Open Stent Research Articles

Retrograde open mesenteric stenting and outcomes for acute mesenteric ischemia.

Data regarding retrograde open mesenteric stenting (ROMS) for urgent mesenteric ischemia is limited to small single center and case series, with variable utilization across patient populations and ill-defined outcomes. We aimed to evaluate characteristics and outcomes of patients with acute mesenteric ischemia requiring urgent surgical intervention. Retrospective cohort study of patients with mesenteric ischemia requiring urgent surgical intervention from 2018 to 2020 was queried from the National Inpatient Sample (NIS) database. Study groups were defined as those requiring an open bypass (BYPASS), an open superior mesenteric artery embolectomy (OPEN), or ROMS. Descriptive statistics were used to report variables. Comparisons were mad using t test, chi-squares tests, and multivariate regression reported as odds ratio (OR), 95% confidence interval (CI) where appropriate. 898 patients with mesenteric ischemia requiring urgent surgical intervention were included: Bypass: 284, OPEN: 363, ROMS: 251. There was no difference in gender or race between groups. Patients requiring ROMS were more likely to be older 70.2 + 11.3versus Bypass 66.81 + 11.6 and OPEN 67.17 + 14.5, p = 0.0035. ROMS patients had the highest Charlson Comorbidity Index (CCI) 2.9 versus 2.5 Bypass and 2.6 OPEN, p = 0.0292 with the most frequent comorbidities: Diabetes 37% (p = 0.01), renal disease 24.3% (p = 0.5), and previous preoperative myocardial infarction 9.2%, p = 0.05; however, the lowest mortality rate was seen within this Group 15.9% versus bypass 19.7%, OPEN 34.5%, p < 0.0001. Patients requiring bypass were more likely to have chronic pulmonary disease 34.5% versus OPEN 24.2% and ROMS 31.5%, p = 0.013, peripheral vascular disease (PVD) 38% versus OPEN 16%, and ROMS 29.9%, p < 0.0001. On multivariate regression, ROMS was associated with 50% decreased incidence of mortality (OR 0.45, 95% CI 0.27-0.75). Open SMA embolectomy was associated with nearly 2x mortality rate compared to bypass procedures OR 2.0, 95% CI 1.3-3.0, p < 0.001. Previous MI was also associated with nearly 2x incidence of mortality (OR 1.9, 95% CI 1.01-3.6), while pre-existing PVD conferred a protective effect (OR 0.56, 95% CI 0.36-0.89). Higher CCI and age were associated with slightly increased risk for mortality OR 1.2 and 1.03, p < 0.05 for both. In patients with acute mesenteric ischemia, ROMS demonstrated a significant mortality benefit compared to traditional open procedures. Advanced age, history of MI, and open SMA embolectomy were associated with increased mortality. Little data exists regarding ROMS in a real-world population evaluating ROMS, which is a newer technique. These data suggest that ROMS may be a superior alternative to restore mesenteric flow in the acute setting and further prospective studies evaluating ROMS to other procedural types in urgent and elective settings are needed.

Posttraumatic aortic regurgitation and root pseudoaneurysm following blunt chest trauma: a case report

BackgroundThe simultaneous diagnosis of severe aortic regurgitation and aortic root pseudoaneurysm resulting from traffic injury is extremely rare. This report presents the case of a patient with Marfan syndrome who experienced aortic root pseudoaneurysm and subacute severe aortic regurgitation following a traffic accident.Case presentationA 64-year-old woman was diagnosed with Marfan syndrome 16 years ago and is undergoing ongoing follow-up at an outpatient clinic. Eight years previously, the patient underwent total arch replacement combined with J-graft open stent graft® (JGOS; Japan Lifeline Co., Tokyo, Japan) deployment for acute type A dissection. Five months before presentation, the patient suffered a left rib fracture in a traffic accident and received conservative management at a local hospital. The patient presented to the emergency room with worsening shortness of breath and orthopnea. Echocardiography revealed severe aortic regurgitation and moderate tricuspid regurgitation. Computed tomography revealed new-onset pseudoaneurysm at the aortic root. Surgical repair was successfully performed using a modified Bentall procedure with a bioprosthetic valve and tricuspid annuloplasty. Intraoperative findings revealed pseudoaneurysm with perforation of the right sinus of Valsalva. Although the left and right aortic valve leaflets were normal, the noncoronary leaflet exhibited a ruptured fibrous strand of a cusp fenestration, resulting in acute aortic regurgitation.ConclusionsThis case report highlights the rare occurrence of aortic root pseudoaneurysm and subacute aortic regurgitation following a traffic accident. In cases of blunt chest trauma, particularly in patients with Marfan syndrome, frequent examination is crucial to assess the possibility of posttraumatic aortic regurgitation and aortic injury.

Utilizing a sutureless valve for prosthetic valve endocarditis after aortic root replacement

BackgroundReoperation following aortic root replacement is associated with significantly high operative mortality. Etiologies related to infection are known to increase the operative mortality rate more than other etiologies. In such a clinical setting, a sutureless valve could lower the operative mortality by shortening the cardiac arrest and the operative time.Case presentationA 61-year-old male underwent emergent aortic root and total arch replacement with an open stent graft for acute type-A aortic dissection. A bioprosthetic valve was employed for aortic root replacement using the double-sewing ring technique. A fungal infection by Candida parapsilosis was postoperatively detected and improved with intravenous antifungal drug administration. However, he developed congestive heart failure one year later, and the blood cultures turned positive repeatedly for Candida parapsilosis. The prosthetic valve infection was suspected upon identifying vegetation on the bioprosthetic valve through transthoracic echocardiography. The computed tomography scan and operative findings confirmed that the infection was localized on the prosthetic valve. Consequently, the infected valve was removed without a vascular conduit, and a sutureless valve was implanted. The postoperative course was uneventful, without any evidence of recurrent fungal infection, and the patient was discharged on postoperative day 28.ConclusionsDeploying a sutureless valve can facilitate a more straightforward and minimally invasive redo procedure. Preoperative computed tomography can predict the valve size, which is the key to implanting a sutureless valve successfully after the modified Bentall procedure.

A decade's experience with retrograde open mesenteric stenting for acute mesenteric ischemia

ObjectiveRetrograde open mesenteric stenting (ROMS) is an alternative to mesenteric bypass in patients with acute mesenteric ischemia (AMI) with variable reported 30-day mortality rates. Large studies evaluating patient outcomes following ROMS are scarce. Our study aims to assess the results of this approach among patients presenting with AMI. MethodsWe reviewed all the patients with AMI who were treated with ROMS (2011-2022). Patient demographics, presentation, operative details, and outcomes were analyzed. Primary end points were in-hospital, 30-day, and 1-year mortality. Kaplan-Meier estimate for 1-year mortality and primary patency loss were generated. Secondary end points included postoperative 30-day complications. ResultsBetween 2011 and 2022, ROMS was attempted on a total of 42 patients. The median age was 70 ± 15 years and the majority of patients were female. Pain out of proportion to the physical examination was the most common presenting symptom (n = 18, 42.9%) followed by peritonitis (n = 14, 33.4%). All patients underwent preoperative intravenous contrast computed tomography imaging. In situ thrombosis was identified as the etiology of AMI in 36 patients (85.7%). Technical success was achieved in 40 patients (95.2%). Conventional, non-hybrid operating rooms were used for the majority of cases. Revascularization of all 40 patients involved angioplasty and stenting of superior mesenteric artery. A single stent was placed in 35 patients (87.5%) and the reminder had more than one stent. Eighty percent of patients required bowel resection. A second-look laparotomy was required in 34 patients (85.0%). The mean operative time, including both the general surgery and vascular surgery portions of the index procedure, was 192 ± 57 minutes. Sepsis was the most common complication observed within 30 days, occurring in 8 patients (20.0%). In terms of mortality, 13 patients (32.5%) died during their index hospitalization, and 9 died (22.5%) within 30 days. On Kaplan-Meier analysis, the 1-year overall patient survival rate was 58.6%, and the primary patency rate for stents was 51.4%. ConclusionsROMS has an excellent technical success rate in management of AMI with lower than traditionally reported mortality rates for AMI. The dual benefits of rapid revascularization and bowel evaluation should make this surgical modality an alternative approach for treatment of AMI.

Hybrid noncovered open stents in repair of DeBakey type 1 acute aortic dissections.

The indications for use, evidence base and experience with the novel noncovered open hybrid surgical stents for acute type A aortic dissection repair for concurrent stabilization of the 'downstream' aorta remains limited. We review the evidence base and the development of these stents. Data were collected from Pubmed/Medline literature search to develop and review the evidence base for safety and efficacy of non-covered surgical stents. Existing guidelines for use and developments were reviewed. A single randomized control trial and 4 single-centre studies were included in the review with a total worldwide experience of 241 patients. The deployment was easy and did not add significantly to the primary operation. The mortality and new stroke ranged from 6.3-18.7%. Safe and complete deployment was accomplished in 92-100%. There was no device-related reintervention. There was a significant improvement in malperfusion in over 90% of the cases with varying degrees of remodelling (60-90%) of the downstream aorta. Open noncovered stent grafts represent a major technical advancement as an adjunct procedure for acute dissection repairs, e.g. hemiarch repair. It has potential for wider use by non-aortic surgeons due to simplicity of technique. Limited safety and efficacy data confirm the device to be safe, feasible and reproducible with potential for wider adoption. However, long-term trial and registry data are required before recommendations for standard use outside of high-volume experienced aortic centres.

Open Retrograde Stenting of Proximal Innominate and Common Carotid Artery Stenosis.

The evidence regarding the treatment of open retrograde stenting of innominate artery (IA) or common carotid artery stenosis (CCA) is limited, and is suspected to carry a high risk of stroke and death. Therefore, the objective of this study was to evaluate the outcomes of such hybrid procedures. A retrospective, monocentric study of all patients who underwent retrograde stenting of proximal IA and CCA stenosis via surgical cutdown of the CCA, with or without concomitant CEA, between 2016 and 2023 was performed. Overall, 33 patients were treated. A total of 15 patients (45.5%) were male, with the mean age being 67 ± 9.1 years, and 58% (n = 19) of the patients presented with neurological symptoms. Open retrograde stenting was performed in 67% (n = 22) in ACC, and in 33% (n = 11) in IA stenosis. A total of 20 patients (61%) underwent retrograde stenting with synchronous ipsilateral CEA for concomitant stenosis of the carotid bifurcation. There was no 30-day mortality. The perioperative stroke rate was 3% (n = 1) with complete symptom recovery. During the follow up at 32 months (95% CI: 24-39), three late deaths (9.1%) and one symptomatic stent occlusion were observed and, in five patients (15.2%), re-intervention for restenosis was necessary. Open retrograde stenting for of proximal IA or CCA stenosis with or without CEA, in case of tandem carotid lesions, can be performed safely with a low rate of early adverse events. Continuous follow up examinations are necessary due to relevant instent re-stenosis rates.

Abstract TMP68: Proximal Balloon Occlusion With Forced Aspiration (POWER) Technique Should Be Effective in Preventing Distal Microembolization During Carotid Artery Stenting With the Filter Protection Device

Purpose: Since the balloon protection device became unavailable in Japan three years ago, the DWI-positive rate after carotid artery stenting (CAS) has increased. We have developed a Proximal balloon Occlusion With forcEd aspiRation (POWER) technique to prevent distal embolization in CAS with the filter protection device. The concept of this technique was to standardize the three points: (1) aspiration force, (2) timing of aspiration and (3) use of balloon guiding. To standardize (1), a VACLOK (vacuum pressure) syringe-like system was used instead of manual aspiration, so that the same aspiration force was applied. To standardize (2), aspiration was to be initiated just before PTA balloon deflation during pre- and post-dilatation. Methods: From June 2020 to the present, CAS cases using the Filter protection device were enrolled and divided into two groups before and after the introduction of the POWER technique. Patient backgrounds, carotid artery characteristics (symptomatic, stenosis rate and length, MRI and echographic findings), PTA balloon size, stent type, the postoperative DWI positive rate and the number of DWI spots, and the symptomatic stroke rate were compared between the two groups, respectively. Results: Of the 55 CAS cases, 36 were enrolled in the without-POWER group and 19 in the with-POWER group. Between the two groups, postoperative DWI positivity was 32 (88.9%) vs. 9 (47.4%) (p&lt;0.001), DWI spot lesions (n, median (quartiles)) was 9 (3-20) vs. 0 (0-2) (p&lt;0.001), and symptomatic stroke was 6 (16.7%) vs. 0 (0%) (p=0.06), all with-POWER group were less common. Symptomatic stenosis (63.9% vs. 94.7%, p&lt;0.05) was more common in the with-POWER group. There were no differences in age, gender, stenosis rate and length, open cell stent, PTA balloon size, MRA TOF high, MRI T1BB high, hypoechoic plaque, HT, DL, DM, CKD, smoking or DAPT use. Conclusion: POWER technique was associated with lower postoperative DWI positivity and lesion counts in CAS with filter protection device.

Quality of Life after Venous Stenting for Post-thrombotic Syndrome and the Effect of Inflow Disease.

Patients with PTS experience an impaired quality of life (QoL). We aimed to study QoL in patients stented for post thrombotic syndrome (PTS) and analyze the influence of different parameters. Patients stented for PTS after iliofemoral deep vein thrombosis were asked to complete the Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20) and the Short Form Health Survey (SF-36) in this cross-sectional study. All other data were collected retrospectively. Primary endpoints were median CIVIQ-20 and physical (PCS) and mental (MCS) component summary SF-36 scores. The influence of age, sex, and years between the procedure and completion of questionnaire were investigated using a multivariate linear regression model. Wilcoxon signed rank test compared the PCS and MCS with the normative. Effects of inflow from the deep femoral vein (DFV) and/or the femoral vein (FV) on QoL was analyzed in patients with patent stents. The response rate was 70.3% (n = 45/64). Time period (median) from stenting to questionnaire completion was 6.6 years (IQR: 8.0). Most stents were placed unilateral left-sided (73.3%). For patients with patent stents (n = 42) median CIVIQ-20 was 35.5 (IQR: 17.3), higher than the minimum of 20.0 (P < .001). Median PCS of 44.7 (IQR: 14.2) was lower (P < .001), and MCS of 55.9 (IQR: 7.1) higher (P = .001) than the normative (50.0). Time since stenting and sex were not associated with QoL. Age was a significant predictor [standardized coefficient ß = .36, P = .04] for QoL using the CIVIQ-20, but not for the SF-36. Inflow disease did not impact QoL, but patients with occluded stents (n = 3) had poor functioning levels. Quality of life is impaired after venous stenting for PTS, particularly physical functioning, among patients with an open stent, but was similar between patients with good and impaired inflow. Patients with a permanent stent occlusion had the lowest QoL.

Open surgical treatment for aortic arch and coronary artery aneurysms associated with immunoglobulin G4-related disease: a case report

BackgroundImmunoglobulin G4-related disease (IgG4RD) is a systemic autoimmune disease characterized by a dense lymphoplasmacytic infiltrate containing IgG4-positive plasma cells that can cause aneurysms in various organs and tissues. There have been many reports of IgG4RD aneurysms; however, the surgical procedures adopted remain controversial. Herein, we report a case in which surgical treatment for IgG4-related aneurysms was successful.Case presentationAn 83-year-old woman with IgG4-related disease developed multiple aneurysms, including thoracic aortic aneurysm (TAA), right coronary artery aneurysm (CAA), abdominal aortic aneurysm, and common iliac artery aneurysm. Enhanced computed tomography (CT) revealed progressive enlargement of the TAA, while positron emission tomography-CT revealed intense 18F-fluorodeoxyglucose uptake around the TAA and CAA, suggesting the presence of adhesive tissue caused by adventitial inflammation around the aneurysms. Open aortic arch replacement with frozen elephant trunk procedure and coronary artery bypass grafting with ligation of the coronary artery were performed to treat the TAA and CAA. No surgical complications occurred. The postoperative CT scan showed no endoleak around the open stent graft and the coronary artery was patent. The patient is being followed up on an outpatient basis after discontinuing steroid therapy.ConclusionsWe report the successful surgical treatment of IgG4-related multiple aneurysms. Our findings reveal that the main site of inflammation in aneurysms of IgG4RD is the adventitia and the frozen elephant trunk procedure is useful for avoiding complications.

Modified a Frozenix J graft as reversed elephant trunk to simplify re-do aortic arch repair

Re-sternotomy aortic arch repair is a complicated procedure. The newly developed commercial open stent graft (OSG) can facilitate the supra-aortic vessels being rebuilt during arch aneurysm repair, but difficulties remain. To simplify the reconstruction of the distorted arch branched vessels and create an easier way for anastomosis to occur, we demonstrate the procedure by using the reversed non-stented, fabric portion of the Frozenix J graft prosthesis to simplify re-do aortic arch repair.

Fracture and embolization of a metal stent after a frozen elephant trunk procedure.

The Frozenix J graft open stent graft has been available since 2014 in Japan. This stent is widely used for the frozen elephant trunk technique in many institutions, mainly for cases of acute type A aortic dissection and also for cases of a true aneurysm and chronic aortic dissection. We treated a rare case in which the metal wires of the Frozenix J graft were broken and embolized to the periphery half a year after being implanted.

Endovascular Management of the Ascending Aorta: State of the Art.

Endovascular stent graft repair (EVAR) has revolutionized the management of aneurysms and dissections of the thoracic and abdominal aorta and is considered the first-line treatment in such pathologies. Initially designed for patients unfit for open repair, EVAR and thoracic endovascular aortic stent graft repair are associated with improved morbidity and mortality and a faster recovery process. The endovascular revolution of the aorta continues moving proximally, with fenestrated and branch stent grafts currently in clinical trials for the management of thoracoabdominal aortic aneurysms, and several branched thoracic devices are either approved or in trial for management of aortic arch pathologies. The final frontier in the endovascular management of the aorta is the aortic root and ascending aorta. The first early feasibility trial for management of type A aortic dissection has recently concluded with a multicenter phase 2 study slated for the spring of 2023. The following article updates the reader on the unique challenges of endovascular management of the ascending aorta and a look at the future technologies that will define this space.

Carotid stenting: Does stent design matter?

Carotid artery stenting (CAS) is considered an important tool in carotid revascularization. Carotid artery stenting is usually performed by using self-expandable stent with different designs. The stent design influences many physical characteristics. Also, it may affect the complication rate with special relevance to perioperative stroke, hemodynamic instability, and late restenosis. This study comprised all consecutive patients who underwent carotid artery stenting for atherosclerotic carotid stenosis from March 2014 to May 2021. Both symptomatic patient and asymptomatic patients were included. Patients with a symptomatic carotid stenosis of ≥50% or asymptomatic carotid stenosis of ≥60% were selected for carotid artery stenting . Patients with fibromuscular dysplasia and acute or unstable plaque were not included. Variables of clinical relevance were tested in multivariable analysis using binary logistic regression model. A total of 728 patients were enrolled. The majority of this cohort was asymptomatic (578/728, 79.4%), while 150/728 (20.6%) were symptomatic. The mean degree of carotid stenosis was 77.82 ± 4.73%, with a mean plaque length of 1.76 ± 0.55cm. A total of 277 (38%) patients were treated with Xact® Carotid Stent System. Successful carotid artery stenting was achieved in 698 (96%) of patients. Of these patients, stroke rate in symptomatic patients was nine (5.8%), while in asymptomatic patients was 20 (3.4%). In a multivariable analysis, the open-cell carotid stent was not associated with a differential risk for combined acute and sub-acute neurologic complications as compared with closed-cell stents. Patients treated with open cell stents had a significantly lower rate of procedural hypotension (P 0.0188) at bivariate analysis. Carotid artery stenting is considered a safe alternative to CEA that can be used in selected average surgical risk patient. Different stent designs can affect the rate of major adverse events in carotid artery stenting patients, but further studies are necessary with avoiding different bias to study the effect of different stent designs.

Abstract Number ‐ 71: Management of Delayed Carotid Stent Fracture with an Overlapping Open Cell Design Stent: Case Report

Introduction Stent fracture after carotid angioplasty and stenting is rare. Risk factors include presence of angulation, calcification, and restenosis increasing the risk of stent fracture. Although literature indicates that not all carotid stent fractures are associated with adverse outcomes, there is limited details on successful endovascular management of this entity. We describe a unique case of carotid stent fracture with symptomatic restenosis treated with an overlapping open cell stent with no residual stenosis and resolution of symptomology. Methods Case Report. Results A 79‐year‐old man with medical history of right sided symptomatic carotid artery stenosis which had been previously treated with endarterectomy and subsequently carotid stenting after a follow up carotid ultrasound demonstrated recurrence of severe right internal carotid artery (RICA) stenosis. Approximately 2 years after this index procedure, the patient returned with acute onset of left‐hand numbness. Cerebral angiography was performed that demonstrated 85% stenosis with a fractured carotid stent at segment of stenosis (Figure 1A, B). Furthermore, the lesion was found to be heavily calcified. This was determined to be the primary contributing factor in resultant artery wall stress, which over time led to carotid stent fracture. Angioplasty with placement of a new open cell stent and distal embolic protective device was performed successfully. The open cell stent was chosen for this approach as closed cell stents have been associated with an increased odds of in‐hospital stroke/death for carotid lesions, attributable to the lower degree of conformability with closed cell stents. After our stent placement, there was no significant residual stenosis visualized (Figure 1C, D). The patient’s symptoms resolved without any subsequent complaints on follow‐up visit. Conclusions While carotid stent fractures are a rare occurrence, we report a case of symptomatic carotid artery restenosis with a fractured stent due to significant lesion calcification and wall stress. This case was successfully treated with angioplasty and new open cell stent placement due to its potential advantages over closed cell stents in carotid artery lesions. Current literature indicates that carotid stent fractures have a low prevalence. However, there is a paucity of studies on the mechanism of stent fracture as well as optimal management of these fractured stents, suggesting a need for further study and characterization.

Influence of different postballoon expansion procedures: A finite element analysis.

Postballoon expansion is considered as an appropriate procedure for adequate stent expansion for coronary bifurcation lesions. Two postballoon expansion procedures are currently recommended: proximal optimization technique (POT)/side/POT and POT/kiss/POT. However, the effects of the two postballoon expansion treatments are different. There is a lack of biomechanical study to quantify the difference. It is recognized that biomechanical factors influence the occurrence of Major Cardiovascular Adverse Events (MACE), which includes recurrent angina pectoris, acute myocardial infarction and coronary heart disease death. The current paper evaluated the two postexpansion strategies and quantified biomechanical parameters to provide a basis for clinical decisions. Based on the CT angiography (CTA) data of a patient diagnosed with coronary bifurcation lesions, a personalized coronary bifurcation lesion model was constructed, and the surgical procedure after two expansions was simulated. The POT/side/POT and POT/kiss/POT expansion procedures were analyzed from the perspective of biomechanics through finite element analysis. The biomechanics factors, including the percentage of stent malapposition and stent occlusion at the side branch (SB) opening, the stent ellipse index of proximal main vessel (PMV) segment, the minimum lumen area of the stent vessel segment and the stress distribution of the vessel wall, were used to quantify clinician concerns about factors affecting patient outcomes. The factors include stent adhesion, SB open stent occlusion, poor stent deformation, patency effect of vessel stenosis, and vessel wall damage. Both postexpansion procedures were successfully simulated. The malapposition rate during POT/side/POT was larger (1.2%vs. 0.42%) and stent occlusion at the SB opening from the cross-section perpendicular to the SB opening after the POT/side/POT procedure was 0.20%, compared with 0.00% after POT/kiss/POT. POT/kiss/POT produced a larger PMV segment stent ellipse index. Minimum lumen area after POT/side/POT was 5.6 mm2 and after POT/kiss/POT 5.9 mm2 . POT/kiss/POT produces an effect of greater vascular stress than POT/side/POT. Numerical simulations provide a quantitative analysis to inform clinicians of the differences between preoperative planning and surgical procedures. Biomechanical analysis of the differences between the two postexpansion strategies found that the POT/kiss/POT procedure resulted in better stent fit, less occlusion of the SB open stent and better vascular patency but also resulted in poor stent deformation and caused greater vessel wall stress. The current study informs rationales for clinical understanding of postexpansion strategies.

Comparative effectiveness and safety of open triple-branched stent graft technique with stented elephant trunk implantation in treating Stanford type A aortic dissection: A trial sequential meta-analysis.

The optimal surgical intervention for Stanford type A aortic dissection is controversial. The aim of this trial sequential meta-analysis was to investigate the comparative effectiveness and safety of open triple-branched stent graft and stent elephant trunk implantation for total aortic arch reconstruction in Sandford type A aortic dissection. PubMed, Embase, Cochrane library, Chinese Biomedical Literature database (CBM), and China National Knowledge Infrastructure (CNKI) were searched for retrieving relevant studies from inception to February 28, 2022. We evaluated 30-day mortality, procedure-related time including cardiopulmonary bypass (CPB), aortic cross-clamp (ACC), and selective cerebral perfusion (SCP),the incidence of postoperative complications including paralysis, cerebral embolism, and acute renal failure, intensive care unit (ICU) time, and medical expenditure. Statistical analysis was performed by RevMan 5.4 and trial sequential analysis (TSA) software. Six studies involving 260 dissection cases were included eventually. Total aortic arch reconstruction with open triple-branched stent graft was comparable to the stented elephant trunk implantation in 30-day mortality, incidence of postoperative complications, ICU time, and medical expenditure, but open triple-branched stent graft was related to shorter procedure-related time including CPB (mean difference [MD] = -46.11, 95% confidence interval [CI] = -67.24 to -24.98, p < .001), ACC (MD = -42.82, 95%CI = -66.74 to -18.90, p < .001), and SCP (MD = -17.88, 95%CI = -33.36 to -2.39, p = .02). TSA confirmed robustness of findings. Our analysis suggested that total aortic arch reconstruction with open triple-branched stent graft may be an effective and simplified procedure than the stented elephant trunk implantation.

Treatment of Stanford Type A dissection with E-vita Open stent graft, a life-saving surgery

Treatment of Stanford Type A dissection with E-vita Open stent graft, a life-saving surgery

Midterm Clinical Outcomes of Retrograde Open Mesenteric Stenting for Mesenteric Ischemia

Retrograde open mesenteric stenting (ROMS) has become a mainstay in treatment of mesenteric ischemia; however, follow-up in contemporary studies is limited. A single-center retrospective review of patients undergoing ROMS from 2007 to 2020 was conducted. Demographics, presentation, and procedural details were reviewed. End points were morbidity and mortality, technical success, primary patency, reinterventions, and freedom from clinical recurrence. ROMS was performed in 34 patients, 19 female (56%). Mean age was 71±10years. Eighteen patients (53%) presented with acute mesenteric ischemia (AMI), 11 (32%) with acute-on-chronic, and 5 (15%) with chronic mesenteric ischemia. Etiology was chronic atherosclerosis with/without in-situ thrombosis in 28 patients (82%), superior mesenteric artery dissection in 3, and 1 each with embolic, vasculitic, and nonocclusive ischemia. Four patients (12%) had prior mesenteric procedures (3 Celiac/1 superior mesenteric artery stent) and 1 had unsuccessful transbrachial stenting attempt. Technical success, defined as successful stenting through a retrograde approach was attained in 31 patients (91%), with the 3 remaining patients treated with transbrachial stenting in 2 and iliomesenteric bypass in 1. Covered stents were used in 21 patients (64%) with or without stent extension with bare-metal stents. Eight patients (23%) required thromboembolectomy and 9 (26%) underwent patch angioplasty. Thirty-day mortality rate was 35%, all in patients with AMI (10) or acute-on-chronic (2). Eighteen patients (53%) underwent bowel resection, all presenting acutely. Early reinterventions within the first 30days were required in 5 patients (15%), including 2 redo ROMS with thrombectomy and endarterectomy, 2 percutaneous stent extensions, and 1 aortic septum fenestration with coiling of a jejunal branch pseudoaneurysm. With a median follow-up of 3.7 (interquartile range: 0.8-5.0) years, in patients surviving discharge, 5 required reintervention yielding freedom from reintervention rates of 87% at 1year and 71% at 3years. All postdischarge reinterventions were endovascular with no conversion to bypass. The overall 1-year and 3-year primary patency rates were 70% and 61% (primary-assisted patency at 1 and 3years was 87% and secondary patency at 1 and 3years was 97%). The freedom from symptom recurrence was 95% at 1 and 3years. ROMS carries high rates of technical success in patients with mesenteric ischemia, despite a high chronic atherosclerotic burden. Although mid-term patency rates are acceptable, AMI is still associated with high early morbidity and mortality, with high rates of associated bowel resection. ROMS is a valuable tool in the armamentarium of vascular surgeons.

Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A

ObjectiveTotal arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury.MethodsWe evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA.ResultsThe surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow.ConclusionsFeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

The systemic immune response due to cholesterol crystal embolization syndrome: a case report

BackgroundCholesterol crystal embolization syndrome (CES) occurs when an atherosclerotic plaque causes small-vessel embolization, resulting in multi-organ damage. Although CES is pathologically characterized by an infiltration of eosinophils, the implication of the systemic inflammatory response represented by hypereosinophilia is unclear in clinical practice. Herein we present the case of a patient diagnosed with CES who developed multiple allergic organ injuries, including daptomycin-related dermatitis and later vancomycin-induced acute tubulointerstitial nephritis, which was successfully treated by the withdrawal of each medicine with or without corticosteroid therapy, one by one.Case presentationA 76-year-old Japanese man diagnosed with thoracic aneurysm rupture underwent total arch replacement through the open stent graft technique. Postoperatively, he developed methicillin-resistant Staphylococcus epidermidis bacteremia, which was treated with daptomycin. Subsequently, he presented with palpable purpura on both dorsal feet, erythema around his body, and hypereosinophilia. Daptomycin was replaced with vancomycin due to suspicion of drug-induced erythema. The erythema gradually faded. On nine days after vancomycin therapy, the systemic erythema rapidly reappeared followed by acute renal failure. The renal function decline prompted hemodialysis. A skin biopsy revealed cholesterol embolization, whereas a kidney biopsy revealed acute tubulointerstitial nephritis. After vancomycin discontinuation and initiation of systemic corticosteroid treatment, his kidney function was restored to the baseline level.ConclusionsThe present case highlights cholesterol embolization can cause allergic complications in addition to direct organ damage.