Katsuhiko Oka

An Operative Case of Inferior Vena Cava Stenosis Due to Fibrosis Around Permanent Pacemaker Leads

SHIMADA, Y., et al.: An Operative Case of Inferior Vena Cava Stenosis Due to Fibrosis Around Permanent Pacemaker Leads. A 56‐year‐old woman presented with general fatigue, dyspnea on exercise, and hepatomegaly subsequent to secondary implantation of a pacemaker. On admission, cardiac echo examination showed tricuspid valve regurgitation due to a migrated looped lead. At surgery, there was evidence of severe stenosis at both orifices of the superior and inferior vena cavae due to fibrous tissue around the leads. We removed the fibrous tissue, pacing leads, and generator. New leads were anchored onto the epicardium and a generator was inserted under the rectus muscle. The postoperative course was satisfactory and the symptoms disappeared.

A case of iatrogenic subclavian artery injury successfully treated with endovascular procedures.

We report a case of a life-threatening massive hemothorax caused by iatrogenic injury of the right subclavian artery. The patient was successfully treated with placement of a covered stent. During the procedure, occlusion balloon catheters rapidly controlled the massive bleeding.

Endovascular Repair of Traumatic Aortic Injury Using a Modified, Commercially Available Endograft to Preserve Aortic Arch Branches

A 25-year-old woman was admitted to our hospital after being involved in a high-speed motorcycle accident. Computed tomography angiography revealed a blunt traumatic aortic injury of the lesser curvature of the distal aortic arch accompanied by splintered fractures of the seventh thoracic vertebra and left clavicle. If the pseudoaneurysm had been treated with open surgical repair, then arch replacement under cardiopulmonary bypass, which was considered to be too invasive, would have been necessary. Therefore, thoracic endovascular aortic repair (TEVAR) was preferred as a first-line treatment to prevent pulmonary complications and hemorrhaging. Because the proximal landing zone for TEVAR was insufficient, we used a modified (fenestrated) commercially available endograft to preserve the branches of the aortic arch. Postoperative computed tomography scans confirmed that the pseudoaneurysm had been excluded without the endoleaks, and the aortic arch branches were patent. The patients postoperative course was uneventful, and she was discharged from the hospital to have surgery for a vertebral fracture on postoperative day 6.

Aneurysm formation at both ends of an endograft associated with maladaptive aortic changes after endovascular aortic repair in a healthy patient.

We report a case in which saccular aneurysms formed at both ends of an endograft that exhibited maladaptive aortic changes after endovascular aortic repair in a patient without significant evidence of connective tissue disease. A 66-year old male underwent thoracic endovascular aortic repair (TEVAR) for a distal aortic arch aneurysm. A follow-up computed tomography (CT) scan performed at 6 months after the TEVAR detected a small saccular aneurysm at the distal edge of the endograft. At 10 months after the TEVAR, a new large aneurysm appeared at the proximal edge of the endograft. To prevent the latter aneurysm rupturing, total arch replacement with endograft fixation was performed. A CT scan obtained at 18 months after the TEVAR demonstrated that the aneurysm at the distal edge of the endograft had progressed and so we considered reintervention. Unfortunately, the patient died of intracranial haemorrhaging before the second procedure could be carried out. A histopathological examination of the aneurysm wall did not detect any significant background factors, such as connective tissue disease, inflammation or infection. The present case involved unexpected late complications, which might have been caused by changes in the form of the aorta after TEVAR.

Two-Stage Hybrid Repair of Kommerell Diverticulum with Supra-Aortic Debranching

OBJECTIVES The surgical treatment of Kommerell diverticula is associated with high mortality and morbidity rates. In the mid-2000s, hybrid aortic arch repair was developed, and the procedure has since been used to repair Kommerell diverticula. In the present study, we focused on the postoperative outcomes of two-stage hybrid repair of Kommerell diverticula that required supra-aortic debranching (type I hybrid arch repair). METHODS From August 2010 to July 2013, a total of four patients (aged 73.5 ± 9.5 years) underwent two-stage hybrid repair (type I hybrid arch repair) for Kommerell diverticula, and their cases were retrospectively studied. All four patients had right aortic arches and aberrant left subclavian arteries. The repair procedure consisted of two stages: (1) debranching of the supra-aortic vessels via a median sternotomy; (2) exclusion of the Kommerell diverticulum by performing thoracic endovascular repair via a femoral approach and coil embolization of the orifice of the aberrant subclavian artery. RESULTS There were no in-hospital deaths. One patient developed an acute kidney injury and required hemodialysis on postoperative day 2, although his renal function recovered within 48 hours. No strokes, paraplegia, or early aortic events were observed in our series. The mean follow-up period was 19.5 months (range, 5-47 months). All patients remained free from aortic events and endoleaks during the follow-up period. CONCLUSION The early and mid-term outcomes of hybrid repair for Kommerell diverticula that require supra-aortic debranching, which are less invasive and do not involve hypothermic circulatory arrest, are acceptable. However, this procedure requires the insertion of an endograft into the ascending aorta, and careful and long-term follow-up is required to confirm its efficacy.

Infectious pseudoaneurysm at the proximal edge of the endograft, after hybrid aortic arch repair

A 77-year old woman who underwent hybrid aortic arch repair using a Gore-TAG (Gore-Associates, Flagstaff, AZ, USA) endograft (Fig. 1A) complained of chest pain 5 months after operation. Blood cultures revealed Serratia marcescens. Computed tomography (CT) demonstrated dislocation of the endograft with formation of a pseudoaneurysm (Fig. 1B). Ascending aorta replacement with re-debranching was emergently performed (Fig. 2).

Two-stage hybrid repair for a Kommerell diverticulum in a right-sided aortic arch associated with multivessel coronary disease and atrial septal defect

Since the 2000s hybrid endovascular repair has been established as a suitable procedure for treating thoracic aortic aneurysm in high-risk patients, demonstrating excellent midterm results compared with conventional graft replacement. Recently, hybrid endovascular repair has also been used for the treatment of Kommerell diverticulum. However, the treatment algorithm varies if the concomitant cardiac procedures are required. Herein, we report the successful treatment of a Kommerell diverticulum associated with multivessel coronary disease and atrial septal defect via 2-stage hybrid repair.

In Situ Graft Replacement for a Ruptured Abdominal Aortic Aneurysm Infected with Listeria monocytogenes after Endovascular Aneurysm Repair

Listeria monocytogenes infection and rupture of the aneurysm sac, after endovascular aneurysm repair (EVAR), are both rare. We report the case of an 82-year-old man who presented with a ruptured aneurysm by infection with L. monocytogenes after EVAR. We successfully treated him by in situ reconstruction with a bifurcated expanded polytetrafluoroethylene (ePTFE) graft, with partial removal of the infected stent graft. At 30 months from the reoperation, the patient was in good health at home, with no symptoms of infection, and the gallium-67-citrate single-photon emission computed tomography/computed tomography (SPECT/CT) fusion images confirmed no fluid accumulation.

Endovascular Repair of Thoracic Aortic Aneurysms

Endovascular repair of thoracic aortic diseases is one of the hopeful alternatives to conventional open surgery that is sometimes responsible for the tragic complications. Conventional total arch repair of aortic aneurysm is requiring cardiopulmonary bypass and deep hypothermic circulatory arrest. Despite recent improvements in surgical technique, total arch repair still has significant morbidity and mortality.