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Endovascular Abdominal Aortic Aneurysm Repair with on Excluder for Proximal Neck Angulation

Atsushi Aoki ; Takanori Suezawa ; Mitsuhisa Kotani ; Jun Sakurai ; Mamoru Tago

Japanese Journal of Cardiovascular Surgery.2012;41(3):107-112. doi:10.4326/jjcvs.41.107

The results of endovascular abdominal aortic aneurysm repair (EVAR) for severe neck angulation with an Excluder were evaluated. We performed EVAR in 51 patients, using an Excluder, from September 2007 to September 2011. The angle between proximal neck and the aneurysm (Angle) was less than 61° in 31 patients (Group I), 61-90° in 13 patients (Group II) and more than 90° in 7 patients (Group III). In Groups I and II, the angled proximal neck was straightened with a stiff guide wire and a Trunkipsilateral device was deployed slowly (aortic modification technique). In Group III, the device modification technique was applied. In this technique, the stiff guide wire was inserted in the aortic root. The Trunkipsilateral device was bent to the contra lateral limb side and was inserted into the aorta. The stiff guide wire was pushed in with a fulcrum at the aortic valve. This procedure resulted in bending of the wire and the trunk-ipsilteral device became parallel to the proximal neck. The renal artery position was confirmed on angiographys and the main body was deployed slowly. We performed angiography after planned device deployment to evaluated Type Ia endoleak, and if it was observed, an additional procedure such as Aortic Extender or Palmaz XL stent deployment was performed and the Type Ia endoleak was evaluated during the procedure by completion angiography. The Angle change was measured by enhanced CT at 7 days and 6 month after EVAR. The Angle were 97-137° in Group III. The frequency of Type Ia endoleak after planned device deployment (35% in Group I, 55% in Group II and 17% in Group III), additional procedure for Type Ia endoleak (29% in Group I, 23% in Group II and 14% in Group III) and Type Ia endoleak by completion angiography (0% in Group I, 8% in Group II and 14% in Group III) did not differ significantly between the 3 groups. When Group I was sub divided into those with Angle less than 41° (Group Ia, 15 patients) and those with an Angle from 41 to 60° (Group Ib, 16 patients), Type Ia endoleak after planned device deployment (18% in Group Ia, 63% in Group Ib) was significantly more frequent in Group Ib and the additional procedure for Type Ia endoleak (7% in Group Ia, 50% in Group Ib) was more frequent in Group Ib. The Angle significantly decreased 7 days after EVAR and did not change thereafter in all 3 groups. EVAR with an Excluder for severe neck angulation was feasible by device modification with the bending technique. This technique might be useful for patients with an Angle of more than 41°.

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Total Arch Replacement with Frozen Elephant Trunk Technique for Aortic Arch Aneurysm Complicated with Left Subclavian Artery Aneurysm

Taro Nakazato ; Teruya Nakamura ; Naosumi Sekiya ; Naomichi Uchida ; Yoshiki Sawa

Japanese Journal of Cardiovascular Surgery.2012;41(3):113-116. doi:10.4326/jjcvs.41.113

A 61-year-old man who had hypertension and renal dysfunction (serum creatinine : 1.5-2.0 mg/dl) was referred to our hospital for an abnormal shadow on chest roentgenogram. Chest CT scan with contrast revealed a distal aortic arch aneurysm (maximum diameter 52 mm) and left subclavian artery aneurysm (maximum diameter 30 mm). For the surgical treatment of the aneurysms, left hemi-collar incision and left subclavian incision followed by median sternotomy were performed. After the left subclavian artery was secured distal to the aneurysm, a ringed dacron graft was anastomosed with the distal left subclavian artery. Cardiopulmonary bypass was commenced, and selective cerebral perfusion was instituted at 25°C. The aorta was transected at the origin of the left common carotid artery. A 30 mm stent graft (length 13 cm) was inserted and was fixed on the transected aorta using 4-0 Prolene continuous suture. Then a branched dacron graft was sewn onto the transected aorta and the stent graft. The left common carotid artery and the brachiocephalic artery were anastomosed onto side branches of the graft. The left subclavian artery was reconstructed by anastomosing the ringed bypass graft onto one of the side branches. The left subclavian artery was ligated between the aneurysm and the origin of the vertebral artery, thereby interposing the subclavian artery aneurysm. After proximal anastomosis was done and the heart was reperfused, the patient was weaned from cardiopulmonary bypass. The patient was discharged without any major complication. Two years after the operation, the patient is doing well and there is no evidence of aneurysmal dilatation or endoleak. In conclusion, frozen elephant trunk technique provides an alternative to conventional graft replacement, resulting in complete exclusion of these aneurysms in a single stage. However, long-term follow up is warranted in order to ensure the durability of the stent graft.

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A Case of Postoperative Paraparesis after Ascending Aortic Replacement for Type A Acute Aortic Dissection

Yoshie Sakasai ; Motoo Osaka ; Tadashi Koishizawa

Japanese Journal of Cardiovascular Surgery.2012;41(3):117-120. doi:10.4326/jjcvs.41.117

Although paraplegia following descending thoracic and thoracoabdominal aortic repair is well known, paraplegia after repairing ascending aorta has been rarely reported. We describe a very rare case of postoperative paraparesis after repairing type A acute aortic dissection. A 64-year-old man with type A acute aortic dissection whose aortic false lumen was all thrombosed, was treated with rest and his blood pressure was strictly controlled. The follow-up computed tomography revealed that blood flow in the false lumen was recognized in the ascending aorta 8 days after admission. At the same time the diameter of the ascending aorta was enlarged. We performed emergency ascending aortic replacement under deep-hypothermic circulatory arrest and selective cerebral perfusion. We recognized that he showed paraparesis 4 days after operation and magnetic resonance imaging showed high signals in the spinal cord, which indicated spinal cord infarction. He received rehabilitation for 5 months, and fully recovered neurologically. The causes of paraplegia after repairing type A acute aortic dissection have not been clarified. In our case, we presumed the causes included over 60 min circulatory arrest which invoked low spinal perfusion, the anterior spinal artery was thrombosed by selective cerebral perfusion, some intercostals arteries were occluded by postoperative change of the descending aortic false lumen pressure. This case is very rare, and we had to take all possible precautions.

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A Case of Solitary Inferior Mesenteric Artery Aneurysm

Minoru Okamoto ; Mutsuo Tanaka

Japanese Journal of Cardiovascular Surgery.2012;41(3):121-123. doi:10.4326/jjcvs.41.121

A 74 year-old man visited our hospital complaining of increasing sensory disorder of the left lower extremity. On physical findings, a pulsatile mass was detected in abdomen, but he had been aware of it for 5 years. Further examination revealed on inferior mesenteric artery aneurysm 8 cm in diameter. It had no communication with other visceral arteries or veins. Surgical treatment was performed to resect the aneurysm without revascularization. The postoperative course was uneventful. The pathological examination of the aneurysm showed atherosclerotic change. The chief complaint on admission was unchanged following surgery and was thought to have no relation to the aneurysm. It was thought that to derive from lumbar vertebral disease. After operation, regular follow-up is necessary to check for pseudoaneurysms formation at the surgical margin and development of other visceral artery diseases.

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Emergency Operation for an Unconscious Patient Caused by Stanford Type A Acute Aortic Dissection with Occlusion of the Right Common Carotid Artery

Hideaki Yamabi ; Kazuhito Imanaka ; Takahiro Matsuoka ; Mitsuhiro Kawata

Japanese Journal of Cardiovascular Surgery.2012;41(3):124-127. doi:10.4326/jjcvs.41.124

A 65-year old unconscious man with left hemiplegia was found to have acute Stanford type A aortic dissection (AAD) and occlusion of the brachiocephalic and right carotid artery. He underwent emergency surgery. Before midline sternotomy, arterial cannulas were inserted into the femoral artery and the true lumen of the right carotid artery and were connected thorough a Y-shaped extracorporeal circulation circuit to restore the cerebral perfusion. During the aortic procedure, both arteries were used as arterial inflow sites.The patient regained consciousness 6 h later and was extubated on the next day. He suffered infarction of the right cerebral hemisphere, but neurologic deficits were totally resolved. He was given an ambulatory discharged 46 days later and has been reinstated in his former job 6 months after the operation. The indications for emergency surgery for AAD complicated by stroke or coma remains controversial. Especially soon after the onset, surgery may be applicable for such AAD patients if neurological deficits are not obviously irreversible.

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A Surgical Case for Acute Heart Failure in a 1-month-old Infant with a Right Cervical Aortic Arch

Koji Nomura ; Takayuki Abe ; Yoshihiro Ko

Japanese Journal of Cardiovascular Surgery.2012;41(3):128-131. doi:10.4326/jjcvs.41.128

A 2-day-old male baby was referred to our hospital because of a heart murmur. We diagnosed as a right cervical aortic arch, and coarctation between the right carotid and right subclavian artery. On echocardiography, the velocity at the coarctation was 1.8 m/s, the left ventricular ejection fraction (LVEF) was 53%, and he was asymptomatic during the neonatal period. A chromosome examination showed a deletion of 22q11 syndrome. At 1 month, he weighted 3.8 kg and was readmitted to our hospital for wheezing. Echocardiography showed a left ventricular dysfunction with LVEF of 24%. The coarctation velocity increased to 5.1 m/s. An urgent operation was performed because of a severely depressed cardiac function. His LVEF increased to 67%, and the velocity was less than 1 m/s postoperatively, and he was discharged on postoperative day 32. We report a rare neonatal surgical case of a right cervical arch with a coarctation.

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Stanford Type A Acute Aortic Dissection with Left Extra-pleural Hematoma and Lung Hemorrhage

Yoshinori Kuroda ; Tetsuro Uchida ; Kazue Nakashima ; Hideaki Uchino ; Takao Shimanuki

Japanese Journal of Cardiovascular Surgery.2012;41(3):132-134. doi:10.4326/jjcvs.41.132

A 68-year-old woman with a sudden onset of back pain was brought to our hospital by ambulance. Computed tomography (CT) showed Stanford type A (DeBakey type II) acute aortic dissection, left hemothorax, and hematoma extending along the pulmonary artery ; therefore, the patient underwent emergency operation. We performed a median sternotomy. Pericardial effusion was not observed ; however, a hematoma was found around the ascending aorta. Preoperative CT showed left hemothorax, but pleural effusion was not observed in the left pleural cavity. The left hemothorax, which was detected on preoperative CT, was diagnosed as an extrapleural hematoma. The dissection entry site was located at the proximal aortic arch ; therefore, ascending aorta-hemiarch replacement was performed. After weaning from cardiopulmonary bypass, the patient experienced sudden airway bleeding. The bleeding was attributed to the hematoma extending along the pulmonary artery. Here, we have reported a rare case of Stanford type A acute aortic dissection with the left extrapleural hematoma and lung hemorrhage.

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Three Cases of Lambl's Excrescence

Nobuko Yamamoto ; Yoshitaka Okamura ; Yoshiharu Nishimura ; Shunji Uchita ; Koji Toguchi ; Kentaro Honda ; Takeo Nakai

Japanese Journal of Cardiovascular Surgery.2012;41(3):135-138. doi:10.4326/jjcvs.41.135

Lambl's excrescences are the fibrous structures which are attached to the heart valve, and usually the presence of Lambl's excrescences alone is not an indication of operation. The operative indications of isolated Lambl's excrescence is still controversial, because some reports indicated cross relationship between Lambl's excrescences and cerebral embolism. Based on these facts, we discussed our 3 cases of Lambl's excrescences. Two of the cases had been complicated with severe mitral regurgitation and Lambl's excrescences were resected at the time of mitral valve plasty. In another case, Lambl's excrescence was found with echocardiography during chronic heart failure therapy. This patient had a past history of cerebral infarction, but no relationship of cerebral infarction was suggested. In this case, cardiac surgery was not required, so we followed isolated Lambl's excrescence without resection in this case. One operated case, which had infective endocarditis was suspected by echocardiography, had slighted inflammatory reaction but blood culture was negative. Diagnosis of Lambl's excrescence was made by histopathological examination. One report suggested that the cause of the cerebral infarction is not Lambl's excrescence itself but the thrombi around Lambl's excrescence. However, we hesitate to operate on isolated Lambl's excrescence. Based on some reports, it is useful to resect Lambl's excrescence when a concurrent cardiac operation is carried out to avoid cerebral embolic events.

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Reoperation in Two Patients with SJM Toronto SPV and Medtronic Freestyle Stentless Bioprosthetic Valves

Yuki Ichihara ; Akihiko Kawai ; Satoshi Saito ; Kenji Yamazaki

Japanese Journal of Cardiovascular Surgery.2012;41(3):139-143. doi:10.4326/jjcvs.41.139

Stentless bioprosthetic valves have been implanted for treatment of aortic valve disease, especially in elderly patients ; these valves have the advantage of durability and excellent hemodynamics compared with stented bioprosthetic valves. Although good long-term results in patients with stentless bioprosthetic valves have been reported recently, reoperation has been gradually increasing. We performed reoperation for the SJM Toronto SPV and Medtronic Freestyle valves in one patient each. The SJM Toronto SPV was used in a 30-year-old woman ; however, 8 years later, the valve showed severe calcification and adhesions, and could not be completely removed (Case 1). The other reoperation case, wherein a 69-year-old man underwent aortic valve replacement with the Medtronic Freestyle 4 years previously, showed no adhesion around the implanted valve, which could be easily removed from the autologous aortic annulus. Consequently, the first patient required reimplantation of a small mechanical valve (SJM #19). In contrast, we were able to use a stentless bioprosthetic valve (Prima Plus #23) for the second patient. Further observations on stentless bioprosthetic valves are required.

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Successful Endovascular Treatment of Ureteroarterial Fistula and Anastomotic Pseudoaneurysms

Akiyoshi Mikuriya ; Katsuyuki Hoshina ; Masaaki Kato ; Nobukazu Ohkubo

Japanese Journal of Cardiovascular Surgery.2012;41(3):144-147. doi:10.4326/jjcvs.41.144

A 79-year-old man who had undergone aneurysmectomy and graft replacement for an abdominal aortic aneurysm developed abdominal distension and massive hematuria. A computed tomography (CT) scan revealed the presence of anastomotic pseudoaneurysms and an ureteroarterial fistula between the ureter and iliac artery (distal anastomotic pseudoaneurysm). On admission, the patient's vital signs were stable. The patient was considered a high-risk case for open surgery because of his renal dysfunction which required dialysis, chronic heart failure and hostile abdomen. We initially recommended open surgery because of possible graft infection, however, the patient refused to undergo the high-risk open surgery. We performed emergency surgery for the ureteroarterial fistula via coverage with off-label use of the stent-graft leg. Intraoperative angiography revealed that there was no leakage. After 1 month, we confirmed that the inflammatory laboratory data was normalized, subsequently, we performed endovascular re-intervention for the proximal aortic anastomotic pseudoaneurysm. The endoleak was finally repaired after off-label use of the stent-graft (aortic cuff exclusion) twice within 2 months. The patient did not develop any operation-related adverse events for 4 months, but subsequently he died of pneumonia that developed from a common cold. Thus, we successfully performed endovascular treatment for a high-risk patient with an ureteroarterial fistula and pseudoaneurysms, without any surgery-related infection.

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