5 months after surgery revealed a minor leakage from the patch to the excluded left ventricle. However, no residual left to the right shunt was found in calculation from the oxygen saturation in blood samples. Echocardiography 1 year after surgery showed no residual patch leakage at all. We suggest that this modified sack technique is a simple and easy method by which to exclude the VSP.