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Objective: We performed a multicenter prospective comparative study to determine the impact of a Japanese frozen elephant trunk device on total arch replacement compared with conventional repair without it., Methods: Between 2016 and 2019, a total of 684 patients (frozen elephant trunk procedure; n = 369; conventional repair, n = 315) from 41 institutions were enrolled. The 2 procedures were selected according to each center's strategy., Results: The frozen elephant trunk procedure was applied more for aortic dissection, whereas the conventional repairs were predominantly performed for aneurysms. In the former, only hypothermic circulatory arrest time was reduced among the intraoperative parameters. Although there were no differences in the 30-day and in-hospital mortality rates (0.8% and 1.6%, respectively, for the frozen elephant trunk procedure vs 0.3% and 0.6%, respectively, for conventional repair), the neurologic complication rates were significantly higher in stroke (5.7% vs 2.2%; P = .022) and paraplegia (1.6% vs 0%; P = .023). In the propensity score matching analyses using 11 variables, statistical significance disappeared in the differences for mortality and neurologic morbidity (stroke and paraplegia/paraparesis) rates of 194 patients of each group, although they were still higher for the frozen elephant trunk procedure., Conclusions: The early outcomes of total arch replacement with the frozen elephant trunk procedure were acceptable despite its higher prevalence of emergency or redo surgery, which was comparable to that of the conventional repair. This procedure had higher rates of spinal cord injury than the conventional repair, which is a disadvantage of this approach., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: The goal of this study was to evaluate the fate of the downstream aorta following total arch replacement., Methods: Between October 1999 and March 2018, a total of 740 patients underwent total arch replacement. After excluding connective tissue disease, previous descending or thoracoabdominal aortic surgery, patients without adequate preoperative images or operative mortality, late outcomes consisting of additional surgery for distal dilation and distal aortic events were evaluated in 623 survivors (240 aortic dissections, including 139 patients with acute dissection and 383 with a non-dissection aneurysm). The mean follow-up was 5.0 ± 4.0 years., Results: The mean preoperative maximum diameter of the descending aorta was 36.9 ± 8.0 mm. An elephant trunk was inserted in 232 patients, including 183 patients with aortic dissection. Freedom from additional surgery for distal dilation was 88.5% at 5 years and 80.2% at 10 years. Freedom from distal aortic events was 81.9% at 5 years and 70.5% at 10 years. Multivariable regression analysis demonstrated that the preoperative diameter of the descending aorta was a significant risk factor for unfavourable distal aortic events. Computed tomography evaluation demonstrated a significant increase in the descending aortic diameter over time (P < 0.001). Positive aortic remodelling was observed in the proximal descending (P < 0.001) to mid-descending (P < 0.001) aorta exclusively in patients with acute aortic dissection., Conclusions: The diameter of the descending aorta increased significantly after total arch replacement, particularly in the distal descending aorta. The preoperative descending aortic diameter portended a significant risk for unfavourable distal aortic events., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The study objective was to report the clinical outcomes of open surgery for acute aortic dissection by using the Japan Cardiovascular Database., Methods: Between 2013 and 2018, a total of 29,486 patients with acute aortic dissection who underwent open surgery were registered in the Japan Cardiovascular Database. Some 50% of patients were male. Age of patients at surgery was 59.8 ± 14.2 years; 61% of patients were aged less than 65 years, and 21% of patients were aged more than 75 years. Connective tissue disease was found in 1.2% of patients. Some 13% of patients had disturbed consciousness, and 12% of patients had cardiogenic shock. Some 11% of patients had moderate or severe aortic valve regurgitation, and 2.3% of patients had acute myocardial infarction. Some 94% of patients underwent surgery within 24 hours after diagnosis. Antegrade cerebral perfusion was used in 74% of patients, hypothermic circulatory arrest with retrograde cerebral perfusion was used in 17.1% of patients, and deep hypothermic circulatory arrest was used in 9.4% of patients. Cardiopulmonary bypass time was 216 ± 90 minutes, and cardiac ischemic time was 132 ± 60 minutes. Lowest body temperature was 24.6°C ± 3.2°C. Replacement of the ascending aorta (zone I) was performed in 69% of patients, and total arch replacement (zone 0 to zone II, III-) was performed in 29% of patients. The aortic valve was replaced in 7.9% of patients and repaired in 4.4% of patients., Results: The 30-day mortality was 9.2%, and in-hospital mortality was 11%. The number of operations has increased through the study periods. The in-hospital mortality has been stable or in a decreasing trend. Major complications consisted of stroke in 12% of patients, new hemodialysis in 7.3% of patients, spinal cord ischemia in 3.9% of patients, and prolonged ventilation in 15% of patients., Conclusions: Approximately 30,000 patients with acute aortic dissection in the recent 6 years (2013 - 2018) underwent open surgery according to the nationwide Japanese database. The number of operations has increased, and in-hospital mortality has been stable or in a decreasing trend. Although the early outcomes are acceptable, there is still room for improvement in patients with preoperative comorbidities., (Copyright © 2020. Published by Elsevier Inc.)

The effect of acute kidney injury (AKI) on mid-term outcomes following thoracoabdominal aortic aneurysm (TAAA) repair is not well known. We hypothesized that postoperative AKI would reduce mid-term survival and aimed to analyze the effect of AKI on mid-term outcomes after TAAA repair. This retrospective study identified 294 consecutive TAAA repairs at Kobe University Hospital from October 1999 to March 2019. Patients with preexisting end-stage renal disease that required hemodialysis (n = 11) and patients who died intraoperatively (n = 2) were excluded. Finally, 281 patients were analyzed. AKI was defined according to Kidney Disease: Improving Global Outcomes guidelines (KDIGO) classification. Of the 281 patients, 178 (63.3%) developed AKI, of which 98 (34.9%) had mild, 34 (12.1%) had moderate, and 46 (16.4%) had severe AKI. Twenty-six patients (12.8%) required renal replacement therapy after surgery. Twenty-three in-hospital deaths (8.2%) were recorded, including 2 (0.7%) without AKI, 0 (0%) with mild AKI, 1 (0.4%) with moderate AKI, and 20 (7.1%) with severe AKI (p < .001). The 4-year survival was 91.9 ± 3.0% for no AKI, 91.3 ± 3.2% for mild AKI, 72.4 ± 8.5% for moderate AKI and 32.6 ± 7.4% for severe AKI (p < .001). Multivariable Cox-hazard regression analysis demonstrated that moderate and severe AKI, older age and emergency surgery were significant risk factors for mid-term survival. In patients undergoing TAAA repair, severe AKI was associated with an increase in in-hospital mortality and both moderate and severe AKI were negatively associated with mid-term survival. Preventing moderate/severe AKI may improve mid-term survival after TAAA repair., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This review discusses the clinical applications of the frozen elephant trunk procedure for patients with acute aortic dissection. Sub-analysis of the multicenter Japanese Frozenix study, J-ORCHESTRA, are presented, and recent reports of frozen elephant trunk usage for acute aortic dissection are discussed.

Background: Despite recent advances in the diagnosis and management, the mortality of acute aortic dissection remains high. This study aims to clarify the current status of the management and outcome of acute aortic dissection in Japan., Methods: A total of 18,348 patients with acute aortic dissection (type A: 10,131, type B: 8217) in the Japanese Registry of All Cardiac and Vascular Diseases database between April 2012-March 2015 were studied. Characteristics, clinical presentation, management, and in-hospital outcomes were analyzed., Results: Seasonal onset variation (autumn- and winter-dominant) was found in both types. More than 90% of patients underwent computed tomography for primary diagnosis. The overall in-hospital mortality of types A and B was 24.3% and 4.5%, respectively. The mortality in type A patients managed surgically was significantly lower than in those not receiving surgery (11.8% (799/6788) vs 49.7% (1663/3343); p <0.001). The number of cases managed endovascularly in type B increased 2.2-fold during the period, and although not statistically significant, the mortality gradually decreased (5.2% to 4.1%, p =0.49). Type A showed significantly longer length of hospitalization (median 28 days) and more than five times higher medical costs (6.26 million Japanese yen) than those in type B. The mean Barthel index at discharge was favorable in both type A (89.0±22.6) and type B (92.6±19.0). More than two-thirds of type A patients and nearly 90% of type B patients were directly discharged home., Conclusions: This nationwide study elucidated the clinical features and outcomes in contemporary patients with acute aortic dissections in real-world clinical practice in Japan.

Background: The aim of this study was to evaluate the impact of diffuse aortic atherosclerosis-related thrombosis, or "shaggy aorta" on the outcomes of open thoracoabdominal aortic aneurysm repair (TAAA)., Methods: From October 1999 to March 2018, 251 patients underwent open TAAA repair using segmental-staged aortic clamping. Twenty-eight patients (11.2%) received emergent or urgent operations. Patients were classified into 3 groups: dissection aneurysm (139 patients, 55.4%), degenerative aneurysm without shaggy aorta (76 patients, 30.3%), and degenerative aneurysm with shaggy aorta (36 patients, 14.3%). Shaggy aorta was assessed using enhanced computed tomography and defined as patients with atheroma thickness ≥5 mm with irregular atheroma surface. Mean follow-up was 4.3 ± 4.1 years., Results: Operative mortality was 8% (20 patients) and spinal cord injury occurred in 25 patients (10.0%), 16 of whom (6.4%) had permanent neurologic dysfunction. Operative mortality was significantly worse in patients with shaggy aorta (dissection: 2.2%, non-shaggy: 6.6%, and shaggy: 33.3%, P < .001) and shaggy aorta was a significant risk factor for spinal cord injury (dissection: 7.2%, non-shaggy: 6.6%, and shaggy: 27.8%, P < .003). Multivariable analysis demonstrated that shaggy aorta was a significant risk factor for composite outcome consisted of operative mortality, spinal cord injury, and acute renal failure (odds ratio, 4.78; 95% confidence interval, 1.91-12.3, P < .001)., Conclusions: Preoperative enhanced computed tomography assessment of shaggy aorta could predict high-risk patients for open TAAA repair., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We report early and midterm outcomes of elderly patients who underwent valve-sparing root replacement (VSRR) compared with younger patients and those with Bentall procedure., Methods: From October 1999 to October 2017, 73 patients greater than or equal to 65 years of age who underwent VSRR procedure were assigned as group S. Two hundred thirty-two VSRR patients who were between 15 and 64 years of age were assigned as group Y. Forty-five patients greater than or equal to 65 years of age who underwent Bentall procedure were assigned as group R. Preoperative grades of aortic regurgitation were 3.4 of 4 in group S, 3.1 of 4 in group Y, and 3.3 of 4 in group R (p = 0.07)., Results: Hospital mortality was found in 1 (1.4%) patient in group S, 3 (6.7%) in group R, and 2 (0.9%) in group Y. Postoperative survival at 5 years was 88.5% in group S, 98.7% in group Y, and 82.4% in group R (p < 0.01). Freedom from more than mild aortic regurgitation at 5 years was 81.0% in group S and 85.4% in group Y. Follow-up echocardiography disclosed an effective aortic valve orifice area of 1.76 cm 2 in group R, 2.40 cm 2 in group Y, and 2.41 cm 2 in group S (p < 0.01), and peak pressure gradient across the aortic valve was 17.7 mm Hg in group R, 13.6 mm Hg in group Y, and 10.8 mm Hg in group S (p < 0.01)., Conclusions: Similar early and late outcomes were achieved in elder VSRR patients compared with younger patients. A better postoperative valve performance was demonstrated in VSRR patients than patients undergoing valve-replacement., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery disease (CAD) is associated with increased morbidity and mortality after open repair of thoracic aorta. Nevertheless, the efficacy of preoperative coronary angiography (CAG) and revascularization is controversial. The aim of this study was to clarify the effect of preoperative CAD on surgical outcome by reviewing the Japan Adult Cardiovascular Database. Methods and Results: This study involved 4,596 patients who underwent open surgery for true thoracic aortic aneurysm between 2004 and 2009. After excluding patients with concomitant cardiac operation, except coronary artery bypass grafting (CABG), the remaining 1,904 patients with coronary artery stenosis included 995 cases of simultaneous CABG. The prevalence of CAD was significantly higher in patients with diabetes, renal dysfunction, hyperlipidemia, cerebrovascular disorders, peripheral artery lesions, old myocardial infarction (MI), and coronary intervention. Patients with simultaneous CABG had severe CAD compared with those without, with no other major differences in patient background noted. Thirty-day postoperative and in-hospital mortalities were higher in CAD patients. Incidence of perioperative MI was higher in patients who underwent open aortic repair with simultaneous CABG, but simultaneous CABG did not affect operative mortality., Conclusions: In patients with surgically treated true aortic aneurysm, CAD was frequently observed, suggesting that aggressive preoperative coronary evaluation is needed.

Objectives: In a multicentre, randomized-controlled, phase III trial in complex cardiovascular surgery (Randomized Evaluation of Fibrinogen vs Placebo in Complex Cardiovascular Surgery: REPLACE), single-dose human fibrinogen concentrate (FCH) was associated with the transfusion of increased allogeneic blood products (ABPs) versus placebo. Post hoc analyses were performed to identify possible reasons for this result., Methods: We stratified REPLACE results by adherence to the transfusion algorithm, pretreatment fibrinogen level (≤2 g/l vs >2 g/l) and whether patients were among the first 3 treated at their centre., Results: Patients whose treatment was adherent with the transfusion algorithm [FCH, n = 47 (60.3%); placebo, n = 57 (77.0%); P = 0.036] received smaller quantities of ABPs than those with non-adherent treatment (P < 0.001). Among treatment-adherent patients with pretreatment plasma fibrinogen ≤2 g/l, greater reduction in 5-min bleeding mass was seen with FCH versus placebo (median -22.5 g vs -15.5 g; P = 0.071). Considering patients with the above conditions and not among the first 3 treated at their centre (FCH, n = 15; placebo, n = 22), FCH was associated with trends towards reduced transfusion of ABPs (median 2.0 vs 4.0 units; P = 0.573) and greater reduction in 5-min bleeding mass (median -21.0 g vs -9.5 g; P = 0.173). Differences from a preceding single-centre phase II study with positive outcomes included more patients with pretreatment fibrinogen >2 g/l and fewer patients undergoing thoracoabdominal aortic aneurysm repair., Conclusions: None of the patient stratifications provided a clear explanation for the lack of efficacy seen for FCH in the REPLACE trial versus the positive phase II outcomes. However, together, the 3 factors demonstrated trends favouring FCH. Less familiarity with the protocol and procedures and unavoidable differences in the study populations may explain the differences seen between the phase II study and REPLACE., Clinical Trial Registration: NCT01475669 https://clinicaltrials.gov/ct2/show/NCT01475669; EudraCT trial no: 2011-002685-20., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To investigate whether administering fibrinogen concentrate or cryoprecipitate is associated with increased postoperative thromboembolic events and improved mortality in patients undergoing thoracic aortic surgery., Design: Multicenter retrospective cohort study using propensity-score analyses and multivariate logistic regression analysis to control for confounders., Setting: Four hospitals (1 national cardiovascular center and 3 university hospitals)., Participants: Patients undergoing thoracic aortic surgery with cardiopulmonary bypass between January 2010 and October 2012 (n = 1,047)., Interventions: Outcomes in patients treated with fibrinogen concentrate or cryoprecipitate (fibrinogen group) were compared with those who did not receive these products (no fibrinogen group) based on propensity-score matching. Multivariate logistic regression analysis then was performed to confirm the results., Measurements and Main Results: Among 1,047 patients enrolled in this study, 247 patients received fibrinogen concentrate or cryoprecipitate. The median amount of administered fibrinogen was 3 g (interquartile range 2-4 g). Eighty-seven patients were excluded from the propensity-score matching because of missing data. Propensity-score-matched analysis showed no significant difference in the incidence of thromboembolic events or 30-day mortality rate between the groups. Multivariate analysis revealed that the fibrinogen group showed no significant difference in thromboembolic events (odds ratio 1.22; 95% confidence interval 0.76-1.95; p = 0.408) or mortality rate (odds ratio 0.44; 95% confidence interval 0.18-1.12; p = 0.081) compared with those in the no fibrinogen group., Conclusions: Administering fibrinogen concentrate or cryoprecipitate was associated with neither thromboembolic events nor 30-day mortality in patients undergoing thoracic aortic surgery. Administering fibrinogen concentrate or cryoprecipitate is safe and does not appear to increase thromboembolic events and mortality in thoracic aortic surgery patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Presenting our experience of direct perfusion of the carotid artery in patients with brain malperfusion secondary to acute aortic dissection., Patients: Among 381 patients who underwent aortic repair for acute type A aortic dissection from October 1999 to August 2017, brain malperfusion was recognized in 50 patients. Nine patients had direct perfusion of the right carotid artery in patients with brain malperfusion secondary to acute aortic dissection. Age at surgery was 65.7 ± 13.5 years and three patients were male. Preoperative consciousness level was alert in one patients, drowsy in six, and coma in two. Five patients had preoperative hemiplegia. All patients showed a blood pressure difference between the upper extremities and eight patients showed more than 15% difference of rSO 2 . Seven patients had a temporary external active shunt from the femoral artery to the right common carotid artery preoperatively. Two patients had direct perfusion to the right common carotid artery during cardiopulmonary bypass or in the intensive care unit after surgery because of a sudden decrease of rSO 2 and cessation of carotid artery flow. Antegrade cerebral perfusion was used in all patients. Total arch replacement was performed in six patients and hemiarch in three., Results: The hospital mortality was 33% (3 patients). Causes of death were huge hemispheric brain infarction or anoxic brain damage in two patients and myocardial infarction in one. The postoperative neurological outcome was alert in four, hemiplegia in two, and coma in three, but five patients showed some improvement of neurological signs., Conclusion: Aggressive direct reperfusion of the carotid artery before the aortic repair may reduce neurological complications in patients with preoperative brain malperfusion secondary to acute aortic dissection.

Objectives: This study evaluated the early and long-term outcomes of open surgery after thoracic endovascular aortic repair., Methods: We conducted a retrospective review of 41 patients who underwent open surgery following thoracic endovascular aortic repair between October 1999 and July 2017. The mean interval from primary intervention to open surgery was 3.1 ± 3.7 years. Indications for open repair were endoleak in 14 patients, graft infection in 10 patients, false lumen dilatation in 9 patients, retrograde dissection in 5 patients, migration in 1 patient and additional aneurysm in 2 patients. Eight patients underwent emergent surgical conversions. The mean follow-up period was 4.2 ± 4.0 years., Results: Descending aortic replacement was performed in 15 patients; thoraco-abdominal aortic repair, in 14 patients; extensive arch to descending aortic replacement, in 5 patients; and total arch replacement, in 7 patients. Six (14.6%) patients died in the hospital. The 5-year survival rate was 73.7 ± 7.2%, and freedom from reintervention was 88.5 ± 6.4%., Conclusions: Early outcomes of open surgical procedures after thoracic endovascular aortic repair were still suboptimal. However, hospital survivors had excellent long-term outcomes.

Objectives: To investigate the long-term durability of aortic valves, we reviewed the outcomes of patients who underwent valve-sparing root replacement with acute Type A aortic dissection., Methods: We included patients who underwent emergent aortic repair for acute Type A aortic dissection at our university hospital between 2000 and 2016. We identified patients who underwent valve-sparing root replacement from the included cohort and assessed their survival and long-term valve durability., Results: We identified 24 of 328 patients who underwent valve-sparing root replacement (age: mean ± SD 49 ± 11 years; 17 men). All patients underwent reimplantation procedures and 2 had concomitant cusp repairs (central plication). Prolapsed cusps caused by detached commissures in 12 cases were noted and reattached with buttress sutures with or without glue. There was no in-hospital mortality. Median follow-up period was 84 months (range 1-202 months) and survival was 100% at 5 and 10 years. Freedom from moderate or greater aortic insufficiency was 82% ± 10% at 5 years and 65% ± 13% at 10 years. Freedom from aortic valve reoperation was 83% ± 9% at 5 years and 69% ± 12% at 10 years. Valve reoperations were indicated for endocarditis in 1 patient, perforation of the aortic cusp in 1 patient and redetachment of commissures that had been attached with gelatin-resorcinol-formaldehyde glue at the initial operations in 3 patients., Conclusions: The durability of valve-sparing root replacement in acute aortic dissection was suboptimal. The major cause of late failure was commissure detachment after primary repair with buttress sutures and glue. Gelatin-resorcinol-formaldehyde glue should be avoided for commissural resuspension in patients with acute aortic dissection.

Objectives: We present our experience with one-stage replacement of thoracic aneurysm from the ascending aorta to the thoracoabdominal aorta., Patients and Methods: Fourteen patients (10 male and 4 female; mean age 53.6 ± 12.4 years) with extended thoracic aortic aneurysms underwent graft replacement. The pathology of the diseased aorta was chronic aortic dissection in 13 patients and intraoperative retrograde aortic dissection in 1 patient. Five patients had Marfan syndrome. In a previous operation, 1 patient had undergone the Bentall procedure, 4 had hemiarch replacement for acute type A dissection, and 1 had a Y-graft for abdominal aortic aneurysm. The approach to the aneurysm was posterolateral thoracotomy with rib-cross incision extended to the retroperitoneal abdominal aorta. Arterial inflow for cardiopulmonary bypass consisted of the femoral artery in 13 patients and abdominal aortic aneurysm graft in 2. Venous drainage site was the femoral vein in 7, femoral vein and pulmonary artery in 3, and pulmonary artery in 1. All patients had antegrade cerebral perfusion and visceral perfusion., Results: Hospital mortality occurred in 1 patient due to acute myocardial infarction. Actuarial survival at 5 years after the operations was 96.5 ± 9.8%. Freedom from the subsequent aortic events was 91.0 ± 2.9% at 5 years., Conclusions: Our treatment method for extensive thoracic aneurysm, from the ascending aorta to the thoracoabdominal aorta, achieved satisfactory results via the use of specific strategies and appropriate organ protection according to the aneurysm extension in the selected patients., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

A 30-year-old man with Marfan syndrome who underwent Crawford type II extension aneurysm repair about 9 years ago was referred to our hospital with persistent fever. Computed tomography (CT) showed air around the mid-descending aortic prosthetic graft. Because the air did not disappear in spite of intravenous antibiotics, (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) was performed. FDG-PET/CT revealed four high-uptake lesions. After dissecting the aortic graft particularly focusing on the high-uptake lesions, this patient underwent in situ graft re-replacement of descending aortic graft with a rifampicin-bonded gelatin-impregnated Dacron graft and omentopexy. The patient remains well without recurrent infection at 3 months after surgery.

Objective: The present study aimed to determine the impact of the extent of graft replacement on early and late outcomes in acute DeBakey type I aortic dissection., Methods: Between October 1999 and July 2014, 197 consecutive patients were surgically treated for acute DeBakey type I aortic dissection. The extent of graft replacement (hemiarch, partial, or total arch replacement) was mainly determined by the location of the primary entry. Early and late results were compared in patients after total arch replacement (n = 88) and combined hemiarch and partial arch replacement: non-total arch replacement (n = 109)., Results: The in-hospital mortality rates of the total arch replacement and non-total arch replacement groups were 10.2% and 14.7%, respectively (P = .47). Multivariate analysis revealed preoperative cardiopulmonary resuscitation and visceral organ malperfusion as significant risk factors for in-hospital mortality, but not total arch replacement. During a mean follow-up period of 60 ± 48 months, the 5-year survivals in the total arch replacement and non-total arch replacement groups were 88.6% ± 4.2% and 83.8% ± 4.4%, respectively (P = .54). Rates of distal aortic events (defined as freedom from surgery for distal aorta dilation or distal arch diameter expanding to 50 mm) at 5 years were significantly better in the total arch replacement group than in the non-total arch replacement group (94.9% ± 3.5% vs 83.6% ± 4.9%, P = .01)., Conclusions: The operative mortality of patients with acute DeBakey type I aortic dissection treated by total arch replacement was acceptable with good long-term survival after both total arch replacement and non-total arch replacement. The frequency of distal aortic events might be reduced in patients after total arch replacement compared with non-total arch replacement., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the impact of preoperative identification of the Adamkiewicz artery (AKA) on prevention of spinal cord injury (SCI) through the multicenter Japanese Study of Spinal Cord Protection in Descending and Thoracoabdominal Aortic Repair (JASPAR) registry., Methods: Between January 2000 and October 2011, 2435 descending/thoracoabdominal aortic repairs were performed, including 1998 elective repairs and 437 urgent repairs, in 14 major centers in Japan. The mean patient age was 67 ± 13 years, and 74.2% were males. There were 1471 open repairs (ORs), including 748 descending and 137 thoracoabdominal extent [Ex] I, 136 Ex II, 194 Ex III, 115 Ex IV, and 138 Ex V, and 964 endovascular repairs (EVRs). Of the 2435 patients, 1252 (51%) underwent preoperative magnetic resonance or computed tomography angiography to identify the AKA., Results: The AKA was identified in 1096 of the 1252 patients who underwent preoperative imaging (87.6%). Hospital mortality was 9.2% (n = 136) in those who underwent OR and 6.4% (n = 62) in those who underwent EVR. The incidence of SCI was 7.3% in the OR group (descending, 4.2%; Ex I, 9.4%; Ex II, 14.0%; Ex III, 14.4%; Ex IV, 4.2 %; Ex V, 7.2%) and 2.9% in the EVR group. The risk factors for SCI in ORs were advanced age, extended repair, emergency, and occluded bilateral hypogastric arteries. In ORs of the aortic segment involving the AKA, having no AKA reconstruction was a significant risk factor for SCI (odds ratio, 2.79, 95% confidence interval, 1.14-6.79; P = .024)., Conclusions: In descending/thoracoabdominal aortic repairs, preoperative AKA identification with its adequate reconstruction or preservation, especially, in ORs of aortic pathologies involving the AKA, would be a useful adjunct for more secure spinal cord protection., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR)., Methods: Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres)., Results: Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively)., Conclusions: ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim was to evaluate computed tomography angiography (CTA) volumetric and diametric analysis after endovascular repair of descending thoracic aortic aneurysms (DTAAs) and its correlation with and applicability for clinical follow up., Methods: Fifty-four consecutive endovascular repairs for DTAA were retrospectively evaluated from 2008 to 2014. All patients underwent pre-operative CTA and at least one post-operative CTA at 6 months. Fifty-four pre-operative and 137 post-operative CTAs were evaluated (using the Ziosoft 2 software) to analyze the aneurysm and thrombus volume, the maximum aneurysm diameter, and their changes at the last follow up CTA (mean 30.5 months; range 6.5-66.4 months). A statistical analysis was performed to assess the correlation between diameter and volume changes, as well as association with endoleaks. The cut off point to predict endoleaks was determined using a receiver operating characteristic (ROC) curve. The predictive accuracy of volume change versus diameter change for Type I endoleak was analyzed., Results: The mean pre-operative aneurysm diameter, aneurysm volume, and thrombus volume were 56.7 ± 11.7 mm, 145.8 ± 120.0 mL, and 48.8 ± 54.8 mL, respectively. Within the observational period, a mean decrease of -27.9 ± 30.5% in the aortic volume and -15.9 ± 15.4% in diameter was observed. Correlation between aneurysm diameter and volume changes was good (r = 0.854). Volume and diameter changes were significantly different between groups with and without endoleaks (volume change 16.9 ± 38.8% vs. -35.6 ± 23.1%, p < .001; diameter change 8.0 ± 12.1% vs. -18.8 ± 14.3%, p < .001). A pre-operative thrombus volume percentage of <11.3% and increase in aneurysm volume +11.6% were predictive factors for Type II and Type I endoleak, respectively. The accuracy of a >10% volume increase in predicting a Type I endoleak was higher (accuracy 96.3%, sensitivity 75%, and specificity 98%) than a >5 mm diameter increase (accuracy 92.6%, sensitivity 25%, and specificity 98%)., Conclusions: CT volumetric analysis is a more reliable modality for predicting endoleaks after endovascular repair for DTAA than diameter analysis., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: Antegrade cerebral perfusion and hypothermic circulatory arrest, with or without retrograde cerebral perfusion, are 2 major types of brain protection that are used during aortic arch surgery. We conducted a comparative study of these methods in patients undergoing total arch replacement to evaluate the clinical outcomes in Japan, based on the Japan Adult Cardiovascular Surgery Database., Methods: A total of 16,218 patients underwent total arch replacement between 2009 and 2012. Patients with acute aortic dissection or ruptured aneurysm, or who underwent emergency surgery were excluded, leaving 8169 patients for analysis. For the brain protection method, 7038 patients had antegrade cerebral perfusion and 1141 patients had hypothermic circulatory arrest/retrograde cerebral perfusion. A nonmatched comparison was made between the 2 groups, and propensity score analysis was performed among 1141 patients., Results: The matched paired analysis showed that the minimum rectal temperature was lower in the hypothermic circulatory arrest/retrograde cerebral perfusion group (21.2°C ± 3.7°C vs 24.2°C ± 3.2°C) and that the duration of cardiopulmonary bypass and cardiac ischemia was longer in the antegrade cerebral perfusion group. There were no significant differences between the antegrade cerebral perfusion and hypothermic circulatory arrest/retrograde cerebral perfusion groups with regard to 30-day mortality (3.2% vs 4.0%), hospital mortality (6.0% vs 7.1%), incidence of stroke (6.7% vs 8.6%), or transient neurologic disorder (4.1% vs 4.4%). There was no difference in a composite outcome of hospital death, bleeding, prolonged ventilation, need for dialysis, stroke, and infection (antegrade cerebral perfusion 28.4% vs hypothermic circulatory arrest 30.1%). However, hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a significantly higher rate of prolonged stay in the intensive care unit (>8 days: 24.2% vs 15.6%)., Conclusions: Hypothermic circulatory arrest/retrograde cerebral perfusion and antegrade cerebral perfusion provide comparable clinical outcomes with regard to mortality and stroke rates, but hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a higher incidence of prolonged intensive care unit stay. Antegrade cerebral perfusion might be preferred as the brain protection method for complicated aortic arch procedures., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We present a series of patients who underwent in situ total aortic arch replacement for infected distal aortic arch aneurysms., Methods: Between 2002 and 2013, 9 patients with infected distal aortic arch aneurysms underwent total aortic arch replacement using antegrade selective cerebral perfusion. There were 4 male and 5 female patients with a mean age of 72.7±9.0 years. All patients had penetrating atherosclerotic ulcer in the distal aortic arch, which formed saccular aneurysms. Four patients had preoperative hoarseness. Maximum preoperative white blood cell count was 10,211±4375/μL, and mean serum C-reactive protein concentration was 12.7±7.2 mg/dL. Causative microorganisms were identified by blood culture or aortic wall culture and were as follows: Candida albicans, Pseudomonas aeruginosa, Edwardsiella tarda, Streptococcus dysgalactiae, Listeria monocytogenes, Staphylococcus aureus (2 cases), and unknown (2 cases). Radical debridement with in situ total aortic arch replacement was performed in all patients, followed by the omental flap grafting in 7 patients. All surgery was performed on an urgent or emergency basis., Results: Average cardiopulmonary bypass time and lower body circulatory arrest time were 199.7±50.7 minutes and 66.6±13.8 minutes, respectively. There was no in-hospital mortality, but 1 patient died of asphyxia 5 months after hospital discharge. Freedom from recurrence of infection was 100%., Conclusions: Surgical treatment with the combination of radical debridement with in situ total aortic arch replacement using antegrade selective cerebral perfusion and omental flap grafting was a reliable procedure for the treatment of infected distal aortic arch aneurysms., (Copyright © 2014. Published by Elsevier Inc.)

Four cases of simultaneous surgery for aortic root aneurysm with aortic regurgitation and coarctation of the aorta were presented. Age at surgery ranged from 18 to 37 years and all were male. All had annuloaortic ectasia and dilatation of the ascending aorta, 3 had bicuspid aortic valve and 1 had acute localized aortic dissection. Preoperative grade of aortic regurgitation was trivial in 1, moderate in 2 and severe in 1. Three had aortic valve-sparing root replacement with reimplantation technique and 1 had plication of the sinotubular junction. All patients had total arch replacement, coarctectomy and orthogonal anastomosis to the descending aorta. Antegrade cerebral perfusion was used for brain protection. All patients survived and postoperative pressure difference between the upper and lower extremities disappeared. Postoperative aortogram was satisfactory., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The present study analyzes the early patency of intercostal artery reconstruction, using graft interposition and aortic patch anastomosis, and determines the fate of reattached intercostal arteries after repair of thoracoabdominal aortic aneurysms., Methods: We selected 115 patients (mean age, 63 ± 15 years; range, 19-83 years; male, n = 83) treated by thoracoabdominal aortic aneurysm repair with 1 or more reconstructed intercostal arteries at the Kobe University Graduate School of Medicine between October 1999 and December 2012. The intercostal arteries were reconstructed using graft interposition (n = 66), aortic patch anastomosis (n = 42), or both (n = 7)., Results: The hospital mortality rate was 7.8% (n = 9). Eleven patients (9.6%) developed spinal cord ischemic injury (permanent, n = 6, transient, n = 5). The average number of reconstructed intercostal arteries per patient was 3.0 ± 1.5 (1-7), and 345 intercostal arteries were reattached. The overall patency rate was 74.2% (256/345) and that of aortic patch anastomosis was significantly better than that of graft interposition (90.8% [109/120] vs 65.3% [147/225], P < .01), but significantly worse for patients with than without spinal cord ischemic injury (51.9% [14/27] vs 76.1% [242/318], P = .01). There was no patch aneurysm in graft interposition during a mean of 49 ± 38 (range, 2-147) postoperative months, but aortic patch anastomosis including 4 intercostal arteries became dilated in 2 patients., Conclusions: Aortic patch anastomosis might offer better patency rates and prevent spinal cord ischemic injury compared with graft interposition. Although aneurysmal changes in intercostal artery reconstructions are rare, large blocks of aortic wall reconstruction should be closely monitored., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Midsternotomy in patients with a coexisting tracheostomy is associated with a risk of deep sternal wound infection (DSWI) or mediastinitis. We herein present two cases of total arch replacement using a surgical technique designed to avoid the danger of DSWI. Total arch replacement via an antero-lateral thoracotomy with partial sternotomy can be one of the options for patients with a tracheostoma or after laryngectomy, and can both protect organs and avoid DSWI.

Identification of the Adamkiewicz artery (AKA) using CT angiography (CTA) is crucial in patients with thoracic aortic aneurysm (TAA) or aortic dissection (AD). The purpose of this study was to compare the AKA detection rate of intravenous injection with a 64-slice MDCT (IV64) versus a 16-slice MDCT (IV16) as well as by CTA using intra-arterial injection with a 16-slice MDCT (IA16). A retrospective review of 160 consecutive patients who underwent CTA was performed. There were 108 TAA and 52 AD cases, 105 of whom were examined with IV64, 15 with IV16, and 40 with IA16. The AKA detectability for each imaging method was assessed, and the factors influencing the detectability were analyzed by multivariate analysis. The detection rates for IV64, IV16, and IA16 were 85.7, 60.0, and 80.0 %, respectively, with IV64 being more sensitive than IV16 (P = 0.025). The detection rate for AD patients was 66.7 % with IV64, which was similar to IV16 (57.1 %) and IA16 (66.8 %). On the other hand, the detection rate for TAA patients was 93.3 % with IV64, which was higher than IV16 (62.5 %, P = 0.021) and similar to IA16 (88.0 %). Multivariate analysis demonstrated the independent factors for AKA detectability were TAA versus AD (P = 0.005, Odds ratio = 3.98) and IV64 versus IV16 (P = 0.037, Odds ratio = 4.03). The detection rate was higher for IV64 than for IV16, especially for TAA patients, while the rate was similar between IV64 and invasive IA16. A 64-slice MDCT thus provides a less invasive visualization of the AKA.

Thoracic endovascular aortic repair for a descending thoracic aortic aneurysm is an excellent alternative to open surgery, especially in patients with a number of comorbidities. It may cause fatal complications, including aortoesophageal fistula, but these are very rare. Here, we report the case of secondary aortoesophageal fistula four months after the procedure for a huge descending thoracic aortic aneurysm, which presented with new-onset high-grade fever accompanied by elevated inflammatory markers.

Objectives: We present our experience of total aortic arch replacement., Methods: Twenty-nine patients (21 males and 8 females; mean age 63.3 ± 13.3 years) with extended thoracic aortic aneurysms underwent graft replacement. The pathology of the diseased aorta was non-dissecting aneurysm in 11 patients, including one aortitis and aortic dissection in 18 patients (acute type A: one, chronic type A: 11, chronic type B: six). Five patients had Marfan syndrome. In their previous operation, two patients had undergone the Bentall procedure, three had endovascular stenting, one had aortic root replacement with valve sparing and 12 had hemi-arch replacement for acute type A dissection. Approaches to the aneurysm were as follows: posterolateral thoracotomy with rib-cross incision in 16, posterolateral thoracotomy extended to the retroperitoneal abdominal aorta in seven, mid-sternotomy and left pleurotomy in three, anterolateral thoracotomy with partial lower sternotomy in two and clam-shell incision in one patient. Extension of aortic replacement was performed from the aortic root to the descending aorta in 4, from the ascending aorta to the descending aorta in 17 and from the ascending to the abdominal aorta in eight patients. Arterial inflow for cardiopulmonary bypass consisted of the femoral artery in 15 patients, ascending aorta and femoral artery in seven, descending or abdominal aorta in five and ascending aorta in two. Venous drainage site was the femoral vein in 10, pulmonary artery in eight, right atrium in five, femoral artery with right atrium/pulmonary artery in four and pulmonary artery with right atrium in two patients., Results: The operative mortality, 30-day mortality and hospital mortality was one (cardiac arrest due to aneurysm rupture), one (rupture of infected aneurysm) and one (brain contusion), respectively. Late mortality occurred in three patients due to pneumonia, ruptured residual aneurysm and intracranial bleeding. Actuarial survival at 5 years after the operations was 80.6 ± 9.0%. Freedom from the subsequent aortic events was 96.0 ± 3.9% at 5 years., Conclusions: Our treatment method for extensive thoracic aneurysms achieved satisfactory results using specific strategies and appropriate organ protection according to the aneurysm extension in the selected patients.

Background: When treating dissecting aneurysm of the thoracoabdominal aorta surgically in patients with Marfan syndrome, we have usually performed graft replacement- including the entire thoracoabdominal aorta and reconstruction of all visceral branches, even if dilatation is mild in some segments-to avoid further aortic operations in the follow-up period., Methods: From October 1999 through July 2011, 20 consecutive patients with Marfan syndrome underwent repair of dissecting aneurysm of the thoracoabdominal aorta (median age, 45 years; range, 19-65 years). All patients underwent surgical intervention with cerebrospinal fluid (CSF) drainage and distal aortic and selective organ perfusion. Deep hypothermia was used in 13 patients for spinal cord protection., Results: No in-hospital mortality was observed. One patient had temporary spinal cord ischemia but was fully recovered by discharge. Other complications included exploration for bleeding (n=1), prolonged ventilation (n=1), and graft infection (n=1). At a mean follow-up of 54 months (range, 9-129 months), 1 patient had died of interstitial pneumonia at 38 months postoperatively. Survival at 8% years was 91.2±9.0%. Two patients required additional aortic procedures (total arch replacement and aortic valve-sparing surgery). Actuarial rate of freedom from aortic operations at 8 years was 83.9%±10.5%, but no patient needed required repeated thoracotomy for an aortic procedure. Neither false nor patch aneurysms were observed using computed tomography (CT) during follow-up surveillance., Conclusions: Graft replacement for dissecting aneurysm of the thoracoabdominal aorta in Marfan syndrome offers good early and long-term results. We believe total aortic replacement including the entire thoracoabdominal aorta and reconstruction of all visceral arteries should be recommended for selected patients with Marfan syndrome., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study was performed to investigate the early and late outcomes of total aortic arch replacement (TAR) with or without coronary artery bypass grafting (CABG)., Methods: From October 1999 to December 2010, 200 consecutive patients underwent elective TAR for nondissecting aneurysm through a median sternotomy. Of this number, 131 (65.5%) had isolated TAR (TAR group) and 69 (34.5%) underwent concomitant CABG (TAR/CABG group). Patients in the TAR/CABG group were older and had more advanced chronic kidney disease and higher additive/logistic European System for Cardiac Operative Risk Evaluation and Japan scores than patients in the TAR group., Results: Overall 30-day mortality was 0.5% (1 of 200) and hospital mortality was 3.5% (7 of 200). Hospital mortality was 1.5% (2 of 131) in the TAR group and 7.2% (5 of 69) in the TAR/CABG group (p=0.036). Multivariate analysis showed that operation time (odds ratio [OR] 1.01, p=0.013) was a risk factor for hospital mortality, but failed to demonstrate concomitant CABG as a risk factor. Cox proportional hazard analysis showed that age (OR 1.08, p=0.05), female sex (OR 3.58, p=0.0004), chronic kidney disease (OR 7.70, p<0.0001), and operation time (OR 1.01, p=0.0002) were risk factors for midterm mortality, whereas concomitant CABG was not (OR 0.92, p=0.87). There was a significant difference in midterm survival and freedom from major cerebrocardiovascular events in the TAR group versus the TAR/CABG group., Conclusions: Concomitant CABG was not a risk factor for hospital morality with TAR. However, patients with concomitant CABG have more preoperative comorbidities, which may adversely affect outcomes, and which may therefore deserve special attention., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Recent advancements in total aortic arch replacement achieved by our approach were presented., Methods: From January 2002 to December 2010, 321 consecutive patients (mean age 69.8 ± 13.3 years) underwent total arch replacement through a median sternotomy at our institute. Aortic dissection was present in 94 (28.3%) patients and shaggy aorta in 36 (11.2%), with emergency/urgent surgery required in 106 (33.0%). Our current approach included the following: (1) meticulous selection of arterial cannulation site and type of arterial cannula; (2) antegrade selective cerebral perfusion; (3) maintenance of minimal tympanic temperature between 20 °C and 23 °C; (4) early rewarming just after distal anastomosis; (5) after 2004, bolus injection of 100 mg of sivelestat sodium hydrate into the pump circuit at the initiation of cardiopulmonary bypass; (6) after 2006, maintaining fluid balance below 1000 mL during cardiopulmonary bypass., Results: Overall hospital mortality was 4.4% (14/321) and was 1.9% (4/215) in elective cases. Permanent neurologic deficit occurred in 4.4% (14/321) of patients and in 2.8% (6/215) of elective cases. Prolonged ventilation was necessary in 53 (16.5%), with a significant reduction after 2006 (22.8% vs 12.6%; P = .02). Multivariate analysis demonstrated that risk factors for hospital mortality were octogenarian (odds ratio, 4.32; P = .03), brain malperfusion (odds ratio, 21.2; P = .001) and cardiopulmonary bypass time (odds ratio, 1.01; P = .04). Survival at 3 and 5 years after surgery was 82.4% ± 2.5% and 78.5% ± 3.1%, respectively., Conclusions: Our current approach for total aortic arch replacement was associated with low hospital mortality and morbidities and with favorable long-term outcome., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Thoracoabdominal aortic aneurysm (TAAA) repair is the most invasive aortic surgery, requiring wide aortic exposure and reconstruction of branches of vital organs. Spinal cord ischemic injury( SCII) remains the most devastating complication. There has been a significant improvement in operative mortality and the incidence of SCII during past 2 decades in the treatment of TAAA repair. A number of adjuncts have been successfully used intraoperatively and postoperatively to minimize the risk of SCII. However, TAAA repair is a still surgical challenge for many cardiothoracic surgeons because there is no definite method to prevent SCII. As the cause of SCII has been considered to be multifactorial from many experimental and clinical studies, multidisciplinary approach is essential in the surgical treatment of TAAA. This review describes the recent advances and operative management of TAAA repair in the current era.

Background: Dilatation of the sinotubular junction (STJ) causes aortic regurgitation (AR) in patients with ascending aneurysm. These patients can regain valve competence by simple reduction of the diameter of STJ. Results of this technique were investigated clinically and echocardiographically., Methods: Replacement of the ascending aorta with reduction of the diameter of the STJ to correct AR (mean grade, 2.7 +/- 0.7) was performed in 29 consecutive patients (mean age, 73.2 +/- 6.2). Two required repair of cusp prolapse. All underwent ascending aortic aneurysm replacement. Echocardiographic studies were performed at discharge and during latest clinical follow-up (mean follow-up, 3.8 +/- 2.5 years)., Results: No hospital deaths occurred. The AR grade at discharge was 0.7 +/- 0.5. No valve related-deaths occurred. Actual survival at 8 years was 91% +/- 9%. Failure occurred 4.1 years postoperatively in a patient with bicuspid valve. Three patients had late recurrence of AR that was caused by aortic root dilatation in bicuspid valves in 2. Multivariate analysis showed bicuspid aortic valve was the predictor of late progression of AR. The freedom from more than grade II AR at 8 years was 79.5% +/- 10.7%., Conclusions: Adjustment of the diameter of STJ could treat AR secondary to ascending aortic aneurysm with nearly normal aortic cusps. Midterm results of this procedure were acceptable. Although bicuspid aortic valve is the risk factor for late AR due to dilation of remaining aortic root, this procedure provides satisfactory long-term outcomes among the patients with tricuspid valve.

Objective: To present our experience of total aortic arch replacement through a left posterolateral thoracotomy., Methods: Sixteen patients (13 males; mean age 62.1+/-11.3 years) with extended thoracic aortic aneurysms, including those in the thoracoabdominal aorta, underwent replacement through a left posterolateral thoracotomy. The pathology of the diseased aorta was non-dissecting aneurysm due to aortitis in 1 patient and aortic dissection in 15 patients (acute type A: 1, chronic type A: 12, chronic type B: 2). In a prior operation, the patient with aortitis had undergone the Bentall procedure with endovascular stenting of the brachiocephalic artery, and among the other 15 patients, one previously had endovascular stenting for the aortic arch and 12 had hemi-arch replacement for acute type A dissection. Extension of arch replacement was the aortic arch and descending aorta in eight patients, the ascending arch and descending aorta in five patients and the descending arch, and thoracoabdominal aorta in three patients. Additional retroperitoneal dissection was required for the repair of a thoracoabdominal aortic aneurysm., Results: One patient died of traumatic cerebral hemorrhage on day 145 (hospital mortality 6.3%). Average duration of ventilation support was 19.4+/-17.0h and length of ICU stay was 3.6+/-1.6 days. Actuarial survival at 2 years after the operations was 67.7%. However, no aortic-related mortality was observed during follow-up., Conclusions: Early results of extended aortic arch replacement through a left posterolateral thoracotomy were satisfactory in selected patients.

Background and Purpose: CT and MR angiographies have been reported to visualize the artery of Adamkiewicz (AKA) noninvasively to prevent spinal cord ischemia in surgery of thoracic descending aortic aneurysms. The purpose of this work was to compare the usefulness of CT angiography (CTA) with intra-arterial contrast injection (IACTA) with that of conventional CTA with intravenous contrast injection (IVCTA)., Materials and Methods: We enrolled 32 consecutive patients with thoracic or thoracoabdominal aortic aneurysms who were scheduled for surgical repair or endovascular stent-graft treatment. All of the CTA images were obtained using a 16-detector row CT scanner and 100 mL of contrast material (370 mg/mL) injected at a rate of 5 mL/s. Contrast was injected via the antecubital veins of 15 patients and via a pig-tail catheter placed at the proximal portion of the descending aorta in 17 patients who underwent IVCTA and IACTA, respectively. Two datasets were reconstructed from 2 consecutive scans. The AKA was identified as a characteristic hairpin curved vessel in the anterior midsagittal surface of the spine and by the absence of further enhancement in the second rather than in the first phase. Continuity between the AKA and aorta was confirmed when the vessel could be traced continuously by paging the oblique coronal multiplanar reconstruction or original axial images., Results: Intra-arterial contrast injection was significantly more sensitive in identifying the AKA than IVCTA: 16 (94.1%) of 17 versus 9 (60.0%) of 15 (P = .033). Continuity between the AKA and aorta through intercostal or lumbar artery was confirmed in 14 (87.5%) of 16 and 5 (55.6%) of 9 of the IACTA and IVCTA groups, respectively., Conclusion: Intra-arterial contrast injection detected the AKA at a high rate and verified continuity from the aorta to the AKA.

Postoperative paraplegia after repairing type A acute aortic dissection has been rarely reported and the causes have not been clearly elucidated. We had three cases of newly developed paraplegia after repair of type A acute aortic dissection. In these cases, we speculated that some intercostal arteries were occluded by completely thrombosed false lumen with late onset of systemic hypotension, which might have reduced spinal cord perfusion followed by paraplegia.

Background: The purpose of this study is to investigate the influence of perioperative circulation on spinal cord during the repair of descending thoracic or thoracoabdominal aortic aneurysms., Methods: From October 1999, 92 patients (aged 66 +/- 13 years; 65 men) underwent the repair of descending thoracic (n = 30) or thoracoabdominal aortic aneurysm (Crawford I, 9; II, 14; III, 35; IV, 4). We measured the time duration of hypotension, defined as follows, and evaluated the relationship between the incidence of paraplegia and each duration: T1, systolic arterial pressure less than 80 mm Hg, or mean pressure less than 60 mm Hg during aortic cross-clamping; T2, distal aortic pressure less than 60 mm Hg during aortic cross-clamping; T3, systolic arterial pressure less than 80 mm Hg after coming off bypass; T4, systolic arterial pressure less than 80 mm Hg in the intensive care unit., Results: Hospital mortality was 8% (7 patients). Neurologic deficits occurred in 10 patients (10.9%). The T1 and T2 periods showed no difference between paraplegia cases (group P) and normal cases (group N). The T3 periods in both groups were 54 +/- 52 and 6.6 +/- 18, and the T4 periods were 62 +/- 89 and 2.3 +/- 14, respectively. The T3 and T4 periods in group P were significantly longer than in group N (p < 0.0001). Multivariate analysis demonstrated that T3 was an independent risk factor for paraplegia. When divided according to body temperature, the T2 period under mild hypothermia was significantly longer in group P than in group N, as well as the T3 and T4 periods., Conclusions: Perioperative hemodynamics stability is of vital importance for spinal cord protection during thoracoabdominal aortic surgery. In particular, the duration of hypotension after coming off bypass was an independent risk factor for paraplegia.

Total arch replacement (TAR) for aneurysm of the aortic arch through the midsternotomy has several advantages over left thoracotomy. The purpose of this study was to identify the factors that might have an effect on the distal anastomosis through midsternotomy. From October 1999 to August 2005, 125 patients underwent TAR for aneurysm of the aortic arch through midsternotomy. Ninety-four patients with antegrade cerebral perfusion were selected. Distal anastomosis was performed under circulatory arrest (CA) of the lower body. Preoperatively, the diameter of aneurysm, the depth of distal end of aneurysm from anterior skin surface and the anteroposterior diameter of body trunk were measured. Postoperatively, the distance from the carina to the distal anastomosis was measured. There were six early deaths (6.4%). Duration of CA was 37+/-7.6 min. Diameter of the aneurysm was 60.6+/-13.2 mm and the depth of the distal end of aneurysm was 139+/-20.6 mm. There was no correlation between CA time and these factors. The anteroposterior diameter of body trunk was 200+/-18.0 mm and has a correlation with CA time. The depth of distal end of aneurysm from anterior skin surface was the only factor that affected duration for distal anastomosis.

Background: The purpose of this study was to evaluate the efficacy of myogenic transcranial motor evoked potentials (tc-MEPs) for spinal cord ischemia in the repair of descending thoracic or thoracoabdominal aortic aneurysms., Methods: Intraoperative tc-MEPs was used in 72 patients who underwent the repair of descending thoracic (n = 24) or thoracoabdominal aortic aneurysms (n = 49) classed as Crawford I in 10 patients, II in 12, III in 23, and IV in 3. There were 52 men and 20 women, and their mean age was 64.9 +/- 12.8 years. Tc-MEPs were recorded by transcranial electrical stimulation and compound muscle action potentials., Results: The hospital mortality rate was 5.6% (n = 4), and the incidence of neurologic deficits was 11.1% (n = 8). All patients whose MEP amplitude recovered to more than 75% of the baseline showed normal spinal function, and 8 of 9 patients whose MEP amplitude decreased to below 75% of the baseline at the end of the procedure showed neurologic deficits postoperatively. The sensitivity of tc-MEPs was 100% and specificity was 98.4%. Latency in patients with postoperative paraplegia was 123% +/- 9% and was significantly prolonged at the end of the procedure., Conclusions: Tc-MEPs were very sensitive and specific to spinal cord ischemia with reduced amplitude and prolongation of the latency period. Tc-MEPs are considered a useful monitor of spinal cord ischemia during descending thoracic or thoracoabdominal aortic surgery.

A 69-year-old hypertensive man who had 7 pseudoaneurysms caused by penetrating atherosclerotic ulcers underwent 2-staged endovascular grafting in the thoracic and thoracoabdominal aorta and a conventional graft replacement of the abdominal aorta. He had an uneventful postoperative course; follow-up computed tomography demonstrated that all aneurysmal lesions treated by endovascular grafting completely disappeared. He has been free from any aortic events 20 months after the last surgery.

A 52-year-old man underwent a replacement of the thoracoabdominal aorta. The aorta was severely calcified, and was replaced by a 24-mm woven Dacron (Vascutek, Renfrewshire, Scotland) graft wrapped with the calcificated aneurysmal wall. His postoperative course was uneventful; however, he collapsed on the 18th postoperative day. He underwent an emergent thoracotomy and the wrapped aneurysmal wall was taken down. The prosthesis graft had a 1-mm disruption in the middle portion, which did not relate to the anastomoses. Experimental study ex vivo showed that disruption of the prosthesis could have occurred after a 3-week pulsatile force caused by a seashell simulating aortic calcification.

Four patients who underwent secondary elephant trunk fixation by endovascular stent grafting are presented and the advantage of this method to treat multiple/extensive thoracic aortic aneurysm is discussed. In two of them, the elephant trunk installation has been performed at another hospital for extensive aortic aneurysm. In two other patients, the aortic arch replacement and the elephant trunk installation were performed through median sternotomy, initially for multiple aortic lesions, including both arch and descending aorta. No neurological deficit, stroke nor spinal cord injury was encountered during the follow-up period (24-40 months). The diameter of the aneurysms decreased markedly in three patients. In one patient, the aneurysm expanded gradually and type II endoleak was treated by coil embolization. In one patient, who showed marked shrinkage of the aneurysm, the stent graft kinked mildly. Based on the low mortality rate of well-established aortic arch surgery, concomitant elephant trunk installation which was followed by the secondary fixation with endovascular stent grafting might be useful to treat multiple/extensive thoracic aneurysm from distal arch to descending aorta.

The number of patients with thoracic aortic aneurysm has been increasing in Japan. The annual report by the Japanese Association for Thoracic Surgery 2001 demonstrated that 4,133 patients underwent surgery for thoracic aortic aneurysm. Among them, ruptured cases consisted of 11% (460 patients) and its early mortality was 32%. At the emergency room, initial accurate diagnosis, using echocardiography and computed tomography (CT), is mandatory for the next step and catastrophic shock status should be corrected if possible, such as pericardiocentesis or transfusion. For patients with ruptured descending or thoracoabdominal aortic aneurysms, the endovascular stent-grafting should be first choice of treatment. Otherwise, patients should be sent for the operation room as quickly as possible for initialing cardiopulmonary bypass and for controlling bleeding. Special attention should be paid for not injuring the left lung after left thoracotomy. Mycotic false aneurysms, including the aorto-esophageal fistula and prosthetic graft infection, remained as one of challenging entities in aortic emergency. The standard treatment for this fatal disease resection of the infected both aneurysm and esophagus, and has been reconstruction with an extra-anatomical bypass, however, recent advancement of technologies, including allograft and tissue engineering might enable to have in situ reconstruction of the aorta.