Impact of glucose control on early vein graft failure after coronary artery bypass grafting: one-month angiographic results.

Objectives: To identify factors that determine early saphenous vein graft failure (VGF) within 1 month after coronary artery bypass grafting (CABG). Methods: Seven hundred forty-nine consecutive patients underwent primary isolated CABG with saphenous vein grafts at three Japanese centres from 1 January 2005 to 31 December 2014. According to angiographic findings within 1 month of CABG surgery, 63 patients (8.4%) developed early VGF. We examined the relationships between variables and early VGF by using multivariable logistic regression analysis. Results: The preoperative clinical characteristics were similar between patients with and without early VGF, except for median preoperative haemoglobin A1c levels, which were significantly higher among patients with early VGF (6.7 vs 6.4%, P = 0.046). Additionally, anastomosis to the vessel with chronic total obstruction was performed more frequently among patients with early VGF (22/63 [34.9%] vs 140/686 [20.4%], P = 0.007), and myocardial infarction during the hospital admission occurred more frequently among patients with early VGF (4/63 [6.3%] vs 2/686 [0.3%], P < 0.0001). Results of multivariable analysis showed that the preoperative haemoglobin A1c level was associated with early VGF (odds ratio per unit increase, 1.30; 95% confidence interval, 1.06-1.60; P = 0.013). Conclusions: An increased preoperative haemoglobin A1c level was strongly associated with early VGF after CABG. Thus, VGF happened more frequently in patients with poorly controlled diabetes mellitus.

Effect of dipeptidyl peptidase-4 inhibitor in patients undergoing bypass surgery.

OBJECTIVES: Patients with diabetes mellitus often have more complicated postoperative courses and worse outcomes after coronary artery bypass grafting than those without this condition. Dipeptidyl-peptidase-4 inhibitors are a new class of oral medication for treating type 2 diabetes mellitus. We investigated how these drugs influence the postoperative course after coronary artery bypass in patients with type 2 diabetes mellitus. METHODS: We retrospectively reviewed the clinical records of 177 patients with type 2 diabetes who has undergone coronary artery bypass surgery between 2009 and 2013; 107 were treated with dipeptidyl-peptidase-4 inhibitors postoperatively, and 70 who did not receive dipeptidyl-peptidase-4 inhibitors served as a control group. The rates of overall survival and major adverse cardiac and cerebrovascular events were compared between groups. RESULTS: Analysis of all-cause deaths showed that survival at 4 years was 92.8% and 83.6%, respectively, for the treated and control groups (p = 0.052). There was a lower incidence of major adverse cardiac and cerebrovascular events in the treated group (85.6% vs. 73.1%, p = 0.042). Cox regression analysis of the entire population revealed that dipeptidyl-peptidase-4 inhibitor use (hazard ratio 0.46, p = 0.048) and deep sternal wound infection (hazard ratio 11.89, p = 0.003) were independent predictors of major adverse cardiac and cerebrovascular events. CONCLUSIONS: Dipeptidyl-peptidase-4 inhibitors reduced the incidence of major adverse cardiac and cerebrovascular events and improved the long-term prognosis after coronary artery bypass in patients with type 2 diabetes mellitus.

Fusiform aneurysm of the anterior communicating artery treated by vascular reconstruction: case report.

OBJECTIVE: Fusiform aneurysm of the anterior cerebral artery is rare and difficult to treat because of perforators. We encountered a patient with subarachnoid hemorrhage due to rupture of a fusiform aneurysm of the anterior communicating artery complex, and treated this patient with cerebral revascularization. CASE PRESENTATION: A 39-year-old man presented with sudden severe headache resulting from subarachnoid hemorrhage. Digital subtraction angiography showed dilatation from the distal A1 segment to the proximal A2 segment of the left anterior cerebral artery. Despite intensive conservative treatment, repetitive angiography showed aneurysmal growth from this dilated portion. INTERVENTION: Proximal clipping and clip-on wrapping on the A2 segment was successfully performed with a A3-A3 bypass. He was discharged without neurological deficit. CONCLUSION: Cerebral revascularization technique is necessary to achieved appropriate obliteration without ischemic complications.

Simulation of and training for cerebral aneurysm clipping with 3-dimensional models.

OBJECTIVE: With improvements in endovascular techniques, fewer aneurysms are treated by surgical clipping, and those aneurysms targeted for open surgery are often complex and difficult to treat. We devised a hollow, 3-dimensional (3D) model of individual cerebral aneurysms for preoperative simulation and surgical training. The methods and initial experience with this model system are presented. METHODS: The 3D hollow aneurysm models of 3 retrospective and 8 prospective cases were made with a prototyping technique according to data from 3D computed tomographic angiograms of each patient. Commercially available titanium clips used in our routine surgery were applied, and the internal lumen was observed with an endoscope to confirm the patency of parent vessels. The actual surgery was performed later. RESULTS: In the 8 prospective cases, the clips were applied during surgery in the same direction and configuration as in the preoperative simulation. Fine adjustments were necessary in each case, and 2 patients needed additional clips to occlude the atherosclerotic aneurysmal wall. With these 3D models, it was easy for neurosurgical trainees to grasp the vascular configuration and the concept of neck occlusion. Practicing surgery with these models also improved their handling of the instruments used during aneurysm surgery, such as clips and appliers. CONCLUSION: Using the hollow 3D models to simulate clipping preoperatively, we could treat the aneurysms confidently during live surgery. These models allow easy and concrete recognition of the 3D configuration of aneurysms and parent vessels.

Surgical treatment of a dural arteriovenous fistula in the superior petrosal sinus of an elderly patient with minimal suboccipital craniotomy: case report.

An 85-year-old woman presented with a dural arteriovenous fistula of the superior petrosal sinus manifesting as venous infarction of the cerebellum. Magnetic resonance imaging and angiography revealed right cerebellar swelling, venous engorgement, and an arteriovenous fistula in the superior petrosal sinus. Our initial attempt to obliterate the lesion through a transvenous endovascular approach failed, so we successfully treated the fistula via surgical interruption of the superior petrosal vein through a small suboccipital craniotomy. Careful examination of the pattern of venous drainage is important to determine surgical indications. This case indicates that minimally invasive open surgery can be effective even in an elderly patient.