Usefulness of Motor Evoked Potential Measurement and Analysis of Risk Factors for Spinal Cord Ischaemia from 300 Cases of Thoracic Endovascular Aortic Repair.

OBJECTIVE: This study investigated the usefulness of motor evoked potentials (MEPs) for intra-operative monitoring to detect the risk of spinal cord ischaemia (SCI) during thoracic endovascular aortic repair (TEVAR). Risk factors for SCI in TEVAR were also analysed. METHODS: Among 330 TEVARs performed from February 2009 to October 2018, 300 patients underwent intra-operative MEP monitoring. SCI risk groups were extracted based on MEP amplitude changes using a cutoff value of 50%. When the amplitude decreased to < 50% of the pre-operative value, intra-operative mean arterial pressure (MAP) was increased by about 20 mmHg using noradrenaline, whereas MAP was usually controlled to about 80 mmHg during surgery. Other efforts were also made to increase MEP amplitude by increasing cardiac output, correcting anaemia, and finishing the surgery promptly. Based on MEP amplitude data, SCI risk groups were extracted and risk factors for SCI in TEVAR were analysed. RESULTS: A total of 283 non-SCI risk patients and 17 SCI risk patients by MEP monitoring were extracted; only 1.0% developed immediate paraplegia and none developed delayed paraplegia. Bivariable analysis showed significant differences in chronic kidney disease, haemodialysis, artery of Adamkiewicz closure, and stent graft (SG) covered length ≥ 8 vertebral bodies. Logistic regression analysis showed hyperlipidaemia (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.08 - 11.67; p = .037), SG covered length ≥ 8 vertebral bodies (OR 1.35, 95% CI 1.02 - 1.78; p = .034), and haemodialysis (OR 27.78, 95% CI 6.02 - 128.22; p < .001) were the most influential risk factors for SCI in TEVAR. CONCLUSION: MEPs might be a useful monitoring tool to predict SCI in TEVAR. In addition, hyperlipidaemia, SG covered length ≥ 8 vertebral bodies, and haemodialysis represent key risk factors for SCI during TEVAR.

Simultaneous upper and lower body perfusion using hypothermia during thoracoabdominal aortic surgery.

BACKGROUND: In open thoracoabdominal aortic aneurysm (TAAA) repair, we have been performing vascular reconstruction under moderate to deep hypothermia and assisted circulation using simultaneous upper and lower body perfusion. This method is effective for protecting the spinal cord and the brain, heart, and abdominal organs and for avoiding lung damage. METHODS: TAAA repair was performed under hypothermia at 20-28 °C in 18 cases (Crawford type I in 0 cases, type II in 5, type III in 3, type IV in 4, and Safi V in 6) between October 2014 and January 2023. Cardiopulmonary bypass was conducted by combined upper and lower body perfusion, with perfusion both via the femoral artery and either transapically or via the descending aorta or the left brachial artery. RESULTS: The ischemic time for the artery of Adamkiewicz and the main segmental arteries was 40-124 min (75 ± 33 min). No spinal cord ischemic injury or brain or heart complications occurred. One patient with postoperative right renal artery occlusion and one with an infected aneurysm required tracheostomy, but the intubation time for the other 16 was 32 ± 33 h. The duration of postoperative intensive care unit stay was 6.5 ± 6.2 days, the length of hospital stay was 29 ± 15 days, and no in-hospital deaths occurred. CONCLUSIONS: Simultaneous upper and lower body perfusion under moderate to deep hypothermia during thoracoabdominal aortic surgery may avoid not only spinal cord injury, but also cardiac and brain complications.

Mechanism of Increased Spinal Cord Blood Flow due to Noradrenaline Administration Using Vascular Resistance: An Experimental Study Using a Canine Model.

Background: During thoracoabdominal aortic surgery, the spinal cord is placed under ischemic conditions. Elevation of systemic blood pressure is thus recommended as a method of increasing the blood supply from collateral networks. This study examined the mechanisms by which noradrenaline administration increases spinal cord blood flow (SCBF) by elevating systemic blood pressure. Methods: In beagles (n = 7), the thoracoabdominal aorta and L2-L7 spinal cord segmental arteries (SAs) were exposed and a distal perfusion bypass was created to simulate clinical practice. SCBF was measured by laser flowmetry at the L5 dura mater and spinal cord perfusion pressure (SCPP) was measured inside the clamped aorta. The six pairs of SAs from L2 to L7 were clamped, and mean systemic blood pressure (mSBP), SCBF, and SCPP were measured before and after clamping and after starting continuous infusion of noradrenaline at 0.5 µg/kg/min. Rates of change in systemic vascular resistance (SVR) and spinal cord vascular resistance (SCVR) were calculated from the measured values. Results: With no SA clamping (control), the rate of increase in SCVR was 0.74 times the rate of increase in SVR (y = 0.2 + 0.74x, r = 0.889, r2 = 0.789; P < 0.01). When all six pairs of SAs were clamped, a weak correlation was evident between rate of change in SCVR and rate of change in SVR, and the rate of increase in SCVR was lower than the rate of increase in SVR (y = 0.39 + 0.07x, r = 0.209, r2 = 0.039; P < 0.01). When all six pairs of SAs were clamped in the absence of distal perfusion, a weak correlation was also evident between rate of change in SCVR and rate of change in SVR, and the rate of increase in SCVR was lower than the rate of increase in SVR (y = 0.19 + 0.08x, r = 0.379, r2 = 0.144; P < 0.01). Conclusions: The rate of increase in SCVR induced by noradrenaline administration was lower than the rate of increase in SVR in the control group with no spinal cord SA clamping and in both experimental groups with clamped SAs (with and without distal perfusion), creating an environment conducive to spinal cord flow distribution.

[Celiac Artery Bypass Grafting from the Ascending Aorta Following Aortic Repair for Treatment of Stanford Type A Acute Aortic Dissection Complicated by Abdominal Malperfusion:Report of a Case].

A 73-year-old woman presented with sudden chest and back pain. Computed tomography (CT) revealed Stanford type A acute aortic dissection complicated by occlusion of the celiac artery and stenosis of the superior mesenteric artery. Because there was no clear sign of critical abdominal organ ischemia before surgery, central repair was performed first. Then, after cardiopulmonary bypass, laparotomy was performed to check the blood flow in the abdominal organs. Malperfusion of the celiac artery remained. We therefore made an ascending aorta-common hepatic artery bypass using a great saphenous vein graft. Postoperatively, the patient was saved from irreversible abdominal malperfusion, however, her condition was complicated by paraparesis due to spinal cord ischemia. After a long period of rehabilitation, she was transferred to another hospital for rehabilitation. She is currently doing well at 15 months after treatment.

Open Repair for Patent Ductus Arteriosus Aneurysm in an Adult.

Ductus arteriosus aneurysm (DAA) is rarely encountered in adults. There have been several hypotheses regarding its origin and potential indications for intervention in asymptomatic cases. If left untreated, rupture, compression of surrounding organs, and serious complications due to thromboembolism may occur, and aggressive surgical intervention appears desirable for patients who can tolerate surgery. We report a case involving a 30-mm, saccular, patent DAA that was incidentally discovered in a 49-year-old man on computed tomography. Open repair was performed by femorofemoral bypass assistance, which allowed decompression of the aorta and aneurysm and successful closure of the aortic and pulmonary artery ends.

Survival and cause of death after aortic arch aneurysm repair.

BACKGROUND: This study aimed to identify differences in prognosis, causes of death, and outcomes between open and endovascular repair for aortic arch aneurysms. METHODS: We retrospectively analyzed the survival status and causes of death determined from the medical records of 124 consecutive elderly patients (age>70 years) with aortic arch aneurysms that were treated between 2010 and 2018 at our hospital. Forty patients (male, N.=30; mean age, 76 years) underwent open repair and 84 (male, N.=68; mean age, 78 years) underwent endovascular repair. RESULTS: Early postoperative complications (10.0% vs. 6.3%; P=0.4) and rates of in-hospital death (2.5% vs. 6.3%; P=0.2) did not significantly differ between open and endovascular repair. Cumulative long-term and event free survival rates at eight years were similar in both groups (78.7% vs. 66.3%, P=0.1 and 66.6% vs. 58.4%; P=0.4, respectively). The causes of death at follow-up after endovascular repair comprised malignancies in 11 (52.4%) patients and cardiopulmonary and cerebral events unrelated to aortic aneurysms in 10 (47.6%). CONCLUSIONS: Early and late outcomes did not statistically differ after both procedures. However, the prevalence of cancer-related death occurring late after arch repair was significantly higher after endovascular repair. The most important observation from this series was that significantly more patients died of malignant disease during follow-up after endovascular repair than open repair.

Transapical aortic perfusion using a deep hypothermic procedure during descending thoracic or thoracoabdominal aortic surgery.

BACKGROUND: In descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) surgery, though proximal anastomosis using deep hypothermic circulatory arrest (DHCA) is often selected, there are issues surrounding brain and heart protection. In this study, the usefulness of concomitant upper body perfusion via transapical aortic cannulation during deep hypothermic surgery was examined. METHODS: Between October 2014 and May 2019, 5 patients (Crawford extent II chronic dissection, N.=3; extent IV aneurysms, N.=1; DTAA, N.=1) underwent DTAA/TAAA repair under deep hypothermia using transapical aortic perfusion. A proximal anastomosis and artery of Adamkiewicz (AKA) reconstruction were performed under continuous perfusion of the upper and lower body at 20 °C. RESULTS: The time from aortic cross-clamping to proximal anastomosis was 69±33 minutes, and it took 86±47 minutes to AKA reperfusion. There was no spinal cord ischemic injury or brain or heart complications. One patient required tracheostomy, and the average postoperative intubation time for the other patients was 57±52 hours. All patients were discharged, and the average postoperative hospital stay was 25.6±8.1 days. CONCLUSIONS: Concomitant upper body perfusion by the transapical aortic approach contributes to avoidance of brain and heart complications and maintaining spinal cord circulation under deep hypothermic DTAA/TAAA surgery.

Thymoma appearing 9 years after the resection of squamous cell carcinoma of the lip: A case report of triple primary tumors and literature review.

The occurrence of second primary tumor (SPT)following malignancy treatment is common. In patients with head and neck (H&N) cancer, SPTs principally occur in the H&N region, lungs or esophagus. Therefore, patient follow-up after cancer treatment is important in order to detect recurrence, metastasis and new primary tumors. However, no standard guidelines on lifelong follow-up imaging are available. Herein, we report a patient who presented with three metachronous primary tumors-squamous cell carcinoma (SCC) of the tongue, SCC of the lip and type A thymoma. The third tumor was incidentally detected during follow-up using contrast-enhanced computed tomography (CT) 9 years following resection of the second tumor. To the best of our knowledge, this specific combination of metachronous tumors has not yet been reported. Based on the literature review, we observed that thymoma occurs following H&N cancer treatment. Therefore, to ensure that the presence of subsequent thymomas is not overlooked, we suggest regular lifelong follow-up using contrast-enhanced CT in patients who had previously been diagnosed with H&N cancer. The literature review revealed that thymomas occur in patients with H&N cancer and should be detected at the earliest convenience.

Direct Monitoring of Reconstructed Segmental Arterial Pressure during Deep Hypothermic Thoracoabdominal Aortic Aneurysm Surgery.

Deep hypothermia in thoracoabdominal aortic aneurysm operations is considered extremely useful for ensuring sufficient time to reconstruct the segmental arteries feeding the spinal cord. However, because the amplitude of motor evoked potentials (MEPs) decrease or disappear during deep hypothermia, feasible methods for assessing spinal cord circulation have not yet been reported. Performing additional segmental arterial reconstructions that rely on MEPs is also impractical. In the present case, to ascertain spinal cord circulation under deep hypothermia, we intraoperatively measured the reconstructed segmental arterial pressure in real time and investigated whether sufficient spinal cord blood flow had been attained.

Direct reopening of the occluded hepatic veins of Budd-Chiari syndrome: verification of our operative method by the perioperative course of esophageal varices.

OBJECTIVE: A total of 69 patients with Budd-Chiari syndrome (BCS) were operated by direct approach under cardiopulmonary bypass (CPB). To assess the operative procedure, the perioperative course of esophageal varices (EVs) was evaluated. PATIENTS AND METHODS: Of the 69 patients, 59 (22 females) were enrolled in this study because they had complete follow-up data for endoscopic evaluation of EVs. Their mean age was 46.3 ± 13.0 years (range 21-73.3 years). EVs were found in 52 patients. Under partial cardiopulmonary bypass, the inferior vena cava (IVC) was incised. The obstruction of the IVC was excised, and the occluded hepatic veins were reopened. The incised IVC was reconstructed with an auto-pericardial patch. RESULTS: Postoperatively, the repaired IVC was patent in all patients. The average number of patent hepatic veins (HVs) increased from 1.23 ± 0.81 to 2.21 ± 0.97/patient. The pressure gradient between the IVC and right atrium (RA) decreased from 12.4 ± 5.52 to 4.46 ± 3.21 mmHg. The indocyanine green clearance test (ICG) at 15 min decreased from 31.57 ± 17.44 to 22.27 ± 15.23%. EVs had disappeared in 13 patients at discharge and in 6 patients at late postoperative follow-up. CONCLUSION: Our operative procedure for BCS is useful for decreasing portal pressure, which is reflected by disappearance of EVs. Therefore, the high risk of EV rupture could be avoided by reopening the occluded HVs.

Prevention of Pulmonary Edema after Minimally Invasive Cardiac Surgery with Mini-Thoracotomy Using Neutrophil Elastase Inhibitor.

PURPOSE: Unilateral re-expansion pulmonary edema (RPE) is a rare but one of the most critical complications that may occur after re-expansion of a collapsed lung after minimally invasive cardiac surgery (MICS) with mini-thoracotomy. METHODS: We performed a total of 40 consecutive patients with MICS by right mini-thoracotomy with single-lung ventilation between January 2013 and June 2016. We divided the patients into control group (n = 13) and neutrophil elastase inhibitor group (n = 27). Neutrophil elastase inhibitor group received continuous intravenous infusion of neutrophil elastase inhibitor at 0.2-0.25 mg/kg per hour from the start of anesthesia until extubation during the perioperative period. RESULTS: There were no relations with operative time, cardiopulmonary bypass (CPB) time, aortic clamp time, and intraoperative water valances for postoperative mechanical ventilation support time. Compared with the neutrophil elastase inhibitor group, the control group had significantly higher initial alveolar-arterial oxygen gradient and significantly lower initial ratio of partial pressure of arterial oxygen to fraction of inspired oxygen at the intensive care unit (ICU). The control group had significantly longer postoperative mechanical ventilation support time and hospital stay compared with the neutrophil elastase inhibitor group. CONCLUSIONS: Neutrophil elastase inhibitor may have beneficial effects against RPE after MICS with mini-thoracotomy.

[Acute Leg Ischemia at Acute Aortic Dissection].

Legs ischemia might be associated with acute aortic dissection, in acute phase or even in subacute phase. In general, immediate central repair for acute aortic dissection is mandatory prior to intervention of leg ischemia because central repair might improve leg ischemia. Depending on condition of leg ischemia, revascularization of occluded artery should be considered. The perfusion to ischemic leg during central repair is useful to diminish leg injury. There are some useful modalities for revascularization such as some route of extra-anatomical bypass, placing of stent graft for closing entry site of dissected aortic wall. Multiple organs injury are occurred simultaneously by occlusion of organ branches on aortic dissection. Leg ischemia is associated frequently with other organs ischemia, and could be a pilot sign for abdominal organ ischemia.

Transapical aortic perfusion using a deep hypothermic procedure to prevent dissecting lung injury during re-do thoracoabdominal aortic aneurysm surgery.

BACKGROUND: Avoiding various complications is a challenge during re-do thoracoabdominal aneurysm surgery. CASE PRESENTATION: A 56-year-old man had undergone surgery for type I aortic dissection four times. The residual thoracoabdominal aortic aneurysm that had severe adhesions to lung parenchyma was resected. Since the proximal anastomotic site was buried in lung parenchyma, deep hypothermia was essential to avoid lung dissection and to protect the spinal cord during the proximal anastomosis. The deep hypothermia was induced with bilateral infusion of cardiopulmonary bypass by femoral artery cannulation for the lower body and by transapical cannulation for the upper body because of easy access. There was no hemorrhagic tendency after deep hypothermic bypass. The patient was discharged uneventfully. CONCLUSIONS: For upper body perfusion, transapical aortic cannulation was a simple and effective procedure during left thoracotomy.

Long-term Treatment of Teicoplanin for Methicillin-resistant Staphylococcus aureus Sternal Osteomyelitis with Renal Impairment: A Case of High Teicoplanin Trough Levels Maintained by Therapeutic Drug Monitoring.

Teicoplanin, a glycopeptide antibiotic for methicillin-resistant Staphylococcus aureus, is recommended for therapeutic drug monitoring during treatment. Maintaining a high trough range of teicoplanin is also recommended for severe infectious disease. However, the optimal dose and interval of treatment for severe renal impairment is unknown. We report a 79-year-old man who received long-term teicoplanin treatment for methicillin-resistant Staphylococcus aureus bacteremia due to postoperative sternal osteomyelitis with renal impairment. Plasma teicoplanin trough levels were maintained at a high range (20-30 µg/mL). Although the patient required long-term teicoplanin treatment, a further decline in renal function was not observed, and blood culture remained negative after the start of treatment. Teicoplanin treatment that is maintained at a high trough level by therapeutic drug monitoring might be beneficial for severe methicillin-resistant Staphylococcus aureus infection accompanied by renal impairment.

Low-Grade Endometrial Stromal Sarcoma with Intravenous and Intracardiac Extension: A Multidisciplinary Approach.

Background. A rare case of low-grade endometrial stromal sarcoma (LG-ESS) extending to inferior vena cava (IVC) and cardiac chambers. Case Report. A 40-year-old woman had IVC tumor, which was incidentally detected by abdominal ultrasonography during a routine medical checkup. CT scan revealed a tumor in IVC, right iliac and ovarian veins, which was derived from the uterus and extended into the right atrium and ventricle. The operation was performed, the heart and IVC were exposed, and cardiopulmonary bypass was initiated. A right atriotomy was performed, and the intracardiac mass was removed. Then the tumor in IVC and the right internal iliac vein were removed after longitudinal venotomies in the suprarenal and infrarenal vena cava, the right common iliac vein. Next the pelvis was explored. Tumors were found originating from the posterior wall of the uterus and continuing into both the right uterine and ovarian vein. The patient underwent total hysterectomy with bilateral salpingooophorectomy. Complete tumor resection was achieved. Histopathological analysis confirmed a diagnosis of LG-ESS. She showed no evidence of disease for 2 years and 3 months. Conclusions. Our case highlights the importance of a multidisciplinary approach in treating this rare cardiovascular pathological condition through preoperative assessment to final operation.

Experimental Reconstruction of the Trachea with Urinary Bladder Wall.

PURPOSE: To investigate tracheal reconstruction with autologous bladder wall using modern refined surgical procedures. METHODS: Experiments were performed on 16 female beagle dogs. Six tracheal cartilages were resected to create a tracheal deficit, then tracheal replacement with autologous bladder wall was performed. In the first 10 dogs (first series), the transplant site was covered with pedicled omental flap. In the next six dogs (second series), we performed tracheal reconstruction without omental covering, and secured tracheal cartilages above and below the graft with sutures to prevent excessive graft stretching. RESULTS: No surgical mortality or lethal infection of the transplant site was encountered in either series. Complications in the first series comprised tracheal stenosis in four dogs. One dog died suddenly at 4 months postoperatively due to stent migration, so cartilage sutures were adopted in the second series. The lumen surface of the grafts was covered with squamous metaplastic epithelium. Osseous tissue was present in the submucosa of grafts, particularly prominently in areas lacking omental covering. CONCLUSIONS: Tracheal reconstruction using bladder wall may become clinically useful. A pedicled omental covering does not appear always necessary to prevent graft necrosis and infection. Ischemic stimulation may be involved with bone formation in grafts.

Early-Stage Induction of SWI/SNF Mutations during Esophageal Squamous Cell Carcinogenesis.

The SWI/SNF chromatin remodeling complex is frequently inactivated by somatic mutations of its various components in various types of cancers, and also by aberrant DNA methylation. However, its somatic mutations and aberrant methylation in esophageal squamous cell carcinomas (ESCCs) have not been fully analyzed. In this study, we aimed to clarify in ESCC, what components of the SWI/SNF complex have somatic mutations and aberrant methylation, and when somatic mutations of the SWI/SNF complex occur. Deep sequencing of components of the SWI/SNF complex using a bench-top next generation sequencer revealed that eight of 92 ESCCs (8.7%) had 11 somatic mutations of 7 genes, ARID1A, ARID2, ATRX, PBRM1, SMARCA4, SMARCAL1, and SMARCC1. The SMARCA4 mutations were located in the Forkhead (85Ser>Leu) and SNF2 family N-terminal (882Glu>Lys) domains. The PBRM1 mutations were located in a bromodomain (80Asn>Ser) and an HMG-box domain (1,377Glu>Lys). For most mutations, their mutant allele frequency was 31-77% (mean 61%) of the fraction of cancer cells in the same samples, indicating that most of the cancer cells in individual ESCC samples had the SWI/SNF mutations on one allele, when present. In addition, a BeadChip array analysis revealed that a component of the SWI/SNF complex, ACTL6B, had aberrant methylation at its promoter CpG island in 18 of 52 ESCCs (34.6%). These results showed that genetic and epigenetic alterations of the SWI/SNF complex are present in ESCCs, and suggested that genetic alterations are induced at an early stage of esophageal squamous cell carcinogenesis.

Successful left ventricular assist device re-implantation with omental covering for MDRP device infection.

We present a case of paracorporeal left ventricular assist device (p-LVAD)-related infection, caused by multi-drug resistant Pseudomonas aeruginosae (MDRP), and successfully treated by p-LVAD re-implantation with omental covering. A 59-year-old man underwent p-LVAD implantation and coronary artery bypass grafting after percutaneous cardiopulmonary support and intra-aortic balloon pumping for cardiogenic shock due to acute myocardial infarction. Then, he was registered for heart transplantation. He suffered from blood stream infection causative organism of Pseudomonas aeruginosa, 2 months after that operation. He underwent re-median sternotomy and open drainage, 15 months after the p-LVAD implantation. However, he suffered from septic shock due to MDRP. He underwent p-LVAD re-implantation under hypothermic circulatory arrest and iodine gauze packing, followed by omental covering of the all artificial materials in his body 10 days after that operation. Soon after that, the infection was well controlled and the intravenous antibiotics could be discontinued 2 months after that operation. He successfully underwent heart transplantation, 17 months after that procedure. We concluded that p-LVAD re-implantation with omental covering is seemed to be useful in the treatment of massive device infection. This procedure might be a novel treatment for severe VAD-related infection until heart transplantation.

The impact of preoperative identification of the Adamkiewicz artery on descending and thoracoabdominal aortic repair.

OBJECTIVE: To investigate the impact of preoperative identification of the Adamkiewicz artery (AKA) on prevention of spinal cord injury (SCI) through the multicenter Japanese Study of Spinal Cord Protection in Descending and Thoracoabdominal Aortic Repair (JASPAR) registry. METHODS: Between January 2000 and October 2011, 2435 descending/thoracoabdominal aortic repairs were performed, including 1998 elective repairs and 437 urgent repairs, in 14 major centers in Japan. The mean patient age was 67 ± 13 years, and 74.2% were males. There were 1471 open repairs (ORs), including 748 descending and 137 thoracoabdominal extent [Ex] I, 136 Ex II, 194 Ex III, 115 Ex IV, and 138 Ex V, and 964 endovascular repairs (EVRs). Of the 2435 patients, 1252 (51%) underwent preoperative magnetic resonance or computed tomography angiography to identify the AKA. RESULTS: The AKA was identified in 1096 of the 1252 patients who underwent preoperative imaging (87.6%). Hospital mortality was 9.2% (n = 136) in those who underwent OR and 6.4% (n = 62) in those who underwent EVR. The incidence of SCI was 7.3% in the OR group (descending, 4.2%; Ex I, 9.4%; Ex II, 14.0%; Ex III, 14.4%; Ex IV, 4.2 %; Ex V, 7.2%) and 2.9% in the EVR group. The risk factors for SCI in ORs were advanced age, extended repair, emergency, and occluded bilateral hypogastric arteries. In ORs of the aortic segment involving the AKA, having no AKA reconstruction was a significant risk factor for SCI (odds ratio, 2.79, 95% confidence interval, 1.14-6.79; P = .024). CONCLUSIONS: In descending/thoracoabdominal aortic repairs, preoperative AKA identification with its adequate reconstruction or preservation, especially, in ORs of aortic pathologies involving the AKA, would be a useful adjunct for more secure spinal cord protection.

[Ruptured Non-dissecting Thoracic Aortic Aneurysm].

Although the operative results for non-dissecting thoracic aneurysm has been improving markedly, that of the ruptured one is still poor. Once aneurysmal rupture is occurred, a patient can almost never survive. Only few patients could arrive to an emergency hospital. It is reported that about 60% of the patients are died suddenly and the remaining 40% of the patients may undergo surgery or endovascular intervention. In the annual report in 2012 published by "Journal of General Thoracic and Cardiovascular Surgery", the mortality rates during postoperative 30 days of the non-ruptured and the ruptured nondissecting thoracic aneurysm are 2.71% and 19.0% respectively. Thoracic endovascular aortic repair (TEVAR) is predominant alternatives for the patients with poor hemodynamic condition by rupture of aortic aneurysm. The mortality rate after TEVAR for ruptured thoracic aneurysm is reported to be 10.87%, and is lower than that of the open surgery. It is essential for preventing the death by aneurysmal rupture that the open surgery or TEVAR for thoracic aortic aneurysm should be carried out electively.