Physician-modified endograft using three-dimensional model-assisted planning.

Objective: Case-specific and true-to-scale three-dimensional (3D) models have become increasingly useful tools for physician-modified endovascular grafting. This study aimed to validate the use of 3D model-assisted planning for fenestration design. Methods: Thirty-two consecutive patients (2019-2021) presenting with pararenal or juxtarenal abdominal aortic aneurysm (n = 16), paravisceral abdominal and Crawford's extent IV thoracoabdominal aortic aneurysm (n = 12), and type I endoleak after endovascular repair (n = 4) were analyzed retrospectively. All cases were planned manually with a standard method using curved planar reconstruction stretch images and multiplanar images perpendicular to the centerlines. The design was finalized by intraoperative 3D model-assisted planning. Intermethod agreements were assessed for geometrical relationships (separation heights and angles) between the superior mesenteric and renal arteries. The datasets from 55 double measurements of the entire cohort in this series were used to assess measurement discrepancies (≥3 mm separation height or ≥15° angle difference) and fenestration mismatches (≥3 mm separation between the manually planned and 3D model-assisted-planned renal arterial centers on the device surface) between manual and 3D model-assisted planning. Statistical analyses were performed to test the impact of anatomical factors on the discrepancies and mismatches. The imposition accuracy of 3D model-assisted planning and short-term clinical results of the 32 cases were also evaluated. Results: Fourteen fenestration measurement discrepancies were detected. The size of the stent graft (P = .0381), the aortic angle (P = .0008), and the prior existence of stent graft (P = .0123) were found to have a statistically significant impact on the measurement discrepancy, using single logistic and Fisher's exact tests. Twelve fenestration mismatches were observed and found to be significantly affected (P = .0039) by aortic angle. A cutoff value for fenestration mismatch was found to be 36.5°, with a sensitivity and specificity of 69.2% and 80.5%, respectively, using receiver operating characteristic analysis (area under the curve, 0.782 ± 0.081; P = .0023). A high level of branch preservation (100%) was achieved. During the observation period (1.3 years on average; range, 0.5-2.5 years), no patient experienced complications related to fenestration. Conclusions: The differences between the planning methods were non-negligible. However, 3D model-assisted planning increased the precision of the fenestration design when the conformation of the stent graft to the aortic anatomy is taken into account.

[Cardiac Surgery for Mitral Regurgitation Associated with Essential Thrombocythemia].

An 80-year-old woman with essential thrombocythemia was diagnosed with severe mitral regurgitation and moderate tricuspid regurgitation. Preoperatively, she had been treated with hydroxycarbamide and low-dose aspirin since her platelet count was high( 96.2×104/µl). After the platelet count was reduced to 46.2×104/µl, she underwent mitral valve repair and tricuspid valve annuloplasty. Atypical heparin resistance was noted intraoperatively. After initial heparin infusion, the activated clotting time(ACT) increased as expected. However, it decreased after initiation of cardiopulmonary bypass, despite additional heparin infusion and heparin concentration maintenance. A correlation between platelet factor 4 and heparin resistance was suggested. On discharge, she had no complications. We should consider the possibility of heparin resistance in essential thrombocythemia even when platelet count is adequately controlled.

Preoperative Planning for Physician-Modified Endografts Using a Three-Dimensional Printer.

The medical uses of three-dimensional (3D) printing are evolving at a rapid pace. The current roles and the future outlooks of this technology for physician-modified endovascular graft (PMEG) in patients with juxtarenal aneurysm are discussed. Fenestrations of PMEG are designed taking into account the geometry of the stent graft. Designing of such stent grafts is extremely complicated, especially when PMEG is planned for the angulated portion of the aorta. A 3D model enables the designing of branch fenestrations, with consideration for the geometrical adaptation of the stent graft in a complex aortic anatomy. With the aid of 3D-printing technology, patients with juxtarenal aortic pathologies can be treated using fenestrated stent grafts, preserving the vital organ circulation and securing a robust length of proximal sealing zone.

One Technique to Modulate a Device Implantation Path in a Short Treatment Length Using the Gore IBE Device.

The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE; W. L. Gore and Associates, Flagstaff, AZ, USA) applicability is limited by the aorto-iliac length (AOL). The shortage may be a major exclusion criterion. An 85-year-old male presented with an abdominal aortic and left common iliac arterial aneurysm. The left-side AOL was 146-mm, which was deemed 19-mm too short for IBE usage. To increase implantation length, the contra-lateral connection stent graft was deployed along the implantation line, wound half-circumferentially around the ipsilateral limb. Any form of endoleak, limb occlusion, and device migration has not been observed for twelve months.

[Aortic Valve-preserving Root Remodeling in a Patient with Bicuspid Aortic Valve and Severe Annulo-aortic Ectasia].

A 48-year-old man underwent aortic root remodeling for a giant aneurysm of sinus of Valsalva, 98 mm in diameter, as well as a bicuspid aortic valve. The aortic valve was defined as type 0(L-R) according to Sievers classification and the aortic annulus was highly dilated up to 35 mm. Geometric height of the left and right cusps were 22 mm and 32 mm in diameter, respectively. Dacron straight graft of 24 mm was chosen and each tongue was then created in a 180°fashion. After completion of root reconstruction, external circular suture annuloplasty using CV-0 expanded polytetrafluoroethylene (ePTFE) was made to adjust the annulus down to 22 mm in diameter. The free margin of both cusps were centrally plicated to raise the effective height to 9 mm. Postoperative echocardiography at 2 year showed trivial aortic regurgitation but no root re-dilatation. Remodeling with external circular suture annuloplasty is a reproducible and reliable method to stabilize the root, even for the patient with a giant aneurysm of sinus of Valsalva.

[Myocardial Ischemia in Acute Type A Aortic Dissection; Coronary Artery Dissection and Functional Ischemia].

Myocardial ischemia due to acute type A dissection is a fatal complication. This study was undertaken to evaluate the surgical results of acute type A aortic dissection with myocardial ischemia. Between 1986 and 2014, 364 patients were treated for acute type A dissection in our hospital. Twenty-four patients were underwent myocardial revascularization. Preoperative coronary artery stent placement was involved in 2, coronary-artery bypass grafting (CABG) 18 (right 12, left 4, both 2), reCABG 2, and Carrel patch with coronary orifice restoration 2. Seven of CABG group had no symptom of myocardial ischemia, but right coronary artery was circumferentially detached from the intimal ostia. Hospital mortality was 20.1% in patients who underwent CABG. Sixteen patients with significant electrocardiogram ischemic change were not undertaken with CABG, because coronary artery was not involved by dissection. In these cases, acute aortic valve regurgitation, loss of backward pressure from distal aorta, or valve formation by intimal tear in ascending aorta might decrease diastolic pressure at aortic root and make myocardial ischemia.

Endovascular Aneurysm Repair of Acute Occlusion of Abdominal Aortic Aneurysm with Intra-Aneurysmal Dissection.

BACKGROUND: To report a rare case of acute abdominal aortic aneurysm (AAA) occlusion successfully treated by endovascular aneurysm repair (EVAR). CASE REPORT: An 89-year-old man complained of severe back pain and weakness in the bilateral lower extremities. Although there were neither acute ischemic signs on the brain computed tomography (CT) nor critical leg ischemia, the patient presented progressing weakness in the bilateral lower extremities and decreased sensation in the perianal and saddle area. Contrast-enhanced CT demonstrated an infrarenal AAA, the formation of an ulcer-like lesion in the aneurysmal wall, and the complete occlusion of distal AAA because of the caudal extension of intramural hematoma. Both common iliac arteries were patent because of the development of collateral vessels. The neurologic symptoms were considered to be caused by the occlusion of lumbar radicular arteries. EVAR seemed anatomically feasible, if the occlusion could be crossed by guidewires from both side of the common femoral artery. Wires easily traversed the occlusion, and the stent graft could be smoothly unwrapped and opened. The patient could recover decent iliac arterial flow. The neurovascular deficits recovered within 4 days after the procedure. CONCLUSIONS: Although our experience may not be reproduced in all case of AAA occlusion, EVAR warrants consideration to reduce the high mortality rate associated with the classical treatments.

[Successful endovascular treatment under cardiopulmonary resuscitation for spontaneous rupture of the thoracic aorta].

The patient was a 67-year-old man. He was admitted to a local hospital with severe back pain, and left hydrothorax was noted by a chest X-ray. Then, he went into shock and was transferred to our hospital. Enhanced computed tomography (CT) showed massive liquid retention of the left thorax, but no aortic dissection or aneurysms. He was diagnosed with spontaneous aortic rupture, and endovascular treatment was chosen because of his unstable hemodynamics. He fell into cardiac arrest 10 minutes after the operation started, and we implanted 2 stent-grafts while giving cardiac massage. After 23 minutes cardiac massage, he was resuscitated. He was discharged without any complication. Even if no signs of aortic aneurysms or aortic dissection were detected, the possibility of spontaneous aortic rupture should be suspected. Endovascular treatment is a reliable option in the case of unstable hemodynamics.