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Purpose: To examine the surgical findings of ruptured abdominal aortic aneurysm (RAAA) based on the open-first strategy in the last decade, and to analyze the predictors of in-hospital mortality for RAAA in the endovascular era., Methods: The subjects of this retrospective study were 116 patients who underwent RAAA repair, for whom sufficient data were available [25% female, median age 76 (70-85) years]. Sixteen (13.8%) patients were managed with endovascular aneurysm repair (EVAR) and 100 patients (86.2%) were managed with open surgical repair (OSR)., Results: Univariate analysis identified base excess (BE) (odds ratio [OR] 0.88; 95% confidence interval [CI] 0.79-0.96; p = 0.006), and preoperative cardiopulmonary arrest (CPA) [OR] 15.4; 95% [CI] 1.30-181; p = 0.030), BE (OR 0.88; 95% CI 0.79-0.96; p = 0.006), shock index (OR 2.44; 95% CI 1.01-5.94; p = 0.050), lactic acid (Lac) (OR 1.18; 95% CI 1.02-1.36; p = 0.026), and blood sugar (BS) > 215 (OR 3.46; 95% CI 1.10-10.9; p = 0.034) as positive predictors of hospital mortality., Conclusions: The findings of this study suggest that a first-line strategy of OSR for ruptured AAAs is acceptable. Poor preoperative conditions, including a high shock index, CPA, low BE, high Lac, and a BS level > 215 mg/dl, were identified as predictors of hospital mortality, rather than the procedures themselves., (© 2023. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Objectives: The optimal treatment for acute type A aortic dissection (AAAD) with thrombosed false lumen (T-FL) of the ascending aorta remains controversial. The goal of this study was to evaluate clinical outcomes of initial medical treatment (IMT) and the effectiveness of thoracic endovascular aortic repair (TEVAR) for AAAD with T-FL., Methods: We retrospectively analysed 60 patients with AAAD with T-FL. Emergency aortic repair was performed in 33 patients, and IMT was selected in 27 uncomplicated patients with ascending aortic diameter < 50 mm and ascending T-FL thickness ≤ 10 mm., Results: Among the 27 patients who received IMT, 14 had intramural haematomas at admission; however, new ulcer-like projections appeared in 7 (50%) during hospitalization. Before discharge, 12 (44%) were given medical treatment only, and 15 (56%) required delayed aortic repair including TEVAR in 8 and open repair in 7. The median interval from onset to delayed repair was 9 days, and significantly more patients received TEVAR compared to those receiving emergency repair (53% vs 21%; P = 0.043). Between the TEVAR (n = 15) and the open repair (n = 33) groups, 1 (7%) 30-day death occurred in the TEVAR group, whereas no in-hospital deaths occurred in the open repair group. During the median follow-up time of 24.8 months, no aorta-related death was observed, and there were no statistically significant differences in the rate of freedom from aortic events (TEVAR: 92.8%/3 years vs open repair: 88.4%/3 years; P = 0.871)., Conclusions: Our management, using a combination of emergency aortic repair, IMT and delayed aortic repair for AAAD with T-FL, achieved favourable clinical outcomes. Among the selected Japanese patients, IMT with repeated multidetector computed tomography could detect a new intimal tear that could be closed by TEVAR in some cases. Using EVAR for this pathology resulted in acceptable early and midterm outcomes. Further investigations are required to validate the safety and efficacy of this management procedure., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The optimal indications and contraindications for thoracic endovascular aortic repair of retrograde Stanford type A acute aortic dissection (R-AAAD) are not well known. The goal of this study was to determine the outcomes of thoracic endovascular aortic repair for R-AAAD at our institution and to discuss optimal indications., Methods: The medical records of 359 patients admitted to our institution for R-AAAD between December 2016 and December 2022 were reviewed, and 83 patients were finally diagnosed with R-AAAD. We selected thoracic endovascular aortic repair as an alternative, considering the anatomy of aortic dissection and the risk to patients undergoing open surgery., Results: Nineteen patients underwent thoracic endovascular aortic repair for R-AAAD. No in-hospital deaths or neurologic complications occurred. A type Ia endoleak was detected in 1 patient. All other primary entries were successfully closed. All dissection-related complications, such as cardiac tamponade, malperfusion distal to the primary entry and abdominal aortic rupture, were resolved. One patient required open conversion for intimal injury at the proximal edge of the stent graft; all other ascending false lumens were completely thrombosed and contracted at discharge. During the follow-up period, no aortic-related deaths or aortic events proximal to the stent graft occurred., Conclusions: The indications for thoracic endovascular aortic repair were expanded to low-risk and emergency cases at our institution. The early- and midterm outcomes of thoracic endovascular aortic repair for R-AAAD were acceptable. Further long-term follow-up is required., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: Debranching thoracic endovascular aortic repair (d-TEVAR) for zone 0 landing (Z0-TEVAR) remained challenging in aortic arch aneurysms. This study aimed to compare the mid-term outcomes between Z0-TEVAR and Z1/2-TEVAR to assess the appropriateness of Z0-TEVAR as the first-line therapy for aortic arch aneurysms in high-risk patients., Methods: Medical records of 200 patients who underwent d-TEVAR from 2007 to 2019 were retrospectively reviewed. Of these, 40 patients who underwent Z0-TEVAR (70% males; the median age of 82 years) and 160 Z1/2-TEVAR (78% males; the median age of 77 years) were compared. In each group, 39 patients were matched using propensity scores (PS) to adjust for differences in patient backgrounds., Results: Freedom from all-cause mortality (p < 0.001), aorta-related mortality (p < 0.001), and stroke (p = 0.001) were significantly lower in Z0-TEVAR than in Z1/2-TEVAR. Freedom from reintervention was similar between the two groups (p = 0.326). Type A dissection post-TEVAR was observed in 3 (7.5%) of Z0-TEVAR, but none in Z1/2-TEVAR (p = 0.006). Pneumonia was also more frequent in Z0-TEVAR (n = 8, 30%) than Z1/2-TEVAR (n = 4, 2.5%) (p < 0.001). PS matching also yielded worse outcomes (all-cause mortality, p = 0.017; aorta-related mortality, p = 0.046; and stroke, p = 0.027) in Z0-TEVAR than Z1/2-TEVAR., Conclusions: Higher mid-term mortality and stroke rates after Z0-TEVAR were confirmed by PS matching. Z0-TEVAR would be an alternative for high-risk patients with arch aneurysms requiring zone 0 landing but not a reliable method., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Objectives: We investigated whether prophylactic preoperative cerebrospinal fluid drainage (CSFD) was effective in preventing spinal cord ischemia (SCI) during thoracic endovascular aortic repair of degenerative descending thoracic aortic aneurysms, excluding dissecting aneurysms., Methods: We retrospectively reviewed the medical records of patients who underwent thoracic endovascular aortic repair involving proximal landing zones 3 and 4 between 2009 and 2020., Results: Eighty-nine patients with preemptive CSFD [68 men; median (range) age, 76.0 (71.0-81.0) years] and 115 patients without CSFD [89 men; median (range) age, 77.0 (74.0-81.5) years] were included in this study. Among them, 59 from each group were matched based on propensity scores to regulate for differences in backgrounds. The incidence rate of SCI was similar: 8/89 (9.0%) in the CSFD group and 6/115 (5.2%) in the non-CSFD group (P = 0.403). Shaggy aorta (odds ratio, 5.13; P = 0.004) and iliac artery access (odds ratio, 5.04; P = 0.005) were identified as positive predictors of SCI. Other clinically important confounders included Adamkiewicz artery coverage (odds ratio, 2.53; P = 0.108) and extensive stent graft coverage (&gt;8 vertebrae) (odds ratio, 1.41; P = 0.541) were not statistically significant. Propensity score matching yielded similar incidence of SCI: 4/59 (6.8%) in the CSFD group and 3/59 (5.1%) in the non-CSFD group (P = 0.697)., Conclusions: Aggressive use of prophylactic CSFD was not supportive in patients without complex risks of SCI., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: We reviewed the results of endovascular aneurysm repair in patients from the Japanese Committee for Stentgraft Management registry to determine the significance of persistent type II endoleak (p-T2EL) and the risk of late adverse events, including aneurysm sac enlargement., Methods: The prospectively captured medical records of 17 099 patients <75 years of age who underwent endovascular aneurysm repair for abdominal aortic aneurysm from 2006 to 2015 were reviewed. Patients were divided into 2 groups (with or without p-T2EL) and compared to examine the correlation between p-T2EL and the occurrence of aneurysm sac enlargement after endovascular aneurysm repair., Results: Of the patients, 4957 (29.0%) had p-T2EL and 12 142 (71.0%) had no p-T2EL (non-T2EL). Mean age was significantly higher ( P <0.001), and there were fewer men ( P <0.001) in the p-T2EL group. Among comorbidities, hypertension ( P =0.019) and chronic kidney disease ( P =0.040) were more prevalent and respiratory disorders were less prevalent ( P <0.001) in the p-T2EL group. From each group, 4957 patients were matched according to propensity score to adjust for differences in patient characteristics. The cumulative incidence rates of abdominal aortic aneurysm-related mortality (p-T2EL: 52 of 4957 [1.0%] versus non-T2EL: 21 of 12 142 [0.2%]), rupture (p-T2EL: 38 of 4957 [0.8%] versus non-T2EL: 13 of 12 142 [0.1%]), sac enlargement (≥5 mm; p-T2EL: 1359 of 4957 [27.4%] versus non-T2EL: 332 of 12 142 [2.7%]), and reintervention (p-T2EL: 739 of 4957 [14.9%] versus non-T2EL: 91 of 12 142 [0.7%]) were significantly higher in the p-T2EL than the nonpT2EL group ( P <0.001). Propensity score matching yielded higher estimated incremental risk, including abdominal aortic aneurysm-related mortality, rupture, sac enlargement (≥5 mm), and reintervention for p-T2EL ( P <0.001). Cox regression analysis revealed older age ( P =0.010), proximal neck diameter ( P =0.003), and chronic kidney disease ( P <0.001) as independent positive predictors and male sex as an independent negative predictor ( P =0.015) of sac enlargement., Conclusions: The Japanese Committee for Stentgraft Management registry data show a correlation between p-T2EL and late adverse events, including aneurysm sac enlargement, reintervention, rupture, and abdominal aortic aneurysm-related mortality after endovascular aneurysm repair. Besides p-T2EL, older age, female sex, chronic kidney disease, and dilated proximal neck were associated with sac enlargement.

Objectives: This study aimed to reveal additional factors potentially contributing to the multifactorial ethiopathogenesis of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (TAA)., Methods: The medical records of 293 patients who underwent TEVAR without debranching procedures for descending TAA between 2011 and 2018 were retrospectively reviewed. We excluded the following cases from the study: 72 patients with aortic dissection; 15 with rupture; 14 with anastomotic pseudoaneurysm; 22 with re-TEVAR; 34 without evaluation of the artery of Adamkiewicz (AKA). Sufficient data were available for 136 patients (79% men; mean age of 76 ± 7.4 years). We conducted univariable and multivariable analyzes using the logistic regression analysis to assess the relationship between pre-/intraoperative factors and postoperative SCI., Results: SCI was observed in nine patients (6.8%). Severe intraluminal atheroma [odds ratio (OR), 6.23; p = 0.014] and iliac artery access (OR 4.65; p = 0.043) were identified as the positive predictors of SCI by univariable analysis. Risk factors of SCI were determined additionally as follows: coverage of the intercostal artery branching AKA (ICA-AKA) (OR 4.89; p = 0.054); coverage of the ICA-AKA combined with iliac access (OR 10.1; p = 0.002); that combined with severe intraluminal atheroma (OR 13.7; p = 0.001)., Conclusion: Severe intraluminal atheroma and iliac artery access were the independent predicting factors of SCI after TEVAR for degenerative descending TAA. In patients with complicated aortoiliofemoral access route, coverage of the ICA-AKA is associated with the risk of SCI., (© 2021. The Japanese Association for Thoracic Surgery.)

Objectives: This study aimed to determine the optimal surgical procedure for arch aneurysm in the elderly based on preoperative comorbidities, especially focusing on renal function., Methods: The medical records of 374 patients who experienced arch surgery between 2008 and 2019 were reviewed. Among the 374 patients, 92 who underwent total arch replacement (TAR) were assigned to the TAR group and the remaining 152 who underwent debranching thoracic endovascular aortic repair (DTEVAR) were assigned to the DTEVAR group., Results: Chronic kidney disease (CKD) was an independent risk factor of mortality (hazard ratio, 2.85; p = 0.029) in the TAR group but not in the DTEVAR. In the Grade I/II category CKD (estimated glomerular filtration rate (eGFR) > 60 mL/min), freedom from all-cause mortality was significantly higher in the TAR group than in the DTEVAR group (p = 0.0155, log-rank). Freedom from all-cause mortality was comparable between the two groups in the Grade IIIa CKD (eGFR, 45-60) (p = 0.584, log-lank), Grade IIIb (eGFR, 30-45) (p = 0.822), and Grade IV/V (eGFR < 30) (p = 0.548)., Conclusion: In elderly patients who underwent TAR, CKD was the independent risk factor of the mortality, but not in the patients who underwent debranching TEVAR. Conversion of surgical strategy from TAR to debranching TEVAR in the treatment of aortic arch aneurysms in the elderly with CKD below Grade IIIa is acceptable considering that less-invasiveness. While, in the elderly with Grade I/II CKD, TAR still remains as a primary choice for the arch repair for better mid-term survival.

Objective: The purpose of this study was to determine the clinical outcomes of thoracic endovascular aortic repair in 8 patients with acute type A aortic dissection with an entry tear in the descending aorta., Subjects and Methods: From January 2016 to December 2018, eight patients (mean age 76 years; range 54-92 years) were treated by thoracic endovascular aortic repair due to high operative risk for conventional open repair. All patients had significant comorbidities, and two had critical organ malperfusion due to aortic dissection. Surgical outcomes were retrospectively reviewed., Results: All procedures were technically successful with complete coverage of the entry tear. The proximal landing zone was Zone 1 in 2, Zone 2 in 1, Zone 3 in 4, and Zone 4 in 1 patient. Patients requiring Zone 1 and 2 thoracic endovascular aortic repair underwent aortic arch bypass simultaneously. Mean operation time was 132 min. There were no hospital deaths and no serious complications, including stroke and spinal cord ischemic injury. All patients had complete thrombosis and shrinkage of the false lumen in the ascending aorta before discharge. During up to 36-month follow-up (mean 20 ± 12 months), there were no adverse aortic events except one who died due to ischemic colitis 4 months after the procedure., Conclusion: Thoracic endovascular aortic repair could be a useful alternative surgical option for patients with retrograde acute type A aortic dissection with an entry in the descending aorta who are not suitable for conventional open surgery. Careful follow-up of such patients is mandatory.

Background: Because endovascular abdominal aortic repair (EVAR) lowers the lumbar arterial blood flow, we hypothesized that the volume of the psoas muscle decreases after surgery. When internal iliac artery (IIA) embolization is performed, the lumbar arterial blood flow further decreases; therefore, we also hypothesized that the decrease in the volume of the psoas muscle becomes more significant. This study was performed to assess the volume change in the psoas muscle after EVAR., Methods: Fifty-three consecutive patients who underwent EVAR from January 2016 to December 2016 were included. The psoas muscle volume was measured by preoperative and postoperative computed tomography (CT). Postoperative CT scans were performed 6-12 months after EVAR. Axial CT images with a 2-mm slice thickness were used to measure the psoas muscle volume. Data were transferred to a 3-dimensional workstation, and the psoas muscle volume was measured., Results: In the EVAR group, the volume of the psoas muscle decreased by an average of 5.8 mL (4.6%) from 114.8 ± 32.0 mL preoperatively to 109.0 ± 30.3 mL postoperatively (P < 0.01). There was a significant difference in the change in the psoas muscle volume between patients with and without IIA embolization (embolization group: preoperative 118.1 ± 31.0 mL, postoperative 107.5 ± 29.2 mL, mean volume change rate -8.8%; nonembolization group: preoperative 114.0 ± 32.3 mL, postoperative 109.4 ± 30.7 mL, mean volume change rate -3.6%; P < 0.05)., Conclusions: The psoas muscle volume is reduced with EVAR. Moreover, when the IIA is embolized, the psoas muscle volume is further reduced., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: This study aimed to assess differences in midterm outcomes between total arch replacement (TAR) and debranching thoracic endovascular aortic repair (d-TEVAR) and to evaluate the validity of d-TEVAR as the preferred treatment choice for aortic arch aneurysm in the elderly., Methods: We reviewed the case histories of 86 patients who had undergone TAR (64 men; mean age 78 ± 2.9 years) and 121 patients who had undergone d-TEVAR (90 men; mean age 82 ± 4.5 years) between 2007 and 2017; of these patients, 50 from each group were matched based on propensity scores to adjust for differences in patient characteristics., Results: Rates of freedom from all-cause mortality at 2 and 4 years were similar between the 2 groups (88% and 77% in the TAR group vs 82% and 64% in the d-TEVAR group, P = 0.11), but rates of freedom from reintervention at 2 and 4 years were significantly higher in the TAR group (100% and 96%) than in the d-TEVAR group (97% and 88%) (P = 0.004). Propensity score matching yielded similar survival rates of 88% and 85% for TAR vs 86% and 71% for d-TEVAR (P = 0.53) and comparable freedom from reintervention rates (100% and 97% in TAR, 98% and 90% in d-TEVAR, P = 0.16) at 2 and 4 years. Cox regression analysis identified previous cerebral infarction [hazard ratio (HR) 3.9; P = 0.005 in TAR/HR 3.1; P = 0.002 in d-TEVAR] as an independent positive predictor of overall mortality in both groups., Conclusions: Midterm outcomes after TAR and d-TEVAR were satisfactory and propensity score matching-based evaluation revealed no significant differences in outcomes, implying that d-TEVAR is an acceptable first-choice procedure for aortic arch aneurysm in patients older than 75 years., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Since 2012, we have routinely applied balloon protection of the proximal left subclavian artery to prevent embolic events through the left vertebral artery during debranching thoracic endovascular aortic repair. This study aimed to study the effectiveness of balloon protection of the proximal left subclavian artery., Methods: We reviewed the medical records of 157 patients who underwent debranching thoracic endovascular aortic repair between 2007 and 2017. Of these, 71 patients for whom balloon protection of the proximal left subclavian artery was used were assigned to the balloon protection of the proximal left subclavian artery group (58 men; age: 78 ± 6.7 years), and 86 patients were assigned to the control group (66 men; age: 78 ± 8.9 years). A total of 51 patients from each group were matched by their propensity scores to adjust for differences in the patients' characteristics., Results: Perioperative stroke was significantly lower in the balloon protection of the proximal left subclavian artery group than in the control group (0%: 0/71 vs 7.9%: 7/86, P = .014). Freedom from all causes of mortality at 2 and 4 years was significantly higher in the balloon protection of the proximal left subclavian artery group compared with the control group (93%/76% vs 77%/59%, P = .015). Freedom from aortic death at 2 and 4 years was similar in both groups (97%/97% vs 91%/86%, P = .094). Propensity score matching yielded similar results of better freedom from all causes of mortality in the balloon protection of the proximal left subclavian artery group (93%/93% vs 81%/63%, P = .017) and equivalent aortic death in both groups (95%/95% vs 92%/88%, P = .30)., Conclusions: Debranching thoracic endovascular aortic repair using balloon protection of the proximal left subclavian artery demonstrated more appropriate early and late outcomes. Evaluation using propensity score matching enhanced the efficacy of balloon protection of the proximal left subclavian artery., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study aimed to review our clinical results and determine how preoperative patent lumbar arteries (LAs) influence the occurrence of type II endoleaks or aneurysm sac enlargement after endovascular aneurysm repair (EVAR) and to identify the preoperative computed tomography findings of persistent type II endoleaks from patent LAs that indicate the need for preventive procedures during EVAR., Methods: A total of 293 patients who underwent EVAR for infrarenal abdominal aortic aneurysm (AAA) between August 2007 and July 2013 were reviewed. Follow-up data were available for 194 patients (76% male, mean age 78 ± 6.8 years), and the mean follow-up time was 57 ± 23 months., Results: The number of patent LAs was identified as a significant positive predictor of persistent type II endoleaks (hazard ratio [HR], 1.4; 95% confidence interval [CI]: 1.2-1.7; P < 0.001) and sac enlargement (≥5 mm) at the 2-year follow-up period (HR, 1.3; 95% CI: 1.1-1.8; P = 0.009) after EVAR, using Cox regression analysis. The receiver operating characteristics curve (AUC: 0.72) showed that a cutoff of 4 patent LAs resulted in a sensitivity of 87% and specificity of 48%. The rates of freedom from sac enlargement (≥5 mm) at 3 and 5 years after EVAR were significantly lower in patients with 4 or more patent LAs than in those with fewer (90% and 76% vs. 96% and 89%; P = 0.0008)., Conclusions: The number of patent LAs is associated as a significant risk factor with the development of persistent type II endoleaks and sac enlargement after EVAR. Four or more patent LAs should be recognized as the group having an elevated risk of developing late sac enlargement after EVAR., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: This study aimed to reveal the differences in intermediate outcomes between TAR and d-TEVAR in octogenarians and to identify risk factors for adverse events after aortic arch repair in octogenarians., Methods: We reviewed medical records of 125 patients aged > 80 years who underwent surgical intervention for aortic aneurysm between 2008 and 2016. Of these, 60 underwent conventional TAR (43 men; age, 82 ± 2.2 years) and 65 underwent d-TEVAR (49 men; age, 84 ± 3.4 years)., Results: Freedom from all causes of mortality at 2 and 4 years was similar (80 and 66% in TAR, 80 and 51% in d-TEVAR, p = 0.17). Freedom from aortic death at 2 and 4 years was similar (88 and 88% in TAR, 87 and 76% in d-TEVAR, p = 0.86). Using Cox regression analysis, chronic obstructive pulmonary disease (COPD) [hazard ratio (HR), 6.0; p = 0.008], malignancy (HR, 8.8; p = 0.004), previous cardiac and thoracic aortic surgery (required median sternotomy) (HR, 65.9; p = 0.012), perioperative stroke (HR, 12.6; p = 0.012), and postoperative pneumonia (HR, 5.8; p = 0.026) were identified as independent positive predictors of overall postoperative mortality for TAR, whereas neurological dysfunction (HR, 3.0; p = 0.016) and perioperative stroke (HR, 12.1; p = 0.023) were identified for d-TEVAR., Conclusions: TAR in octogenarians with COPD and/or malignancy showed higher mortality rates; d-TEVAR is more appropriate in these situations. The prevention of perioperative stroke, which is related with poor prognosis in both the groups, is critical.

Objectives: Actin, alpha-2, smooth muscle, aorta (ACTA2) mutations are one of the major causes of familial thoracic aortic aneurysms and dissections. The aim of this study was to review our clinical results of young adult patients with aortic disease caused by ACTA2 mutations., Methods: We reviewed the medical records of 251 patients (<50 years old) who underwent surgery for thoracic aortic diseases between 2004 and 2014. Among them, nine patients (3.5%) had ACTA2 mutations. Their average age was 35 years (range 22-47) and two patients (22.2%) were males. No patients fulfilled the diagnostic criteria for Marfan syndrome. Preoperative diagnoses included annulo-aortic ectasia (n = 2), localized dissection of the sinus of Valsalva (n = 2), acute type B aortic dissection (n = 1), and chronic type B (n = 4). Eight patients (88.9%) had hypertension., Results: A thoracoabdominal aortic replacement was required in three patients who had descending replacement for residual chronic type B aortic dissection. A patient who had thoracic endovascular aortic repair for complicated acute type B aortic dissection showed no aortic dilatation for 7 years after TEVAR. Histological results revealed cystic medial necrosis (CMN) in most cases (7/8; 87.5%)., Conclusion: Surgical outcomes for patients with ACTA2 mutations were satisfactory. CMN was a major histological finding and family history of aortic event was detected in only half of the patients with ACTA2 mutations. Despite no characteristic physical findings besides hypertension, connective tissue disease including ACTA2 mutations should be considered for aortic dissection in young adult patients.

Objectives: This study aims to determine whether warfarin therapy influences the occurrence of endoleaks or aneurysm sac enlargement after endovascular aortic repair (EVAR)., Methods: A total of 367 patients who underwent EVAR for abdominal aortic aneurysm between 2007 and 2013 were recruited for this study. Satisfactory follow-up data including completed computed tomography scan follow-up for more than 2 years were available for 209 patients, and the mean follow-up time was 37 ± 12 months. Twenty-nine (16%) patients were on warfarin therapy (warfarin group), whereas 180 (84%) patients were not on warfarin therapy (control group)., Results: Two- and four-year freedom rates for persistent type II endoleaks were significantly lower in patients of the warfarin group compared with the control group (85 and 49% vs 93 and 91%, respectively; P = 0.0001). Similarly, 2- and 4-year freedom rates for sac enlargement (>5 mm) were significantly lower in patients of the warfarin group compared with the control group (83 and 61% vs 92 and 82%, respectively; P = 0.0036). Using Cox regression analysis, the warfarin therapy was identified to be an independent positive predictor of sac enlargement after EVAR [hazard ratio (HR): 2.4; 95% confidence interval (CI): 1.08-5.40; P = 0.032], together with persistent type II endoleak. Warfarin therapy was also an independent predictor for persistent type II endoleak (HR: 3.7; 95% CI: 1.81-7.41; P < 0.0001) together with the number of patent lumbar arteries., Conclusions: Results suggested that warfarin therapy was significantly associated with an increased risk for persistent II endoleak and sac enlargement after EVAR., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The method of hybrid arch thoracic endovascular aortic repair (TEVAR) to treat aneurysm with zone 0 landing has changed according to its invasiveness and complications. The real chimney technique allows supra-aortic bypass from ascending aorta without side clamp is the current choice of treatment. The comprehensive strategy to prevent stroke during hybrid arch TEVAR consisting of magnetization-prepared rapid acquisition with gradient-echo for evaluation of the atheromatous change and balloon protection of the left subclavian artery has contributed for the marked reduction of stroke. Our current strategy of hybrid arch TEVAR with zone 0 landing is discussed.

Background: The purpose of this study was to analyze the risk factors for an adverse outcome after endovascular therapy (EVT) for critical limb ischemia (CLI) with tissue loss due to infrainguinal artery disease., Methods: We retrospectively reviewed the charts of patients with tissue loss (Rutherford class 5 and 6) due to infrainguinal artery disease who were managed with endovascular therapy (EVT) between January 2006 and December 2013. The primary endpoint was amputation-free survival (AFS), while the secondary endpoints were freedom from a major adverse limb event (MALE) plus perioperative (30 days) death (POD), limb salvage, and survival rates at one year. Multivariable perioperative predictors of AFS were identified using the stepwise Cox proportional hazards regression model., Results: A total of 65 patients underwent EVT for infrainguinal artery disease on 72 limbs. The technical success rate was 94% (68/72), while the clinical success was attained in 54 of 72 limbs (72%). The AFS, MALE + POD, limb salvage, and survival rates at one year were 76%, 86%, 91%, and 81%, respectively. The multivariate analysis demonstrated that major tissue loss classified as Rutherford class 6 (HR, 5.68; 95% CI, 2.29-14.13; P<0.05) was negatively associated with decreased AFS, while clinical success (HR, 0.25; 95% CI, 0.11-0.60; P<0.05) was positively associated with increased AFS., Conclusions: EVT resulted in an acceptable rate of AFS, MALE+POD, limb salvage, and survival. However, we must keep in mind that there are significant limitations to be considered for EVT in patients with major tissue loss, and that, even if revascularization could be successfully performed, a significant number of the treated limbs are still in a critical situation, such as major amputation or death.

We report a rare case of massive type IIIb endoleaks from an abdominal endograft, which were difficult to diagnose and required hybrid repair (including open surgery). The patient had previously undergone three catheter interventions for type Ia and II endoleaks after abdominal endografting. However, the abdominal aortic aneurysm gradually enlarged and required hybrid treatment (including an open repair), to successfully perform aneurysmorrhaphy and additional endograft insertions for the massive type IIIb endoleaks., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We describe a previously unreported case of abscess formation around the right internal iliac artery (IIA) after coil embolization prior to endovascular aneurysm repair (EVAR). A 75-year-old man was admitted for elective repair of a right common iliac aneurysm. The right IIA coil embolization and EVAR procedures were uncomplicated and assessment by postoperative computed tomography (CT) was satisfactory. The patient was readmitted 2 weeks after EVAR with right buttock pain and pyrexia. CT indicated an isolated abscess around the coil-embolized IIA. The patient was successfully treated with CT-guided percutaneous drainage., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)