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OBJECTIVES We aimed to identify predictors of postoperative permanent neurological deficits (PNDs) and evaluate the early management of cerebral perfusion in patients undergoing surgical repair of acute type A aortic dissection with cerebral malperfusion. METHODS Between October 2009 and September 2018, a total of 197 patients with acute type A aortic dissection underwent aortic replacement. Of these, 42 (21.3%) patients had an imaging cerebral malperfusion (ICM). ICM was assessed preoperatively, which also revealed whether dissected supra-aortic branch vessels were occluded or narrowed by a thrombosed false lumen. After September 2017, early reperfusion and extra-anatomic revascularization were performed in cases with ICM. RESULTS Hospital mortality rates for cases with ICM were 4.8% (2/42). Before September 2017, PND were observed in 6 patients (54.5%) with preoperative neurological symptoms (n  = 11), and 7 patients (33.3%) without neurological symptoms (n  = 21) in patients with ICM. Occlusion or severe stenosis of supra-aortic branch vessels (odds ratio, 7.66; P  <   0.001), regardless of preoperative clinical neurological symptoms, was a risk factor for PND. After September 2017, 7 of 10 patients with ICM underwent early reperfusion and extra-anatomic revascularization. PND did not occur in any of these 7 patients. CONCLUSIONS Occlusion or severe stenosis of supra-aortic branch vessels is a predictor of PND risk in patients undergoing surgery for acute type A aortic dissection. Early reperfusion and extra-anatomic revascularization may reduce the risk of neurological complications in patients with ICM, with or without neurological symptoms. [ABSTRACT FROM AUTHOR]

Background: Thoracic endovascular aortic repair is now widely applied to the treatment of blunt aortic injury. However, its long-term outcomes remain unclear. Endoleakage and migration might occur in the long term, especially when younger patients undergo endovascular aortic repair. In open stent grafting, the proximal end of the open stent graft is directly sutured to the native aorta, which may reduce the risk of endoleakage and migration. We applied open stent grafting to the treatment of blunt aortic injury in the subacute phase and herein report the patient's clinical course.Case Presentation: A 20-year-old man with a developmental disorder collided with a steel tower while skiing. He was transferred to our hospital by helicopter. X-ray examination and computed tomography revealed fractures of left humeral head and femoral neck and aortic isthmus dissection. We did not perform an acute-phase operation because of the presence of multiple trauma and instead performed open stent grafting with an upper-half sternotomy 42 days after the injury. He recovered uneventfully without psychological problems other than his preexisting developmental disorder. No endoleakage or aneurysm was observed during an 18-month follow-up period.Conclusions: Open stent grafting might be an alternative to open surgery and thoracic endovascular aortic repair for blunt chest trauma, although intensive follow-up is needed. [ABSTRACT FROM AUTHOR]

A 41-year-old man stuck himself with needle through his pericardium during suicide attempt. Chest radiography revealed several needles in the bilateral lung fields as well. Computed tomography (CT) and echocardiography showed massive pericardial effusion and a needle penetrating the pericardium. The patient was initially treated conservatively, including pericardial drainage, and, seven days later, we removed the needle using syngo Needle Guidance in hybrid operating room. The length of skin incision was only 2 cm, and the postoperative course was uneventful. No previous studies, to the best of our knowledge, have shown the use of syngo Needle Guidance to remove a needle in the pericardial cavity. This surgical procedure is minimally invasive for the patient.

Case 1:a 47-year-old woman who complained of sweating, finger tremor, and chest pain was diagnosed with coarctation of the aorta and hyperthyroidism. She had been diagnosed with hypertension at 25 years of age but had not undergone further examination. Graft replacement was performed without cardiopulmonary or temporary bypass. Case 2:a 30-year-old woman was diagnosed with coarctation during infertility treatment. Although health screening had revealed hypertension 8 years previously, no further assessment took place. She underwent graft replacement with partial cardiopulmonary bypass. In both cases, we conducted a clamp test to decide whether cardiopulmonary or partial bypass was necessary for graft replacement. Blood pressure discrepancy between upper and lower extremities disappeared immediately after surgery, and no ischemic complications were observed. Hypertension in young adults should prompt further scrutiny for anatomical disorders such as coarctation. A clamp test is considered helpful regarding the surgical approach to graft replacement for coarctation.

We describe a 76-year-old woman with cardiac tamponade who was admitted to our hospital. She underwent ascending and partial arch aortic replacement to treat acute type A aortic dissection. However, postoperative respiratory failure developed and a chest X-ray revealed right lung pneumothorax. The lung was finally expanded after difficulties with prolonged tube drainage. Chest computed tomography(CT) showed multiple cystic changes in the bilateral lungs. Her sister and her daughter also had a history of spontaneous pneumothorax. We finally diagnosed Birt-Hogg-Dube syndrome after deoxyribonucleic asid(DNA)sequencing of folliculin( FLCN) gene.

Shortage of medical doctors has been conspicuous since the residency program has been changed in 2004. We investigated the changes in the number of cardiovascular surgeons, surgical cases and institutes of Nagano from 1996 to 2008. The number of cardiovascular surgeons decreased from 28 to 19. The number of newly joined cardiovascular surgeons were 2.7 +/- 1.4/year from 1996 to 2001 and 1.1 +/- 0.4/year from 2002 to 2008. The number of retirement were 0.7 +/- 0.8/year and 2.3 +/- 1.0/year from 1996 to 2001 and from 2002 to 2008, respectively. The number of surgery cases increased from 340 in 1996 to 771 in 2008. Kaplan-Mayer analysis showed the 50% of cardiovascular surgeons retired in 19 years of their career, and the only 20% of surgeons survived after 29 years. The number of newly joined general surgeons was the only 3 since 2004. We are consolidating the institutes of cardiovascular surgery in Nagano to perform more surgery by fewer surgeons. It is important that working condition of cardiovascular surgeon adapt to young doctor's favor, and new positions should be created for elder cardiovascular surgeons to prevent early retirement.