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Purpose: Zone 0 landing in thoracic endovascular aortic repair (TEVAR) has recently gained increasing attention for the treatment of high-risk patients. The aim of this study was to compare the outcomes of total endovascular aortic arch repair between branched TEVAR (bTEVAR) and chimney TEVAR (cTEVAR) in the landing zone (LZ) 0. Materials and Methods: This was a single-center, retrospective, and observational cohort study. From January 2010 to March 2020, 40 patients (bTEVAR, n=25; cTEVAR, n=15; median age: 79 years) were enrolled in this study, with a median follow-up period of 4.1 years. These patients were considered unsuitable for open surgical treatment. Results: All procedures were successful and no cases of conversion to open repair were noted during the 30-day postoperative period. The 30-day mortality was 2.5% (n=1; bTEVAR [0 of 25, 0%] vs cTEVAR [1 of 15, 6.7%]; p=0.375), the perioperative stroke rate was 10.0% (n=4; bTEVAR [4 of 25, 16.0%] vs cTEVAR [0 of 15, 0%], p=0.278), and type 1a endoleak rate was 15.0% (n=6; bTEVAR [0 of 25, 0%] vs cTEVAR [6 of 15, 40.0%], p=0.001). The risk factor for stroke was atheroma grade of ≥2 in the brachiocephalic artery (pConclusions: Total endovascular aortic arch repair using bTEVAR and cTEVAR is feasible for the treatment of aortic arch diseases in high-risk patients who are unsuitable for open surgery. However, as the rate of stroke is high, strict preoperative evaluation to prevent stroke is needed. No rupture of the aneurysm was observed in cTEVAR, but patients should be selected carefully because of the high incidence of type 1a endoleak.

BACKGROUND Although the preoperative risk factors associated with the occurrence of type II endoleak (ETII) after endovascular aortic repair (EVAR) have gradually become more evident, the preoperative risk factors associated with aneurysm sac enlargement caused by ETII remain unclear. This study aimed to determine the preoperative risk factors associated with aneurysm sac enlargement caused by ETII after EVAR. METHODS This retrospective cohort study reviewed 519 EVARs performed for true abdominal aortic aneurysm between January 2006 and December 2018 at our institution. EVARs using commercially available bifurcated devices with no type I or III endoleaks during follow-up and with ≥12 months follow-up were included. A total of 320 patients were enrolled in the study. To identify the preoperative risk factors of sac enlargement after EVAR, Cox regression analysis was used to assess preoperative data. RESULTS The median follow-up period was 60.8 months. Overall, 135 of 320 patients (42%) had ETII during follow-up, and 47 of 135 patients (35%) developed aneurysm sac enlargement. Multivariate analysis revealed that chronic kidney disease (CKD) stage ≥4 (hazard ratio [HR], 4.65; 95% confidence interval [CI], 2.13-10.15; P = 0.001), patent inferior mesenteric artery (IMA) (HR, 17.85; 95% CI, 2.46-129.73; P< 0.001), and number of patent lumbar arteries (LAs) (HR, 1.37; 95% CI, 1.13-1.68; P= 0.002) were risk factors of aneurysm sac enlargement caused by ETII. CONCLUSIONS CKD stage ≥4, patent IMA, and number of patent LAs were independent risk factors for aneurysm sac enlargement after EVAR. In particular, patent IMA had the highest HR and seemed to have the greatest impact on long-term aneurysm sac enlargement. Hence, taking preoperative measures to address a patent IMA appears to be important in reducing the incidence of sac enlargement.

We present the case of a patient with a graft-duodenal fistula after renovisceral debranching thoracic endovascular aortic repair. 18F-fluorodeoxyglucose positron emission tomography with computed tomography showed that the infection was localized to the renovisceral bypass grafts and the right kidney. Based on the preoperative imaging findings, a limited surgery with resection was performed in the fistula, right kidney, and fluorodeoxyglucose-positive bypass grafts, while preserving the fluorodeoxyglucose-negative grafts. No signs of reinfection were reported 2 years after the surgery. Accurate assessment of infection with 18F-fluorodeoxyglucose positron emission tomography with computed tomography may be useful for performing adequate excision of infected lesions.

Fibroblast-to-myofibroblast transition (FMT) is the primary inducer of cardiac fibrosis. ONO-1301, a synthetic prostacyclin agonist, reportedly promotes tissue fibrosis repair by enhancing anti-fibrotic cytokine production. We hypothesized that ONO-1301 attenuates pressure-overloaded cardiac fibrosis by modulating FMT and generated a pressure-overloaded murine model via transverse aortic constriction (TAC) to evaluate the in vivo effects of ONO-1301. Cardiac fibrosis, left ventricular dilatation, and systolic dysfunction were established 4 weeks after TAC; however, ONO-1301 treatment initiated 2 weeks after TAC significantly attenuated those effects. Furthermore, ONO-1301 treatment significantly upregulated expression levels of cardioprotective cytokines such as vascular endothelial growth factor and hepatocyte growth factor in TAC hearts, whereas FMT-related factors, including transforming growth factor (TGF)-β1 and connective tissue growth factor, were significantly downregulated. The number of α-smooth muscle actin (α-SMA)- and vimentin-positive cells, representing fibroblast-originated cells transitioned into myofibroblasts, was significantly reduced in ONO-1301-treated TAC hearts. We isolated cardiac fibroblasts (CFs) from the left ventricles of adult male mice and assessed the effects of ONO-1301 on CFs stimulated by TGF-β. Results showed that ONO-1301 co-incubation significantly suppressed TGF-β-induced α-SMA expression and collagen synthesis, and significantly inhibited TGF-β-induced CF proliferation and migration. Our findings suggest that ONO-1301 ameliorates pressure overloaded cardiac fibrosis by inhibiting TGF-β-induced FMT., Graphical Abstract, ONO-1301SR, a sustained-release drug-delivery system of a synthetic prostacyclin agonist, attenuates pressure overload-induced cardiac fibrosis by inhibiting TGF-β-induced fibroblast-to-myofibroblast transition in addition to enhancing the production of protective cytokines, such as hepatic growth factor (HGF), vascular endothelial growth factor (VEGF), and stromal cell-derived factor 1 (SDF-1).

Clinical outcomes of pulmonary arterial hypertension (PAH) may be improved using targeted delivery system. We investigated the efficacy of ONO1301 (prostacyclin agonist) nanospheres (ONONS) in Sugen5416/hypoxia rat models of PAH. The rats were injected with saline (control) or ONONS (n = 10, each) on days 21 and 28, respectively. Hepatocyte growth factor (HGF)-expressing fibroblasts and inflammatory cytokines were measured. Cardiac performance was assessed and targeted delivery was monitored in vivo, using Texas red-labeled nanoparticles. Compared with control, HGF-expressing fibroblasts and HGF expression levels were significantly higher in the ONONS group, while the levels of interleukin-6, interleukin-1β, transforming growth factor-β, and platelet-derived growth factor were lower. Histological assessment revealed significant amelioration of the percent medial wall thickness in pulmonary vasculature of rats in the ONONS group. Rats in the ONONS group showed decreased proliferating cell nuclear antigen-positive smooth muscle cells and improved right ventricle pressure/left ventricle pressure. No difference was seen in the accumulation of Texas red-labeled nanoparticles in the brain, heart, liver, and spleen between PAH and normal rats. However, a significant area of nanoparticles was detected in the lungs of PAH rats. ONONS effectively ameliorated PAH, with selective delivery to the damaged lung.

Introduction We describe the successful treatment of a patient with extended-aortic prosthetic graft infection (PGI) by surgery limited to the infected lesion based on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) findings. Presentation of case A 54-year-old man, who had undergone three graft replacements (GRs) for extended-thoracic aortic aneurysms, was diagnosed with PGI complicated by an aorto-esophageal fistula. On the basis of 18F-FDG PET/CT findings, we performed a redo total arch replacement, preserving the other prosthesis where abnormal FDG uptake was not detected. All the resected tissues were positive for gram positive coccus. There were no signs of infection recurrence at 2 years postoperatively. Discussion Since activated inflammatory cells such as macrophages uptake FDG, FDG-PET/CT clarifies the localization of the infected prosthesis precisely. Conclusion Surgery localized to the infected sites detected by FDG-PET/CT can be an effective option for PGI in cases with previous multiple GRs.

Thoracic endovascular aortic repair has become widely accepted as a useful, less invasive procedure for type B aortic dissections by covering the primary entry.1 However, depending on the location of the primary entry, it is often difficult to cover the entry from the true lumen without hybrid procedures.2 Here, we describe a successful endovascular treatment using a double-barreled endografting technique for chronic type B aortic dissection, which excludes the dilated false lumen by endografting into the false lumen without covering the primary entry.

Objectives Stent graft-induced distal re-dissection (SIDR) is a burdensome complication after thoracic endovascular aortic repair (TEVAR) for Type B aortic dissection. We developed a novel method to prevent SIDR by placing a small-diameter short stent graft [Excluder Aortic Extender (Cuff)] at the distal landing zone (DLZ) and reviewed its effectiveness in this study. Methods Ninety patients who underwent TEVAR for Type B aortic dissection using commercially available devices between January 2008 and September 2016 were retrospectively reviewed. Among them, TEVAR with the Cuff technique was performed in 36 (40%) cases, in which a Cuff was placed at the DLZ in the descending aorta prior to the main stent graft deployment to avoid excessive stent graft oversizing at the distal end. The effectiveness of the Cuff technique was assessed by evaluating mid-term clinical results, including the incidence of SIDR. Results Technical success was achieved in all 90 cases. During a median follow-up time of 40.4 months (range 0.2-90.6 months), 8 SIDRs were documented using multidetector computed tomography images. Freedom from SIDR was significantly lower in the Cuff group (Cuff: 100%/5 years vs non-Cuff: 84.6%/5 years; P = 0.04), whereas no difference was observed between both groups in the oversizing rate at the DLZ (19.9 ± 8.5% vs 17.8 ± 9.9%; P = 0.29). Conclusions Placement of a small-diameter short stent graft at the DLZ (Cuff technique) in TEVAR for aortic dissection is an easy procedure that may reduce the incidence of SIDR.

OBJECTIVES The risk of spinal cord injury after thoraco-abdominal aortic aneurysm repair increases when the segmental arteries (SAs) in the critical segment are sacrificed. Such critical SAs cannot be reconstructed when performing thoracic endovascular aortic repair (TEVAR). We aimed to elucidate extrathoracic collaterals to the critical SAs (T9–L1) that develop after TEVAR. METHODS Between 2006 and 2018, the critical SAs (T9–L1) of 38 patients were sacrificed during TEVAR. Nineteen of these patients who underwent multidetector row computed tomography 6 months after surgery were included (mean age 60 ± 13 years; 10 male; Crawford extent II:III, 14:5). We retrospectively assessed extrathoracic collaterals to the sacrificed critical SAs. RESULTS Ninety-four collaterals to the critical SAs were observed, originating from the subclavian (26/94), external iliac (50/94) and internal iliac (18/94) arteries. Twenty-five of the 26 (96%) collaterals from the subclavian artery were from its lateral descending branch, and 19 of the 26 (73%) collaterals fed into T9. Forty-three of the 50 (86%) collaterals from the external iliac artery were from its lateral ascending branch, and 25 of the 50 (50%) collaterals communicated with T11. Patients with a history of left thoracotomy (no collaterals in 6 patients) had fewer collaterals via the lateral descending branch of the left subclavian artery in comparison with the patients without (10 collaterals in 13 patients) (P = 0.009). CONCLUSIONS After critical SAs were sacrificed, extrathoracic collaterals developed with certain regularity. Previous left thoracotomy could influence the development of extrathoracic collaterals from the left subclavian artery.

Objectives The objective of this study was to evaluate the effectiveness of embolic protection filter device in stroke prevention during hybrid endovascular arch repair in patients with significant aortic atheroma. Methods Twenty-two patients (20 men, mean age 79.0 years, mean logistic EuroSCORE 23.9%) with aortic arch/proximal descending aortic diseases and significant aortic atheroma (atheroma grade ≥ II) who were deemed unfit for conventional open surgery underwent endovascular aortic arch repair with protection of the supra-arch vessels using a balloon catheter and filter devices. The effectiveness in preventing stroke was evaluated by a postoperative neurological examination protocol, which was followed by neuroimaging with computed tomography/DW-magnetic resonance imaging (MRI) study in cases with neurological deficits. Results The atheroma grades of the aortic arch were II, III and IV in 36%, 14% and 50% of the patients, respectively. In total, 37 filter devices were placed in the supra-aortic vessels (5 brachiocephalic arteries, 23 carotid arteries, 5 subclavian arteries and 4 vertebral arteries). Technical success was achieved in all patients, and 30-day mortality was 4.5% (1/22 cases). Two (9.1%) cases showed neurological symptomatic stroke postoperatively. With DW-MRI examination, a major new region was detected in the filter-protected left carotid artery in one case and in the balloon-protected left vertebral artery in another case. Conclusions In high-risk patients with significant aortic arch atheroma, hybrid endovascular aortic arch repair with embolic protection using a filter device showed satisfactory early results. Filter protection could be an attractive adjunct manoeuvre for preventing critical stroke during endovascular arch repair.

Objectives Optimal methods to quantitatively evaluate the blood flow in each cerebral artery after zone 1-2 thoracic endovascular aortic repair (TEVAR) remain unknown. Our objective was to evaluate the differences between preoperative and postoperative cerebral artery blood flows after zone 1-2 debranching TEVAR (dTEVAR). Methods Between January 2016 and August 2018, a prospective analysis of the blood flow in both the internal carotid artery and the vertebral artery in 16 patients before and after zone 1-2 dTEVAR was conducted. Zone 1 dTEVAR with right axillary artery-left common carotid artery-left axillary artery (RAxA-LCCA-LAxA) bypass was performed on 7 patients. Zone 2 dTEVAR was performed on 9 patients: 4 underwent RAxA-LAxA bypass and 5 underwent LCCA-LAxA bypass. Quantitative magnetic resonance angiography was performed before and after zone 1-2 dTEVAR. Results Total intracranial blood flow was preserved postoperatively [The median (interquartile range) preoperatively vs postoperatively: 621 (549-686) vs 638 (539-703) ml/min, not significant]. The anterior [469 (400-504) vs 475 (404-510) ml/min, not significant] and posterior cerebral blood flows [157 (121-199) vs 163 (123-210) ml/min, not significant] were also maintained postoperatively. In the 3 debranching procedures, the postoperative anterior and posterior cerebral blood flows were maintained at rates similar to preoperative rates, with the proportion of anterior and posterior cerebral circulations reaching almost 75% and 25%, respectively. No significant differences between preoperative and postoperative distributions of internal carotid artery blood flows were observed. Regarding vertebral artery blood flows, the distribution of blood flow through the left vertebral artery was significantly lower postoperatively than preoperatively; however, the postoperative right vertebral artery blood flow distribution significantly increased compared with the preoperative flow. Conclusions In zone 1-2 dTEVAR, total intracranial blood flow was preserved postoperatively, and the postoperative anterior and posterior cerebral circulations were maintained at rates similar to their preoperative rates.

Objectives Silent cerebral infarction is the most common brain injury incidentally detected on imaging and can be associated with increased risks of future stroke and cognitive decline. However, the incidence and risk factors of silent cerebral infarction after thoracic endovascular aortic repair (TEVAR) for aortic arch pathologies remain unclear. This study aimed to examine silent cerebral infarction following TEVAR using diffusion-weighted (DW) magnetic resonance imaging (MRI). Methods Nineteen patients (16 men, mean age 73.3 years) who underwent elective debranching TEVAR (zone 0/1/2 = 3/8/8) were included. Perioperative brain injury was assessed via cerebral DW-MRI before and after the procedure. The atheroma ratio was calculated from preoperative computed tomography images, and we examined the association between the atheroma ratio and development of new postoperative DW-MRI lesions. Results Technical success was achieved in all patients, and no patient died within 30 days postoperatively. Postoperative DW-MRI detected a total of 24 new lesions in 5 (26%) patients (1-9 lesions per patient): 4 (21%) patients with silent cerebral infarction and 1 (5%) patient with clinical stroke. The atheroma ratio of the aortic arch (23.8 ± 2.7% vs 18.3 ± 3.9%; P = 0.023), especially at the proximal landing zone (19.5 ± 2.8% vs 14.7 ± 2.7%; P = 0.014), was significantly higher in patients with new postoperative DW-MRI lesions than that in patients without. Conclusions The incidence of silent cerebral infarction following TEVAR with supra-aortic debranching for aortic arch pathologies was 21%, and the severity of atheromatous change in the aortic arch, especially in the proximal landing zone, was positively associated with the development of silent cerebral infarction.

Para-aortic malignant lymphoma invading the thoracic aorta can cause aortic rupture. Thoracic endovascular aortic repair (TEVAR) is a good option to treat aortic rupture associated with para-aortic malignancies. It is essential to detect the exact tumour location during TEVAR; however, it is often difficult to confirm the location with conventional 2-dimensional fluoroscopic or angiographic images. We describe successful TEVAR using syngo DynaCT (Siemens AG, Forchheim, Germany) in a 64-year-old man with para-aortic malignant lymphoma invading the descending aorta.

Cardiovascular surgery with cardiopulmonary bypass during pregnancy is associated with high foetal mortality. The foetal heart rate should be monitored, because foetal circulation is rate dependent, and experimental evidence supports the efficacy of pulsatile perfusion. We describe a novel foetal monitoring technique and successful foetal heart rate control by switching non-pulsatile to pulsatile perfusion in a 43-year-old woman with a sinus of Valsalva aneurysm who underwent valve-sparing partial aortic root remodelling at 18 weeks of gestation.

Objectives Type 1a endoleak is one of the most severe complications after thoracic endovascular aortic repair (TEVAR), because it carries the risk of aortic rupture. The association between bird-beak configuration and Type 1a endoleak remains unclear. The purpose of this study was to analyse the predictors of Type 1a endoleak following Zone 1 and Zone 2 TEVAR, with a particular focus on the effect of bird-beak configuration. Methods From April 2008 to July 2015, 105 patients (mean age 68.6 years) who underwent Zone 1 and 2 landing TEVAR were enrolled, with a mean follow-up period of 4.3 years. The patients were categorized into 2 groups, according to the presence (Group B, n = 32) or the absence (Group N, n = 73) of bird-beak configuration on the first postoperative multidetector computed tomography. Results The Kaplan-Meier event-free rate curve showed that Type 1a endoleak and bird-beak progression occurred less frequently in Group N than in Group B. Five-year freedom from Type 1a endoleak rates were 79.7% and 100% for Groups B and N, respectively (P = 0.007). Multivariable logistic regression analysis showed that dissecting aortic aneurysm (odds ratio 3.72, 95% confidence interval 1.30-11.0; P = 0.014) and shorter radius of inner curvature (odds ratio 1.09, 95% confidence interval 0.85-0.99; P = 0.025) were significant risk factors for bird-beak configuration. Multivariable Cox proportional hazard regression showed that Z-type stent graft (hazard ratio 2.69, 95% confidence interval 1.11-6.51; P = 0.030) was a significant risk factor for bird-beak progression. Conclusions Appropriate stent grafts need to be chosen carefully to prevent Type 1a endoleak and bird-beak configuration after landing Zone 1 and 2 TEVAR. Patients with bird-beak configuration on early postoperative multidetector computed tomography require closer follow-up to screen for Type 1a endoleak.

Objectives In recent years, supra-aortic rerouting and thoracic endovascular aortic repair (TEVAR) for treating aortic arch pathology have emerged as a less invasive option for high-risk patients. This study aimed to assess our strategy for preventing stroke and improving late outcomes after supra-aortic rerouting and TEVAR. Methods Between July 2008 and July 2015, we performed 280 cases of TEVAR for arch pathologies, using manufactured stent grafts. This study reviewed 101 patients who underwent supra-aortic rerouting and TEVAR for degenerative distal arch aneurysms (80 men, mean age 73.1 years, Zone 1/Zone 2 = 48/53). Since 2011, we have routinely used the brain protection method, which comprises blocking native forward flow from the left common carotid artery (LCA) and left subclavian artery (LSA) for zone 1 cases and the LSA for zone 2 cases before TEVAR. Results The mean operation time was 178 ± 65 min. The stroke and 30-day death rates were 3 and 1%, respectively. Before the brain protection method was introduced, the perioperative risk factor for stroke was atheroma Grade ≥III (P = 0.035). Proximal landing zone (P = 0.58) and LSA sacrifice (P = 1.00) were not risk factors for stroke. No strokes occurred after using the brain protection method (before protection: 6% and after protection: 0%). Regarding late results, the rate of freedom from aorta-related death at 1 and 4 years was 97 and 95%, respectively. The rate of freedom from aortic events at 1 and 4 years was 91 and 86%, respectively. During follow-up, no type Ia endoleak developed and one type A dissection was observed. Conclusions Our strategy for supra-aortic rerouting and TEVAR showed satisfactory early and late results. The chief risk factor for perioperative stroke was atheroma, and blocking native forward flow from the LCA and the LSA prior to the TEVAR procedure helped prevent stroke.