Takanori Suezawa

Effect of type II endoleaks and antiplatelet therapy on abdominal aortic aneurysm shrinkage after endovascular repair

OBJECTIVE Endovascular repair of abdominal aortic aneurysm (EVAR) has been shown to be safe, and its use is increasing rapidly, but the long-term results of this procedure remain unclear. A decrease in the diameter of the aneurysm sac is considered to represent successful exclusion of the aneurysm from the circulation, but it has been reported that aneurysm shrinkage occurs in only about 60% of patients who have undergone EVAR. We analyzed several factors to determine whether they were related to aneurysm shrinkage after EVAR. METHODS From March 2007 to January 2010, EVAR was performed in 65 patients, 58 of whom underwent an enhanced computerized tomographic evaluation 6 months after the procedure. One patient was found to have a type Ia endoleak and was excluded from the study. In the remaining 57 patients, univariate and multiple regression analyses were used to determine whether there was a relationship between aneurysm shrinkage and various patient characteristics, aneurysm dimensions, and procedural outcomes. Aneurysm shrinkage was defined as a decrease in diameter of at least 4 mm. RESULTS On univariate analysis, a lack of aneurysm shrinkage by 7 days and 6 months after EVAR was significantly associated with hyperlipidemia, ongoing multiagent antiplatelet therapy with clopidogrel, ticlopidine, or cilostazol as well as aspirin, length of the proximal neck of the aneurysm, preprocedure maximum aneurysm diameter, and the presence of a type II endoleak. On multiple regression analysis, only multiagent antiplatelet therapy and type II endoleak were significantly related to a lack of aneurysm shrinkage 6 months after EVAR. Multiagent antiplatelet therapy and type II endoleak 6 months after EVAR were not significantly associated with each other. CONCLUSION Patients with a persistent type II endoleak and patients undergoing multiagent antiplatelet therapy are at an increased risk of a lack of aneurysm shrinkage 6 months after EVAR.

Circulatory Load During Hypoxia Impairs Post-transplant Myocardial Functional Recovery in Donation After Cardiac Death

BACKGROUND Circulatory load during hypoxia is unavoidable in donation after cardiac death (DCD) hearts, but it causes severe myocardial damage. The impact of circulatory load on donor heart function has not been investigated. The purpose of this study was to evaluate its effect on post-transplant functional recovery of DCD hearts. METHODS Twelve donor pigs (20 kg) were used. Cardiac arrest was induced by asphyxiation (turning off the ventilator) in the load group (n = 6) and by exsanguination (dividing the vena cava) in the unload group (n = 6). Left ventricle end-diastolic volume (LDEDV) and end-systolic pressure (LVESP) were monitored until cardiac arrest. Orthotopic transplantation was performed after 30-minute warm ischemia following cardiac arrest. After weaning from cardiopulmonary bypass, left ventricular end-diastolic pressure-volume ratio (LV Emax) and creatine kinase (CK-MB) were measured while on 0.1 microg/kg/min epinephrine. RESULTS During the agonal period, the maximum LVEDV and LVESP in the load group were 132 +/- 1% of baseline at 10 minutes and 148 +/- 16% of baseline at 4 minutes, respectively. Recovery rates of post-transplant cardiac function in the load group were worse than in the unload group (LV Emax: 64 +/- 8 vs 84 +/- 5%, p < 0.05). Levels of post-transplant CK-MB in the load group were higher than in the unload group (639 +/- 119 vs 308 +/- 70 IU/liter, p < 0.05). CONCLUSIONS Cardiac arrest with circulatory load by asphyxiation caused more myocardial damage than unloaded arrest. This difference between the modes of death should be considered when evaluating the DCD hearts for clinical application.

Effect of antifibrinolytic therapy with tranexamic acid on abdominal aortic aneurysm shrinkage after endovascular repair

OBJECTIVE The long-term outcomes of endovascular abdominal aortic aneurysm repair (EVAR) remain to be determined, but patients with aneurysm shrinkage after EVAR appear to have a good prognosis. We previously observed that antiplatelet therapy is a risk factor for lack of aneurysm shrinkage, a finding suggesting that coagulation and fibrinolysis play roles in shrinkage. We therefore studied the effect of antifibrinolytic therapy with tranexamic acid (TXA) on aneurysm shrinkage after EVAR. METHODS From May 2007 to May 2012, EVAR was performed in 187 patients, 165 of whom had an enhanced computed tomographic evaluation 6 months after their procedure. Six of the 165 patients were excluded from the study because they had a type Ia endoleak or coil embolization to treat a type II endoleak ≤ 6 months after EVAR. Of the remaining 159 patients, 110 underwent EVAR before we started to use TXA in our centers. TXA therapy (1500 mg/d for 6 months) began in January 2011, and 48 patients completed the treatment regimen. Patients not treated with TXA were compared with those given TXA. Analyses to identify risk factors for lack of aneurysm shrinkage were performed. RESULTS No patient had a thromboembolic event. There were no significant differences between the no-TXA and TXA groups in demographics, aneurysm characteristics, prosthesis implanted, type II endoleak occurrence during EVAR or 1 or 6 months afterward, or aneurysm shrinkage at 1 month. However, at 6 months after EVAR, the TXA group had significantly greater aneurysm shrinkage (P = .035) and a significantly higher percentage of patients with >4 mm in shrinkage (P = .010). Multiple regression analysis showed aneurysm diameter, type II endoleak 6 months after EVAR, and TXA treatment were independently associated with aneurysm shrinkage or lack of shrinkage. CONCLUSIONS Antifibrinolytic therapy with TXA was associated with aneurysm shrinkage after EVAR. Studies to identify the dosage of TXA that is optimally safe and effective in this application, as well as investigations of the best timing and route (parenteral vs oral) for TXA administration, are warranted.

Forty-Year Survival With Smeloff-Cutter and Starr-Edwards Prostheses

This case study describes a 40-year follow-up of a man who had a double valve replacement with Smeloff-Cutter aortic (Cutter Laboratories, Berkeley, CA) and Starr-Edwards mitral prostheses (Edwards Laboratories, Santa Ana, CA) when he was 34 years old. Double valve replacement was performed for aortic and mitral valve stenosis and insufficiency. To date, no surgical treatment has been required except a pacemaker implantation. The patient presented with a New York Heart Association functional class of I to II. Echocardiography revealed intact prostheses.

Bronchial and cardiac ruptures due to blunt trauma

Tracheobronchial and cardiac injuries following blunt thoracic trauma are uncommon but can be life-threatening. We report a case in which the patient with bronchial and right atrial ruptures due to blunt trauma survived after emergent repairs. An 18-year-old female driver was transported to our hospital after a traffic accident and was hemodynamically stable on arrival. Chest computed tomography revealed cervicomediastinal emphysema and hemopericardium, and fiberoptic bronchoscopy showed a tear in the right main bronchus. She was intubated with a double-lumen endotracheal tube guided by bronchoscopy. A median sternotomy was undertaken, and a laceration of the right atrium was oversewn without the use of cardiopulmonary bypass. After that, right-sided thoracotomy was performed. The tear in the membranous portion of the right main bronchus was repaired with interrupted sutures, and the suture lines were wrapped with a pedicled flap of intercostal muscle.

Endovascular repair and pharmacotherapy of an inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula.

An inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula was successfully treated by stent grafting. Pharmacotherapy with octreotide after endovascular aneurysm repair was also performed with the expectation of spontaneous and rapid closure of the fistula. Gastrointestinal endoscopy performed 10 days after endovascular aneurysm repair showed closure of the large aortoduodenal fistula, and oral intake was started on the operative day 16. To date, 16 months after the initial operation, the patient is doing well without any symptoms or signs of infection and without any antibiotic therapy.

Coronary Artery Bypass Grafting with Left Inferior Epigastric Artery as Collateral

We report a case of co-existent coronary and peripheral vascular disease with collaterals to the lower extremities in a 72-year-old female. The patient had triple-vessel coronary artery disease, an occlusion of the bilateral iliac arteries, and the left internal mammary-inferior epigastric artery collateral pathway was a major route to the lower extremities. Coronary artery bypass grafting and right axillo-bifemoral bypass were performed. The well-developed left inferior epigastric artery was used as a conduit to the circumflex artery.

Successful transcatheter repair of severe aortic valve stenosis with a fishhook-like calcification

An 84-year-old extreme frail woman presented with symptomatic severe aortic valve stenosis. Transthoracic echocardiography (TTE) revealed a tricuspid aortic valve with eccentric calcification. The aortic annulus area was 399 mm as observed using multidetector computed tomography (CT), which also revealed a huge fishhook-like calcification extending from the commissure between the left and right coronary cusp to the sinotubular junction through the aortic annulus and the sinus of Valsalva (Fig. 1a–c). Transcatheter aortic valve implantation (TAVI) was scheduled. The calcification was not deformed during intraoperative balloon aortic valvuloplasty, and a cineangiogram during the procedure revealed a balloon indentation on the calcified leaflet (Fig. 1d). CT re-evaluation showed a 22-mm distance between the sinus of Valsalva and the calcified commissure (Fig. 1c). Therefore, a 23-mm SAPIEN XT valve (Edwards Life-science, Irvine California) was implanted with 1 mL filling lesser than the recommended volume. A cineangiogram found that the calcification was not deformed and that the prosthetic valve was mainly expanded toward the noncoronary cusp (Fig. 1e). Postoperative CT showed that the prosthetic valve was implanted in an elliptical shape (Fig. 1f). The patient remains well 12 months after the procedure, with trivial paravalvular leakage on TTE, aortic valve mean pressure gradient of 13 mmHg, and aortic valve area of 1.5 cm.

Endovascular management for ruptured Stanford B acute aortic dissection

Surgery for a complicated Stanford B acute aortic dissection, such as rupture or malperfusion, is still a challenge. We undertook endovascular therapy for ruptured Stanford B acute aortic dissection in two patients. A homemade stent graft was deployed in an 84-year-old woman with a massive mediastinal hematoma; and an aortic extender of Excluder was used for a 76-year-old man with left hemothorax. Both patients recovered without major complications. Careful follow-up is mandatory. Endovascular therapy for a ruptured Stanford B acute aortic dissection seems feasible and efficient.