The Effect of Steroid Therapy on Postoperative Inflammatory Response after Endovascular Abdominal Aortic Aneurysm Repair.

Objectives: Unexpected systemic inflammatory response with high fever and increase in C-reactive protein (CRP) occurred frequently after endovascular abdominal aortic aneurysm repair (EVAR). This excessive inflammatory response affects the postoperative course. We evaluated the effects of steroid on the postoperative inflammatory response after EVAR. Methods: Steroid therapy, intravenous infusion of methylprednisolone 1000 mg just after the anesthesia induction, was started since December 2012. After induction of the steroid therapy, 25 patients underwent EVAR with steroid therapy (Group S). These patients were compared with the 65 patients who underwent EVAR without steroid therapy (Group C) in white blood cell count (WBC), CRP and maximum body temperature (BT) on postoperative day 1-5. Results: There was no significant difference in age, female gender, operation time, maximum aneurysm diameter between the two groups. There was no postoperative infective complication in the both groups. WBC did not differ between the two groups; however, CRP was significantly suppressed in Group S than in Group C on POD 1, 3 and 5. Also BT was significantly lower in Group S than Group C on POD 1, 2 and 3. Conclusions: Steroid pretreatment before implantation of the stent graft reduces the early postoperative inflammatory response after EVAR, without increasing postoperative infection. (This is a translation of Jpn J Vasc Surg 2015; 24: 861-865.).

Effect of the septal adjustment technique for tricuspid annuloplasty with an MC3 ring.

OBJECTIVES: Functional tricuspid regurgitation (FTR) is a significant negative prospective factor for long-term survival in patients with mitral valve disease. Tricuspid annuloplasty (TAP) for FTR is recommended as a concomitant procedure during left-sided valvular surgery. The MC3 annuloplasty ring is designed to restore the dilated tricuspid annulus to its natural three-dimensional shape, but selection of the optimal ring size during TAP is sometimes difficult. One solution is the septal adjustment technique (SAT), in which the point of fixation of the septal portion to the septal annulus is adjusted under confirmation with the water test. Here, we evaluated early outcomes with this new technique. METHODS: Between January 2008 and September 2014, 56 patients (mean age 67.6 ± 9.0 years, male/female 28/28) with FTR underwent TAP with an MC3 ring. We retrospectively compared early outcomes, including mortality, morbidity and postoperative residual tricuspid regurgitation (TR), between patients undergoing TAP with the SAT (n = 19, Group A) and those undergoing TAP with the conventional technique (n = 37, Group C). RESULTS: Although preoperative TR grade was significantly higher in Group A than Group C (3.2 ± 0.6 vs. 2.8 ± 0.6, p = 0.032), postoperative TR grade was significantly lower in Group A than Group C (0.9 ± 0.6 vs. 1.4 ± 0.8, p = 0.039), and TR grade was significantly decreased in Group A compared to Group C (2.2 ± 0.9 vs. 1.4 ± 0.8, p = 0.004). TR area reduction was significantly larger in Group A than in Group C (5.21 ± 2.34 vs. 2.85 ± 3.09, p = 0.006). CONCLUSIONS: The SAT for TAP with an MC3 ring provided better control of postoperative TR than the conventional technique.

[Mitral valve repair in a patient with giant left atrial myxoma;report of a case].

In patients with left atrial myxoma, mitral valve regurgitation is often encountered. However, preoperative assessment of the mitral valve is difficult in cases with giant left atrial myxoma occupying the left atrial cavity. We experienced a patient with giant left atrial myxoma who underwent tumor excision and mitral valve repair. A 40-year-old woman was transferred to the emergency room due to respiratory failure. On admission, her hemodynamic status was unstable and percutaneous cardiopulmonary support was immediately started. Transesophageal echocardiography was performed, which showed giant left atrial tumor with the pedicle on the atrial septum with mitral valve regurgitation, but the severity of regurgitation was unclear. After excision of left atrial myxoma with atrial septum, the mitral valve was examined. The anterior leaflet( A3 scallop) prolapse due to a torn chordae was found. The mitral valve was repaired with leaflet resection and prosthetic ring annuloplasty. Postoperative course was uneventful and postoperative echocardiography showed no residual mitral valve regurgitation. The mitral valve should be carefully inspected intraoperatively after resection of left atrial myxoma, especially when the tumor is gigantic.

[Staged operation of aortic valve stenosis with concomitant sigmoid colon cancer by minimally invasive cardiac surgery; report of a case].

Severe aortic stenosis was found by preoperative echocardiography in a 79-year-old female patient with sigmoid colon cancer. Staged operation was planned. First, bioprosthetic aortic valve replacement was performed by minimally invasive cardiac surgery. She underwent concomitant colostomy to avoid malnutrition which may have occurred in case of colon obstruction. On 25th day after cardiac surgery, curative sigmoidectomy was performed. One year after the operation, she is doing well without any major complications.

Thoracic endovascular repair for aorto-esophageal fistula in patients with esophageal carcinoma: report of 3 cases.

Aorto-esophageal fistula (AEF) is a rare complication of esophageal carcinoma. Left untreated, it may be lethal due to massive upper gastrointestinal bleeding, while open thoracic surgery is associated with high operative mortality and morbidity. In contrast, thoracic endovascular aortic repair (TEVAR) for AEF is less invasive than open thoracic surgery. Here, we report 3 successful cases of AEF with esophageal carcinoma treated using TEVAR under local anesthesia in the emergent or urgent phase. General condition of all the patients was dramatically improved, but 1 patient with exsanguinations developed infection of the implanted stent-graft and died due to sepsis. The other 2 patients were treated before esophageal bleeding and remained alive for 1 year without infection. The TEVAR should be considered as early as possible in patients with advanced esophageal carcinoma receiving radiation or chemotherapy who develop early signs of AEF such as symptoms of chest discomfort or descending aortic irregularity on computed tomography scan.

Antero-lateral partial sternotomy for extensive thoracic aortic aneurysm.

OBJECTIVES: Surgical strategies for patients with aortic arch aneurysm extending to the descending aorta remain controversial. The antero-lateral partial sternotomy (ALPS) approach has been developed as a less invasive alternative single-stage strategy for extensive thoracic arch aneurysm (ETAA). METHODS: From September 2007 to April 2011, 18 patients underwent elective total arch replacement for ETAA by the ALPS approach (ALPS group). In this approach, a skin incision was made from the bottom of the xiphoid to the anterior axillary line at the third intercostal space with a convex curved line. The thorax was entered through the third intercostal space and a partial lower sternotomy was done. Surgical outcomes were compared with those of 22 patients with ETAA who underwent elective total arch replacement by median sternotomy alone (MS) with regard to the level of distal anastomosis, postoperative complications and mortality. RESULTS: In the ALPS group, no hospital mortality occurred and one patient experienced pneumonia. No significant difference between the ALPS and MS groups was seen in operative time (384.1 ± 41.6 min vs 402.3 ± 85.3 min P = 0.423) and cardiopulmonary bypass time (220.8 ± 47.1 min vs 236.9 ± 45.4 min P = 0.286). In contrast, distal anastomosis was at a significantly lower vertebral level in the ALPS than in the MS group (5.5 ± 0.4 vs 4.3 ± 0.9, respectively: P < 0.0001). CONCLUSIONS: The ALPS approach provides good surgical exposure for distal aortic arch aneurysms extending to the descending aorta and ensures the accurate reconstruction of the distal anastomosis without major complications.

Surgical treatment for right aortic arch with Kommerell's diverticulum.

Kommerell's diverticulum causes compression of the esophagus between the aberrant origin of the left subclavian artery and ascending aorta, leading to dysphagia or dyspnea. We describe 3 cases of successful surgical treatment of right aortic arch with Kommerell's diverticulum and aberrant origin of the left subclavian artery, using a right anterolateral partial sternotomy. This allows both resection of the Kommerell's diverticulum as well as reconstruction of the aberrant origin of the left subclavian artery anatomically.

Acute subdural hematoma following thoracoabdominal aortic repair in a patient with Marfan syndrome: a rare complication of cerebrospinal fluid drainage.

Cerebrospinal fluid (CSF) drainage is a routinely used adjunct in operation of thoracoabdominal aortic aneurysm (TAAA), which may reduce the incidence of perioperative paraplegia by improving spinal cord perfusion. Neurological complications of CSF drainage have been reported, possibly due to excessive CSF drainage, and acute subdural hematoma (SDH) in particular may lead to catastrophic complications. We present a rare case of acute SDH due to CSF drainage that was not excessive, after TAAA repair in a patient with Marfan syndrome, who recovered without invasive treatment.