Tatsuya Itonaga

Adventitial inversion technique for type A aortic dissection distal anastomosis

OBJECTIVE Anastomosis in dissected aorta management remains challenging. The patent false lumen of remnant aorta influences the growth of the residual aorta after hemiarch replacement. We evaluated the beneficial effect of adventitial inversion technique for distal anastomotic reinforcement of hemiarch replacement in acute type A aortic dissection. METHODS From 2006 to 2014, 90 patients with DeBakey type I aortic dissection who underwent hemiarch replacement for acute type A aortic dissection management at the National Cerebral and Cardiovascular Center were retrospectively analyzed. Patients were divided according to the technique used: the adventitial inversion technique in group A and the original Sandwich method with Teflon felt in group S. Surgical variables and aortic morphology from distal aortic anastomosis were evaluated by computed tomography after surgery. RESULTS The mean follow-up time was 2.2 ± 2.1 years with a follow-up rate of 91.1%. Cardiopulmonary bypass time was 208.2 ± 93.9 minutes in group A and 220.6 ± 93.9 minutes in group S; lower body circulatory arrest time was 51.6 ± 10.2 minutes in group A and 54.5 ± 17.8 minutes in group S. No significant differences were observed between groups. The overall hospital mortality rate was 10.0%. Postoperative false lumen thrombosis rate at proximal descending aorta on enhanced delayed phase computed tomography was significantly higher in group A than in group S. CONCLUSIONS The adventitial inversion technique may facilitate thrombotic closure of the distal false lumen in acute type A aortic dissection management by hemiarch replacement.

Insights of stroke in aortic arch surgery: identification of significant risk factors and surgical implication.

PurposeAlthough the outcomes of aortic arch surgery have improved, stroke remains one of the most devastating complications. Therefore, identification of true risk factors and understanding the pathogenesis of intraoperative stroke are necessary to decrease its occurrence.MethodsFrom January 2002 to December 2010, a total of 251 consecutive patients underwent aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion in our hospital. Hemiarch replacement cases were excluded. Of the remaining patients, 190 elective cases that could be reviewed with full perioperative clinical data were analyzed. Strokes were classified into three subtypes according to their distribution on imaging studies: multiple-embolism type, hypoperfusion type, and solitary-embolism type.ResultsOperative death occurred in 1.1% of patients (2/190), and aortic arch surgery-related in-hospital death occurred in 5.3%. Among the 188 survivors, intraoperative strokes occurred in 5.9%. Multiple-embolism, hypoperfusion type, and solitary-embolism stroke occurred in 2.7%, 2.1%, and 1.6%, respectively. Multivariate analysis revealed that the risk factor for multiple-embolism stroke was high-grade atheroma in the ascending aorta [P < 0.001, odds ratio (OR) 118.0], and that for hypoperfusion type stroke was prolonged brain ischemia time over 120 min (P = 0.004, OR 31.5). No significant risk factor was found for solitary-embolism stroke.ConclusionIntraoperative strokes during elective aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion are strongly influenced by the presence of a high-grade atheroma in the ascending aorta and prolonged brain ischemia time. The results suggest that these are key issues to reduce stroke in aortic arch surgery.

Is Conventional Open Repair Still a Good Option for Aortic Arch Aneurysm in Patients of Advanced Age

BACKGROUND Although thoracic endovascular aortic repair has advantages in elderly patients, it is not always applicable, and some elderly patients require open surgical repair. METHODS Between 2008 and 2014, 157 patients (11 men) older then 75 years (mean age, 79.3 ± 3.3 years) underwent conventional total arch replacement, of which 39 were emergency operations. Coexisting diseases included remote stroke in 54 patients, coronary artery disease in 64, chronic obstructive pulmonary disease in 25, and chronic kidney disease in 112. Concomitant procedures were performed in 46 patients. RESULTS Mean follow-up time was 2.9 ± 1.8 years. Mean cardiopulmonary bypass time was 251.1 ± 68.4 minutes. Mean lowest nasopharyngeal temperature was 23.2° ± 3.4 °C. The hospital mortality rate was 7.6% (12 of 157) overall, 5.1% in elective cases, and 15.4% in emergency cases. Postoperative complications included permanent neurologic dysfunction in 5.7% of patients and prolonged ventilation time exceeding 72 hours in 13.4%. No spinal cord complications occurred. The 1-year and 5-year survival rates were 88.2% and 69.2% in all cases and 91.3% and 77.0% in elective cases, respectively. Univariate analysis demonstrated that risk factors for hospital death in elective cases were chronic kidney disease (odds ratio, 4.00; p = 0.028) and ventilation time exceeding 72 hours (odds ratio, 13.3; p = 0.001). CONCLUSIONS Even in patients older than 75 years, recent surgical results of conventional open arch repair were acceptable, especially in elective cases. Thus, conventional open surgical aortic arch replacement remains a good option, especially in patients with preserved renal function.

Total Aortic Replacement for a 9-Year-Old Boy With Loeys-Dietz Syndrome

Loeys-Dietz syndrome (LDS) is a recently identified rare connective tissue disorder caused by mutations of the transforming growth factor-β receptors and first described in 2005. It is an autosomal dominant syndrome with 2 different phenotypic expressions-LDS I and II. LDS is characterized by the triad of arterial tortuosity and aneurysm, hypertelorism, and a bifid uvula or cleft palate. We present a case of a 9-year-old boy diagnosed with LDS who underwent urgent thoracoabdominal aortic aneurysm repair followed by total arch replacement and aortic valve-sparing root replacement (AVSRR).

Utility of Proximal Stepwise Technique for Acute Aortic Dissection Involving the Aortic Root

Proximal anastomosis is an important operative procedure in type A acute aortic dissection. We report our experience with the proximal stepwise technique, which is widely used during distal anastomosis in total arch replacement, in a series of 53 patients. We treated 53 patients for aortic dissection using this technique in our center. There were no bleeding adverse events during the operations and no early death caused by bleeding. This hemostatic technique was simple to use and demonstrated excellent early and midterm operative results.

Influence of warfarin therapy on the occurrence of postoperative endoleaks and aneurysm sac enlargement after endovascular abdominal aortic aneurysm repair

Objectives This study aims to determine whether warfarin therapy influences the occurrence of endoleaks or aneurysm sac enlargement after endovascular aortic repair (EVAR). Methods A total of 367 patients who underwent EVAR for abdominal aortic aneurysm between 2007 and 2013 were recruited for this study. Satisfactory follow-up data including completed computed tomography scan follow-up for more than 2 years were available for 209 patients, and the mean follow-up time was 37 ± 12 months. Twenty-nine (16%) patients were on warfarin therapy (warfarin group), whereas 180 (84%) patients were not on warfarin therapy (control group). Results Two- and four-year freedom rates for persistent type II endoleaks were significantly lower in patients of the warfarin group compared with the control group (85 and 49% vs 93 and 91%, respectively; P = 0.0001). Similarly, 2- and 4-year freedom rates for sac enlargement (>5 mm) were significantly lower in patients of the warfarin group compared with the control group (83 and 61% vs 92 and 82%, respectively; P = 0.0036). Using Cox regression analysis, the warfarin therapy was identified to be an independent positive predictor of sac enlargement after EVAR [hazard ratio (HR): 2.4; 95% confidence interval (CI): 1.08-5.40; P = 0.032], together with persistent type II endoleak. Warfarin therapy was also an independent predictor for persistent type II endoleak (HR: 3.7; 95% CI: 1.81-7.41; P < 0.0001) together with the number of patent lumbar arteries. Conclusions Results suggested that warfarin therapy was significantly associated with an increased risk for persistent II endoleak and sac enlargement after EVAR.

Occlusion of Left Coronary Artery Ostium by Left Coronary Cusp Fusion

We report two cases of adults who had occlusion of the left coronary artery ostium by the left coronary cusp. Both patients were treated with the Bentall procedure, and both revealed a good, long-term course. We offer proper strategy of perioperative management consisting of precise preoperative diagnosis with a multimodality imaging study and adequate operative technique.

A Recovery Cardiopulmonary Bypass Model Without Transfusion or Inotropic Agents in Rats

Cardiopulmonary bypass (CPB) is indispensable in cardiovascular surgery. Despite the dramatic refinement of CPB technique and devices, multi-organ complications related to prolonged CPB still compromise the outcome of cardiovascular surgeries, and may worsen postoperative morbidity and mortality. Animal models recapitulating the clinical usage of CPB enable the clarification of the pathophysiological processes that occur during CPB, and facilitate pre-clinical studies to develop strategies protecting against these complications. Rat CPB models are advantageous because of their greater cost-effectiveness, convenient experimental processes, abundant testing methods at the genetic or protein levels, and genetic consistency. They can be used for investigating the immune system activation and synthesis of proinflammatory cytokines, compliment activation, and production of oxygen free radicals. The rat models have been refined and have gradually taken the place of large-animal models. Here, we describe a simple CPB model without transfusion and/or inotropic agents in a rat. This recovery model allows the study of the long-term multiple organ sequelae of CPB.

A simple and effective method to apply TachoSil® Tissue Sealing sheet using Esmarch’s bandage

We report a novel hemostatic method for using hemostatic patches impregnated with human fibrinogen and thrombin (TachoSil®) together with Esmarch’s bandage. The combined use of TachoSil® with Esmarch’s bandage is easy and inexpensive. Further, it would ensure sustained and appropriate pressure on the bleeding site, while providing further adhesive strength to TachoSil® at the site.