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Objectives: Suture line disruption is a serious complication after aortic surgery. We previously reported in a canine model that basic fibroblast growth factor-incorporated biodegradable polyglycolic acid (PGA) felt prevented tissue derangement at the anastomotic site. This study sought to evaluate the safety and durability of this biodegradable felt., Methods: Between January 2007 and December 2011, 67 patients who consented to undergo aortic surgery with the basic fibroblast growth factor-incorporated PGA felt were enrolled (Group P). As a control, we retrospectively reviewed the charts of 129 patients who underwent aortic surgery using a polytetrafluoroethylene felt during the same registration period (Group N). On the basis of 18 preoperative covariates, 60 well-matched patient pairs were identified using propensity matching, and their clinical indices were compared., Results: Among the matched pairs, in-hospital mortality and postoperative complication rates did not statistically differ between the groups. During a median follow-up of 4.8 years, the rate of anastomotic aneurysm was 1.7% (1 patient) in both groups. The rates of overall survival and freedom from aortic events did not differ between the groups. In total, 65 anastomoses in Group P and 54 anastomoses in Group N were monitored via computed tomography, and the diameters of the juxta-anastomotic sites in Group N were more likely to be increased than those in Group P {dilatation ratio [(post-discharge diameter - predischarge diameter)/predischarge diameter × 100 (%)]: 4.3% ± 0.6% vs 2.5% ± 0.5%, P = 0.01}., Conclusions: The basic fibroblast growth factor-incorporated PGA felt was as safe and durable as conventional felt for reinforcement in aortic surgery. The attenuation of juxta-anastomotic aortic dilatation by PGA felt reinforcement may provide more beneficial effects on long-term outcomes.

Objectives: Increased hemodynamic stress on vein grafts used in the arterial system is associated with vein graft disease. We determined whether a novel biodegradable external mesh stent could inhibit medial-intimal hyperplasia by suppressing hemodynamic stress on vein grafts and improve long-term patency., Methods: Twenty-four beagles underwent bilateral femoral interposition grafting using reversed femoral veins. Vein grafts were externally supported by a novel poly L-lactide-ε-caprolactone copolymer (P(LA/CL)) biodegradable mesh stent or a nonabsorbable mesh stent. Vein grafts with no reinforcement were used as controls. The grafts were harvested 6 and 12 months after implantation for morphometric and immunohistochemical assessment., Results: The endoluminal circumferential vein graft length was smaller in the P(LA/CL) and nonabsorbable groups (17.2 ± 2.9 and 19.0 ± 0.3 mm, respectively), than that in the control group (25.0 ± 2.6 mm, P < 0.01) at 12 months. The mean intimal-medial thickness was thinner in P(LA/CL) and nonabsorbable stent groups (0.18 ± 0.05 and 0.16 ± 0.05 mm, respectively), than that in the control group (0.30 ± 0.08 mm, P < 0.01). Differences in the intimal-medial thickness among the groups were associated with the magnitude of cellular proliferating activity. The graft patency ratio (100 %) was higher in the P(LA/CL) group than that in the nonabsorbable and control groups (72.2 and 63.6%, respectively, P < 0.05)., Conclusions: The biodegradable P(LA/CL) external mesh stent improved vein graft patency for 12 months and prevented vein graft dilatation and intimal hyperplasia associated with suppressed neointimal layer cellular proliferating activity.

A 70-year-old male underwent a transthoracic echocardiography as a screening test for hypertension and an unruptured aneurysm was detected in the right sinus of Valsalva. The right sinus of Valsalva aneurysm obstructed the right ventricle outflow tract but he did not have any symptoms. The sinus of Valsalva aneurysm was treated successfully by a patch closure with a bovine pericardial patch.

Objective: It is reported that hypothermia has some protective effect against ischemia of the spinal cord during thoracoabdominal aneurysm repair. However, it has not been elucidated clinically whether regional spinal cord hypothermia by epidural perfusion cooling is effective and safe. The purpose of this study was to assess the effect and safety of perfusion cooling of the epidural space during most or all of descending thoracic or thoracoabdominal aneurysm repair., Methods: From January 1998 to December 2007, a total of 102 patients with a mean age of 61 years underwent replacement of most or all of the descending thoracic aorta or thoracoabdominal aorta with the aid of mild hypothermia via epidural perfusion cooling and cerebrospinal fluid (CSF) drainage. Risk factors for spinal cord injury and hospital death were analyzed using univariate and multivariate analyses. The actuarial survival rate was calculated by the Kaplan-Meier method., Results: The mean lowest CSF temperature was 23.3 degrees C during epidural perfusion cooling. The mean temperature difference between the nasopharynx and CSF was 8.4 degrees C. The incidence of spinal cord injury was 3.9% (4/102), and that of hospital death was 5.9% (6/102). There was no significant risk factor associated with spinal cord injury. Type III aneurysm and postoperative cerebrovascular accident, respiratory failure, liver failure, and infection were predictors of hospital death. The actuarial survival rates at 3 and 5 years were 82.1% and 75.9%, respectively., Conclusion: Epidural perfusion cooling is a safe method to employ in clinical situations. Our contemporary management strategies enabled patients to undergo thoracoabdominal aneurysm repair with excellent early and late survival and acceptable morbidity.

Objectives: We investigated the outcomes of reinforcing anastomotic sites using (1) nonbiodegradable polytetrafluoroethylene (PTFE) felt, (2) biodegradable polyglycolic acid (PGA) felt, and (3) PGA felt with basic fibroblast growth factor (bFGF) in a canine descending thoracic aortic replacement model., Methods: Thirty-seven beagles underwent descending thoracic aorta replacement using a prosthetic graft with one of the above-mentioned reinforcements or no reinforcement for controls. Histologic evaluations were carried out 1 month and 3 months after surgery. The biomechanical strength of the anastomosis was assessed along the longitudinal axis of the aortic segments using a tensile tester. Local compliance at the anastomotic site was also evaluated in the circumferential direction., Results: The media was significantly thinner in the PTFE group than in the control group (65.8% +/- 5.1% vs 95.0% +/- 9.3% of normal thickness; P < .05). Relative to the control group, the adventitial layer was significantly thinner in the PTFE group (42.3% +/- 8.2% of control; P < .05) but significantly thicker in the PGA and the PGA + bFGF groups (117.2% +/- 11.3% and 134.1% +/- 14.2% of control, respectively; P < .05). There were more vessels in the adventitial layer in the PGA + bFGF group than in the control, PTFE, and PGA groups (29.2 +/- 2.1/mm(2) vs 13.8 +/- 0.8, 5.4 +/- 0.7, 17.0 +/- 1.3/mm(2), respectively; P < .01). There were no significant differences between the four groups in the failure force at anastomotic sites. Local compliance at the anastomotic site was higher in the PGA group than that in the PTFE group (11.6 +/- 1.6 10(-6) m(2)/N vs 5.6 +/- 1.9 10(-6) m(2)/N; P < .05)., Conclusion: Reinforcement of the experimental aortic wall with PTFE felt resulted in thinning of the media and adventitia and fewer vessels at the anastomotic site. These histologic changes were not observed when biodegradable felt was used. The bFGF failed to augment the modification of the aortic wall with the exception of increased adventitial vessel number. Biomechanical strength of the anastomosis along the longitudinal axis was comparable in all four groups; however, local vascular compliance was better in the biodegradable PGA felt group., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Prosthetic vascular graft infection is an unsolved fatal complication after aortic surgery. We hypothesized that increased vascularity around a prosthetic graft may exert a preventive role against bacterial infection., Methods: Eighty-three Fischer rats were divided into five groups according to the types of subcutaneously implanted prosthetic graft and granulocyte-colony stimulating factor (G-CSF) treatment. The groups G and C had gelatin hydrogel microspheres-incorporated graft (gel graft) with or without concomitant systemic administration of G-CSF (50 microg/kg), respectively. The groups FG and F had the gel graft impregnated with 100 mug of basic fibroblast growth factor (bFGF) with or without systemic G-CSF. The group N received untreated grafts. Seven days after graft implantation, broth containing methicillin-sensitive Staphylococcus aureus (4.0 x 10(3) colony-forming units) was inoculated onto the graft. All the grafts and the surrounding tissues were explanted 2 days later. Quantitative culture for methicillin-sensitive Staphylococcus aureus from the grafts and histologic assessment for capillary number in the tissue were performed., Results: Positive infection rates in the groups N, C, and G were 34.7%, 30.4%, and 15.3%, respectively; whereas those were zero in the F and FG groups. Tissue around the grafts demonstrated significantly higher number of capillaries in the groups F and FG compared with the groups C and G. The number of bacterial colonies inversely correlated with the number of capillaries around the implanted graft (r = -0.32, p < 0.05)., Conclusions: Basic fibroblast growth factor incorporated into a prosthetic graft with or without systemic G-CSF can induce angiogenesis around the graft and prevent prosthetic graft infection.

Little experience exists with the vacuum-assisted closure (VAC) therapy in the high-risk group of patients with perigraft abscess containing a large amount of prosthetic vascular grafts. We report our experience in the VAC therapy for patients with mediastinitis after aortic arch replacement. Between February 2003 and December 2006, five patients with a mean age of 72.2 years developed postoperative mediastinitis after aortic arch replacement, and were treated with the VAC system. In all the patients the mediastinal fluid and tissue examinations turned out to be negative for microbiological cultures, and successful closure of the midline incision was achieved with concomitant omental transfer after a mean duration of 22.6 days of VAC treatment. Four of the five patients survived to discharge and have been free from recurrent sign of mediastinal or graft infection at long-term follow-up. Our study indicates that the VAC treatment may reduce early mortality of life-threatening deep sternal wound infection complicated by a prior aortic arch replacement and become a preferred therapeutic option for the patients to whom another replacement is too risky.

Aortoesophageal fistula is a relatively rare but highly fatal condition, especially in the case of secondary aortoesophageal fistulas after previous thoracic aortic surgery in which the aortic prosthetic graft itself may be involved in the infection, resulting in an esophagoparaprosthetic fistula. In this report, we describe a complicated case of esophagoparaprosthetic fistula arising after descending thoracic aortic replacement and endovascular pseudoaneurysm repair that was successfully treated by surgical resection and in situ aortic graft replacement using a homograft completely covered with an omental flap, combined with subtotal esophagectomy and staged reconstruction of the alimentary tract. The patient has been doing well for 24 months without signs of recurrent infection.

A 77-year-old man developed deep sternal wound infection with Enterobacter cloacae 4 days after total aortic arch replacement for distal aortic arch aneurysm. Reexploration and open drainage of the mediastinum was carried out for 4 days, and the vacuum-assisted closure system was applied and continued for 10 days. During the treatment, granulation formation and neovascularization was apparently enhanced which lead us to perform omental transfer and chest closure on the 18th postoperative day. The patient has been free from recurrent sign of mediastinal infection or graft infection for the 19 months of the follow-up period.

Objective: Although several methods of stent-grafting for patients with aortic arch aneurysm have been reported, these methods have been associated with several complications such as endoleak and migration. We developed a new method using Matsui-Kitamura (MK) stent-graft following extra-anatomic arch vessels bypass by selective cerebral perfusion (SCP) under left heart bypass (LHB)., Methods: Between December 2001 and December 2003, 12 patients with aortic arch aneurysm were treated according to this new method. All patients were male with an average age of 71.3+/-6.4 years. There were 5 patients with severe pulmonary dysfunction, 4 with renal dysfunction, one with severe cardiac dysfunction and 3 with preoperative cerebral infarction. Under SCP using LHB, the extra-anatomic arch vessel bypass was established. The MK stent-graft was delivered into the aortic arch. Coronary artery bypass grafting (CABG) was concomitantly performed in one patient., Results: There were no cases of endoleak, migration or hospital death. One patient, who had a past history of cerebrovascular disease, suffered a minor stroke, and one patient, who was performed CABG to the mid-left anterior descending branch (LAD) using the left internal thoracic artery (LITA), presented paraparesis. Although two patients of chronic renal failure underwent scheduled CHDF on account of using the contrast medium during the procedure, all of them were weaned from hemodialysis. However, there were no other postoperative complications such as, respiratory failure or cardiac dysfunction., Conclusions: Endovascular stent grafting EVSG using the MK stent with extra-anatomic arch vessel bypass under SCP using LHB could be a useful and less invasive method for patients with aortic arch aneurysm who are at a high surgical risk.

A 76-year-old man underwent endovascular stent-grafting therapy for chronic aortic dissection. The preoperative multi detector row helical computed tomography (CT) revealed that Adamkiewicz's artery originated from the level of thoracic 9 intercostal artery. Intraoperative monitoring of motor evoked potentials showed no reduction of amplitude in the anterior tibialis muscle after deployment retrievable stent-graft. Postoperative CT showed that stent-graft blocked the ostium of intercostal arteries including Adamkiewicz's artery. On the other hand, the distal portion of the Adamkiewicz's artery was clearly enhanced. Our result showed that there is a collateral network supplying to Adamkiewicz's artery.

Emergency or urgent thoracoabdominal aortic replacement in octogenarians has high morbidity and mortality rates due to decrease in the potential of other organs because of their age and the high invasiveness. Here, report a case of an 81-year-old woman who was diagnosed as having an impending rupture in an acute type A dissecting aneurysm complicated with a thoracoabdominal aortic aneurysm, who was rescued successfully by replacement of the thoracoabdominal aorta, under epidural perfusion cooling.

To identify significant predictors of late mortality, multivariate analysis were applied to the clinical outcome of 150 consecutive patients with true aneurysm of the ascending aorta and/or aortic arch operated between January, 1987 and December, 2000. Mean follow-up was 53.0 months with a total of 6,682 patient-months of follow-up. Multivariate analysis revealed that operation date (before December, 1996), presence of preoperative cerebrovascular disease, rupture and postoperative phrenic nerve palsy were independent determinants of late mortality. The overall 5-year and 10-year actuarial survival rates were 66.0% and 48.2%. The 5-year and 10-year event free rate of cardiovascular and/or cerebrovascular death were 88.9% and 71.7%. Preoperative evaluation of the brain, operation prior to aneurysm rupture and phrenic nerve protection during operation is necessary to improve long-term survival rate.

A 62-year-old woman with a history of esophageal resection and colon interposition with anterosternal subcutaneous tunnel required replacement of the ascending aorta due to dissecting aortic aneurysm. Preoperative three-dimensional computed tomography enabled us to reveal that right thoracotomy could offer an ascending aortic operation. The patient underwent successful operation under hypothermic circulatory arrest and the right anterolateral thoracotomy provided safe exposure of the diseased ascending aorta even when the suprasternal tunnel precluded conventional median sternotomy.

We reviewed ten cases who underwent aortic root replacement after operation for the ascending aorta and/or aortic valve. As initial operation, aortic valve replacement (AVR) was performed in five patients, replacement of the ascending aorta in two, original Bentall operation in two, and entry closure and suspension of the aortic valve in one. At reoperation, three patients were diagnosed as aneurysm of the ascending aorta, two were annulo-aortic ectasia, and one was acute aortic dissection, chronic dissecting aneusym, pseudoaneurysm of the ascending aorta, prosthetic valve endocarditis, and massive aortic regurgitation. Aortic root replacement was performed using mechanical valved composite graft in all cases. One patient who underwent repeat aortic root replacement for prosthetic valve endocarditis was died of septemia and ventricular fibrillation. Five patients had nine complications (two low output syndrome, respiratory failure and cerebral infarction, one gastrointestinal bleeding, septemia and ventricular fibrillation). In conclusion, aortic root replacement after operation for the ascending aorta and/or aortic valve was performed with acceptable morbidity and mortality.

We report a rare case of a 39-year-old man with type A aortic dissection involving a right-sided aortic arch with the symptom of vascular ring. Computed tomography scanning and angiography were performed to define the extent of the dissection and the anatomy of the branching vessels. The ascending aorta was replaced through a median sternotomy and right thoracotomy using a hypothermic cardiopulmonary bypass associated with selective cerebral perfusion and partial circulatory arrest, and his symptom of vascular ring disappeared postoperatively.

The technique of open distal anastomosis or application of aortic balloon occlusion catheter designed to occlude the descending thoracic aorta have been used in 33 and 19 patients, respectively, to control bleeding during the procedure of distal anastomosis for complete aortic arch replacement with a prosthetic graft. These two techniques allowed us a simple approach to the lesion and the avoidance of clamp injury to the fragile aortic tissue. Open distal anastomosis was applied for 91% patients of operated aortic dissection and all emergent cases, it's duration ranged from 10 to 110 minutes with an average of 58 minutes under 18.2 degrees C of lowest esophageal temperature. On the other hand, aortic occlusion balloon was inserted for mainly true aortic aneurysm patients without an emergency, and helped to maintain the perfusion pressure on a lower part of body around 50 mmHg by the 1550 ml/min in an average of perfusion flow femoral artery under 21.2 degrees C of temperature. The difference of postoperative renal and liver function evaluated by serum enzyme levels of total bilirubin, GOT, GPT, LDH, creatinine and BUN did not reach to statistical significance between the patients using open distal anastomosis and balloon occlusion, however, the incidence of postoperative complication including either renal, liver dysfunction, abdominal problem or paraplegia was significantly higher in the patient group with open distal technique. Either open distal anastomosis or aortic balloon occlusion technique would be appropriately selected according to the patient's characteristics or the condition of aortic disease to be operated.

A 79-year-old hypertensive woman, with fusiform shaped atherosclerotic aneurysm in the descending thoracic aorta whose medial layer was maintained by an extensive solid calcium plate (porcelain aorta), was successfully treated using a sutureless intraluminal ringed graft. Spools of the ring were fixed by circumferential ligatures at both proximal and distal sites of anastomosis and a dilated segment of the aorta was replaced with the tube graft.

The purpose of this study is to analyze our treatment experience on patients with ascending aortic aneurysms, with aortic regurgitation. From January 1974 to December 1995, 49 patients underwent replacement of the aortic valve and ascending aorta with a composite graft, in which primary operation cases were 44 and reoperation ones were 5. The Bentall technique was used in 20 patients, the button technique in 11, the interposition graft technique in 11, and a combination of the interposition graft and button technique in 7. All but one reoperation cases underwent the interposition graft technique. Hospital mortality was 30% for the Bentall technique, and 9.1% for the button technique and 9.1% for the interposition graft technique; there was no hospital mortality in the combination of the interposition graft and button technique. Hospital mortality of interposition graft technique in primary operation cases was 9.1%, and that in reoperation cases was 0%. Hospital mortality in patients underwent from 1974 to 1985 was 30.8%, 27.8% from 1986 to 1991, and 0% from 1992 to 1995. Five late deaths occurred in the Bentall group (35.7%) and one late death in the button technique (9.1%). Not late deaths in the other groups have occurred. In summary, operative mortality in Bentall technique group was higher than that of the other groups. Operative results were improved by the change of operative methods. The interposition graft technique is preferable for patients undergoing reoperation or when tension on the ostial anastomoses may occur. The button technique is best for patients with aortic dissection or inflammation involving the coronary ostia.

From 1987 to 1994, 116 patients received replacement of the ascending and/or aortic arch using selective cerebral perfusion. They were 82 male and 34 female, with average age of 64 years. There were 63 dissecting and 53 true aneurysms. Extent of replacement was: ascending aorta in 13, aortic root in 2, aortic arch in 93, and aortic root and complete arch in 8. Aortic arch replacements were composed of: 29 partial proximal aortic arch replacements, 44 complete aortic arch replacements, and 20 partial distal aortic arch replacements. Nineteen (16.4%) hospital deaths occurred. Univariate testing of pre-, intra-, and post-operative variables followed by stepwise logistic regression analyses identified elderly, ischemic heart disease, postoperative neurologic complication, cardiac dysfunction, renal failure, and massive bleeding as factors having independent association with hospital mortality. Neurologic complication was found in 10 patients (8.6%), and risk factor for this complication was preoperative peripheral vascular disease. Follow-up of hospital survivors documented an overall cumulative 5-year survive rate of 69%. There was no significant difference between dissection and true aneurysms in 5-year survive ratios, which were 63% and 82%, respectively. During follow-up periods, 18 patients died. Half of these cases were vascular deaths, caused by rupture, sudden death and secondary operation. Univariate analyses followed by stepwise Cox testing indicated that chronic obstructive pulmonary disease and a history of postoperative massive bleeding were associated with decreased later survival. Our experience suggests that selective cerebral perfusion is a safe technique for the repair of ascending aorta and/or aortic arch problems. High-risk subgroups of patients with these aortic problems can be identified by risk factors. Aggressive and careful management is necessary for such subgroups to improve early and late survival rates.