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The patient was a 48-year-old man who had undergone fenestrated frozen elephant trunk (FET) technique for acute type A aortic dissection. Postoperative enhanced computed tomography (CT) imaging revealed a type 1a endoleak from the fenestration. Nevertheless, the stented portion of the FET exhibited circular expansion. However, 2 months after surgery, enhanced CT imaging revealed the flattening of the FET due to the persistent endoleak and we performed an urgent zone 2 thoracic endovascular aortic repair (TEVAR). When type 1a endoleak from the fenestration is observed, the FET can be flattened, as in this patient, additional intervention should be considered.
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BACKGROUND: The purpose of this study was to evaluate the risk factors of distal stent graft-induced new entry (dSINE) after frozen elephant trunk (FET) procedure for aortic dissection (AD) and to consider strategies to prevent this complication. METHODS: This retrospective review included 52 patients who had undergone aortic arch repair for AD with the FET procedure using J Graft FROZENIX from 2014 to 2020 at a single center. Baseline characteristics, aortic characteristics and mid-term outcomes were compared between patients with and without dSINE. The extent of unfolding of the device and movement of the distal edge of the device were analyzed by multidetector computed tomography. The primary endpoints were survival and freedom from reintervention. RESULTS: dSINE was the most prevalent complication after FET procedure, with an incidence of 23%. Eleven of 12 patients with dSINE underwent secondary interventions. dSINE was common in chronic aortic dissection (P = 0.001) and was associated with the residual false lumen area (P < 0.001) and movement distance of the distal edge of the device in the cranial direction (P < 0.001). CONCLUSIONS: The distal edge of the FET is more likely to move in the cranial direction, and this movement may cause dSINE.
Assuntos
Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Humanos , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/etiologia , Stents/efeitos adversos , Resultado do Tratamento , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/cirurgia , Prótese Vascular/efeitos adversos , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Estudos RetrospectivosRESUMO
OBJECTIVES: The incidence rate of distal stent graft-induced new entry (d-SINE) after frozen elephant trunk technique for aortic dissection remains controversial. The aim of this study was to investigate the incidence and seek the clinical and anatomical predictive factors. METHODS: This study is a retrospective multicentre evaluation of complications including d-SINE, aortic events and reintervention after the frozen elephant trunk procedure for aortic dissection. RESULTS: Our cohort included a total of 177 consecutive patients who underwent the frozen elephant trunk procedure for acute and chronic aortic dissection at 5 centres in Japan from May 2014 to March 2021. The incidence rate of d-SINE was 14.1% (25/177 patients). The cumulative incidence of d-SINE was 7.1%, 12.4% and 21.4% after 12, 36 and 60 months, respectively. d-SINE was not associated with mid-term survival rate. After competing risk regression analysis, onset time >48 h (subdistribution hazard ratio, 3.80; 95% confidence interval, 1.13-12.79; P = 0.031) was detected as an independent predictor. CONCLUSIONS: Awareness that there is a relatively higher incidence of d-SINE after frozen elephant trunk procedures is important. Non-hyper-acute phase was detected as an independent risk factor. Pre-emptive endovascular repair may be appropriate to protect new entry in high-risk patients.
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Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Procedimentos Endovasculares , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/efeitos adversos , Humanos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Stents/efeitos adversos , Resultado do TratamentoRESUMO
OBJECTIVES: The number of hemodialysis patients requiring aortic valve replacement (AVR) is increasing. Although bioprosthetic valves are increasingly popular, they are associated with a risk of structural valve deterioration (SVD). The aim of this study is to examine the outcomes of bioprosthetic valves in hemodialysis patients undergoing AVR and to identify treatment strategies that can decrease the risk of SVD. METHODS: Between February 2010 and November 2019, 61 patients on hemodialysis underwent AVR using bioprosthetic valves at our hospital. Five patients died while still in the hospital. Kaplan-Meier estimates of overall survival and univariate Cox proportional hazards regression analyses were performed for the remaining 56 patients. RESULTS: During follow-up, there were six SVD events (10.7%) related to the bioprosthetic valves. The survival rate was 67.9% at 3 years and 39.5% at 5 years. In all SVD cases, SVD was caused by aortic stenosis. The mean interval between AVR and the discovery of SVD was 41.5 months. The SVD-free rate was 88.6% at 3 years and 65.3% at 5 years. Preoperative phosphorus levels are associated with SVD risk. High preoperative phosphorus concentration is associated with elevated SVD risk. CONCLUSIONS: In this study, we determined that the risk of SVD can be influenced by preoperative phosphorus level. Strict control of the phosphorus concentration of hemodialysis patients may decrease structural valve deterioration after aortic valve replacement.
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Estenose da Valva Aórtica , Bioprótese , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Fósforo , Desenho de Prótese , Falha de Prótese , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: The appropriate timing of aortic repair in patients with bicuspid aortic valve-related aortopathy remains controversial. We describe the changes in diameter of the non-aneurysmal ascending aorta after aortic valve replacement for bicuspid or tricuspid aortic valve stenosis. METHODS: This retrospective review included 189 patients who had undergone aortic valve replacement for severe stenotic aortic valve with a non-aneurysmal ascending aorta diameter of 45 mm or less between January 2008 and December 2018. A linear mixed-effect model was used to analyze and compare the enlargement rates of the non-aneurysmal ascending aorta at the tubular portion after aortic valve replacement in bicuspid and tricuspid aortic valve patients. RESULTS: The enlargement rate of the non-aneurysmal ascending aorta after aortic valve replacement was significantly greater in the bicuspid aortic valve group than in the tricuspid aortic valve group (0.36 mm/year vs. 0.09 mm/year, p < 0.001). The specific form of bicuspid aortic valve also affected aorta diameter enlargement: the enlargement rate of 0.85 mm/year in the Type 0 (according to Sievers' classification) group was approximately five times that in the Non-Type 0 group (p < 0.001). No aortic events were observed, and no patients needed reoperations for the ascending aorta, in either the bicuspid or tricuspid aortic valve groups. CONCLUSION: The persistent possibility of progressive ascending aortic dilatation after aortic valve replacement for bicuspid aortic valve stenosis, especially in Type 0 bicuspid aortic valve patients, demands careful post-procedural evaluation of the ascending aorta.
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Valva Aórtica , Próteses Valvulares Cardíacas , Aorta/diagnóstico por imagem , Aorta/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Constrição Patológica , Dilatação Patológica , Humanos , Estudos RetrospectivosRESUMO
Rapidly growing papillary fibroelastoma complicated by myxoma is extremely rare. An 80-year-old male was transported to our hospital because of cerebral hemorrhage. Echocardiogram revealed a massive pedunculated tumor in the septum of the left atrium. The tumor extended to the mitral valve orifice and posed a risk of strangulation, yet removing it immediately would have required cardiopulmonary bypass with anticoagulant, which would have posed a serious risk of rebleeding. Magnetic resonance imaging showed that the tumor stalk was sufficiently thick for us to perform a standby surgery 1 month after cerebral hemorrhage. Follow-up echocardiogram prior to this surgery revealed a new, high-mobility tumor in the right ventricular septum. We resected these two tumors together. Histopathological examination showed that the tumor of the left atrium was a myxoma and the tumor of the right ventricle was a papillary fibroelastoma. The patient had a good postoperative course and was discharged without complications.
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Objective: In this study, we report our experience using the frozen elephant trunk (FET) technique for chronic aortic dissection. Methods: Between January 2011 and December 2017, 15 patients underwent total arch replacement (TAR) with the FET technique for chronic aortic dissection (CAD). Results: Hospital mortality was 6.7% (n=1). No patients experienced spinal cord injury. Distal stent-induced new entry (dSINE) occurred in the early postoperative period in one patient. There were four unplanned additional operations to manage dSINE. Five patients suffered from dSINE, and aortoesophageal fistula developed in three of them. Short insertion length of the FET and large angle between the distal edge of the FET and the descending aorta were significantly more common in the dSINE group than in the non-dSINE group. The cumulative survival rates at 1, 3, and 5 years were 93.3%, 93.3%, and 66.4%, respectively. The cumulative aortic event-free rates at 1, 2, and 3 years were 85.7%, 77.1%, and 52.9%, respectively. Conclusion: The FET technique for CAD provided good early results. Short insertion length of the FET, however, can induce dSINE, which requires an additional operation at mid-term. Thus, surgical indication of the FET technique for CAD must be discussed.
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When patients with extensive mitral annular calcification undergo mitral valve replacement, excessive debridement of calcification may result in fatal complications and may protract operation time. We report a case of supra-annular MVR using "the chimney technique" on a high-risk patient for severe mitral stenosis with extensive mitral annular calcification. This technique is usually used in small infants whose mitral annulus is smaller than the smallest available prosthetic valve. We apply this technique to minimize the debridement of calcification and shorten the operation time. The operation was successfully completed, and the postoperative course has been uneventful. This technique was safely and easily performed, and eliminated the need for aggressive debridement of the calcification. We believe this technique may be a good choice for high-risk patients with mitral annular calcification.
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Calcinose/cirurgia , Implante de Prótese de Valva Cardíaca , Estenose da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Idoso , Anticoagulantes/administração & dosagem , Pressão Sanguínea , Calcinose/diagnóstico por imagem , Calcinose/etiologia , Ponte Cardiopulmonar , Ecocardiografia , Feminino , Cardiopatias Congênitas/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Insuficiência da Valva Mitral/cirurgia , Estenose da Valva Mitral/diagnóstico por imagem , Estenose da Valva Mitral/etiologia , Tomografia Computadorizada por Raios X , Varfarina/administração & dosagemRESUMO
INTRODUCTION: Aortoesophageal fistula (AEF) is a fatal complication results in sudden massive hematemesis. Although thoracic endovascular aortic repair (TEVAR) is an established method of treating aortic aneurysms or aortic dissection, the number of AEF after TEVAR is recently increasing due to the spread of TEVAR. However, the therapeutic strategy for AEF remains controversial. PRESENTATION OF CASE: We describe a 71-year-old man with Stanford B aortic dissection and aortic aneurysm rupture treated by TEVAR who developed AEF between the thoracic aorta and upper thoracic esophagus 20 months thereafter. We applied a three-step surgical procedure for this patient comprising resection of the esophagus as the infectious source, removal of an aortic aneurysm with stent-graft and replacement of the aorta, and final reconstruction of the esophagus. Thereafter, the patient resumed oral intake and has remained relapse-free for 24 months without adverse events. DISCUSSION: Previous reports have described simultaneous resection of the esophagus and aortic stent-graft via a left thoracotomy followed by a two-step surgical reconstruction of the esophagus. We applied a three-step procedure consisting of resections of the esophagus and aortic stent-graft on separate occasions followed by esophageal reconstruction in this patient. The first procedure in the three-step approach is less stressful than that of the two-step approach. CONCLUSION: The three-step surgical approach to treating AEF after TEVAR resulted in a good outcome for this patient. Thus, this surgical strategy is a useful option for treating AEF after TEVAR.
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We describe the case of a 71-year-old man with an asymptomatic saccular-type thoracic aortic aneurysm and severe atheroma in the distal arch. As he had previously undergone coronary artery bypass grafting, we decided to perform thoracic endovascular aortic repair rather than open repair to avoid injury to the bypass grafts. Owing to severe atheroma, we completely blocked the native forward flow before deploying the endograft using percutaneous cardiopulmonary support, thus preventing perioperative stroke.
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Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Stents , Acidente Vascular Cerebral/prevenção & controle , Idoso , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico , Humanos , Masculino , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
We present here a case of Kommerell diverticulum (KD) with annuloaortic ectasia, in which single-stage surgical repair was performed via a median sternotomy using frozen elephant trunk (FET) technique. We used this technique for the following reasons: firstly, we could perform surgery only via a median sternotomy without thoracotomy; secondly, we were able to deliver the FET using a guidewire through the severely angulated aortic arch. We here investigate this technique as it could potentially be a good treatment option of KD.
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Aneurisma Aórtico/complicações , Estenose Coronária/etiologia , Seio Aórtico , Idoso , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/cirurgia , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Ponte de Artéria Coronária , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/cirurgia , Feminino , Humanos , Seio Aórtico/diagnóstico por imagem , Seio Aórtico/cirurgia , Resultado do TratamentoRESUMO
We present a case of ruptured thoracic aortic aneurysm (TAA) with type B aortic dissection in which hybrid repair, namely, the frozen elephant trunk (FET) technique with thoracic endovascular aortic repair (TEVAR), was performed. The TAA extended to the proximal descending aorta at the level of the pulmonary trunk bifurcation. We thus employed the FET technique to control the blood flow into the TAA. After performing the FET technique, intraoperative catheter aortography revealed slight type 1B endoleak. We therefore performed additional TEVAR to control the blood flow into the TAA. The patient's postoperative course was uneventful.
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Neoplasias Cardíacas , Ventrículos do Coração , Ecocardiografia , Insuficiência Cardíaca , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/patologia , Neoplasias Cardíacas/cirurgia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/patologia , Ventrículos do Coração/cirurgia , HumanosRESUMO
Endovascular repair of pregnancy-associated aortic disease is controversial because the long-term result is still unclear. We report a rare case of early postpartum spontaneous aortic rupture that was successfully treated by endovascular repair, with a good midterm result. Multiangle thin-slice images of contrast-enhanced computed tomography revealed a very small rupture point. It was successfully repaired by minimally invasive treatment.
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Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Procedimentos Endovasculares/métodos , Período Pós-Parto , Stents , Adulto , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/diagnóstico , Feminino , Seguimentos , Humanos , Tomografia Computadorizada Multidetectores , Gravidez , Ruptura EspontâneaRESUMO
Surgical repair of extensive thoracic aortic disease induced by repeated aortic dissection is challenging due to its invasive nature in some cases. We report a rare case of successful endovascular repair of a dissected 3-channelled thoracic aortic aneurysm using the PETTICOAT (provisional extension to induce complete attachment) technique and false-lumen embolization (the candy-plug technique). The PETTICOAT technique improved visceral flow, and the false lumen of the aneurysm was completely thrombosed by the candy-plug technique. This minimally invasive combination technique might be a good option for the treatment of complex dissected thoracic aorta.
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Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Embolização Terapêutica , Procedimentos Endovasculares , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
Endovascular fenestration on the abdominal aorta is effective for preventing visceral malperfusion in aortic dissection. We report a case of stented balloon fenestration before residual entry repair using the frozen elephant trunk technique for chronic aneurysmal dissection after ascending aortic replacement for DeBakey I aortic dissection. We recognized poor communication between the true lumen and false lumen in the abdominal aorta, and visceral perfusion depended almost entirely on the proximal large entry. Therefore, we scheduled catheter angioplasty on the small re-entry before upstream entry closure. After balloon angioplasty using a PTA catheter, a 10-mm × 4-cm self-expandable stent was deployed at the re-entry. We performed open surgery 5 days after angioplasty. Computed tomography after entry repair showed complete thrombosis of the false lumen on the descending aorta, and the celiac and superior mesenteric arteries were supplied via the abdominal re-entry stent. Stented balloon fenestration before entry repair using frozen elephant trunk with chronic aortic dissection was effective for preventing visceral malperfusion.
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Angioplastia com Balão/métodos , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Imageamento Tridimensional , Stents , Tomografia Computadorizada por Raios X/métodos , Dissecção Aórtica/diagnóstico , Angioplastia , Aneurisma da Aorta Torácica/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , ReoperaçãoRESUMO
OBJECTIVES: We previously performed the frozen elephant trunk (FET) technique for acute type A aortic dissection to try to improve the long-term prognosis. In this study, we report the mid-term results of the FET technique for treating retrograde type A acute aortic dissection using a new device, the J Graft open stent graft (JOSG). METHODS: Between January 2008 and December 2015, 24 patients (mean age: 59.3 ± 13.9 years) underwent total arch replacement with the FET technique using the JOSG for retrograde type A acute aortic dissection. All patients had at least 1 year of follow-up imaging. RESULTS: The average outer diameter of the JOSG was 28 ± 2.8 mm (range: 25-35 mm). The average position of the distal edge of the JOSG was Th 6.6 ± 1.1. The cumulative survival rate at 1 year was 91.6%. Postoperative computed tomography 1 year after surgery showed that complete thrombosis was present in all patients at the level of the distal edge of the stent graft and the aortic valve. At the diaphragmatic level, complete thrombosis was seen in 14 (70%) patients, the false lumen was patent in most patients (90%) at the superior mesenteric artery level. CONCLUSIONS: The use of the FET technique with the JOSG for retrograde type A acute aortic dissection provides good outcomes. With the proper use of the JOSG, it is possible to expand the true lumen and eliminate antegrade false-lumen flow, resulting in good aortic remodelling. Furthermore, there should be obliteration of the false lumen from the stent graft to the aortic valve, and this might reduce long-term complications.
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Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/instrumentação , Stents , Remodelação Vascular , Doença Aguda , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/fisiopatologia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Tempo , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVES: Cerebral malperfusion for patients with acute type A aortic dissection (AAAD) remains an unsolved problem. The present study aimed to evaluate our management of cerebral perfusion and identify predictors of perioperative cerebral malperfusion in patients undergoing surgical repair of AAAD. METHODS: Between January 2004 and December 2015, 137 consecutive patients with AAAD underwent aortic replacement at Tsuchiya General Hospital. The status of the dissected supra-aortic branch vessels (SABVs) was classified as patent or thrombosis by preoperative computed tomographic angiography. Intraoperative cerebral perfusion was monitored by transcutaneous carotid echo and regional oxygen saturation. In cases with neurological symptoms or cerebral malperfusion, quick cerebral perfusion was immediately started using a quick cutdown technique. We assessed clinical outcomes, including mortality and complications, and analysed predictors of early mortality and cerebral malperfusion. RESULTS: The early mortality rate was 8.0%. Postoperative cerebral injury was observed in 4 patients (2.9%). Nineteen patients had perioperative cerebral malperfusion. There were no postoperative cerebral injuries in the patients in whom intraoperative cerebral malperfusion was corrected. Multivariable analysis revealed that preoperative shock (odds ratio [OR] 22.60, P < 0.0001) and extension of dissection to the abdominal aorta (OR 9.31, P = 0.0064) were significant risk factors for early mortality. Preoperative neurological symptoms (OR 12.40, P = 0.0006) and partial or complete thrombosis of the SABV (OR 64.10, P < 0.0001) were identified as independent predictors of perioperative cerebral malperfusion. CONCLUSIONS: Perioperative cerebral perfusion should be carefully managed, especially in the patients with preoperative neurological symptoms or partial or complete thrombosis of the SABV.
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Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Trombose Intracraniana , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Dissecção Aórtica/diagnóstico por imagem , Aneurisma Aórtico/diagnóstico por imagem , Circulação Cerebrovascular/fisiologia , Feminino , Humanos , Trombose Intracraniana/diagnóstico por imagem , Trombose Intracraniana/prevenção & controle , Trombose Intracraniana/terapia , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/terapia , Reperfusão , Fatores de RiscoRESUMO
We report a case of intimal injury caused by the occluder device in the false lumen (FL) after treatment of refractory chronic aortic dissection with FL embolization. We speculate that the intimal injury was due to the disproportionate stress from the FL. We covered the new entry by an additional stent graft in the true lumen. The deployment of a stent device in both lumens at the level of embolization might be indispensable for FL embolization.