Koichi Yuri

Usefulness of fenestrated stent grafts for thoracic aortic aneurysms

OBJECTIVES Endovascular stent grafts (SGs) comprise a novel therapeutic approach to repairing aortic aneurysms. However, endovascular repair of the aortic arch remains challenging. Generally, the repair of sites with SGs requires an extra-anatomical bypass. We introduced SG repair of the aortic arch with strategically positioned fenestrations for each arch branch in 2006. An extra-anatomical bypass is not required for this procedure. This study evaluates the early and mid-term outcomes of fenestrated SG treatment. METHODS We retrospectively analysed the early and mid-term outcomes of 24 of 80 repairs with fenestrated SG among 383 single thoracic aortic aneurysm repairs that were undertaken at our department between January 2006 and March 2012. RESULTS Technical success was obtained in 100% of the patients. However, there was a 30-day perioperative mortality rate of 4.1% (1 of 24) due to a shower embolism. One patient developed a Type 2 endoleak without aneurysm enlargement within a median follow-up time is 25.1 months. However, migrations or device-related complications requiring additional procedures did not arise. CONCLUSIONS Treatment with fenestrated SGs does not require surgical transposition of the arch branches. The procedure is widely applicable and less invasive and outcomes are excellent.

A fenestrated stent graft for endovascular repair of an ascending aortic pseudoaneurysm.

Endovascular stent grafting is a novel therapeutic technique for repairing aortic aneurysms, and is especially useful for descending aortic aneurysm and aneurysm at the distal arch. However, no effective endovascular approach for the ascending aorta has been reported a remaining site for endovascular repair because of the anatomical restrictions and the presence of vital branches to the head and arms that are present in this region. This report describes an endovascular stent graft repair of a pseudoaneurysm at the ascending aorta using a fenestrated stent graft. The fenestrated stent graft is easy to use and less invasive for the endovascular repair of the ascending aorta.

Hemodynamics and Outcomes of Aortic Valve Replacement with a 17- or 19-mm Valve:

When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch is of concern because it may affect postoperative clinical status. We conducted a retrospective study of outcomes in 65 patients with aortic stenosis requiring valve replacement. Fifty were given a 17-mm or 19-mm St. Jude Regent mechanical valve, and 15 were given a 19-mm Medtronic Mosaic bioprosthesis. Echocardiography was carried out preoperatively, at discharge, and at follow-up. There was 1 (2%) operative death in the Regent group and none in the Mosaic group. There was no valve-related event. Follow-up echocardiography in both groups revealed a significant increase in the mean effective orifice area index, a decrease in the mean left ventricular-aortic pressure gradient, and a decrease in the mean left ventricular mass index. Prosthesis-patient mismatch (effective orifice area index <0.85 cm2 · m−2) existed in 13 (26%) patients in the Regent group and 11 (73%) in the Mosaic group at discharge. All patients improved to New York Heart Association functional class II or better. A small-sized prosthesis may provide satisfactory clinical and hemodynamic results in patients with a small aortic annulus.

Urgent Surgical Management of Deep Femoral Artery Aneurysm in a Patient with Pre-Vasculo-Behcet Status

We report a case of deep femoral artery (DFA) aneurysm associated with pre-vasculo-Behcet status. A 34-year-old man with a history of recurring oral and genital ulcers was admitted complaining of worsening left thigh pain over the previous 30 days. Computed tomography showed a left DFA aneurysm (60 mm × 70 mm), concomitant aneurysms in the popliteal and carotid arteries, and deep vein thrombosis. Active pre-vasculo-Behcet status was diagnosed, and DFA ligation was performed urgently. Remission was achieved with postoperative prednisolone and colchicine without vascular complications. DFA aneurysm and vascular pathologies were successfully managed by ligation surgery and medical therapy.

An innovative exclusion technique for ductus arteriosus with a novel stent graft.

A 72-year-old woman who had a patent ductus arteriosus that was anatomically unsuitable for catheter coiling was treated with a pre-curved fenestrated stent graft. This graft was custom-made to configure the patient’s whole aortic arch, and was capable of accurately adjusting its fenestrations to the arch branch orifices. The advantage of this fenestrated stent graft is close sealing, especially on the lesser curvature of the arch. This device could be an excellent option to treat an otherwise normal aortic arch with such a localized lesion.

Surgical treatment for thoracic aneurysms: comparison of stent grafting and open surgery.

OBJECTIVES Early and mid-term results of stent graft (SG) treatment for thoracic aortic aneurysms (thoracic endovascular aneurysm repair: TEVAR) were retrospectively compared with open surgical treatment. METHODS The records of 213 patients in whom single thoracic aortic aneurysm repairs had been performed in our department from January 2006 through August 31, 2009 were reviewed. Acute aortic dissection was excluded. Each case was reviewed for indications for TEVAR from an anatomical standpoint. Among 62 cases in which TEVAR was indicated, 30 (SG group) were treated by TEVAR and 32, by open surgery (OP group). Early and mid-term results were analyzed retrospectively in both groups. RESULTS There were no operative deaths in either group. The SG group demonstrated significantly less operative bleeding, a shorter operative time, and shorter postoperative hospital stay compared with the OP group. There were 3 deaths in the SG group and 4 in the OP group, which occurred within an average of 656.4 days during the follow up period. The 3 year actuarial survival rate was 88.7% in the SG group and 87.1% in the OP group, and there were no significant differences between the groups. CONCLUSION Although early and mid-term results of TEVAR and open surgery were similar, TEVAR is generally less invasive and may be preferable for high-risk patients, compared with open surgical repair. (English Translation of Jpn J Vasc Surg 2010; 19: 51-56.).

Successful treatment of an abdominal aortic aneurysm by endovascular graft placement through a previously placed prosthetic graft: Report of a case

A 77-year-old man with an infrarenal abdominal aortic aneurysm was referred with a complex medical history including pancreatitis, chronic renal failure, atrial fibrillation, and a cerebral infarction. He also had a history of atherosclerosis obliterans, treated with a vascular bypass using an 8-mm prosthetic graft 9 years previously. His complicated anatomy, including a small access route and a large common iliac artery, suggested usage of Powerlink, a bifurcated stent graft through the previously placed graft, as an access route. The patient was discharged from the hospital with a type III endoleak, which was completely resolved 5 months after discharge.

A Challenging Treatment for Aortic Arch Aneurysm With Fenestrated Stent Graft

BACKGROUND The endovascular stent graft is a novel therapeutic technique that is used in the treatment of aortic aneurysms. However, the aortic arch is a still an area that requires endovascular repair. Since 2008, the authors have treated aortic arch aneurysms (AAA) in patients without an extraanatomical bypass using a fenestrated stent graft (FSG). This study aimed to evaluate the early outcomes of FSG treatment. METHODS The authors retrospectively investigated the early outcomes of 54 AAA cases that were performed in their department from January 2008 to May 2016. The early results were analyzed retrospectively. RESULTS The primary technical success rate was 100%. There were 2 operative deaths due to shower embolism and respiratory failure (2 of 54, 3.7%). Two patients suffered central nervous system injury (2 of 54, 3.7%) without remaining sequelae. At a mean follow-up period of 41.4 months, the survival rate was 75.0% and there were no aortic-related deaths. On follow-up, secondary intervention was necessary in 3 cases. The rate of freedom from secondary reintervention was 92.5%. CONCLUSIONS Although further observation and prospective studies involving larger numbers of patients will be needed to validate this process, the outcomes of FSG treatment and our procedures were acceptable. This procedure has the potential to expand the indications for treatment in patients with AAA that are deemed to be suitable for this treatment.

Endovascular repair of thoracic aortic aneurysm associated with right-sided aortic arch: report of two cases.

Right-sided aortic arch (RAA) is a rare congenital disorder. We describe herein two cases of thoracic aortic aneurysm with a right aortic arch and right-sided descending aorta treated with thoracic endovascular aortic repair (TEVAR). In one case, a 70-year-old man with Edwards type 1 RAA underwent TEVAR using a Relay stent-graft (Bolton Medical, Barcelona, Spain). In another case, a 72-year-old woman with Edwards type 3 RAA underwent TEVAR using a Kawasumi Najuta stent-graft (Kawasumi Laboratories, Inc., Tokyo, Japan) with the “buffalo horn chimney technique”, our original method for left subclavian artery flow preservation. The postoperative courses were uneventful. Postoperative computed tomography showed complete exclusion of the aneurysm without endoleakage. Compared to conventional open surgical repair, TEVAR is challenging in patients with a RAA and right-sided descending aorta. However, our results showed that TEVAR might be feasible and a treatment option even in a patient with a RAA and right-sided descending aorta.

Efficacy of multiple arterial coronary bypass grafting in patients with diabetes mellitus.

OBJECTIVES Use of the left internal mammary artery in patients with diabetes mellitus and multivessel coronary artery disease is known to improve survival after coronary artery bypass grafting (CABG); however, the survival benefit of multiple arterial grafts (MAGs) in diabetic patients is debated. We investigated the efficacy of CABG performed with MAGs in diabetic patients. METHODS The overall patient group comprised 2618 consecutive patients who underwent isolated CABG at our hospital between 1990 and 2014. Perioperative characteristics, in-hospital outcomes and long-term outcomes were compared between diabetic (n = 1110) and non-diabetic patients (n = 1508). The long-term outcomes of diabetic and non-diabetic patients were analysed between those who received a single arterial graft (SAG) and those who received MAGs. Both full unmatched patient population and propensity-matched patient population analyses (diabetic cohort = 431 pairs, non-diabetic cohort = 577 pairs) were performed. RESULTS Preoperative comorbidities were much more common in the diabetic patients than in the non-diabetic patients; however, comorbidities were not associated with in-hospital outcomes (diabetes versus non-diabetes group, in-hospital mortality: 2.2 vs 1.5%; deep sternal wound infection: 2.2 vs 1.8%, P > 0.05). Although survival and freedom from major cardiac and cerebrovascular events (MACCEs) at 15 years were lower in the diabetes group than in the non-diabetes group (survival: 48.6 vs 55.0%, P = 0.019; MACCE-free survival: 40.8 vs 46.1%, P = 0.02), cardiac death-free survival at 15 years was similar (81.7 vs 83.9%, P = 0.24). Overall, 12-year survival was higher in both diabetic and non-diabetic patients treated with MAGs than in those treated with an SAG (64.9 vs 56.8%, P = 0.006, and 71.9 vs 60.5%, P < 0.001). Propensity-matched patient cohort analysis revealed improved 12-year survival with MAGs versus SAG in both the diabetes group (64.9 vs 58.8%, P = 0.041) and non-diabetes group (71.4 vs 63.8%, P = 0.014). Similarly, MACCE-free survival was improved in both groups. CONCLUSIONS A long-term survival advantage, with no increase in perioperative morbidity, is conferred with the use of multiple arterial bypass grafts not only in non-diabetic patients but also in diabetic patients.