Hidekazu Nakai

Strategies for the treatment of aorto-oesophageal fistula

OBJECTIVES Presenting a surgical strategy for aorto-oesophageal fistula (AEF). METHODS From October 1999 to August 2013, 16 patients with AEF were treated at Kobe University Hospital. The mean age was 65.5 ± 10.2 years, and the male/female ratio was 13/3. Eight patients had non-dissecting thoracic aneurysm, 3 had chronic aortic dissection, 5 had oesophageal cancer and 1 had fish bone penetration. Five patients were in shock. Four patients had previous thoracic endovascular aortic repair (TEVAR) in the descending aorta and 1 had hemi-arch replacement. As treatment for AEF, 8 patients underwent TEVAR, 2 had a bridge TEVAR to open surgery, 2 had extra-anatomical bypass (EAB) and 5 had in situ reconstruction of the descending aorta. The oesophagus was resected in 8 patients, and an omental flap was installed in 7 patients. For the 4 most recent cases, simultaneous resection of the aorta and oesophagus, in situ reconstruction of the descending aorta using rifampicin-soaked Dacron graft and omental flap installation were performed. RESULTS Hospital mortality was noted in 4 patients (25.0%; persistent sepsis n = 3 and pneumonia n = 1). However, since 2007, only 1 of 5 patients died (pneumonia). All patients with oesophageal cancer died during follow-up. Two patients underwent oesophageal reconstruction using a pedicled colon graft and one is on the waiting list for oesophageal reconstruction. CONCLUSIONS Bridging TEVAR is a useful adjunct in treating AEF patients with shock. One-stage surgery consisting of resection of the aneurysm and oesophagus, in situ reconstruction of the descending aorta and omental flap installation provided a better outcome in the AEF surgical strategy compared with conservative treatment.

Open reconstruction of thoracoabdominal aortic aneurysms

Technical details of our strategy for reconstructing the thoracoabdominal aorta are presented. Between October 1999 and June 2012, 152 patients underwent surgery for thoracoabdominal aortic aneurysms (Crawford classification type I =21, type II =43, type III =73, type IV =15). Mean age was 64.6±13.9 years. Sixty-three (41.4%) patients had aortic dissection, including acute type B dissection in 2 (1.2%) and ruptured aneurysms in 17 (11.2%). Eight (5.3%) patients had mycotic aneurysms, and 3 (2.0%) had aortitis. Emergent or urgent surgery was performed in 25 (16.4%) patients. Preoperative computed tomography (CT) scan or magnetic resonance (MR) angiography detected the Adamkiewicz artery in 103 (67.8%) patients. Cerebrospinal fluid drainage (CSFD) was performed in 115 (75.7%) patients and intraoperative motor evoked potentials were recorded in 97 (63.8%). One hundred and seven (70.4%) patients had reconstruction of the intercostal arteries from T7 to L2, 35 of which were reconstructed with the aortic patch technique and 72 with branched grafts. The mean number of reconstructed intercostal arteries was 3.1±2.5 pairs. Mild hypothermic partial cardiopulmonary bypass at 32-34 °C was used in 105 (69.1%) patients, left heart bypass was used in 4 (2.6%), and deep hypothermic cardiopulmonary bypass below 20 °C was used in 42 (27.6%). Thirty-day mortality was 9 (5.9%), and hospital mortality was 20 (13.2%). Independent risk factors for hospital mortality were emergency surgery (OR 13.4, P=0.003) and aortic cross clamping over 2 hours (OR 5.7, P=0.04). Postoperative spinal cord ischemia occurred in 16 (10.5%, 8 patients with paraplegia and 8 with paraparesis). Risk factors for developing spinal cord ischemic complications were prior surgery involving either the descending thoracic or the abdominal aorta (OR 3.75, P=0.05), diabetes mellitus (OR 5.49, P=0.03), and post-bypass hypotension <80 mmHg (OR 1.06, P=0.03). Postoperative survival at 5 years was 83.6±4.5%; 5-year survival was 47.5±8.6% in patients with spinal cord ischemia and 88.9±10.4% in those without spinal cord ischemia.

Influences of Chronic Obstructive Pulmonary Disease on Outcomes of Total Arch Replacement

BACKGROUND Although an association between chronic obstructive pulmonary disease (COPD) and adverse surgical outcomes has been proposed, the impact of COPD severity on postoperative outcomes remains unclear. Our objective was to analyze the prognostic implication of COPD severity on outcomes after total aortic arch replacement. METHODS Between October 1999 and December 2012, 269 patients undergoing total arch replacement through median sternotomy, who were elective cases with preoperative spirometry records, were retrospectively reviewed. Patients were divided into four groups: control group, with ratio of forced expiratory volume of air in 1 second (FEV1) to forced vital capacity (FVC) of 70% or greater; mild airflow obstruction, with FEV1/FVC ratio less than 70% and FEV1 80% or greater of predicted; moderate airflow obstruction, FEV1/FVC ratio less than 70% and FEV1 50% to 79% of predicted; severe airflow obstruction, FEV1/FVC ratio less than 70% and FEV1 less than 50% of predicted. Symptoms of functional dyspnea and disability were also assessed. Multivariate logistic and Cox regression methods were used to determine if there was an independent association between COPD and short-term and long-term outcomes, respectively. RESULTS The in-hospital mortality rate was 2.2% (6 of 269). A consistent trend of increasing frequency of postoperative respiratory complications with advanced airflow obstruction was noted. In multivariate analysis, in-hospital mortality (p = 0.022), incidence of respiratory complications (p = 0.021) and overall mortality (p = 0.025) was significantly associated with the symptoms of COPD, respectively. CONCLUSIONS The severity of COPD as defined by spirometry and symptoms of functional dyspnea may be an important prognostic marker of patients undergoing total arch replacement.

Surgical techniques of total arch replacement using selective antegrade cerebral perfusion

This detailed illustrated article describes our preferred surgical technique of total arch replacement using selective antegrade cerebral perfusion (SACP). Our current approach includes: (I) meticulous selection of arterial cannulation site and type of arterial cannula; (II) SACP for neuro-protection; (III) whole body hypothermia with minimal tympanic temperatures between 20 and 23 °C and minimal rectal temperatures below 30 °C; (IV) early re-warming after distal anastomosis with SACP flow adjustment while monitoring brain oxygenation by near infrared spectroscopy (NIRS); and (V) after 2006, maintaining strict fluid balance below 1 L by the extracorporeal ultrafiltration method (ECUM) during cardiopulmonary bypass (CPB), with the expectation of more rapid pulmonary functional recovery.

Total arch replacement using selective antegrade cerebral perfusion as the neuroprotection strategy

BACKGROUND Optimal neuro-protection strategy in aortic arch surgery is a controversial issue. The present study reported surgical outcomes of total arch replacement using selective antegrade cerebral perfusion (SACP). METHODS From January 2002 to December 2012, 438 consecutive patients (mean age 69.1±13.4 years) underwent total arch replacement using SACP through a median sternotomy. Acute aortic dissection was present in 86 patients (18.3; 80 type A, 6 type B) and shaggy aorta in 36 (8.2%). Emergent/urgent surgery was required in 144 (32.9%). Our current approach included: (I) meticulous selection of arterial cannulation site and type of arterial cannula; (II) selective antegrade cerebral perfusion; (III) maintenance of minimal tympanic temperature between 20 and 23 °C; (IV) early re-warming after distal anastomosis; and (V) maintaining fluid balance below 1,000 mL during cardiopulmonary bypass. A woven Dacron four branch graft was used in all patients. RESULTS Overall hospital mortality was 4.6% (20/438). Hospital mortality was 9.7% (14/144) in urgent/emergent surgery and 2.0% (6/294) in elective cases. Permanent neurological deficit occurred in 5.3% (23/438) of patients. Prolonged ventilation was necessary in 58 patients (13.2%). Multivariate analysis demonstrated that risk factors for hospital mortality were octogenarian (OR 4.45, P=0.03), brain malperfusion (OR 23.52, P=0.002) and cardiopulmonary bypass time (OR 1.07, P=0.04). The follow-up was completed in 97.9% with mean follow up of 2.3±2.3 years. Survival at 5 and 10 years after surgery was 79.6±3.3% and 71.2±5.0% respectively. In the acute type A dissection group, 10-year survival was 96.8±2.9%, while in the elective non-dissection group 5- and 10-year survival were 81.4±7.2% and 77.0±5.9% respectively. CONCLUSIONS Our current approach for total aortic arch replacement utilizing SACP was associated with low hospital mortality and morbidities leading to favorable long-term outcome.

Surgical strategy for the treatment of aortoesophageal fistula

Objective To present a surgical strategy for aortoesophageal fistula (AEF). Methods From October 1999 to May 2017, 27 patients with AEF were treated at Kobe University Hospital. After 9 patients with malignancies or fish bone penetration were excluded, 18 patients who had AEF secondary to aortic lesions were investigated. The mean age was 67.2 ± 10.4 years, and the male/female ratio was 16:2. Twelve patients had a nondissection thoracic aneurysm, and 6 patients had a chronic aortic dissection. Six patients were in shock. Seven patients had a previous thoracic endovascular aortic repair (TEVAR) in the descending aorta, 2 patients had descending aorta replacement, 1 had hemiarch replacement, and 2 had total arch replacement. As the first treatment for AEF, 3 patients underwent TEVAR as destination therapy, 3 patients had a bridge TEVAR to open surgery, 1 patient had an extra‐anatomical bypass from the ascending aorta to the abdominal aorta, and 11 patients had an in situ reconstruction of the descending aorta. The esophagus was resected in 16 patients, and an omental flap was installed in 16 patients. Additional procedures were extra‐anatomical bypass in 2 patients and in situ reconstruction of the aorta in 3 patients. Results Hospital mortality was noted in 4 patients (22.2% persistent sepsis, n = 3: pneumonia, n = 1). However, since 2007, only 1 of 13 patients has died (pneumonia). Late death occurred in 5 patients, due to pneumonia, cerebral bleeding, diarrhea, sudden death, and persistent infection. Actuarial survival was 42.4 ± 12.8% at 5 years and freedom from aorta‐related death was 59.4 ± 13.5% at 5 years. Nine patients achieved completed reconstruction of the esophagus 172 ± 57 days after initial surgery. Conclusions Although a comparative study was not performed, 1‐stage surgery consisting of resection of an aneurysm and esophagus, in situ reconstruction of the descending aorta, and omental flap installation provided a better outcome in the treatment for AEF. Bridging TEVAR to the open surgery is a useful adjunct in patients with AEF with hemorrhagic shock. Later reconstruction of the esophagus can be performed in the survivors.

A case of type A acute aortic dissection with a common carotid trunk

We present a rare case of common carotid artery with acute type A aortic dissection. A 72-year-old woman underwent emergent aortic arch repair using Antegrade selective cerebral protection. Bottom-tapped cannulae were inserted into three orifices of arch vessels, however, regional cerebral oxygen saturation decreased after rewarming. We found that arch branches were in order from front to back, right subclavian artery, common carotid trunk, and left subcravian artery. The patient complicated stroke in the right middle cerebral artery.

Successful hybrid treatment of a rare case of blunt traumatic rupture of the left atrial basal appendage and aortic arch

Despite advances in emergency care and the emergent transportation system, cardiac and aortic ruptures after blunt trauma are associated with high mortality and morbidity. We present a rare case of a 70-year-old man with a ruptured left atrial basal appendage and distal aortic arch after sustaining blunt trauma to the chest during a motor vehicle accident. The patient was transported to our hospital in a state of shock and taken directly to the operating room. Hybrid treatment was performed, including surgical repair of the left atrium under cardiopulmonary bypass and thoracic endovascular aortic repair, was performed. The patient fully recovered without any complications.

Early and long-term outcomes of open surgery after thoracic endovascular aortic repair†

OBJECTIVES This study evaluated the early and long-term outcomes of open surgery after thoracic endovascular aortic repair. METHODS We conducted a retrospective review of 41 patients who underwent open surgery following thoracic endovascular aortic repair between October 1999 and July 2017. The mean interval from primary intervention to open surgery was 3.1 ± 3.7 years. Indications for open repair were endoleak in 14 patients, graft infection in 10 patients, false lumen dilatation in 9 patients, retrograde dissection in 5 patients, migration in 1 patient and additional aneurysm in 2 patients. Eight patients underwent emergent surgical conversions. The mean follow-up period was 4.2 ± 4.0 years. RESULTS Descending aortic replacement was performed in 15 patients; thoraco-abdominal aortic repair, in 14 patients; extensive arch to descending aortic replacement, in 5 patients; and total arch replacement, in 7 patients. Six (14.6%) patients died in the hospital. The 5-year survival rate was 73.7 ± 7.2%, and freedom from reintervention was 88.5 ± 6.4%. CONCLUSIONS Early outcomes of open surgical procedures after thoracic endovascular aortic repair were still suboptimal. However, hospital survivors had excellent long-term outcomes.

Rupture of abdominal aortic aneurysm between early and late phases of enhanced computed tomography

Ruptured abdominal aortic aneurysm (RAAA) is fatal in >80% of cases, and mortality is as high as 42% of those who survive RAAA and undergo surgery (42%). Sensitivity and specificity of computed tomography (CT) for the diagnosis of RAAA are reportedly not 100% but range from 50% to 94% and 77% to 100%, respectively. However, CT is still essential to verify anatomical details. A 90-year-old woman visited a community hospital with a complaint of right lower-quadrant pain. Plain CT revealed a double infrarenal AAA with respective diameters of 53 mm 60 mm and 55 mm 62 mm but no findings of rupture. The patient was transferred to our hospital with a blood pressure of 100/60 mmHg on arrival. Because the proximal neck of the AAA was short, enhanced CT was indicated to decide whether to perform endografting or replacement. Soon after the contrast was injected, CT showed minor leakage to the right side of the lower aneurysm (A, left panels), and the late-phase image obtained 105 seconds later revealed a massive hematoma in the right retroperitoneal cavity that had caused migration of the right kidney (A, right panels). The patient was successfully resuscitated from cardiopulmonary arrest, after which emergency surgery was indicated. Because no stent graft was available for emergency, replacement of the AAA was selected. After quick placement of an Equalizer aortic occlusion balloon (Boston Scientific, Marlborough, Mass) from the right femoral artery, the suprarenal aorta was exposed and clamped through a median laparotomy after systemic heparinization. Replacement of the AAA with a 16-mm 8-mm bifurcated Intergard graft (Maquet, Hudson, NY) was performed in the usual manner. The laparotomy wound was managed with a vacuum-assisted closure system to avoid abdominal compartment syndrome and was closed 4 days after the operation. The patient could be weaned from ventilator support 10 days later and has survived without any signs of brain ischemia. She gave written consent for publication of details of her case, including the radiologic images.