Published papers

Objective: Type III endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with the Endologix unibody endograft remain a major concern, despite fabric, system, and instructional updates. The purpose of this study was to examine real-world outcomes of repairing AAAs using the current version of the AFX2 main body in combination with an aortic cuff, specifically focusing on type III endoleaks and morphological changes of the endograft. Methods: We recruited facilities in Japan that used AFX2 combined with an aortic cuff for at least five cases between April 2017 and March 2018. A total of 175 cases in 24 facilities were analyzed. Patients’ background information, including anatomic factors, operative findings, device component variations, and midterm outcomes at 3 years after the EVAR were collected. The data on computed tomography scans from cases registered as types I and III endoleaks and migration from each institute were sent to our department for verification. Results: The mean patient age was 74.6 ± 8.1 years, and 48 cases (27%) were saccular aneurysms. The mean fusiform and saccular AAA diameters were 50.5 ± 5.8 mm and 43.5 ± 8.9 mm, respectively. No in-hospital deaths occurred. Data at 3 years, including computed tomography images, of 128 cases were analyzed. Overall survival, freedom from aneurysm-related mortality, and freedom from reintervention rates at 3 years were 85.8%, 99.3%, and 87.3%, respectively. There were three, one, and three cases of types I, IIIa, and IIIb endoleaks without sac dilatations, respectively. Among five migration cases, one case of aortic cuff migration presented as a type Ia endoleak, and four cases demonstrated sideways displacement, one of which presented as a type IIIa endoleak. The sac regression and enlargement rates at 3 years were 41.4% and 20.5% in the fusiform group and 44.2% and 16.7% in the saccular group, respectively. The proximal neck diameter slightly increased from 20.8 ± 2.7 mm before the EVAR to 22.2 ± 4.6 mm after the repair. Conclusions: Midterm outcomes of the AFX2 used in combination with an aortic cuff were acceptable, considering the rates of types I and III endoleaks. However, there were cases of sideways displacement that could cause future type IIIa endoleaks. When the AFX2 is used in combination with an aortic cuff, close surveillance for endograft deformations and subsequent adverse events, including type III endoleaks, is needed.

We report a technique to preserve the internal iliac artery (IIA) using a physician-modified contralateral limb (PMCL) with an inner branch stent-graft (IBS) for patients with common iliac artery aneurysms not suitable for commercially-available iliac branch devices (cIBDs). A fenestration was created in the tapered or 13 mm segment of an Endurant II contralateral limb, and an IBS—2 mm larger in diameter than the fenestration—was inserted and deployed with 15–20 mm inside the PMCL and 5 mm externally. The IBS was fixed at three points in parallel to the limb. A preloaded wire was inserted, and the system reloaded and implanted. Two patients were treated using this method, with the IIA stent-graft deployed into the superior gluteal artery. One had a fenestration in the tapered segment, the other in the 13 mm segment. Follow-up computed tomography showed no endoleaks and satisfactory pelvic perfusion in both cases, with no complications. This technique maintains pelvic and lower extremity blood flow, ensures graft stability, and allows future endovascular reintervention. It may be a valuable alternative for patients for whom cIBDs are not indicated. Clinical Impact: Preserving the internal iliac artery is essential, but maintaining adequate lower-extremity perfusion during treatment of common iliac artery aneurysms is equally important. Our physician-modified contralateral limb with an inner branch stent-graft successfully achieved both goals in two cases. The construct also maintained its shape without deformation and resisted migration, even when additional endovascular procedures involved the inner branch stent-graft.

Prosthetic valve endocarditis, especially when complicated by an aortic root abscess and a left ventricular outflow tract rupture, is a life-threatening condition. We present a case of infective prosthetic aortic valve endocarditis with a ruptured left ventricular outflow tract successfully treated with a root-commando operation using a secure anastomosis for reconstruction of the damaged aortic annulus.

Background: We investigated the safety and efficacy of physician-modified thoracic endovascular aortic repair using a low-profile device for aortic arch lesions. Methods: A total of 42 consecutive patients (mean age 67.2 ± 12.7 years; 32 men) with aortic arch lesions were treated by physician-modified thoracic endovascular aortic repair using a low-profile device (Zenith Alpha Thoracic Endovascular Graft) with four scallops or 13 fenestrations for the common carotid artery and 38 fenestrations or 30 branches for the left subclavian artery. The aortic repair indications were acute type B aortic dissection (n = 17, 40.5%), degenerative aneurysm (n = 14, 33.3%), chronic dissection aneurysmal degeneration (n = 4, 9.5%), and ulcer-like projection (n = 2, 4.8%). The mean iliac artery diameter was 7.6 ± 1.1 mm. Results: There were no branches covered unintentionally or patients who died and suffered from severe spinal cord ischemia perioperatively. One patient (2.4%) experienced a postoperative minor stroke with full neurological recovery. The mean follow-up time was 18 ± 11 months, with 28 patients (66.7%) having at least 12 months. One access-related complication (2.4%) occurred. Two residual Ia (4.8%) and three residual IIIa (7.1%) endoleaks were treated by reintervention. There were no open repair conversions, ruptures, or other aortic complications. Conclusion: Physician-modified thoracic endovascular aortic repair using the low-profile device may be a safe, feasible, and time-saving method for preserving the cervical artery and has high reproducibility and anatomical reconstruction. However, its durability requires long-term follow-up.

We report a rare case of aortic dissection with radiologically documented rupture. A 65-year-old man presented with sudden loss of consciousness. Sequential computed tomography (CT), first non-contrast, then contrast-enhanced— captured the transition from dissection to rupture, revealing the intimal tear at the dorsal aspect of aortic root and increase of pericardial sac perforation. This case demonstrates the power of imaging to anatomically pinpoint rupture intermittently, with potential implications for emergent diagnosis.

Surgeons have been reluctant to adopt minimally invasive combined aortic and mitral valve surgery through a minithoracotomy because of its complexity and prolonged cardiopulmonary bypass and aortic cross-clamping times. Our technique was designed to provide a close and frontal surgical visual field without the need for long-shafted specialized surgical instruments, thereby allowing a standardized and well-visualized surgical visual field in many cases. Here we describe the implementation of our minimally invasive combined aortic and mitral valve surgical procedure through a right minithoracotomy facilitated by the superior septal approach for mitral valve access.

Objective: Proximal ExTension to Induce COmplete ATtachment (PETTICOAT), which uses downstream bare metal stents for structural support, demonstrates potential, yet its adoption is limited by variable outcomes. This study elucidates the potential of PETTICOAT in aortic dissection, emphasizing the determinants that guide patient selection. Methods: A retrospective analysis of 60 patients who underwent full PETTICOAT for aortic dissections was conducted. A multivariate logistic regression model identified predictors of favorable aortic remodeling. Patients underwent standardized follow-up with computed tomography scans to assess size, volumetric changes, and anatomical conditions. Selection criteria included full PETTICOAT application and a minimum of 3 months of follow-up. Demographics, preoperative conditions, and procedural details were collected and analyzed. Results: The analysis identified predictors of favorable aortic remodeling, including age >60 years, a larger downstream aorta stent graft, a smaller abdominal aorta (<450 mm2), and oral angiotensin II receptor blocker administration. Over a median 47.5 months of follow-up, survival rates in the favorable remodeling (97.3%) and unfavorable groups (100%) were similar. Downstream aortic event-free survival rates did not differ significantly (89.2% vs 73.9%), although the unfavorable group had a relatively higher incidence of distal stent-induced new entries (26.1% vs 8.1%). Conclusions: The PETTICOAT concept effectively enhances aortic remodeling in complex aortic dissections. Predictors for favorable remodeling, including age, stent graft sizing, aortic diameter, and angiotensin II receptor blocker therapy, offer insights for optimizing patient selection. This approach improves survival outcomes, mitigates risks associated with untreated aortic segments, and provides a minimally invasive solution for aortic dissections. Despite some outcome variations, the technique holds promise for addressing the challenges of aortic dissections, with the potential for further refinement in patient selection and technique application.

Background: Cold agglutinin disease (CAD) is sometimes incidentally detected before cardiovascular surgery. Several methods to prevent complications associated with CAD after cardiac surgery have been reported, but there are no reports of the use of physician-modified TEVAR to date. Case presentation: A 76-year-old man with an arch aortic saccular aneurysm was scheduled to undergo arch aortic replacement. However, cold agglutinin syndrome was incidentally detected before open heart surgery. The safety of cardiopulmonary surgery under hypothermia for patients with cold agglutinin disease is unknown, as intravascular hemolysis is a source of concern for patients sensitive to cold stimulation. Instead, we performed physician-modified thoracic endovascular aortic repair (3 fenestrations and 1 branch), as the aneurysm in this case was suitable for thoracic endovascular aortic repair (TEVAR). As a result, the patient recovered well without any complication. Conclusions: The long-term prognosis of physician-modified thoracic endovascular aortic repair remains unclear, and its use is limited to high-risk patients who require open chest surgery. Also, the impact of cold agglutination on stent grafts in CAD patients has not been reported. Despite that situation, this case illustrated that physician-modified TEVAR can be safely performed without significant postoperative complications, such as coagulation-fibrinolytic abnormalities or embolic events. Further studies are needed to establish the indications for this procedure in CAD patients.

Objective: This study evaluated the efficacy of the provisional extension to induce complete attachment (PETTICOAT) technique for type B and postoperative residual type B aortic dissections compared with the conventional thoracic endovascular aortic repair (TEVAR) technique. Methods: In this retrospective study, we compared sequential aortic morphologic changes in consecutive patients with type B and postoperative residual type B aortic dissections treated with the PETTICOAT technique between January 2016 and December 2017 with patients treated with the conventional TEVAR between January 2013 and December 2015. Outcomes included aortic remodeling and aorta-related adverse events for 2 years postoperatively. Results: Forty-eight patients were included in this study (24 in the PETTICOAT group, 24 patients in the conventional TEVAR group). Although both groups showed aortic remodeling in the descending thoracic aorta, the PETTICOAT group developed significantly better aortic remodeling in the abdominal aorta compared with the conventional TEVAR group during the observation period. The PETTICOAT group had significantly fewer aorta-related adverse events compared with the conventional TEVAR group (8% vs 54%; P < .001). Aorta-related adverse events more commonly occurred in the poor remodeling group compared with in the good remodeling group (P = .001; hazard ratio, 8.32; 95% confidence interval, 2.26-30.64). Conclusions: This study suggests that the PETTICOAT technique for aortic dissection may promote aortic remodeling and decrease the incidence of aorta-related adverse events. Additional studies are required to confirm these preliminary findings.

OBJECTIVES: The open-style stent graft technique has been changing the strategy for true distal arch aneurysms extending to the descending aorta. Our mid-term results of surgical repair using a J-graft open stent graft are presented. METHODS: Between May 2015 and June 2020, 69 patients with a distal arch aneurysm (53 males, median age 74 years) underwent total arch replacement combined with J-graft open stent deployment. All 59 surviving patients were followed for a median follow-up period of 1.8 (0.6-3.6) years. RESULTS: Antegrade deployment was successfully performed in all patients without any difficulties. The deployed device was securely fixed at the target area, and it initiated thrombus formation. The diameter of the excluded aneurysm was decreased in 54 patients (91.5%) during the follow-up period. There were no type I endoleaks, but there were 3 type II endoleaks; 2 of the 3 type II endoleaks disappeared during the follow-up period. Additional endovascular operations were performed in 3 patients. There were 10 in-hospital deaths (14.5%), and the incidences of stroke, spinal cord injury and distal embolism were 11.6%, 5.8% and 2.9%, respectively. The 1-and 3-year survival rates were 84.8% and 79.4%, respectively, and the 1-and 3-year freedom from reintervention rates were 97.2% and 81.3%, respectively. CONCLUSIONS: The J-graft open stent graft was easy to deploy, and it could shift the distal anastomosis to a more proximal side. The mid-term performance of this device was good. It has the potential to provide one-stage repair.

We describe a total arch replacement using a hybrid frozen elephant trunk device. The procedure required reconstruction of the left vertebral anomalous artery using a triple branched stented anastomosis frozen elephant trunk repair. The novelty of this procedure lies in the impressive results that we obtained at this preliminary stage. The good results indicated an effective safe technique that facilitates aortic arch reconstruction using the hybrid frozen elephant trunk for an arch aneurysm with a left vertebral anomalous artery. Three-dimensional computed tomography performed 6 months postoperatively showed a well-reconstructed aortic arch and left vertebral anomalous artery. The use of self-expandable stent grafts may facilitate reconstruction of the left vertebral anomalous artery and is expected to improve patency. In this case, a longer follow-up with further procedural improvements is still necessary to pass this preliminary stage and obtain a definitive optimal outcome with an advantage in operating time.

Objective: Emergency surgical repair is the standard treatment for acute aortic dissection type A. However, the surgical risk of total arch replacement remains high. The Viabahn Open Revascularization TEChnique has been used for supra-aortic reconstruction during total arch replacement. This Cleveland Clinic technique is called “branched stented anastomosis frozen elephant trunk repair.” Our total arch replacement with reconstructed extended branched stented anastomosis frozen elephant trunk repair requires no unnecessary cervical artery exposure. We compared the outcomes of extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement in acute aortic dissection type A. Methods: We compared the clinical course of patients undergoing total arch replacement using sutureless direct branch vessel stent grafting with frozen elephant trunk (extended branched stented anastomosis frozen elephant trunk repair) for acute aortic dissection type A with patients undergoing conventional total arch replacement. For the procedure, the aortic arch was transected circumferentially distal to the brachiocephalic artery origin. Frozen elephant trunk was fenestrated by heating with a cautery, and the self-expandable stent graft was delivered into the branch vessels through the fenestration. Results: Of 58 cases, 21 and 37 were classified in the extended branched stented anastomosis frozen elephant trunk repair and conventional total arch replacement groups, respectively. The times (minutes) of selective antegrade cerebral perfusion (75 ± 24, 118 ± 47), total operation (313 ± 83, 470 ± 151), and cardiopulmonary bypass (195 ± 46, 277 ± 96) were significantly better in the extended branched stented anastomosis frozen elephant trunk repair group (P < .001). Six surgical deaths occurred: 2 (9%) in the extended branched stented anastomosis frozen elephant trunk repair group and 4 (10%) in the conventional total arch replacement group. In all cases, only 1 patient (2%) in the conventional total arch replacement group had a branch artery–related complication during the postoperative follow-up period. In the extended branched stented anastomosis frozen elephant trunk repair group, blood product use significantly decreased (P < .05). Conclusions: Extended branched stented anastomosis frozen elephant trunk repair has shown comparable safety and efficacy to conventional total arch replacement and can be used for acute aortic dissection type A emergency repair. It optimizes true lumen perfusion and facilitates supra-aortic artery remodeling.