Giant Coronary Aneurysm with Coronary-Pulmonary Artery Fistula in a Jehovah's Witness.

With an incidence of 3 in 100 million, giant coronary artery aneurysm (CAA) with coronary artery fistula (CAF) is a very rare condition. To prevent rupture, giant CAA with CAF should be swiftly treated. We present a Jehovah's Witness patient with giant CAA and coronary-pulmonary artery fistula. We resected the giant CAA in one piece, while ligating the CAF, without allogeneic blood transfusion. Due to rarity of these conditions, many thoracic surgeons lack direct experience in its surgical procedures. Herein, we share footage of this surgery as an example of how to safely resect CAA with minimal bleeding.

Early- and Mid-Term Results of Abdominal Endovascular Aneurysm Repair Using an Aortic Cuff Prior to the Main Body to Prevent Type II Endoleaks.

PURPOSE: Postoperatively persistent type II endoleaks (T2ELs) in abdominal endovascular aneurysm repair (EVAR) are known risk factors for long-term aneurysm enlargement. Therefore, various measures have been proposed to prevent T2ELs. Notably, the Kilt technique, which can be used in patients with dumbbell-shaped morphology, employs an aortic cuff deployed in the distal seal zone before the main body. Although previous studies have successfully applied this technique for preventing T2ELs, the mid- and long-term outcomes remain unclear. This study aimed to report the early- to mid-term outcomes in cases where an aortic cuff technique was used to prevent T2ELs. MATERIALS AND METHODS: This retrospective single-center study analyzed 9 patients (mean age, 79 years; range, 69-88 years; 8 men) with abdominal aortic aneurysms. All patients underwent EVAR using an aortic cuff to prevent T2ELs. The primary end points were technical success (successful deployment) and clinical success (no T2ELs). Secondary end points included morbidity, reintervention, and aortic remodeling during follow-up. RESULTS: The technical success rate was 100%. There were no intraprocedural or postoperative complications. No deaths or reinterventions occurred. Postoperative computed tomography showed no endoleaks in 6 patients, while T2ELs from the lumbar artery outside the aortic cuff deployment range were noted in 3 patients. However, no T2ELs were observed in the artery in the aortic cuff deployment range in any patient. The average number of successfully occluded arteries was 4.2 (range, 2-8). All patients had follow-up >6 (mean, 18.6; range, 6-36) months. Aneurysm sac shrinkage occurred in 5 patients during the follow-up period, whereas aneurysm size was stable in 3 patients. In contrast, only 1 patient showed transient dilation of the aneurysm sac enlargement; however, this dilation remained unchanged even after 1.5 years. CONCLUSION: The aortic cuff technique is a favorable endovascular method for preventing T2ELs in EVAR. The present study showed that a single aortic cuff could easily and reliably occlude arteries branched from the aneurysm sac.

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.

Descending thoracic aorta-abdominal aortic bypass and bilateral renal arterial blood circulation reconstruction are effective in atypical coarctation of the aorta with heart failure: a case report.

BACKGROUND: There are a lot of reports of the renal failure and heart failure due to coarctation of the aorta. However, there are no case reports in which revascularization dramatically improved left ventricular function in patients with progressive decline in left ventricular function. Herein, we present a rare case in which the left ventricular function was dramatically improved by surgical treatment for progressive left ventricular dysfunction due to atypical coarctation of the aorta. CASE PRESENTATION: A 58-year-old man underwent left axillary artery-bilateral femoral artery bypass at another hospital for atypical coarctation of the aorta due to Takayasu's arteritis. Approximately 10 years later, he was re-hospitalized for heart failure, and the left ventricular ejection fraction gradually decreased to 28%. Computed tomography showed severe calcification and stenosis at the same site from the peripheral thoracic descending aorta to the lower abdominal aorta of the renal artery, and aortography showed delayed bilateral renal artery blood flow. An increase in plasma renin activity was also observed. Despite the administration of multiple antihypertensive drugs, blood pressure control was insufficient. We decided to perform surgical treatment to improve progressive cardiac dysfunction due to increased afterload and activated plasma renin activity. Descending thoracic aorta-abdominal aorta bypass and revascularization of the bilateral renal arteries via the great saphenous vein grafts were performed. Postoperative blood pressure control was improved, and the dose of antihypertensive drugs could be reduced. Plasma renin activity decreased, and transthoracic echocardiography 1.5 years later showed an improvement in contractility with a left ventricular ejection fraction of 58%. CONCLUSION: In atypical coarctation of the aorta in patients with decreased bilateral renal blood flow, heart failure due to renal hypertension, and progressive decrease in left ventricular contractility, descending thoracic aorta-abdominal aortic bypass and bilateral renal artery recirculation can be extremely effective.

A case of a giant pulmonary artery aneurysm due to an atrial septal defect with left main coronary artery occlusion.

Cases of coronary artery occlusion due to the exclusion of pulmonary artery aneurysm are extremely rare, and there are few reports of surgical treatment. A 60-year-old woman with pulmonary hypertension due to an atrial septal defect and obstruction of the left main coronary trunk due to the exclusion of a giant pulmonary artery aneurysm underwent surgery. The surgery included atrial septal defect closure, tricuspid annulus plasty, pulmonary artery aneurysmorrhaphy, and coronary artery bypass grafting. One and a half years after the surgery, no re-expansion of the pulmonary artery was observed, and the symptoms of heart failure had improved. There are no reports of improvement in pulmonary valve regurgitation by aneurysmorrhaphy in pulmonary artery aneurysm. Surgery for pulmonary artery aneurysm with the exclusion of other organs was effective, and aneurysmorrhaphy for pulmonary artery aneurysm was acceptable.

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.

Successful Endovascular Repair of an Abdominal Aortic Aneurysm in a Patient with a Horseshoe Kidney and Accessory Renal Arteries Using an Aortic Cuff to Prevent Type II Endoleak.

A 78-year-old man presented with an abdominal aortic aneurysm (AAA) and a horseshoe kidney coexisting with accessory renal arteries. We performed surgical treatment with endovascular aneurysm repair, sacrificing the accessory renal arteries. We used an aortic cuff to prevent a type II endoleak from the inferior mesenteric and accessory renal arteries. Decreased renal function was transient, and postoperative computed tomography showed no endoleak. This case report supports the feasibility of endovascular surgery for treating AAA in patients with a horseshoe kidney.

Postoperative spinal cord ischaemia: magnetic resonance imaging and clinical features.

OBJECTIVES: Ischaemic spinal cord injury (SCI) is one of the most serious complications of aortic surgery. Ischaemic SCIs occur due to various aetiologies, and prediction of the risk is difficult. Magnetic resonance imaging (MRI) is useful to detect the details of spinal cord infarction. There are few studies about MRI for evaluating ischaemic SCI after cardiovascular surgery and aortic events. We report 9 cases of postoperative ischaemic SCI and analyse their MRI features. METHODS: T2-weighted MRI scans of 9 patients who developed ischaemic SCI due to cardiovascular surgery and aortic events between 2012 and 2017 were evaluated. RESULTS: In all patients, high-intensity areas were observed on T2-weighted magnetic resonance images. The site of infarction was the thoracic spinal cord level (9 cases) and additionally at the lumbar spinal cord level (5 cases). The area of infarction area was categorized based on the arterial territory: anterior spinal artery territory (3 cases), posterior spinal artery territory (2 cases), spinal sulcal artery territory (1 case) and artery of Adamkiewicz territory (3 cases). CONCLUSIONS: MRI revealed the infarction sites in all cases and the differences in the infarction patterns in each case. MRI could thus be useful for investigating the aetiology of ischaemic SCI following aortic surgeries and events.

A rare case of pseudoaneurysm at the site of untreated coarctation of the aorta in an adult patient.

Here we report a rare case of pseudoaneurysm at the site of aortic coarctation. Aortic coarctation and a saccular aortic aneurysm protruding from the site of this coarctation were detected in a 50-year-old woman. Owing to the shape of the aneurysm and high risk of rupture, an open surgical repair was performed. The pathological findings of the removed aneurysm revealed a pseudoaneurysm consisting of only a thin adventitial wall. Adult uncorrected aortic coarctation has a poor prognosis. One of its causes may be the formation of such a pseudoaneurysm.

Successful Ascending to Descending Aortic Bypass and Endovascular Embolisation of a Late Pseudoaneurysm Following Patch Aortoplasty for Coarctation of the Aorta.

INTRODUCTION: A late aortic aneurysm at the site of previous open surgery for coarctation of the aorta (CoA) is a life threatening complication. Several strategies have been reported, however, these strategies have issues. This is the report of a case involving successful ascending to descending aortic bypass concomitant with endovascular embolisation for a pseudoaneurysm. REPORT: The patient was a 23 year old man with a history of patch aortoplasty for coarctation of the aorta (CoA) via a left thoracotomy and patch closure of a ventricular septal defect. Enhanced computed tomography (CT) angiography performed in 2014 revealed a pseudoaneurysm at the site of the previous patch aortoplasty. CT also revealed a hypoplastic and severely kinked aortic arch that made it difficult to perform conventional thoracic endovascular aortic repair for this aneurysm. Therefore in order to prevent rupture, a combination of ascending to descending aortic bypass and endovascular embolisation using Amplatzer vascular plugs and coils was employed. Transection of the aortic arch and transposition of the left subclavian artery were performed to prevent antegrade flow into the aneurysm. DISCUSSION: The aneurysm was successfully excluded without complications. CT performed three years after the operation showed that the pseudoaneurysm had shrunk completely. Extra-anatomic bypass concomitant with endovascular embolisation for a late coarctation patched site aneurysm might be an alternative strategy that should be carefully considered in specific cases.

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.

Chronic contained rupture of abdominal aortic aneurism complicated with aortic occlusion: a case report.

BACKGROUND: Chronic contained rupture is a subtype of an abdominal aortic aneurysm rupture. Its diagnosis is sometimes difficult due to lack of typical symptoms. We would like to report the challenge of diagnosing chronic contained rupture of abdominal aortic aneurysm with a retroperitoneal tumor. CASE PRESENTATION: A 60-year-old man reported perceived lower abdominal pain 7 months earlier that spontaneously remitted. A contrast-enhanced computed tomography (CT) indicated an abdominal aortic aneurysm and a mass lesion surrounding the abdominal aorta and iliac arteries. Fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) showed an increased accumulation of FDG in the margin of the lesion, indicating a retroperitoneal tumor. A CT-guided biopsy revealed only retroperitoneal fibrous tissue with chronic inflammation. We were thus unable to reach a definitive diagnosis. At 1 month after the initial examination, intermittent claudication was newly observed. A follow-up contrast-enhanced CT scan revealed abdominal aortic occlusion. Mass resection and bypass surgery were performed for diagnosis and treatment. Intraoperative and pathological findings led to the diagnosis of chronic contained rupture of an abdominal aortic aneurysm. The patient was discharged 19 days after surgery. CONCLUSION: The mass peripheral to the abdominal aorta should be considered the possibility not only of tumor but also of chronic contained rupture of an abdominal aortic aneurysm.

Antegrade thoracic endovascular aortic repair via the left axillary artery in a patient with aortoiliac occlusive disease (Leriche syndrome).

We present the case of a 77-year-old man with a saccular descending thoracic aortic aneurysm who underwent successful antegrade thoracic endovascular aortic repair (TEVAR) via the left axillary artery. The patient had a history of axillo-bifemoral bypass grafting due to aortoiliac occlusive disease (Leriche syndrome), which precluded normal retrograde TEVAR. Upon successful procedure completion, no endoleak was noted on postoperative computed tomography. The patient was discharged from the hospital without any complications. The left axillary artery is useful as an alternative access site in cases wherein conventional retrograde TEVAR is not feasible.

Total arch replacement in a patient with a tracheostoma through a reverse L-shaped partial sternotomy.

A conventional median sternotomy in a patient with a tracheostoma is susceptible to postoperative mediastinitis or graft infection after total arch replacement (TAR). An optimal surgical procedure has still not been established to circumvent these complications in such patients. We report a successful case of a 74-year-old man with a tracheostoma who received TAR through a reverse L-shaped partial sternotomy. This incision was simple and enabled us to secure an adequate operative field similar to that of a conventional median sternotomy. The patient was discharged without any evidence of infection or any other complications.

Two-stage surgery to repair a dissecting abdominal aortic aneurysm in a severely obese patient: Open bifurcated graft replacement after laparoscopic sleeve gastrectomy.

With the increasing prevalence of severe obesity worldwide, surgical treatment for severely obese patients is becoming more popular. Bariatric surgery has occasionally been performed as a precursor to major operations for serious diseases to make these difficult surgeries safer for severely obese patients. We present the case of a severely obese patient with a dissected abdominal aortic aneurysm and left iliac artery aneurysm. Initially, we performed bariatric surgery on this patient to reduce perioperative risk and then subsequently performed bifurcated graft replacement. A 54-year-old man presented at our hospital for bariatric surgery before open abdominal aortic aneurysm repair. Laparoscopic sleeve gastrectomy was performed; 15 months later, the patient's weight and BMI had decreased from 139.0 kg to 97.6 kg and from 48.7 kg/m(2) to 34.2 kg/m(2) , respectively. Bifurcated graft replacement was performed safely without postoperative complications. Bariatric surgery was also effective in controlling the patient's blood pressure during the interval between surgeries.

Strategy for thoracic endovascular aortic repair based on collateral circulation to the artery of Adamkiewicz.

PURPOSE: Spinal cord ischemia (SCI) is a serious complication of thoracic endovascular aortic repair (TEVAR). The purpose of this study was to establish if preoperative identification of the artery of Adamkiewicz (AKA) can help prevent post-TEVAR SCI. METHODS: Of 74 post-TEVAR patients, 51 had the critical segmental artery (CSA) to the AKA pre-identified to help the surgeon deploy stent grafts. RESULTS: None of these 51 patients suffered permanent paraplegia postoperatively, but 5 (23.8 %) of the remaining 23 patients (2 of whom had pre-existing paraplegia) did suffer permanent SCI. The CSA/AKA was preserved in 43 patients with pre-identification of the CSA/AKA; however, in 8 patients, the CSA was completely or partially occluded by a stent graft. Transient SCI developed in one patient from each group, but both of these patients recovered fully before discharge. No change in the anatomical route was identified in 29 of the patients who had postoperative evaluation of the CSA/AKA. Five of eight patients whose CSA was completely occluded had new collateral circulation to the AKA. CONCLUSIONS: None of the 51 patients with the CSA/AKA identified before TEVAR suffered permanent paraplegia, whereas 5 of the 23 without pre-identification did suffer permanent SCI. Thus, careful identification of the CSA/AKA may prove useful for preventing postoperative SCI. Preservation of potential collateral circulation may also reduce the risk of postoperative SCI.

Spontaneous spinal epidural hematoma presenting as paraplegia after cardiac surgery.

An 86-year-old woman was scheduled to undergo aortic valve replacement and coronary artery bypass graft. On postoperative day 3, she developed sudden-onset neck pain followed by weakness in the right arm. Her symptoms worsened with time, and she developed paraplegia. At 60 h after the first complaint, spontaneous spinal epidural hematoma (SSEH) from C2 to C6 with spinal cord compression was diagnosed from a magnetic resonance image of the cervical region. We decided on conservative therapy because operative recovery was impossible. Delayed diagnosis led to grievous results in the present case. When neurological abnormalities follow neck or back pain after open heart surgery, SSEH must be considered in the differential diagnosis. Further, if it is suspected, early cervical computed tomography/magnetic resonance imaging and surgery should be considered.

Room temperature direct imprinting of porous glass prepared from phase-separated glass.

This work describes a room-temperature imprinting of nanoporous glass prepared by selective chemical etching of phase-separated glass. A highly porous (58%) and highly transparent (>90%) porous glass layer can be formed on a transparent phase-separated glass substrate. It is shown that the lateral resolution of the imprinting is a few tens of nanometers. As the porosity increases, the imprint depth increases and reaches up to 90% of the height of the mold pattern. The porous glass has a wider transmittance window (300-2700 nm) and a higher thermal durability (~500 °C) than other materials used for imprinting. The technique has various potential applications such as diffraction optical elements, waveguides, biosensors, and microfluidic devices.

Artery fistula causing aortic regurgitation in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries.

We report a case of aortic regurgitation (AR), coronary artery-to-pulmonary artery (CAPA) fistula, pulmonary atresia with ventricular septal defect (PA/VSD), and major aortopulmonary collateral arteries (MAPCAS). As a result of coronary steal and AR, myocardial ischemia and ventricular dysfunction occurred. When the patient was 2 months old with a body weight of 2.7 kg, we performed fistula ligation, aortic valvuloplasty, unifocalization of the MAPCAS, and right ventricle-to-pulmonary artery shunting. After the operation, the AR volume reduced, and the patient was scheduled for repair.