Yoshimasa Seike

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.

Recent thoraco-abdominal aortic repair outcomes using moderate-to-deep hypothermia combined with targeted reconstruction of the Adamkiewicz artery

OBJECTIVES We retrospectively reviewed the surgical results of thoraco-abdominal aortic repair using moderate-to-deep hypothermia combined with targeted reconstruction of the Adamkiewicz artery (AKA). METHODS Between 2006 and 2014, 100 patients underwent thoraco-abdominal aortic aneurysm repair using moderate-to-deep hypothermia. Their mean age was 58 ± 15 years and 76 (76%) were men. Their aortic pathologies included acute dissection (5), chronic dissection (74), degeneration (20) and infection (1). Thirty-four had connective tissue disorders and 5 had emergency operations. The degrees of repair were Crawford extent I for 11, II for 76 and III for 13. Seven had concomitant arch repair. Preoperative magnetic resonance angiography or computed tomographic angiography was performed to detect the AKA in 95. We used deep hypothermia (18 °C) for those requiring open proximal aortic anastomosis for cerebral protection and moderate hypothermia (25 °C) for those not requiring open proximal aortic anastomosis. RESULTS Two patients had spinal cord injuries and 4 had a stroke. For those in whom the AKA was identified (90%), all had targeted artery reconstruction. The mean pairs of reconstructed intercostal arteries were 1.5 ± 0.7. There were 5 in-hospital deaths for which the causes were lung bleeding (2), infection (2) and iliac aneurysm rupture (1). Temporary dialysis for new-onset renal failure was required for 9. The mean postoperative mechanical ventilation period was 1.7 ± 1.9 days. Six required a tracheostomy due to respiratory failure. CONCLUSIONS Moderate-to-deep hypothermia combined with targeted reconstruction of the AKA provided satisfactory outcomes with thoraco-abdominal aortic repair, particularly for spinal cord protection.

Surgical outcomes for acute type A aortic dissection with aggressive primary entry resection

OBJECTIVES An entry located at aortic arch in acute type A aortic dissection (AAAD) is uncommon. It remains controversial whether or not aggressive primary entry resection should be routinely performed in such patients. We have adopted an aggressive strategy of entry site resection, including total arch replacement (TAR) in patients with arch tears. The purpose of this study was to investigate the efficacy of our surgical management approach, using aggressive primary entry resection. METHODS Between January 2000 and December 2014, we retrospectively reviewed the records of 334 patients with AAAD who underwent emergent surgery. The mean age was 67 ± 13 years (range, 20-95 years). Ninety-five patients (28%) presented with shock vital status, and 84 patients (25%) manifested malperfusion of branched arteries. Primary entry resection was achieved in 95% of patients under an aggressive surgical strategy [hemiarch replacement for 173 (52%) patients and TAR for 161 (48%) patients] concomitant with 22 coronary artery bypass grafts and 38 root replacements. Ninety-six percent of hospital survivors (298/311) were followed for a median of 39 months (range, 0-179 months). RESULTS Operation, cardiopulmonary bypass, cardiac arrest, antegrade cerebral perfusion and lower body circulatory arrest times were 447 ± 170, 236 ± 93, 112 ± 74, 115 ± 81 and 54 ± 18 min, respectively. The 30-day mortality rate was 5.4%. The in-hospital mortality rate was 8.4% (6.9% at our hospital). Incidences of postoperative permanent neurological dysfunction, tracheotomy and newly permanent haemodialysis were 6.9, 8 and 2%, respectively, with no spinal cord injuries observed. Complete false lumen thrombosis was achieved in 57% of patients as visualized by postoperative computed tomography angiography. After 3, 5 and 10 years, overall survival rates were 81, 74 and 65%, respectively, and the percentages of patients free from downstream dissection-related reoperation were 89, 86 and 80%, respectively. Multivariable analysis demonstrated that the risk factors for downstream aortic reoperation were patent false lumen, residual primary entry tear and connective tissue disorder. CONCLUSIONS The surgical outcomes following aggressive treatment of AAAD are satisfactory. False lumen thrombosis can be achieved in a relatively high proportion of patients using this technique, resulting in a low rate of subsequent downstream aortic reoperations.

Novel surgical incision for treatment of extensive aortic aneurysm: a case of straight incision with rib-cross (SIRC) approach

Spiral incision of the thoracic wall through the 5th or 6th intercostal space has been a standard approach for thoracoabdominal and descending aorta replacement (Interact Cardiovasc Thorac Surg 18:278–282, 2014). The exposure of the proximal lesion, however, is often insufficient for patients with a flat chest. In this connection, Asian patients tend to have a narrower chest cavity and the flat chest is frequently seen in Marfan syndrome patients. A novel straight incision with rib-cross approach was applied for such a patient with a narrow or flat chest to make aortic repair easier and safer. We herein present a case of a 37-year-old male diagnosed with extensive aortic aneurysm associated with chronic aortic dissection, who underwent one-stage repair of the aortic arch and thoracoabdominal aortic aneurysm via a novel surgical incision.

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.

Recurrent aortic regurgitation after valve-sparing aortic root replacement due to dilatation of a previously implanted Valsalva graft

Valve-sparing aortic root replacement (David reimplantation) has been recently used for treating annulo-aortic ectasia (AAE), and is associated with excellent survival and a low risk of late aortic valve replacement (AVR). However, the associated long-term durability of the repair remains uncertain because of the complexity of the aortic root and valve function. Previous studies have reported that the incidence of recurrent moderate aortic regurgitation 10 years after David reimplantation ranges from 10 to 30%, with some

Straight incision for extended descending and thoracoabdominal aortic replacement: novel and simple exposure with rib-cross thoracotomy

OBJECTIVES Spiral incision of the thoracic wall towards the tip of a scapula and approach through the sixth intercostal space has been a standard method for the replacement of thoracoabdominal and descending aortic aneurysms. However, the exposure of the proximal lesion of the aorta with the spiral incision is not always sufficient for patients with a lesion extending into the aortic arch. Patients with Marfan syndrome tend to have a flat chest, and exposure using left thoracotomy generally causes difficulty to operate on the aortic arch. METHODS Since May 2012, 47 patients (mean age 51.2 ± 16.1, range 9-79, 33 males) have received a novel incision for better exposure of the extended descending and thoracoabdominal aneurysm. A straight incision instead of the traditional spiral one was made from the axilla to the umbilical region and the fourth to sixth ribs were transected. The latissimus dorsi muscle and thoracodorsal artery were preserved, which could be a source for collateral circulation to the Adamkiewicz artery. There were two emergent operations for acute aortic dissection. Twenty-four patients (51%) had undergone previous proximal aortic operation, and 2 patients undergone debranched thoracic endovascular aneurysm repair of the aortic arch. Connective tissue disorders were diagnosed in 16 (34.0%) patients (Marfan syndrome 13, Loeys-Dietz syndrome 3). All surgeries were performed under profound hypothermia. RESULTS Seven patients underwent total descending aortic replacement, and the others had Type II thoracoabdominal aortic replacements. Three had partial aortic arch replacement, 5 had total aortic arch replacement and 3 had Y-grafting for the abdominal aorta concomitantly. Operation time was 567 ± 141 min and cardiopulmonary bypass time was 259 ± 60 min. Three patients had a major stroke (6.4%), and 1 had a minor stroke. There was no spinal cord complication among survivors. Hospital mortality rate was 4.3% (2/47). These 2 patients underwent thoracoabdominal aortic replacement, and had a major stroke. CONCLUSIONS This new exposure with straight incision with rib-cross thoracotomy provided excellent exposures for the long segment of the thoracoabdominal aorta, and it enabled extended replacement from the ascending aorta to the abdominal aorta.

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.

Preoperative Assessment of High-Risk Aortic Plaque by Magnetization-Prepared Rapid Acquisition with Gradient-Echo Imaging in a Patient with Total Arch Replacement.

We present a case of a 70-year-old male who underwent surgical repair of an aortic arch aneurysm. Preoperative assessment of high-risk aortic plaque was performed using magnetization-prepared rapid acquisition with gradient-echo (MPRAGE) imaging. This preoperative image was compared with a histological analysis of plaque specimens from the aortic arch and neck vessels. A high signal intensity on MPRAGE images coincided with intraplaque hemorrhage. MPRAGE, which could detect a fragile plaque in the aorta, could be a powerful modality to prevent intraoperative stroke during cardiovascular surgery.