Twenty-year outcomes of free and I-composite radial artery grafts for coronary artery revascularization.

PURPOSE: To compare the 20-year outcomes of coronary artery grafting (CABG) using radial artery (RA) grafts (free and I-composite) and internal thoracic artery (ITA) grafts. METHODS: Long-term graft patency was evaluated in patients who underwent isolated CABG between August, 1996 and January, 2022. The long-term graft patency of free RA grafts, I-composite ITA-RA grafts, and saphenous vein (SV) grafts were compared. RESULTS: The RA was used as a coronary bypass conduit in 111 of the 246 patients enrolled in this study. The RA patency after 10 and 20 years was 94.2% and 76.6%, respectively. Landmark analysis showed that although graft patency for up to 10 years did not differ between the RA and ITA grafts (hazard ratio = 0.87; P = 0.8), patency of the ITA grafts was better from 10 to 20 years post-surgery (hazard ratio = 0.19; P = 0.013). The 20-year graft patency of the I-composite RA grafts was better than that of the free RA grafts (80.0% vs. 72.4%; P = 0.029), but not significantly different from that of the ITA grafts (80.0% vs. 90.7%; P = 0.24). CONCLUSIONS: The 20-year patency of the I-composite ITA-RA graft was better than that of the free RA graft; therefore, the I-composite graft may be an effective conduit for CABG.

Comparison of Phenotypes in Subcutaneous Fat and Perivascular Adipose Tissue Surrounding the Saphenous Vein in Coronary Artery Bypass Grafting.

BACKGROUND: The saphenous vein (SV) is used as an essential conduit in coronary artery bypass grafting (CABG), but the long-term patency of SV grafts is a crucial issue. The use of the novel "no-touch" technique of harvesting the SV together with its surrounding tissue has been reported to result in good long-term graft patency of SV grafts. We recently showed that perivascular adipose tissue (PVAT) surrounding the SV (SV-PVAT) had lower levels of metaflammation and consecutive adipose tissue remodeling than did PVAT surrounding the coronary artery. However, the difference between SV-PVAT and subcutaneous adipose tissue (SCAT) remains unclear.Methods and Results: Fat pads were sampled from 55 patients (38 men, 17 women; mean [±SD] age 71±8 years) with coronary artery disease who underwent elective CABG. Adipocyte size was significantly larger in SV-PVAT than SCAT. The extent of fibrosis was smaller in SV-PVAT than SCAT. There were no significant differences between SCAT and SV-PVAT in macrophage infiltration area, quantified by antibodies for CD68, CD11c, and CD206, or in gene expression levels of metaflammation-related markers. Expression patterns of adipocyte developmental and pattern-forming genes differed between SCAT and SV-PVAT. CONCLUSIONS: The properties of SV-PVAT are close to, but not the same as, those of SCAT, possibly resulting from inherent differences in adipocytes. SV-PVAT has healthy expansion with less fibrosis in fat than SCAT.

Temperature analysis of aortic repair with hypothermic circulatory arrest to quantify the injury by cooling.

OBJECTIVES: We analyzed the temperature in proximal aortic repair with moderate hypothermic circulatory arrest (HCA) and evaluated the effect of the cooling status on postoperative outcomes. METHODS: A total of 340 patients who underwent elective ascending aortic replacement or total arch replacement with moderate HCA from December 2006 to January 2021 were studied. The change in body temperature trends recorded during surgery was shown graphically. Several parameters, such as the nadir temperature, cooling speed and the degree of cooling (cooling area), which was the area under curve of inverted temperature trends from cooling to rewarming as calculated by the integral method, were analyzed. The relationships between these variables and a major adverse outcome (MAO) postoperatively defined as prolonged ventilation (>72 h), acute renal failure, stroke, reoperation for bleeding, deep sternal wound infection or in-hospital death were evaluated. RESULTS: An MAO was observed in 68 patients (20%). The cooling area was larger in the MAO group than in the non-MAO group (1668.7 vs 1383.2°C min; P < 0.0001). A multivariate logistic model showed that old myocardial infarction, peripheral vascular disease, chronic renal dysfunction, cardiopulmonary bypass time and the cooling area were independent risk factors for an MAO (odds ratio = 1.1 per 100°C min; P < 0.001). CONCLUSIONS: The cooling area, which indicates the degree of cooling, shows a significant relationship with an MAO after aortic repair. This finding indicates that the cooling status with HCA can affect clinical outcomes.

Morphometric Predictors of Aortic Remodeling after Frozen Elephant Trunk Repair of Type A Dissection.

BACKGROUND: We analyzed the predictors of postoperative aortic remodeling after the frozen elephant trunk technique for type A dissection. METHODS: This retrospective study cohort comprised 20 patients who underwent the frozen elephant trunk technique for type A dissection. The incidence of aortic remodeling was evaluated at 4 levels: middle of the frozen elephant trunk, distal end of the frozen elephant trunk, 10th thoracic vertebra, and proximal to the celiac artery. Several parameters of the residual dissected aorta were analyzed at these 4 levels, and the predictors of aortic remodeling were investigated. RESULTS: The incidence of aortic remodeling was 85% at the middle of the frozen elephant trunk, 70% at the distal end of the frozen elephant trunk, 50% at the 10th thoracic vertebra, and 35% proximal to the celiac artery. In a total of 80 computed tomography images, there were significant differences between the aortic remodeling and nonremodeling groups in the true lumen diameter, false lumen diameter, true lumen/aortic diameter ratio, true lumen area, true lumen/aortic area ratio, and 2 parameters explaining the shape of the true lumen (created using elliptic Fourier analysis). Multivariate analysis revealed that the independent predictors of aortic remodeling were the true lumen/aortic area ratio and principal component 1. CONCLUSIONS: There were high incidences of aortic remodeling at the middle and distal end of the frozen elephant trunk. Multivariate analysis showed that the true lumen/aorta area ratio and the shape of the true lumen may be important predictors of aortic remodeling.

Estimation Model for Hypothermic Circulatory Arrest Time to Predict Risk in Total Arch Replacement.

BACKGROUND: We created an estimation model for hypothermic circulatory arrest time and analyzed the risk factors for major adverse outcomes in total arch replacement. METHODS: This study involved 272 patients who underwent total arch replacement. The estimation model for hypothermic circulatory arrest time was established using multiple linear regression analysis, and the predicted hypothermic circulatory arrest time from this model was analyzed to detect risk factors. RESULTS: Atrial fibrillation, rupture, malperfusion, saccular aneurysm, cardiopulmonary bypass time, and hypothermic circulatory arrest time were identified as independent risk factors associated with major adverse outcomes. The estimation model for hypothermic circulatory arrest time was established as follows: hypothermic circulatory arrest time = 99.3 - 0.19 × age + 0.65 × body mass index + 6.19 × previous cardiac operation + 11.7 × acute dissection + 8.9 × rupture + 0.19 × aortic angulation + 0.15 × length to the distal anastomosis site - 6.17 × total arch replacement surgeon case volume - 3.06 × surgery year. The predicted hypothermic circulatory arrest time calculated by this estimation model was evaluated using multivariate logistic analysis, which identified atrial fibrillation, rupture, malperfusion, saccular aneurysm, and predicted hypothermic circulatory arrest time as risk factors. CONCLUSIONS: As with the actual hypothermic circulatory arrest time, the predicted hypothermic circulatory arrest time using our model detected significant factors associated with major adverse outcomes. These results indicated that this prediction model for hypothermic circulatory arrest time may be effective.

Impact of Instructions for Use and Endoleaks On Long-Term Mortality After Treatment for Abdominal Aortic Aneurysm.

OBJECTIVES: We reported the clinical outcomes after open repair and endovascular aortic repair for abdominal aortic aneurysm and analyzed the risk factors for all-cause mortality and endoleak after endovascular aortic repair. METHODS: Patients who underwent elective treatment for abdominal aortic aneurysm from January 2009 to March 2020 were included in this study. The treatment was according to a procedure selection algorithm based on the Society for Vascular Surgery comorbidity scores and instructions for use. All patients were divided into open repair and endovascular aortic repair groups, and the clinical results were compared between the groups. RESULTS: Of the 278 patients, 116 patients (41.9%) underwent open repair, and 161 patients (58.1%) underwent endovascular aortic repair. The cumulative survival rate with endovascular aortic repair was 78.6%. In the Cox proportional hazard analysis, hemodialysis (hazard ratio = 4.56; 95% confidence interval = 1.5-14.0) and the presence of type I or III endoleak (hazard ratio = 5.7; 95% confidence interval = 1.50-14.5) were independent risk factors for all-cause mortality. The Society for Vascular Surgery comorbidity score was not an independent risk factor (hazard ratio = 1.11; 95% confidence interval = 1.0-1.2). In the multivariate logistic regression analysis to identify the risk factors for type I or III endoleak after endovascular aortic repair, anticoagulation drug therapy (odds ratio = 3.99; 95% confidence interval = 1.8-8.9), untreated thoracic aortic aneurysm (odds ratio = 4.8; 95% confidence interval = 1.8-17.3), and outside instruction for use for the proximal neck (odds ratio = 5.8; 95% confidence interval = 2.3-9.8) were independent risk factors. CONCLUSIONS: We analyzed the risk factors for all-cause mortality after treatment and endoleak after endovascular aortic repair. The results indicated that the instructions for use should be respected to reduce the frequency of endoleaks and that open repair should be chosen more often to improve late survival.

Antiatherosclerotic Phenotype of Perivascular Adipose Tissue Surrounding the Saphenous Vein in Coronary Artery Bypass Grafting.

Background Perivascular adipose tissue (PVAT) is associated with metabolically driven chronic inflammation called metaflammation, which contributes to vascular function and the pathogenesis of vascular disease. The saphenous vein (SV) is commonly used as an essential conduit in coronary artery bypass grafting, but the long-term patency of SV grafts is a crucial issue. The use of the novel "no-touch" technique of SV harvesting together with its surrounding tissue has been reported to result in good long­term graft patency of SV grafts. Herein, we investigated whether PVAT surrounding the SV (SV-PVAT) has distinct phenotypes compared with other PVATs of vessels. Methods and Results Fat pads were sampled from 48 patients (male/female, 32/16; age, 72±8 years) with coronary artery disease who underwent elective coronary artery bypass grafting. Adipocyte size in SV-PVAT was significantly larger than the sizes in PVATs surrounding the internal thoracic artery, coronary artery, and aorta. SV-PVAT and PVAT surrounding the internal thoracic artery had smaller extents of fibrosis, decreased gene expression levels of fibrosis-related markers, and less metaflammation, as indicated by a significantly smaller extent of cluster of differentiation 11c-positive M1 macrophage infiltration, higher gene expression level of adiponectin, and lower gene expression levels of inflammatory cytokines, than did PVATs surrounding the coronary artery and aorta. Expression patterns of adipocyte developmental and pattern-forming genes were totally different among the PVATs of the vessels. Conclusions The phenotype of SV-PVAT, which may result from inherent differences in adipocytes, is closer to that of PVAT surrounding the internal thoracic artery than that of PVAT surrounding the coronary artery or that of PVAT surrounding the aorta. SV-PVAT has less metaflammation and consecutive adipose tissue remodeling, which may contribute to high long-term patency of grafting when the no-touch technique of SV harvesting is used.

Long-Term Clinical Outcomes of Thoracic Endovascular Aortic Repair for Arch Aneurysms with the Najuta Thoracic Stent-Graft System.

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.

Endovascular stent grafting for thoracic aneurysms in Jehovah's Witnesses: report of three cases.

There are few published reports on endovascular stent grafting for thoracic aneurysms in Jehovah's Witnesses. Between 2001 and 2003, we performed endovascular stent grafting for a thoracic aneurysm in three patients of the Jehovah's Witness faith. Two patients had a thoracic aortic aneurysm and one had a chronic type-B dissection. The stent graft was constructed from a self-expanding Z-stent and thin-walled woven polyester fabric. None of the patients required perioperative blood transfusion, there was no postoperative endoleak, and all recovered uneventfully and were discharged from hospital. Thus, stent-graft repair of thoracic aneurysms in Jehovah's Witnesses is feasible and can be achieved without the need for blood transfusion.