What is the Optimal Proximal Landing Zone of the Stent Graft in Treatment of Aortic Type B Dissection?

PURPOSE: Retrograde type A aortic dissection (RTAD) represents a serious complication of endovascular treatment for type B aortic dissection (TBAD). To avoid RTAD, it is recommended to land the proximal end of the stent graft in a non-dissected aortic segment. In this study, we investigated whether landing in the dissection area increased the number of events at the proximal site. METHODS: We conducted a retrospective review of endovascular treatments for TBAD at a single institution between 2009 and 2022. Patients were divided into two groups: group A, with a proximal landing zone entirely within the dissected area, and group B, with the proximal extent of the seal zone in the non-dissected area. We evaluated the occurrence of proximal events, including RTAD, and examined long-term outcomes to assess the validity of landing in the dissection area. RESULTS: The study included eighty-nine patients who underwent endovascular treatment for TBAD. New intimal tears in the proximal landing site occurred in 3 cases (3.4%), with 1 case (2%) in group A and 2 cases (5.1%) in group B, showing no significant difference. Among the three cases, one (1.1%) in group B with zone 2 landing resulted in RTAD. At 60 months, the overall survival was 85%, and freedom from aorta-related mortality was 88%, with no significant difference between the groups. CONCLUSION: Even if the proximal landing is in a dissected area, a treatment strategy performed in zone 3 without proximal landing in zone 2, seeking a non-dissected area, can still provide sufficient therapeutic effects. Level of Evidence 3 Retrospective single-center cohort analysis.

Total arch replacement with frozen elephant trunk technique for Kommerell's diverticulum with a right-sided aortic arch and aberrant left subclavian artery.

BACKGROUND: Kommerell's diverticulum with a right-sided aortic arch and aberrant left subclavian artery is uncommon. We perforemed a single-stage procedure with the frozen elephant trunk technique. CASE PRESENTATION: A 62-year-old man underwent aortic dissection a year ago, and computerized tomographic angiography performed at that time revealed a right aortic arch, Kommerell's diverticulum (42 mm), and an aberrant left subclavian artery. We performed one-stage repair through median sternotomy. The cervical branches were exposed during the operation, and a deep hypothermic circulatory arrest with antegrade cerebral perfusion was established. The aorta was transected distally to the origin of the left carotid artery. We inserted a stent graft into the aorta, followed by peripheral anastomosis using a premade 5-branch Dacron graft. The right subclavian artery and the aorta were reconstructed, and the remaining cervical branches were reconstructed after the cross-clamp had been released. CONCLUSIONS: Total arch replacement through median sternotomy was performed for the right aortic arch, Kommerell's diverticulum, and aberrant left subclavian artery. The frozen elephant trunk technique is allowed to perform a one-stage operation safely.

Entry Site Is Associated With Aortic Enlargement After Pre-emptive Endovascular Repair for Uncomplicated Type B Aortic Dissection.

OBJECTIVES: We aimed to examine the mid-term results corresponding to the entry site in patients who underwent pre-emptive thoracic endovascular aortic aneurysm repair (TEVAR) for uncomplicated type B aortic dissection (TBAD). METHODS: We included 27 patients who underwent pre-emptive TEVAR for uncomplicated TBAD between September 2014 and December 2019. We divided the patients into 2 groups depending on the proximal landing zone (zone 2 group, zone ≥3 group) and retrospectively analyzed the risk of all-cause and aorta-related mortality, aortic events (rupture, open conversion, and secondary intervention), and aortic enlargement (≥5 mm). RESULTS: The median age of the patients was 53 (47-65) years. The median duration from the onset of uncomplicated TBAD to TEVAR was 43 (30-99) days, and the median follow-up duration was 48 (36-57) months. The maximum preoperative diameter of the dissected aorta was 40 mm in the zone 2 group and 35 mm in the zone ≥3 group (p=0.134). There was no case of hospital death or spinal cord ischemia; however, there was 1 (3.7%) case of perioperative stroke in the zone 2 group. Multivariate analysis of the risk factors for aortic enlargement following pre-emptive TEVAR for uncomplicated TBAD revealed that only zone 2 landing was an independent risk factor. The estimated Kaplan-Meier curve showed a higher rate of aortic enlargement in the zone 2 group at 4 years after pre-emptive TEVAR (46.4% vs 0%, log-rank test; p=0.011). CONCLUSIONS: In this study on TBAD, we found that zone 2 landing was associated with aortic enlargement after pre-emptive TEVAR. In cases where the distance from the left subclavian artery to a major entry point was short, there were more cases of aortic dilatation. CLINICAL IMPACT: The effectiveness of entry closure for type B aortic dissection was demonstrated in the INSTEAD XL trial. The cause of aortic enlargement after pre-emptive endovascular treatment for type B aortic dissection remains controversial. In the present study, zone 2 landing was a risk factor for aortic enlargement after pre-emptive thoracic endovascular aortic aneurysm repair (TEVAR) for uncomplicated type B dissection. Patients with zone 2 landing should be closely followed up after pre-emptive TEVAR.

Perivascular radiolucent line during recanalization of superficial femoral artery.

During the recanalization of chronic total occlusions in the superficial femoral artery, severe calcification adds technical difficulty in guidewire crossing due to poor ultrasound visualization and uncontrollable guidewire manipulation. Herein, we present the case of a 70-year-old man with chronic total occlusion of the superficial femoral artery to report the "perivascular radiolucent line" indicating aspirated air in the subintimal space, which could be noted after a failed subintimal angioplasty. The perivascular radiolucent line helped a safe guidewire tail crossing by making the vascular wall visible. Physicians should be aware of the perivascular radiolucent line in case of failed subintimal angioplasty.

Tracheo-innominate artery fistula with continuous bleeding successfully treated through the suprasternal approach: a case report.

BACKGROUND: Tracheo-innominate artery fistula (TIF) is a rare but fatal complication occurring after tracheotomy. Brachiocephalic trunk transection, one of the surgical treatments for TIF, is mostly associated with a full or partial median sternotomy. We describe a case of TIF with continuous bleeding, which was successfully treated with brachiocephalic trunk transection through a collar incision without the need for median sternotomy. CASE PRESENTATION: Case 1. An 18-year-old man was referred to our hospital with bleeding from a tracheal stoma, which had ceased prior to admission. TIF was suspected after examination. Innominate artery transection was performed through a collar incision. TIF was not revealed when we cut the innominate artery anterior wall open; therefore, we opted for preventive surgical intervention. The post-operative course was uneventful, and the patient was asymptomatic at the 3-year follow-up. Case 2. A 14-year-old male patient was admitted to our hospital with bleeding from a tracheal stoma, and TIF was suspected after examination. There was persistent bleeding when the cuff of the tracheotomy tube was deflated. Brachiocephalic trunk transection was performed through a collar incision using balloon occlusion. The post-operative course was uneventful, and rebleeding has not occurred 2 years later. CONCLUSIONS: Brachiocephalic trunk transection without any median sternotomy may offer the benefits of post-operative infection prevention. In patients with suspected continuous bleeding, using a balloon catheter may be a safe and effective method of treatment.

Priming and replenishment in cardiopulmonary bypass with hydroxyethyl starch 130/0.4 decreases fluid overbalance without renal dysfunction or bleeding in adult valve surgery.

The best priming and replenishment solution in cardiopulmonary bypass remains unknown, and the efficacy and drawbacks of artificial colloid are controversial. We retrospectively compared consecutive patients undergoing elective adult valve surgery in cases wherein cardiopulmonary bypass was primed and replenished with hydroxyethyl starch 130/0.4 (n = 12) or crystalloid solution (n = 11). The fluid overbalance during cardiopulmonary bypass was much lower in the hydroxyethyl starch 130/0.4 group (mean ± standard deviation, + 95 ± 1241 mL) than in the crystalloid solution group (+ 2921 ± 1984 mL) (P < 0.001). Renal function, intraoperative and postoperative bleeding, and blood products did not deteriorate with the use of hydroxyethyl starch 130/0.4. The postoperative intubation time was shorter in the hydroxyethyl starch 130/0.4 group (16.0 ± 2.6 h) than in the crystalloid solution group (18.7 ± 2.6 h) (P = 0.018). Although prospective randomized trials are needed to verify our findings, the impact of fluid balance differences requires serious consideration.

De-airing an open stent graft to potentially reduce spinal cord injury.

We have occasionally observed a bubble leaving the suture line of an open stent graft; hence, we hypothesized that de-airing an open stent graft could potentially reduce spinal cord injury. Postoperative computed tomography often showed residual air in thoracic aortic aneurysms, confirmed by the presence of a certain amount of air in an open stent graft in a dry lab. We filled CO2 in the sterilized package of an open stent graft and subsequently filled it with saline, which absorbed the CO2 and entered into the gap of the graft. The clinical benefit of de-airing an open stent graft to reduce the incidence of spinal cord injury needs to be evaluated.

Exophytic Atheroma Mimicking Papillary Fibroelastoma Adjacent to the Aortic Valve.

Follow-up echocardiography in a 69-year-old man with alcoholic cardiomyopathy showed a mass above the aortic valve near the left coronary ostium. Transesophageal echocardiography and computed tomography suggested a papillary fibroelastoma with a high risk of embolism. At operation we found an exophytic atheroma adjacent to the left coronary artery orifice. The atheroma was removed, and the patient made an uneventful recovery. We describe this very rare case of an exophytic atheroma mimicking a papillary fibroelastoma situated at the left coronary orifice.

Cuff leakage, not paravalvular leakage, in the Carpentier Edwards PERIMOUNT Magna Ease aortic bioprosthesis.

Though the Carpentier Edwards PERIMOUNT Magna Ease valve is a bioprosthesis with documented excellent haemodynamics and easy implantability, this valve has a gap between the cobalt-chromium-nickel alloy stent and silicone sewing ring. This gap, which is widest just below each of the three commissural struts, lacks silicone and leaves the two-layer polytetrafluoroethylene fabric unsupported and unprotected. If the needle of a valve suture is placed in this structurally weak area of the sewing ring, the resultant fabric tear may result in a true cuff leakage, not the usual paravalvular leakage. We describe this pitfall in the context of a recent operation to alert surgeons everywhere that suture placement too close to the stent (missing the silicone sewing ring) can result in postoperative cuff leakage. We need to be very careful to include the silicone ring in each stitch to prevent injury to the valve cuff of this prosthesis and to avoid cuff leakage.

An easy and useful exposure technique using a malleable u-shaped retractor for proximal anastomosis in abdominal aortic replacement.

During surgery for an abdominal aortic aneurysm, various problems can occur at the proximal anastomosis. Adequate exposure must be secured, and the proximal anastomosis must be sutured firmly. We have used a malleable U-shaped retractor to easily secure exposure of the proximal anastomosis. Despite recent advances in endovascular treatment, abdominal aortic aneurysm repair often requires open surgery. We describe our malleable U-shaped retractor technique, which is very easy and facilitates the creation of a secure proximal anastomosis.