[Efficacy of Distal Perfusion During Frozen Elephant Trunk Procedure:Continuous Perfusion Versus Intermittent Perfusion]

PURPOSE

To compare the effectiveness of continuous distal perfusion( CDP) with that of intermittent distal perfusion( IDP) during frozen elephant trunk( FET) procedures.

METHODS

There were 54 patients in the CDP group and 15 patients in the IDP group. There were no significant differences in preoperative characteristics between the two groups, but dissection was more common in the IDP group than in the CDP group, and the maximum aneurysmal diameter was larger in the CDP group than in the IDP group.

RESULTS

Emergency surgery was significantly more common in the IDP group than in the CDP group. Operating time, cardiopulmonary bypass time, lower body arrest time, and aortic cross-clamp time were significantly longer in the IDP group. Postoperative paraparesis occurred in one case in each group, and temporary paraparesis occurred in two cases in the CDP group, with no significant differences, including in mechanical ventilation time. There were two in-hospital deaths, one due to respiratory failure and one due to ischemic colitis, in the CDP group and one due to multiple organ failure in the IDP group. Postoperative liver and renal functions did not differ significantly between the two groups.

CONCLUSION

IDP has proven to be almost as effective as CDP during FET for preventing spinal cord ischemia and maintaining respiratory, liver, and renal functions.

Prediction Models for Two Year Overall Survival and Amputation Free Survival After Revascularisation for Chronic Limb Threatening Ischaemia

OBJECTIVE

The aim of this study was to create prediction models for two year overall survival (OS) and amputation free survival (AFS) after revascularisation in patients with chronic limb threatening ischaemia (CLTI).

METHODS

This was a retrospective analysis of prospectively collected multicentre registry data (JAPAN Critical Limb Ischaemia Database; JCLIMB). Data from 3 505 unique patients with CLTI who had undergone revascularisation from 2013 to 2017 were extracted from the JCLIMB for the analysis. The cohort was randomly divided into development (2 861 patients) and validation cohorts (644 patients). In the development cohort, multivariable risk models were constructed to predict two year OS and AFS using Cox proportional hazard regression analysis. These models were applied to the validation cohort and their performances were evaluated using Harrell's C index and calibration plots.

RESULTS

Kaplan-Meier estimates of two year OS and AFS post-revascularisation in the whole cohort were 69% and 62%, respectively. Strong predictors for OS consisted of age, activity, malignant neoplasm, chronic kidney disease (CKD), congestive heart failure (CHF), geriatric nutritional risk index (GNRI), and sex. Strong predictors for AFS included age, activity, malignant neoplasm, CKD, CHF, GNRI, body temperature, white blood cells, urgent revascularisation procedure, and sex. Prediction models for two year OS and AFS showed good discrimination with Harrell's C indexes of 0.73 (95% confidence interval [CI] 0.69 - 0.77) and 0.72 (95% CI 0.68 - 0.76), respectively CONCLUSION: Prediction models for two year OS and AFS post-revascularisation in patients with CLTI were created. They can assist in determining treatment strategies and serve as risk adjustment modalities for quality benchmarking for revascularisation in patients with CLTI at each facility.

[Initial and Long-term Results of Omental Flap Coverage for the Complications after Thoracic Aortic Aneurysm Repair]

OBJECTIVE

Here, we will review the initial remote results of omental flap coverage (OFC) after thoracic aortic aneurysm repair and report on its efficacy and problems.

METHODS

We performed 567 thoracic aortic aneurysm surgeries from January 2007 to December 2021, including OFC in 16 patients( 2.8%, 10 males, mean age 65 years:range 30-82 years) who underwent OFC.

RESULTS

OFC was performed in 14 cases of mediastinitis and 2 cases of perigraft seroma. 13 cases were performed at the same admission as the initial surgery, and 3 cases were performed after the discharge. The causative organisms of mediastinitis were methicillin-resistant Staphylococcus aureus (MRSA) in 4 cases, methicillin-resistant coagulase negative Staphylococcus( MRCNS) in 2 cases, Staphylococcus, Acinetobacter, Klebsiella, and methicillin-resistant Staphylococcus epidermidis( MRSE) in 1 case each, and unknown in 4 cases. All cases underwent successful reoperation with OFC alone, except in 1 case in which redo root replacement was performed for an anastomotic pseudoaneurysm. The overall hospital mortality was 31% (4 cases for MOF, 1 case for anastomotic hemorrhage). Of the 11 patients who were discharged alive, two died remotely (heart failure, senility), and no cases of reinfection were encountered.

CONCLUSION

OFC is an effective treatment not only for mediastinitis but also for perigraft seroma while significantly reducing the risk of reinfection.

Rapidly Progressed Distal Arch Aneurysm with Distal Open Stent Graft-Induced New Entry Caused by "Spring-Back" Force

The J Graft Open Stent Graft (JOSG) is used for the frozen elephant trunk procedure in Japan. We report a 70-year-old male who developed a rapidly progressing distal arch aneurysm caused by a distal stent graft-induced new entry (DSINE) 7 months after the procedure. The JOSG was originally implanted at the curved part of the distal arch. It created its initial DSINE on the greater curve and rapidly "sprang" back in 2 months. Urgent thoracic endovascular aortic repair fixed this serious complication. We should remember such rapid progression of DSINE by JOSG and treat its initial sign earlier.

[The Examination of Spring Back Force in Frozen Elephant Trunk;Matsui-Kitamura Stent versus J Graft Open Stent Graft]

OBJECTIVES

We examined the spring back force (SBF) in the frozen elephant trunk technique between patients receiving a Matsui-Kitamura stent (M group) or a J Graft Open Stent Graft (J group).

METHODS

There were 11 cases in the M group and 10 cases in the J group. For all cases, we performed computed tomography( CT) scan and measured distal arch angle( DAA) and stent graft angle (SGA).

RESULTS

There was no difference between groups with regards to patient characteristics. The insertion graft length[155±19 mm (M group) versus 138±17 mm (J group)]was significantly longer in the M group( p<0.05). In the J group, the SGA at 1 and 2 years postoperatively( 105°±18.5° and 114°±19.1°, respectively) were significantly increased compared to that at 1 month postoperatively (99.9°± 18.7°). In addition, the SGA in the J group was significantly larger than that in the M group during the postoperative period.

CONCLUSIONS

The SBF in the J group was thought to be significantly larger than that in the M group. SBF was thought to be associated with the stent frame characteristic.

Preemptive angioplasty for contralateral leg stenosis following EXCLUDER Iliac Branch Endoprosthesis implantation

The GORE EXCLUDER Iliac Branch Endoprosthesis (IBE) device is designed to seal off a common iliac artery (CIA) aneurysm, preserving the internal iliac artery during endovascular aortic repair. We report the case of an 84-year-old man with isolated saccular right CIA aneurysm (35 mm) and a relatively small terminal aorta (24 mm). The IBE device was successfully placed, and intraoperative angiography revealed no leakage or delay. However, postoperative computed tomography revealed marked compression of the contralateral leg by a bridging component. Although his ankle-brachial index was preserved, its acute occlusion was judged highly possible; we decided to perform preemptive angioplasty. The angiography revealed the stenosis only in the left anterior oblique view, and angioplasty was uneventfully performed. The leg was successfully patent at 1-year follow-up. When compression by IBE and bridging component in the terminal aorta is expected, caution should be preserved at intraoperative angiography following the device deployment.

What Did Endovascular Aortic Repair Bring for the Treatment Strategy of Abdominal Aortic Aneurysm?

Objective: We examined the effects of the introduction of endovascular aortic repair (EVAR) on treatment for abdominal aortic aneurysms (AAAs).

Subjects: We compared patients in the following three periods: period I (January 2002–December 2006, 105 patients), period II (January 2007–December 2011, 242 patients, duration of 5 years after the introduction of EVAR), and period III (January 2012–December 2016, 237 patients, duration of 5 years after period II). We used the American Society of Anesthesiologists (ASA) classification for risk assessment.

Results: In the Open repair (OR) group, the incidences of ASA class 2 increased and classes 3 and 4 decreased significantly in periods II and III compared with period I. In all periods, there were no in-hospital deaths. Suprarenal aortic cross-clamping was required in 18 patients (19.1%) in period III and 5 patients (6.3) in period I, and the difference was significant (P<0.05). In the EVAR group, no differences in age, sex, or ASA classification class were observed between periods II and III. In period II, one patient died due to aneurysm rupture during surgery. Significant differences were observed when comparing both groups in periods II and III: patients in the EVAR group were older (P<0.01) and the OR group had a higher proportion of ASA class 2 patients and the EVAR group had a higher proportion of ASA class 3 or 4 patients (P<0.01). Among all AAA surgeries, rupture occurred in 25 patients (23.8%) in period I, 18 patients (7.4) in period II, and 16 patients (6.8) in period III. The number of ruptures was significantly lower in periods II and III than in period I (P<0.01).

Conclusions: The findings of this study suggest that EVAR should be indicated for high-risk patients and had the good outcome of AAA treatment. (This is a translation of Jpn J Vasc Surg 2018; 27: 27–32.)

[Constrictive Pericarditis with Intractable Ascites after Aortic Valve Replacement;Report of a Case]

We report a 68-year-old man, who developed refractory ascites of unknown cause after aortic valve replacement. He was diagnosed with constrictive pericarditis because of "dip-and-plateau" waveform findings via cardiac catheterization and operated with cardiopulmonary bypass. Following waffle procedure, we incised pericardium for decompression, so that pericardial mobility and diastolic dysfunction was improved. Postoperative computed tomography (CT) image also showed decrease of ascites fluid. We concluded that pericardiotomy is an established surgical procedure and is excellent indication to constrictive pericarditis.

[Emergent Thoracic Endovascular Aortic Repair and Subxiphoid Pericardiotomy for Retrograde Type A Acute Aortic Dissection with Cardiac Tamponade;Report of a Case]

Type A acute aortic dissection has a high rate of mortality. Emergent surgical repair is the gold standard treatment, but some patients cannot tolerate the open surgery. Here, we report an 82-year-old patient with a history of cerebral infarction and cerebral bleeding who presented with a depressed level of consciousness and who was in a state of shock. A computed tomography (CT) scan showed cardiac tamponade associated with retrograde type A aortic dissection(RAAD), with a primary entry tear at a distal site of the left subclavian artery. We therefore performed emergent primary entry closure with stent grafting using the Conformable Gore Tag device and emergent drainage of the cardiac tamponade with subxiphoid pericardiotomy. Postoperative CT scan showed complete closure of the primary entry tear and a completely thrombosed false lumen. Primary entry closure with stent grafting could be an effective option for RAAD that meets anatomical criteria.

[Marked Aneurysmal Expansion Caused by Type II Endoleaks Eight Years after Thoracic Endovascular Aortic Repair;Report of a Case]

We report a case of marked aneurysmal expansion by type II endoleaks 8 years after thoracic endovascular aortic repair. The preoperative chest computed tomography (CT) demonstrated the descending thoracic aorta of 95 mm with type II endoleak. We performed suture closure of 3 endoleaks and partial aneurysmorrhaphy via left thoracotomy under partial cardiopulmonary bypass. The postoperative CT showed no endoleak with shrinkage of the aneurysm. The patient was discharged on the 21th postoperative day uneventfully.

[Efficacy of Total Debranching Thoracic Endovascular Aortic Repair for the Re-operation of Aortic Arch Aneurysm]

Thoracic endovascular aortic repair (TEVAR) combined with all-neck-branch reconstruction (total debranching TEVAR)[td TEVAR] is applied to aortic arch aneurysms as a minimally invasive procedure to improve treatment results. We report the initial and long-term results of td TEVAR for the reoperation of aortic arch aneurysm. By September 2016, td TEVAR for reoperation had been applied in 5 cases. The reasons for the reoperation were dilation of the arch aneurysm after ascending aorta replacement in 4 cases and localized dissection of the proximal landing zone after zone 2 TEVAR in 1 case. We reconstructed the neck branches under cardiopulmonary bypass (CPB). At that time, we kept in mind to perform anastomosis with an artificial graft at just above the sinus of Valsalva by using a single aortic clamp. Both the 30-day operative mortality and CPB-related complication rates were 0%. One patient had paraparesis, and one had left upper limb ischemia. Our strategy of td TEVAR provided durable results in the patients who underwent reoperation for aortic arch aneurysms.

[Strategy of Thoracic Endovascular Aortic Repair for Uncomplicated Type B Aortic Dissection in Subacute and Chronic Phase;Interval From Onset and Maximum Diameter]

We classified 59 patients who underwent thoracic endovascular aortic repair for uncomplicated type B aortic dissection from April 2008 to April 2016 into 3 groups based on time from onset and maximum aortic diameter:SA (2weeks to 1 year since onset;n=29), C (>1 year since onset;n=17), and D(maximum aneurysm size≥60 mm;n=13). We used the Kaplan-Meier method tso analyze survival, major adverse cardiovascular event and the need for additional treatment. There was no significant difference in outcomes between the SA and C groups (p=0.998) or C and D groups (p=0.279), but the results in group D tended to be consistently inferior. The freedom from aneurysm rupture rate was inferior in this group, with a significant difference between groups C and D (p=0.044). The time from onset to the procedure and maximum aortic diameter were not significantly associated with the longterm outcomes;however, more aortic ruptures occurred in the group with maximum aortic diameter≥60 mm. Simultaneous treatment for re-entry closure or conventional surgical procedures should be considered for such cases.

Graft-Wall Endoleak 18 Months after Successful Endoluminal AAA Repair

Purpose:

To describe a case of graft-wall endoleak 18 months after successful endoluminal repair of an abdominal aortic aneurysm (AAA).

Methods and Results:

A 71-year-old man with infrarenal AAA was successfully treated with an endoluminal aortomonoiliac graft and femorofemoral crossover bypass with surgical ligation of the right external iliac artery. The stent-graft was made from 2 Gianturco Z-stents and a tapered thin-walled (0.1-mm) Dacron graft. Eighteen months after endografting, the patient complained of a pulsatile abdominal mass. Angiography and computed tomography showed graft-wall endoleak. Aneurysmectomy was performed, and the aneurysm was successfully replaced with a Y-shaped knitted Dacron graft. A hole in the graft wall was found 3 cm from the proximal edge of the stent-graft.

Conclusions:

This case suggests that the use of thin-walled graft material in endografts may not be sufficiently durable.

The Appearance of Cytokines and Adhesion Molecules in Saphenous Vein Valves in Chronic Venous Insufficiency

Objective:

To evaluate the difference between competent valves and incompetent valves with regards to the development of expression of cytokines and adhesion molecules in primary varicose veins.

Methods:

Specimens were obtained from 13 patients with primary varicose veins during surgery. Valves were classified according to the angioscopic findings: 8 competent and 17 incompetent valves; type I (7 valves with elongated cusps) and type II (10 valves with expansion of commissures). The mRNA levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumour necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and endothelial leucocyte adhesion molecule-1 (ELAM-1) were measured by polymerase chain reaction (PCR) amplification of cDNA reverse-transcribed from RNAs.

Results:

In all cases there were few appearances of IL-6, IL-8 and TNF-α at the valve cusps. TGF-β and VCAM-1 levels were highly elevated in the cusps of incompetent valves compared with competent valves ( p<0.05). At the venous wall IL-6 and IL-8 occurred more frequently in incompetent valves than in competent valves ( p<0.05).

Conclusion:

This study suggests that inflammatory cytokines and adhesions molecules, especially TGF-β, IL-6, IL-8 and VCAM-1, may be related to the occurrence of valve insufficiency.

[Clinical Results of Thoracic Endovascular Aortic Repair (TEVAR) for the Treatment of Aortic Arch Aneruysm]

Thoracic endovascular aortic repair( TEVAR) combined of neck branch reconstruction( debranching TEVAR:dTEVAR) is applied to aortic arch aneurysm for minimally invasive reduction and improvement of treatment results. We report the initial and long-term results of dTEVAR for the treatment of aortic arch aneurysm. TEVAR for zone 0-2 area was applied in 49 cases (Zone 0:1:2;8:5:36 cases). Total dTEVAR was applied in zone 1 cases and 2 dTEVAR was performed in zone 2 cases. One dTEVAR or TEVAR with simple coverage of left subclavian artery was applied in zone 2 cases. Operative mortality within 30 days was 0% and there was 1 case in hospital death due to coronary arterial rupture after percutaneous coronary intervention. Perioperative morbidity included 1 case(2.0%) spinal cord ischemia, 4( 8.2%)arm claudication. In long-term follow-up, 5 cases died during the observation period (stroke in 1 case, heart failure in 1, neoplasma in 2, unknown in 1), but not in aortic rupture. Secondary type1 endoleak occurred in 2 cases(4.1%). Graft occlusion for neck branch reconstruction was complicated with 3 cases(6.1%), however no complications related to the graft occlusion. Our strategy of TEVAR provided durable results in patients treated for aortic arch aneurysm, with few adverse events.

Management strategy of isolated spontaneous dissection of the superior mesenteric artery

OBJECTIVE

Isolated spontaneous dissection of the superior mesenteric artery (SMA) is very rare among of the visceral artery dissection and its treatment is not established. In this paper we present our experiences and consider the treatment of isolated SMA dissection.

METHODS

A retrospective review of our cases from 2005 was performed. Clinical symptoms, radiologic findings and results were evaluated. There were 14 cases of visceral artery dissection, in which all cases were with SMA dissection. There were 12 males and 2 females with a mean age of 57 years (range 41-78 years).

RESULTS

We categorized SMA dissection into the six types according to the Sakamoto's and Zerbib's classification. One patient with type VI underwent emergent endovascular surgery with stent. One patient with type VI received thrombectomy and intimectomy with open surgery. One patient with type II underwent aneurysmectomy due to enlarged dissected SMA 3 months later from onset. The other eleven patients were managed conservatively. At follow-up, the diameter of SMA did not enlarged and the length of the dissection significantly decreased to 20.7 ± 15.7 mm from 38.0 ± 15.1 mm at onset (p <0.01). After treatment, imaging indicated the following changes in classification: type I, one patient; type II, 4 patients; type IV, 4 patients; complete remodeling, one patient, all without any event during the follow-up period of 5-82 months.

CONCLUSION

Most patients with isolated visceral artery dissection occurred in superior mesenteric artery and can be treated conservatively; however, endovascular or surgical procedures including laparotomy are indicated when there is suspicion of severe mesenteric ischemia. Because the dissection configuration will change, long term follow-up is necessary. (English translation of Jpn J Vasc Surg 2013; 22: 695-701).

Long-term results of open stent-grafting using a Matsui-Kitamura stent to treat thoracic aortic aneurysm

PURPOSE

We describe a retrospective study of initial and long-term outcomes with an open stent grafting (OSG) with a Matsui-Kitamura stent for treating thoracic aortic aneurysm.

METHODS

Between August 2005 and September 2013, 50 patients with aortic arch disease extending to the descending aorta underwent OSG. Circulatory arrest with total cardiopulmonary bypass and selective cerebral perfusion were used, and the aorta was transected between the brachiocephalic and left subclavian artery. The stent-graft was inserted, sutured to a transected aortic edge, and anastomosed to a four-branched arch graft. Preoperative, operative, and short- and long-term postoperative data were obtained from the patients' medical records.

RESULTS

The perioperative (within 30 days) mortality rate was 8%. Two patients (4%) had a stroke and 5 patients (10%) had a spinal cord injury resulting in paraplegia or paraparesis (1 patient each) or transient paraplegia (3 patients). Actuarial survival rates at 1, 3, 5, and 7 years postoperatively were 87.8%, 78.3%, 70.7%, and 65.3%, respectively; the rates of freedom from an aortic event were 100%, 89.1%, 82.2%, and 74.7%. There were no complications related to use of the stent-graft.

CONCLUSION

Our OSG method provided durable results in patients treated for thoracic aortic aneurysm, with few adverse events.

[Long-term results of open stent-grafting applied with a Matsui-Kitamura( MK) stent in treatment of arch aneurysm]

We report the initial and long-term results of open stent-grafting (OSG) applied with a Matsui-Kitamura (MK) stent in the treatment of thoracic aortic aneurysm (TAA). From August 2005 to March 2013, OSG for TAA was applied in 46 cases( male/female, 36/10, 54-86 years old, mean age 71). During deep hypothermic circulatory arrest with antegrade selective cerebral perfusion, stent graft was delivered through the transected proximal aortic arch, followed by arch replacement with a 4-branched prosthesis. Operative mortality within 30 days was 6.5%(respiratory failure in 1, multiple organ failure in 1and ischemic enteritis in 1) and there was 1 in hospital death due to brain stem infarction. Perioperative morbidity included 2( 4.3%) stroke, 5( 10.9%) spinal cord injuries( paraplegia in 1, paraparesis in 1 and transient paraparesis in 3). In long-term follow-up, survival was 86.8%, 77.2%, and 72.0% for 1, 3 and 5 years. Freedom from aortic event was 97.3%, 93.8% and 89.1% for 1, 3 and 5 years. Theseresults suggested the OSG method applied with a MK stent is a useful surgical procedure for the treatment of TAA.

Four-dimensional geometric assessment of tricuspid annulus movement in early functional tricuspid regurgitation patients indicates decreased longitudinal flexibility

OBJECTIVES

Functional tricuspid regurgitation (FTR) is generally caused by the dilation of the tricuspid annulus (TA) and the tethering of tricuspid leaflets; however, it also occurs in patients without dilatation of the TA. The aim of this study was to develop and to use a four-dimensional tracking system, utilizing cardiac magnetic resonance imaging (MRI), and to assess TA flexibility in patients with early FTR without right ventricle dilation as a preliminary investigation for the mechanism of early FTR.

METHODS

The structure and movement of the TA were examined in 20 healthy subjects and 19 FTR patients whose right ventricle was not dilated. We analysed the short axis and longitudinal movement of a mid-septal point (S), a mid-lateral point (L), a mid-anterior point (A) and a mid-posterior point (P) on the TA throughout the cardiac cycle. The tethering distance of the tricuspid leaflets and the integrated orbiting volume of the TA were also measured.

RESULTS

The TA area (mm(2)) and AP and LS distances (mm) did not differ significantly between the two groups, but the longitudinally moving distances (mm) of the four points were significantly shorter in patients with FTR than in healthy subjects. Also, the mean tethering distance (mm) was significantly longer in patients with FTR than in healthy subjects (9.0 ± 1.5 vs 4.0 ± 1.3, respectively; P < 0.001), and the integrated volume (mm(3)) of the annular moving track, throughout the cardiac cycle, was significantly larger in healthy subjects than in patients with FTR (40 428 ± 10 951 vs 22 967 ± 6079, P < 0.001).

CONCLUSIONS

The longitudinal flexibility of the TA in FTR patients was significantly less than that in the healthy subjects, and the tethering of the tricuspid leaflets occurred in FTR patients despite the absence of TA and RV dilation, which can be one triggering factor of early FTR. Four-dimensional geometric assessment, using cardiac MRI and the tracking program that we have developed, is capable of determining TA structure and flexibility.

Acute aortic regurgitation due to local avulsion of the aortic valve commissure

A 69-year-old man was transferred to our hospital because of sudden onset precordial pain and dyspnea. Transesophageal echocardiography revealed massive aortic regurgitation, diastolic separation of the closure line of the aortic cusps and prolapsing motion of the cusps during diastolic toward the left ventricular outflow tract. Aortic valve replacement was successfully performed. During the operation, we found a commissure between the left coronary cusp and the non-coronary cusp that had avulsed from the aortic wall and prolapsed into the left ventricular outflow tract. Valvular cusps were excised and replaced with a mechanical prosthesis. The postoperative course was uneventful and the patient was discharged from the hospital, 25 days after his operation. The histopathological examination showed fibrosis, hyalinosis of the avulsed commissure, and mucoid degeneration of the valve. There was no evidence of pathologic changes, such as aortitis, infective endocarditis, or specific connective tissue disorders.

Open aortic stent grafting and prosthetic bypass in a child

Pseudoaneurysm is a major complication of percutaneous balloon angioplasty to treat recoarctation and restenosis after an interrupted aortic arch repair. Endovascular stent grafting to manage this complication has rarely been performed in children. We used a combination of open stent grafting and a prosthetic ascending aorta-to-descending aorta bypass to treat a pseudoaneurysm and ascending aorta stenosis in a 7-year-old child.

[Open stent-grafting using the Matsui-Kitamura stent for a distal arch aneurysm; an idea for insertion of stent graft and organ protection]

For the improvement in the clinical results of open stent-grafting, the development of a device system and prevention of spinal cord injury are important. For that reasons, we devised 2 methods for the open stent-grafting with the Matsui-Kitamura (MK) stent. First, the applicator using transesophagial echo transducer cover made insertion of the stent-graft system easy and safe. Next, to prevent ischemic spinal injury and protect major abdominal organ, blood return to lower body was established from femoral artery with occluding the stent graft by balloon. However, these procedures might need to examine whether it really contributes to the improvement in the clinical results.

Correlation between Changes in Leg Blood Flow and Ankle-Brachial Pressure Index: A Study Using Laser Doppler Flowmeter -The 1st Report-

OBJECTIVE

The objective of this study was to use non-invasive laser Doppler flowmeter to measure changes in blood flow in peripheral vessels in the legs before and after stress induced by leg elevation stress test and investigate correlations with the ankle-brachial pressure index (ABI).

METHODS

Subjects included 28 patients over 20 years of age (mean, 73 years) who reported chiefly of leg symptoms such as intermittent claudication, numbness, chills, or cramps had been examined at the study institution, and agreed to participate in the study. The ABI of both legs was measured, and patients were divided into two groups: low ABI (ABI ≤0.9) and normal ABI (ABI ≥0.9). Blood flow in the big toe was measured using a box-type laser Doppler flowmeter before, during, and after leg-elevation stress. Amplitude of the recorded waveform and changes in blood flow were compared.

RESULTS

Average ABI was 1.09 ± 0.10 in the normal ABI group (33 legs) and 0.68 ± 0.17 in the low ABI group (21 legs). Amplitude before and during stress was significantly smaller in the low ABI group than in the normal ABI group (p <0.01), and there was a significant correlation with ABI before and during stresses (r = 0.4606, r = 0.5048, respectively; p <0.05). Change in blood flow during stress was significantly lower in the low ABI group than in the normal ABI group (p <0.05). There was a significant correlation between change in blood flow during stress and ABI in both groups (r = 0.5073; p <0.05). There was also a significant correlation between change in blood flow and change in amplitude in both groups (r = 0.5477; p <0.05).

CONCLUSION

RESULTS of this study show, that comparing amplitude and change in blood flow before and after leg extension and elevation stress, there was a correlation between change in blood flow and amplitude, and ABI during stress. A box-type laser Doppler flowmeter may provide a means of screening for peripheral arterial disease.

Use of a Matsui-Kitamura stent-graft for endovascular repair of patent ductus arteriosus in an adult patient

Open surgical repair of patent ductus arteriosus is difficult in the case of elderly patients because of calcification of the duct and the possibility of rupture. Furthermore, endovascular repair with the use of a coil or an occluding device poses problems such as residual shunt or migration of the device. We describe a case wherein closure of a large patent ductus arteriosus in an adult patient was achieved using a Matsui-Kitamura curved nitinol stent-graft.

Endovascular Repair of a Kommerell's Diverticulum and Aneurysmal Right-sided Aortic Arch: A Case Report

Right-sided aortic arch with aberrant left subclavian artery is an uncommon anomaly. We describe a case of Kommerell's diverticulum involving the distal portion of a right-sided aortic arch and the origin of an aberrant left subclavian artery in a 74-year-old man with hoarseness. The patient underwent successful endovascular repair of the aneurysm with use of a Gore TAG thoracic endoprosthesis and coil embolization of the left subclavian artery. Postoperative computed tomography showed complete exclusion of the lesion, without endoleaks. Endovascular repair is feasible and can be effective in such cases.

Emergency endovascular repair of a ruptured descending thoracic aortic aneurysm in an octogenarian: report of a case

Emergency conventional surgical repair of the descending thoracic aorta remains a therapeutic challenge and is associated with a high risk of mortality. We describe a case of ruptured descending thoracic aortic aneurysm in an 87-year-old man who presented with chest and back pain. The patient underwent successful endovascular repair of the lesion with the use of Gore TAG thoracic endoprosthesis. Post-procedure computed tomography showed complete exclusion of the aneurysm without endoleaks. Endovascular repair is feasible and can be effective in such cases.

[A prosthetic ring annuloplasty with edge-to-edge repair for a treatment of severe tricuspid regurgitation]

A 59-year-old woman admitted to our hospital with shortness of breath and edema of the lower extremities was diagnosed with right ventricular failure stemming from severe tricuspid valve regurgitation (TR). She had undergone mitral valve replacement (MVR) with a mechanical valve at the age of 42. The approach to the heart was established via a right thoracotomy at the 4th intercostals space. A beating heart cardiopulmonary bypass procedure was performed in which tricuspid valve repair was performed with the edge-to-edge repair and MC3 annuloplasty system. The operative course was uneventful. This technique may be feasible and clinically effective in the treatment of severe TR.

Changes of low back pain after vascular reconstruction for abdominal aortic aneurysm and high aortic occlusion: a retrospective study

BACKGROUND

The purpose of the present study is to clarify the influence of acute and chronic interruption of blood flow from lumbar arteries as well as the influence of vascular reconstruction on low back pain, back muscles, and lumbar discs.

METHODS

Subjects were 34 patients with AAA in whom vascular reconstruction was performed. A second group was comprised of 9 patients with HAO. The presence of low back pain before surgery and at follow-up examination was retrospectively examined in the AAA group and the HAO group to investigate postoperative changes. The CSA and degeneration of the multifidus muscle and the lumbar discs on magnetic resonance imaging were assessed in the AAA group and control group.

RESULTS

Low back pain, significant atrophy, or degeneration of the multifidus muscle or degeneration of the lumbar disc did not newly develop after surgery in the AAA group. These results indicated that acute interruption of lumbar arteries did not induce the development or deterioration of low back pain and organic changes in the back muscles or lumbar discs. The frequency of low back pain before surgery was significantly higher in the HAO group than that in the AAA group. However, the frequency of low back pain after surgery did not differ significantly between the 2 groups because low back pain in the HAO group was improved after surgery.

CONCLUSION

The finding that low back pain was improved by merely performing treatment for the vascular system might provide support for the presence of vascular backache.

[Open stent-grafting applied with the Matsui-Kitamura stent to a distal arch aneurysm]

An open stent-grafting applied with the Matsui-Kitamura (MK) stent to a distal arch aneurysm is presented herein. The graft using the MK stent at its distal end was successfully inserted into the descending thoracic aorta through a J-shaped sheath-introducer. The major advantages of this stent-graft include its flexibility, shape memory, and small profile when compressed, compared with other devices. This technique may be feasible and clinically effective in the treatment of distal arch aneurysm.

Morphological study of abdominal aortic aneurysm: optimal stent-graft size for Japanese patients

PURPOSE

We report on the optimal stent-graft (SG) size for Japanese patients with abdominal aortic aneurysm (AAA).

MATERIALS AND METHODS

Ninety three Japanese patients undergoing elective AAA repair were selected for this study. The parameters measured were the proximal neck (PN) diameter (D1), the diameter of the right and left common iliac arteries (D2 and D3, respectively), the diameter of the right and left external iliac arteries (D4 and D5, respectively), the distance between the lowest renal artery and the common iliac arterial bifurcation (L1), and the distance between the right and left common iliac arterial bifurcations and the internal iliac arterial bifurcation (L2 and L3, respectively).

RESULTS

The following results were obtained: D1: 20.7+/-3.9 mm (14 to 28 mm); D2: 14.0+/-3.0 mm (9.5 to 20 mm); D3: 13.8+/-3.1 mm (9 to 19.5 mm); D4: 7.5+/-1.0 mm (6 to 10 mm); D5: 7.4+/-0.9 mm (6 to 10 mm); L1: 107.7+/-13.4 mm (80 to 130 mm); L2: 40.0+/-10.1 mm (20 to 61 mm); L3: 39.7+/-9.6 mm (20 to 60 mm).

CONCLUSION

The results indicate the necessity of exercising adequate care when selecting a device for Japanese patients.

Valve-on-valve technique for replacement of degenerated tricuspid bioprosthetic valve without explantation

A 73-year-old woman admitted to our hospital with shortness of breath and edema of the lower extremities was diagnosed with right ventricular failure stemming from tricuspid valve regurgitation. She had undergone mitral valve replacement (MVR) with a mechanical valve at the age of 51, and reoperative MVR with mechanical valve, tricuspid valve replacement (TVR) with bioprosthetic valve, and pacemaker implantation at the age of 63. Reoperative TVR was performed when the patient failed to respond to drug therapy. A beating heart cardiopulmonary bypass procedure was performed in which only the bioprosthetic valve leaflet was excised, and reoperative TVR was performed with a 27-mm OptiForm mechanical mitral valve (Sulzer Carbomedics Inc., Austin, TX, USA) by the valve-on-valve technique. The operative course was uneventful. The technique used here appears to be an effective approach to reoperative TVR, in this instance making it possible to avoid the risks associated with excision of the old prosthesis.

Intermittent pneumatic compression of the foot and calf improves the outcome of catheter-directed thrombolysis using low-dose urokinase in patients with acute proximal venous thrombosis of the leg

OBJECTIVE

Catheter-directed thrombolysis (CDT) is a promising treatment of acute proximal deep vein thrombosis (DVT) to prevent the postthrombotic syndrome by early removal of thrombus. During CDT for DVT patients, the calf muscle pump is compromised because of immobility. Intermittent pneumatic compression (IPC) can be used to increase venous flow during bed rest. The CDT with IPC may lyse venous thrombus better than CDT alone. The purpose of this study was to evaluate the efficiency and safety of IPC during CDT for DVT using low-dose urokinase.

METHODS

Twenty-four patients with proximal DVT confirmed by duplex ultrasonography underwent CDT alone (10 cases) and CDT with IPC and a temporary inferior vena cava filter (14 cases) for 3 to 6 days. Pulmonary emboli (PEs) were assessed by pretreatment and posttreatment pulmonary angiogram or spiral computed tomography of the chest, and in the CDT/IPC patients, a posttreatment inferior vena cavogram was performed. The initial results were evaluated by venogram immediately after CDT, and the late results were evaluated by venous disability score and duplex ultrasonography 6 to 36 months after treatment.

RESULTS

There was no symptomatic PE in either group. In CDT with IPC, one new asymptomatic PE was found, but there was no large thrombus in the inferior vena cava. The initial thrombolytic results of CDT with IPC were better than those of CDT alone (five cases of complete lysis in the CDT/IPC group and none in the CDT alone group). In the follow-up, the deep veins were patent and competent in 43% (6/14) in the CDT/IPC group, compared with 17% (1/6) in the CDT-alone group. The venous disability score showed that the CDT/IPC group had less disability than the CDT-alone group.

CONCLUSIONS

This pilot study showed that adding IPC to CDT using low-dose urokinase for DVT treatment of the leg resulted in better early and late outcomes compared with CDT alone and was not associated with an increased risk of symptomatic PEs.

Long-term results of endoluminal grafting for descending thoracic aortic aneurysms

OBJECTIVE

This paper describes the long-term results of endoluminal grafting (EG) for the treatment of descending thoracic aortic aneurysms (dTAA).

METHODS

Until July 2004, EG for dTAA has been applied in 45 cases (male/female, 29/16, 49-86 years old, mean age 67 years old). Locations included the proximal dTAA in 24 cases, and middle or distal dTAA in 21 cases. The stent-grafts (SGs) were constructed of Gianturco Z-stents covered with woven polyester grafts.

RESULTS

Deployment of the SGs was successful in 43 of 45 cases (96%) and complete thrombosis of the aneurysm was achieved in 39 cases (87%). Six minor endoleaks (13%), one migration (2%) and one conversion to surgery (2%) occurred. There was no instance of paraplegia nor hospital death. Over a mean 48 month follow-up (range 3 to 90), there were three persistent endoleaks (6%), four secondary endoleaks (8%), one breakage of wire frame (2%). Four cases were converted to open surgery due to secondary endoleak. There were two aneurysmal ruptures at the site where EG was not performed. The cumulative survival rate was 95.6 +/- 4.4% at 12 months, 85.7 +/- 5.4% at 24 months, and 82.4 +/- 6.1% at 36 and 60 months.

CONCLUSION

These results demonstrated that EG is safe and effective in selected dTAA patients. Improvements in patients selection, surgical techniques and equipment will reduce EG related complications and conversion to open repair over the course of the evaluation.

Clinical Results of Radiofrequency Endovenous Obliteration for Varicose Veins

PURPOSE

Radiofrequency (RF) endovenous obliteration is performed in the United States and several European countries for the minimally invasive treatment of saphenous-type varicose veins. We evaluated the clinical results of RF endovenous obliteration to treat varicose veins at Fukushima Daiichi Hospital.

METHODS

We performed endovenous obliteration of 25 great saphenous varicose veins in 20 patients, under duplex ultrasound guidance. None of the varicose veins were tortuous in the thigh area. Venous occlusion was evaluated by duplex ultrasound under cuff compression with the patient standing, preoperatively, then 1 day and 1 month postoperatively.

RESULTS

Saphenous obstruction was confirmed in all legs 1 day and 1 month postoperatively, as complete obstruction from the saphenofemoral junction in 1, as complete obstruction with only superficial epigastric venous flow in 23, and as near complete obstruction (patent length > 5 cm) in 1. The venous obstruction was caused by shrinkage of the vein (31.2% of the area at the saphenofemoral junction, 44% at the thigh, and 57.7% at the knee) and thrombus formation. The only complications of RF endovenous obliteration were clinical superficial thrombophlebitis (13%) and temporal sensory nerve injury (4%).

CONCLUSION

Radiofrequency endovenous obliteration is as effective as, but less invasive than other treatments for saphenous varicose veins.

[Open stent-grafting for a distal aortic arch aneurysm with a endotracheal tube]

An open stent-grafting for a distal aortic arch aneurysm with a endotracheal tube is presented herein. The graft which has a Gianturco Z stent at its distal end was successfully inserted into the descending thoracic aorta through a endotracheal tube without fluoroscopy. This technique might easily deploy the stent-graft without damage of aortic wall compared with other deployment methods.

Clinical results of open stent grafting applied using an improved endotracheal tube in the treatment of high-risk patients with distal arch aneurysms

Whereas the operative results for thoracic aortic aneurysms (TAA) have improved in recent years, the results for distal arch aneurysms (DAA) remain unsatisfactory. We report herein the initial results of open stent grafting (OSG) applied using an improved endotracheal tube for surgical treatment of high-risk DAA. OSG was used to treat DAA in five men aged 69-80 years (mean, 77 years). Four cases involved chronic obstructive pulmonary disease, and the remaining case involved both ischemic heart disease and chronic renal failure. Previous surgical repairs of an abdominal aortic aneurysm had been performed in four patients, and thoracoplasty and reconstruction of the lower extremities had been performed in the remaining patient. Under selective cerebral perfusion, OSG with revascularization of two cerebral branches was performed in two patients, whereas OSG with total arch replacement was performed in three patients. The procedure was successful in all cases. There were no complications related to cerebrospinal disorders, and complete thrombosis of the aneurismal sac was achieved in all cases. The new deployment method using an endotracheal tube offers numerous advantages, including reduced aortic wall injury and accurate placement of the stent graft in the operative field. These initial results suggest that this specific approach makes OSG a useful surgical procedure in the treatment of high-risk DAA.

Simultaneous open abdominal aortic replacement and thoracic stent-graft placement: report of a case

A 77-year-old man with severe chronic obstructive pulmonary disease was admitted to our hospital for surgical treatment of a proximal descending thoracic aortic aneurysm (dTAA) and an infrarenal abdominal aortic aneurysm (AAA). The patient had poor respiratory function; however, a simultaneous abdominal aortic replacement and thoracic stent-graft placement were successfully performed without any complications. This case report demonstrates that simultaneous abdominal aortic replacement and thoracic stent-graft placement for multiple aneurysms may be feasible and can safely be performed in selected high-risk patients, despite the many problems associated with the treatment of aortic aneurysms using stent grafts.

[Off-pump coronary artery bypass grafting for restenosis after coronary angioplasty in the patient with left main shock syndrome]

A case of left main shock syndrome due to total occlusion of left main trunk was reported. A 65-year-old man with acute myocardial infarction developed cardiogenic shock shortly after admission. An emergency coronary angiogram revealed total occlusion of the left main trunk without collaterals. Immediately, a stent was implanted in the left main trunk and the lesion was successfully improved. However, the left coronary angiogram revealed 90% restenosis of the left main trunk in a coronary angiogram examined 6 months after stent placement. Since the patient suffered from poor cardiac function, off-pump coronary artery bypass grafting (left internal thoracic artery to left descending coronary artery) was successfully performed using an intracoronary shunt. No complications were observed.

[Application of transluminally place endoluminal prosthetic grafts for the treatment of multiple aortic aneurysms]

We have 5 cases with multiple aortic aneurysms who have undergone conventional abdominal aortic replacement with transluminally placed endoluminal prosthetic grafts (TPEGs) into the descending thoracic aorta. Simultaneous operation was done in one patient. A 2-stage operation was done in 4 patients, and the abdominal aortic aneurysm was performed on the first. One patient required urgent surgical intervention to treat migration of a stent-graft. However, there was no hospital death. The mean follow-up interval was 34 months and there were no complications correlated with the procedures. Application of TPEGs for the treatment of multiple aortic aneurysms may be a valuable treatment option.

Results of 256 consecutive abdominal aortic aneurysm repairs using extraperitoneal approach

Two hundred and fifty-six consecutive abdominal aortic aneurysms were repaired using three approaches for extraperitoneal exposure of the aorta and iliac vessels from February 1990 through September 1998. The perioperative mortality rate was 3.1% in 228 elective repairs and 14.3% in 28 ruptured cases. The initial 23 cases were repaired using Sicard's method. The duration of endotracheal intubation was 1.0+/-2.8 h, alimentation initiation was 2.7+/-1.6 days, and narcotic requirements were 1.2+/-1.1 times. Following these initial cases, we employed Williams' method for 192 abdominal aneurysms, however; repeated incisional pain and three cases of deforming bulge led us to avoid dividing muscles. In the last 13 cases, our approach was performed without muscle dividing. The narcotic requirements decreased to 0.3+/-0.7 times. As for postoperative complications, the larger skin incision approach had no shower embolism. However, the shorter skin incision had four cases of shower embolisms, one lymphorrhea and one vascular trauma by the aortic clamp. The extraperitoneal approach offers certain physiologic advantages with minimal disturbance of gastrointestinal and respiratory function. We believe that this method is useful for rapid approach to the proximal aorta in case of emergency. Postoperative wound complications could be prevented via an oblique incision without muscle dividing.

Severe Subarachnoid Hemorrhage With Pulmonary Edema Successfully Treated by Intra-aneurysmal Embolization Using Guglielmi Detachable Coils. Two Case Reports

A 48-year-old male and a 39-year-old female presented with subarachnoid hemorrhage (SAH) due to ruptured anterior communicating artery aneurysms. Both patients were comatose on admission. Chest radiography disclosed pulmonary edema. They were conservatively treated under controlled ventilation, but cardiopulmonary dysfunction persisted over 2 days. The patients were then treated by intra-aneurysmal embolization with Guglielmi detachable coils (GDCs) 2 days after the onset. The postoperative courses were uneventful, and the patients showed full recovery from pulmonary edema and were discharged without neurological deficits. Neurogenic pulmonary edema is one of the serious complications of SAH, and is a leading cause of poor clinical outcome. The favorable outcomes of the present cases suggest that intra-aneurysmal embolization with GDCs is an excellent choice for the patients with severe aneurysmal SAH complicated with pulmonary edema, in whom conventional surgical treatment under general anesthesia is difficult to perform in the acute stage.

Prevention of paraplegia in transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms

OBJECTIVE

To evaluate the efficacy of a temporary balloon occlusion test for the prevention of paraplegia following transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms.

SUBJECTS AND METHODS

Two occlusion balloons were inserted via the brachial and femoral arteries and positioned in the proximal and distal neck of the descending thoracic aortic aneurysms using fluoroscopy. After temporary occlusion of the thoracic aorta by inflation of both the proximal and distal balloons, the evoked spinal potential was measured for 15 mins. A maximum amplitude during temporary balloon occlusion test decreasing by more than 20% of the pre-balloon occlusion level was considered to be significant, enough to not perform transluminally placed endoluminal prosthetic grafts, but instead an open repair. The test was applied in 12 cases (9 males and 3 females, 50-86 years old). All aneurysms were located between the Th6 and Th12 with a maximum diameter of 40-70 mm, and average of 56 mm.

RESULTS

The changes in maximum amplitude of evoked spinal potential remained within 20% of the value before balloon occlusion in 11 cases. Transluminally placed endoluminal prosthetic grafts were performed in these 11 cases and no instance of paraplegia or other complication relating to the test was observed. Deployment of stent-grafts was successful in 10 cases (91%).

CONCLUSION

It is suggested that the preoperative measurement of evoked spinal potential during temporary balloon occlusion is clinically useful for the assessment of the risk to paraplegia occurring in transluminally placed endoluminal prosthetic grafts.

Preoperative cerebrovascular screening before cardiovascular surgery in a high risk area of cerebrovascular events in Japan

BACKGROUND

Cerebrovascular disease and cervical artery diseases are potentially treatable conditions that are associated with an increased incidence of stroke after cardiac surgery. This prospective study was designed to determine the prevalence of cerebrovascular diseases in the high risk population of cerebrovascular event including some young patients in Japan and establish the strategy for cardiac surgery of patients with cerebrovascular disease.

METHODS

100 (71 male, 29 female) of 126 consecutive patients undergoing cardiac surgery under cardiopulmonary bypass were screened for the presence of cerebrovascular disease by intra-arterial angiogram.

RESULTS

In seven patients angiographic evaluation disclosed some evidence of cerebrovascular disease for 50% or greater stenosis or cerebral aneurysm. Preoperative 99mTc-Hexamethyl propylene amino oxime (99mTc-HMPAO) single emission computed tomography (SPECT) with combination of balloon arterial occlusion test provided detailed information of cerebral ischemic tolerance and reliable decision making for surgical repair of cerebrovascular disease. No deaths were recorded and a small stroke in one patient.

CONCLUSIONS

We concluded that cerebrovascular screening in patients with cardiovascular disease may be requested in a high risk population of cerebrovascular events.

Intravascular Imaging Methods for Venous Disorders

The purposes are to assess the problems associated with intravascular imaging methods such as angioscopy and intravascular ultrasound (IVUS) and to evaluate their efficacy through the results of our observations. A total of 54 limbs in 53 patients, 50 patients with chronic venous insufficiency and 3 patients with deep vein thrombosis, were diagnosed and operated on using angioscopy (Olympus OES, order made type) and IVUS (Endosonics, model 82700). The imaging catheters were inserted through a branch of the long saphenous vein and the valves and the intraluminal views were observed. By angioscopy, intraluminal views were clearly observed in 98% of all lesions. However, observation became more difficult in iliac veins compared to in femoral and in long saphenous veins (p < 0.01). Venous wall and thrombus were detected more by IVUS than by angioscopy (p < 0.01), but only 21 valves (24%) were visualized by IVUS among the 88 valves observed by angioscopy. The intravascular imaging method of angioscopy is more suitable for observing valves and intraluminal views compared with IVUS, whereas IVUS is more suitable for observing the cross-sectional venous wall.

[Transluminally placed endovascular graft indications: thoracic aortic aneurysm and abdominal aortic aneurysm]

In 1991, Parodi et al described the first clinical use of a new technique for abdominal aortic aneurysm (AAA) repair using transluminally placed endovascular grafts (TPEG). Subsequently, in 1994 Dake et al reported the use of this new technique for the treatment of patients with aneurysms of the descending thoracic aorta. Since then, TPEG for the treatment of aneurysms have been clinically investigated in a number of centers. Initially, TPEG appeared to be an attractive alternative to standard surgical open repair, since they are less invasive and thereby reduce the operative risk in high-risk patients. The effectiveness and safety of TPEG have been reported by many investigators, and indications for this technique are increasing. However, the placement of TPEG within the artery by insertion via a remote site and fixation by attachment systems, such as various types of expandable stents, is completely different from conventional graft replacement. The long-term durability of TPEG is not yet known, and therefore we must remain cautious in patient selection. The cause and morphology of each aortic aneurysm determine whether TPEG are indicated. At present, TPEG is used to treat patients with aneurysms below the distal arch, and infrarenal abdominal aorta. However, indications in patients with aortic dissections are not clearly defined, because though the procedure is technically feasible, the effectiveness is not yet known and further investigation is required.