Published papers

Zone 0 thoracic endovascular aortic repair (TEVAR) remains technically demanding because of limited proximal landing zones and the need to preserve all supra-aortic branches. Conventional strategies—including branched endografts, chimney or snorkel techniques, and hybrid repairs—have been associated with increased risks of stroke, retrograde type A dissection, and perioperative mortality. We describe a technique using a physician-modified triple-fenestrated endograft with transfemoral delivery of all bridging covered stents (BCSs) to the brachiocephalic, left common carotid, and left subclavian arteries. Cervical and brachial access was used solely for angiography and minimal catheter manipulation, thereby aiming to reduce cerebral embolization risk. A 71-year-old man with a history of coronary artery bypass surgery and reduced left ventricular ejection fraction (31%) presented with fever. Imaging revealed a dissecting aortic aneurysm confined to the arch. Blood cultures were positive for methicillin-susceptible Staphylococcus aureus. After intravenous antibiotic therapy, cultures became negative; however, the aneurysm enlarged. Given the high surgical risk, TEVAR was selected. All BCSs were delivered transfemorally without complications. Postoperative and 1-year follow-up imaging showed no endoleak and a reduction in aneurysm size. This approach may offer a less invasive and embolic risk-reducing option for managing arch pathology in high-risk patients.

Severe true lumen narrowing in chronic dissecting thoracoabdominal aortic aneurysms (dTAAAs) can compromise accurate fenestration alignment and hinder reliable bridging of the renovisceral branches. We evaluated the safety and feasibility of fenestrated endovascular aortic repair using a physician-modified endograft incorporating a visceral segment interrupted constraining suture. This permanent diameter-constraining modification is intended to stabilize the endograft within a narrowed true lumen and improve target vessel access. Sixteen patients with chronic dTAAA underwent elective repair using a low-profile Zenith Alpha Thoracic device. All 60 renovisceral branches were successfully bridged, resulting in 100% intraoperative technical success, defined as completion of the planned procedure with aneurysm sac sealing, with no 30-day mortality. Three patients required early reintervention for endoleak (1 type IC; 2 type IIIC). Follow-up imaging through 12 months demonstrated durable aneurysm exclusion and sustained branch patency. In this early experience, a visceral segment interrupted constraining suture provided reproducible diameter control and facilitated target vessel access in complex dTAAA treated by physician-modified endograft-based fenestrated endovascular aortic repair.

An aortopulmonary window is a rare disorder that occurs in 0.1-0.2% of all congenital disorders. Our patient was a 1-month-old boy weighing 4180 g. The patient had heart failure associated with an aortopulmonary window. We used 3-dimensional computer graphic software (Viewtify, SCIENMENT) for diagnosis based on DICOM data from contrast-enhanced computed tomography. This made it easy to identify anatomical landmarks and findings and select the most suitable approach. We avoided stenosis of the right pulmonary artery and aorta. We encountered a case of an aortopulmonary window in which 3-dimensional computer graphic software was helpful in selecting the surgical technique. We report this case using 3-dimensional computer graphic images and present a review of the literature.

Introduction: Commando surgery carries a substantial risk of bleeding owing to its multiple operative steps, prolonged cardiac arrest time, and the need for many sutures to the fragile tissues of the heart. Prosthetic valve infective endocarditis, especially after multiple valve replacements, can be difficult to treat surgically because of the high degree of adhesions. Case Presentation: We report a 66-year-old man who underwent a Commando procedure for recurrent prosthetic valve endocarditis, following two previous double valve replacement surgeries. Adequate exposure was achieved without injury to surrounding structures by selecting an incision line that avoided extensive dissection of dense adhesions. Bleeding was further minimized by reconstructing the aortic, left atrial, and right atrial walls while preserving adherent tissue as much as possible. Conclusion: The route of incision and reconstruction we have shown in this study may allows for reproducible Commando surgery even in the presence of strong adhesions.

Precise neochord length adjustment can be demanding during minimally invasive mitral valve repairs. Expanded polytetrafluoroethylene neochordae are typically passed twice through the leaflet edge for provisional fixation during saline testing; however, readjustment becomes cumbersome after the second pass. We present a reproducible modification utilizing a temporary silk loop that permits complete release of the second pass during saline testing, allowing precise neochord adjustment. Upon achieving optimal adjustment, the silk loop is removed, and the suture is tied conventionally. This approach provides a complementary option for surgeons who prioritize real-time adjustability while adhering to familiar surgical principles.

Background: The effect of the surgical sealant AQUABRID on outcomes after acute aortic dissection repair has not been evaluated. The objective of this study was to examine whether the use of AQUABRID affects the volume of intraoperative blood transfusion or operative time in patients undergoing emergency surgery to repair acute aortic dissection. Methods: A multicenter retrospective cohort study from January 2007 to December 2021. A total of 399 patients underwent emergency acute aortic dissection repair. Propensity score matching was used to adjust for the type of surgery and other patient characteristics. Results: A total of 387 of the eligible 399 patients were included in this study and propensity score matching yielded 94 patients for whom characteristics were not significantly different between the two groups. The type of surgery was exactly matched (ascending aorta replacement: 19 [40%]; partial arch replacement: 13 [28%]; total arch replacement: 15 [32%] in each group). Within the matched cohort, there was a statistically significant difference in the volume of intraoperative blood transfusion. (AQUABRID vs. control: 34 [26–38] vs. 50 [38–60] U in Japan, p =.03). Operating time was significantly shorter in the AQUABRID group (total operation: mean ± SD, 343 ± 92 vs. 402 ± 161 min, p =.03; reconstruction for arch vessels: 29 ± 17 vs. 56 ± 22, p <.01). The rate of postoperative complications was comparable in the two groups. Failure to use AQUABRID was a significant predictor of the need for massive transfusion (>40 U) (odds ratio: 7.20; 95% confidence interval: 2.56–20.23; p <.01). Conclusions: The use of AQUABRID during emergency acute aortic dissection repair significantly decreased the volume of intraoperative blood transfusion and the duration of surgery.

Background: Carotid blowout syndrome (CBS) is a rare but potentially fatal complication of head and neck cancer (HNC), with radiotherapy being a major risk factor. Because of its high mortality, urgent treatment is essential. Endovascular therapy has become the standard approach, although complications such as stent extrusion may occur. Method: This study reports a single case with a brief review of the relevant literature. Case Presentation: A 67-year-old woman underwent neck dissection and chemoradiotherapy for metastatic cervical carcinoma. Radiation dermatitis developed during treatment and persisted thereafter. Four months later, she developed a carotid artery pseudoaneurysm that resulted in CBS. Emergency endovascular repair was performed using a covered stent from the left common to internal carotid artery. Two months later, the stent spontaneously extruded through the cervical skin. Remarkably, there was no active bleeding or neurological deficit. The stent detached naturally, and the patient remained clinically stable. Conclusion: This case highlights an extremely rare occurrence of carotid stent extrusion. Although endovascular therapy is effective for CBS, serious complications such as hemorrhage and neurological damage may occur. Careful long-term follow-up is essential to detect delayed adverse outcomes. Clinical Impact: This case highlights a rare but clinically important phenomenon of spontaneous carotid stent extrusion following endovascular treatment for carotid blowout syndrome (CBS). While endovascular therapy is widely accepted as the first-line treatment due to its minimally invasive nature, this report emphasizes the potential for delayed and unexpected complications, particularly in irradiated and infected fields. The absence of hemorrhagic or neurological sequelae despite stent extrusion suggests that complete thrombosis and collateral circulation may mitigate catastrophic outcomes. Clinicians should recognize this risk and implement close multidisciplinary follow-up, early wound management, and consider preventive strategies such as flap reconstruction or timely stent removal to improve patient safety.

Background In acute type A aortic dissection (AADA) patients, total arch replacement (TAR) using the frozen elephant trunk (FET) technique has been adopted in emergencies to promote distal false lumen (FL) thrombosis. However, TAR is technically demanding and is associated with prolonged operative time and increased intraoperative blood transfusion. We previously reported the branched stented anastomosis frozen elephant trunk repair (B-SAFER) technique. Comparative data versus conventional TAR (cTAR) adjusted for disease severity remain limited. Here we compared the early surgical outcomes of TAR using B-SAFER versus cTAR in AADA. Methods This retrospective, multicenter, nonrandomized study included patients with AADA and a patent FL who underwent emergency TAR using B-SAFER (n = 63) and cTAR (n = 75). Propensity score matching based on EuroSCORE and JapanSCORE identified 48 matched pairs. After matching, 16 patients (33%) in the comparator group underwent conventional TAR without an FET device because of institutional practice patterns or device-related constraints. Results The 30-day mortality was 7.3% overall (7/96), with no significant difference between the groups (6.2% for B-SAFER vs 8.3% for cTAR; P > .999). Spinal cord ischemia occurred in 0% versus 4.2% ( P = .153). All operative time metrics were significantly shorter with B-SAFER (all P ≤ .024). Transfusion requirements for red blood cells, fresh frozen plasma, and platelets were all significantly lower (all P < .001). Conclusions In propensity score–matched patients with AADA, TAR using B-SAFER was safe and reproducible, with reduced operative times and transfusion requirements compared to cTAR.

Background: Acute aortic dissection (AAD) with concurrent ST-segment elevation myocardial infarction (STEMI) is relatively rare and sometimes overlooked. As D-dimer testing has been reported to have high sensitivity to diagnose AAD in a clinical scale, Aortic Dissection Detection Risk Score (ADD-RS), a point-of-care D-dimer analyzer capable of measuring in 10 min would be useful to deny AAD with concurrent STEMI. However, an optimal cut-off value of D-dimer in such population remains unclear. Therefore, the aim of this study was to elucidate the optimal D-dimer threshold in patients clinically diagnosed with STEMI. Methods: This retrospective cohort study was conducted at two tertiary care centers between 2014 and 2019. Patients clinically diagnosed with STEMI who underwent serum D-dimer measurement on hospital arrival were included. The primary outcome was the diagnosis of AAD. The area under the receiver operating characteristic curve (AUROC) for D-dimer values to diagnose AAD was evaluated, particularly in patients with low to moderate risks of AAD (1 of ADD-RS). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with several cut-off values. Results: A total of 322 patients were included, and 28 were diagnosed with AAD. The AUROC for D-dimer to diagnose AAD was 0.970 (95% confidence interval: 0.948–0.993) in 262 patients with 1 of ADD-RS. If D-dimer ≥750 ng/mL was used as a cut-off value, sensitivity, specificity, PPV and NPV were 100%, 86.4%, 37.7%, and 100%, respectively. AAD could be denied in 209 (79.8%) patients using the cut-off value (D-dimer <750 ng/mL). Conclusions: Serum D-dimer ≥750 ng/mL exhibited high sensitivity and NPV to diagnose AAD with concurrent STEMI, while the ADD-RS originally utilized ≥500 ng/mL as a cut-off for any suspected AAD. A point-of-care D-dimer measurement with the new cut-off would be useful to rule-out AAD among patients with STEMI.

Purpose: The superior septal approach offers improved mitral valve exposure compared to the right-sided left atriotomy or transseptal approach. However, the risk of postoperative sinus node dysfunction remains controversial, with limited data in the context of right mini-thoracotomy. Methods: This retrospective study included 155 patients (64 women; mean age, 60.8 ± 13.4 years) who underwent mitral valve surgery via right mini-thoracotomy between November 2016 and August 2023. Indications included degenerative mitral regurgitation (94.8%) and mitral stenosis (5.2%). Patients were divided into 2 groups: the conventional minimally invasive mitral valve surgery (CM) group (n = 47), using the right-sided left atriotomy, and the drawer-case technique (DCT) group (n = 108), using the superior septal approach. Demographic, intraoperative, and outcome data were analyzed. Results: Baseline characteristics were similar between groups. There were no significant differences in valve repair techniques or postoperative echocardiographic findings. Postoperative junctional rhythm occurred in 6 patients (CM group) and 21 patients (DCT group); all patients with preoperative sinus rhythm returned to sinus rhythm postoperatively. Conclusion: The superior septal approach does not increase the risk of persistent junctional rhythm in right mini-thoracotomy and is a safe and effective option for mitral valve surgery.

Objective: The provisional extension to induce complete attachment (PETTICOAT) technique is a unique thoracic endovascular aortic repair (TEVAR) for aortic dissection, which consists of proximal descending aortic endografting plus distal bare-metal stenting. This study aimed to investigate the efficacy of the PETTICOAT technique in patients with acute-sub-acute complicated type B aortic dissections. In particular, we compared the remodeling effect of full PETTICOAT covering down to the abdominal aorta with that of simple entry closure. Methods: In this retrospective pre-post study, we compared the clinical course of consecutive patients undergoing TEVAR with the PETTICOAT technique in which proximal entry tear was excluded with a covered stent, and extension bare stents were placed down to the abdominal segment for acute-sub-acute complicated type B aortic dissections, between 2015 and 2017, with a control group treated with TEVAR with entry closure between 2011 and 2015. Outcomes included the aortic remodeling rate and the aortic diameter up to 1 year after surgery. Results: Subjects consisted of 47 patients (21 in full PETTICOAT group, 26 in the simple entry closure group). The remodeling rate of the abdominal aorta in the full PETTICOAT group was significantly higher than in the simple entry closure group (p < 0.05), while that of the thoracic aorta was comparable between the two groups. Conclusions: This study suggests that the full PETTICOAT technique achieves better aortic remodeling compared to entry closure alone, and might lead to less reintervention.

Objective: Fenestrated Endovascular Aortic Repair (F-EVAR) using Physician-Modified Endografts (PMEGs) has become an important option in the treatment of complex aortic aneurysms, particularly when custom-made devices are not available. However, difficult target vessel (TV) cannulations, notably with misalignment, often limit total transfemoral repair. To address this condition, we developed the Gap Steering (GPS) technique, which is a transfemoral-only adjunctive method using a steerable sheath to create a controlled gap between the stent graft and the aortic wall, enabling on-demand cannulation. In this study, we aimed to evaluate the technical feasibility and procedural features, outcomes, and risks associated with the GPS technique in difficult target vessel cannulation owing to fenestration misalignment. Methods: We retrospectively reviewed 42 patients (14 thoracoabdominal, 28 complex abdominal aortic aneurysms) undergoing F-EVAR using PMEGs with bridging stent placement between October 2020 and January 2025. Although not designed as a comparative study, patients were stratified by treatment period: Pre-GPS technique group (n = 10, TV = 30) and Post-GPS technique group (n = 32, TV = 114). The GPS technique was used as the primary bailout for difficult cannulations in the Post-GPS technique group. Among the 114 TVs, the GPS technique was selectively applied to 18 challenging vessels (15.8%). Results: Among 18 target vessels treated with the GPS technique, successful cannulation was achieved in 14 (77.8%), with no GPS technique–related complications. At the per patient level, the Post-GPS technique group showed significantly higher technical success (96.8% vs 60.0%, p=0.008) and a higher target vessel success rate (100% vs 80.0%, p=0.052). TV instability was significantly lower (3.1% vs 30.0%, p=0.03). At the per-vessel level, TV technical success was higher (100% vs 93.3%, p=0.042), with lower rates of TV occlusion (0.0% vs 6.7%, p=0.042) and TV instability (0.9% vs 13.3%, p=0.007). All GPS technique-treated vessels remained patent at the 14 month median follow-up. Conclusion: The GPS technique is a feasible adjunct for difficult cannulations in F-EVAR using PMEGs. It avoids additional devices and is particularly suited for total transfemoral repair using currently available steerable sheaths. Clinical Impact: Difficult renovisceral target vessel cannulation remains a major limitation to achieving total transfemoral F-EVAR using physician-modified endografts (PMEGs). This challenge often necessitates upper-extremity access or complex adjunctive maneuvers, increasing procedural invasiveness and access-related risks. The Gap Steering (GPS) technique offers a practical adjunctive strategy using a commercially available steerable sheath to achieve controlled directional guidewire manipulation at the fenestration–aortic wall interface. It enables selective cannulation without additional access routes, larger delivery systems, or device modification. This reproducible and fully transfemoral approach has the potential to improve procedural efficiency and expand the applicability of PMEG-based F-EVAR in complex aortic repair.

Background: Prosthetic valve endocarditis (PVE) and aortic dissection are rare but severe complications of transcatheter aortic valve replacement (TAVR), with no standardized surgical approach. Case Summary: A 74-year-old woman developed PVE 6 months after TAVR with an Evolut PRO+ valve (Medtronic). Echocardiography revealed valve vegetation and perivalvular leakage, and computed tomography showed localized ascending aortic dissection. Emergency surgery involved careful removal of the Evolut PRO+ using sutureless aortic valve replacement and ascending aorta replacement. Discussion: Successful management of TAVR-related PVE with aortic dissection in high-risk patients requires a clear understanding of prosthetic valve characteristics and tailored surgical planning. Techniques such as cold-water explantation and sutureless aortic valve replacement can be particularly useful in minimizing operative risk. Take-Home Messages: This case highlights a reproducible strategy for complex TAVR complications. Cold-water explantation and the snare technique allows safe valve removal, while sutureless aortic valve replacement shortens procedural time, offering practical advantages in high-risk patients.

OBJECTIVES: Our goal was to evaluate early and mid-term outcomes of physician-modified endografting for pararenal and thoraco- abdominal aortic aneurysms from 10 Japanese aortic centres. METHODS: From January 2012 to March 2022, a total of 121 consecutive adult patients who underwent physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms were enrolled. We analysed early and mid-term postoperative outcomes, including postoperative complications and mortality. RESULTS: The pararenal and thoraco-abdominal aortic aneurysm groups included 62 (51.2%) and 59 (48.8%) patients, respectively. The overall in-hospital mortality rate was 5.8% (n =7), with mortality rates of 3.2% (n =2) and 8.5% (n =5) in pararenal and thoraco- abdominal aortic aneurysm groups, respectively (P =0.225). Type IIIc endoleaks occurred postoperatively in 18 patients (14.9%), with a significantly higher incidence (P =0.033) in the thoraco-abdominal aortic aneurysm group (22.0%, n =13) than in the other group (8.1%, n =5). Major adverse events occurred in 7 (11.3%) and 14 (23.7%) patients in pararenal and thoraco-abdominal aortic aneurysm groups (P =0.074), respectively. The mean follow-up period was 24.2months. At the 3-year mark, both groups differed significantly in freedom from all-cause mortality (83.3% and 54.1%, P =0.004), target aneurysm-related mortality (96.8% and 82.7%, P =0.013) and any reintervention (89.3% and 65.6%, P =0.002). Univariate and multivariate regression analyses demonstrated that ruptures, thoraco- abdominal aortic aneurysms and postoperative type IIIc endoleaks were associated with an increased risk of all-cause mortality. CONCLUSIONS: The mid-term outcomes of physician-modified endografting for pararenal and thoraco-abdominal aortic aneurysms were clinically acceptable and comparable with those in other recently published studies. Notably, pararenal and thoraco-abdominal aortic aneurysms represent distinct pathological entities with different postoperative outcomes.