Takeshi Shimamoto

Strategic perspectives on open thoracoabdominal repair following frozen elephant trunk: distal shifting, technical caveats, and the role of stepwise interventions

Objectives: Fibrinogen replacement therapy (FRT) using fibrinogen concentrate (FC) may rapidly correct hypofibrinogenaemia; however, its clinical impact remains unclear, and this retrospective study aimed to evaluate the safety and efficacy of FC in surgically treated acute type A aortic dissection (ATAAD) patients. Methods: A retrospective study analysed 87 consecutive ATAAD patients who underwent emergency surgery. Patients were included in 2 groups: those who received FRT (Group F, n = 42) and those who did not (Group C, n = 45). Using a mixed model for repeated measures, we calculated the least squares (LS) mean differences between groups for intraoperative and postoperative fibrinogen levels and blood loss using the LS method. We also evaluated short-term surgical outcomes (postoperative complications) and long-term surgical outcomes (overall survival) for each group. Results: The change in fibrinogen levels during surgery did not differ significantly between groups. Postoperatively, however, the decrease in fibrinogen was smaller in the F group (LSMeans difference: −60.1; 95% confidence interval [CI]: −79.8, −40.4). Intraoperative blood loss was greater in the F group (LSMeans difference: −622 mL; 95% CI, −1037, −208), but no difference was observed in postoperative blood loss (LSMeans difference: −131 mL; 95% CI, −547, 286). Despite a higher proportion of severe cases in the F group, the difference in postoperative complication rates was approximately 10%. The difference in 1-month survival rate was 4.9%, and the difference in 1-year survival rate was 19.5%. Conclusions: In the surgical treatment of ATAAD, FRT increases fibrinogen levels by approximately 71 mg/dL, achieving adequate haemostasis without increasing adverse outcomes. Additionally, FC is effective in reducing postoperative blood loss in patients with a bleeding tendency whose fibrinogen level is below 150 mg/dL before weaning from cardiopulmonary bypass.

Introduction The prognosis for surgery on acute type A aortic dissection (ATAAD) is poor because the dissected vessel is fragile and prone to bleeding. We have applied a turn-up anastomosis, in which both the Dacron graft and native aortic wall are everted for secure anastomosis. BioGlue (CryoLife, Inc., Kennesaw, GA, USA) has also been occasionally used as an adjunct. However, several potential complications associated with the use of BioGlue have already been reported. This study aimed to compare the clinical impact of BioGlue in patients undergoing ATAAD surgery using proximal turn-up anastomosis. Materials and methods Between November 2020 and March 2024, 78 cases were included for ATAAD. The proximal anastomosis was performed with a turn-up anastomosis in all cases, and BioGlue was used as an adjunct in 49 cases (BG). The cases without BioGlue (NBG: 29) and BG were compared. Results There were no differences in age, gender, preoperative shock, cardiac tamponade or malperfusion between the two groups. The replacement of ascending aorta was more common in NBG (52%, p=0.0004), while the frozen elephant trunk technique was more common in BG (59%, p=0.0004). Operation time was similar (NBG: 302 min, BG: 277 min, p=0.1451), and no significant difference in intraoperative bleeding (NBG: 1487 mL, BG: 1370 mL, p=0.6942). Both groups had no cases requiring re-anastomosis or repair under re-aortic cross-clamp. In-hospital mortality was 0% in NBG and 14% in BG (The risk difference: 0.142857 (0.044879-0.240835), p=0.0419). Re-exploration for bleeding was similar (NBG: 10%, BG: 6.1%, OR=0.565 [0.106-3.00], p=0.6651). These results were similar for the replacement of ascending aorta only. Postoperative CT scans showed no difference in complete thrombosis of the sinus of Valsalva (p=0.7019). The mean follow-up was 20 months, with one case of aortic root enlargement in BG. Conclusions Proximal turn-up anastomosis without BioGlue was shown to be non-inferior to that using BioGlue. Proximal turn-up anastomosis without BioGlue is considered an acceptable technique. The issue of potential late complications remains, and the use of BioGlue should be approached with caution, with its application appropriately limited.

OBJECTIVES: In cardiovascular surgery, frailty is a risk for postoperative dysphagia. This study investigated the effect of preoperative training on strengthening the tongue muscle and its clinical impact. METHODS: Patients scheduled for cardiovascular surgery between 2022 and 2024 who underwent preoperative tongue pressure measurement were included. Preoperative tongue muscle training was conducted using the novel device Pecopanda RESULTS: Forty-two patients who purchased the Pecopanda and received preoperative training were assigned to the training group, and 66 patients without training or with maintained tongue pressure were assigned to the non-training group. Low tongue pressure below 30 kPa was observed in 44.4% of patients. Age was 76 (71–81) years in the training group and 70 (59–75) years in the non-training group. Change in tongue pressure pre- to post-operation was 0.2 (IQR: -1.3 to 7.0) kPa in the training group, and -2.2 (IQR: -4.4 to -0.5) kPa in the non-training group. Multiple regression analysis showed that changes in tongue pressure pre- and post-operation tended to be greater in the training group (β = 1.342, 95% CI: –0.825 to 3.509). Logistic regression analysis suggested a trend towards a protective association between preoperative tongue training and deglutition diets or tube feeding at refeeding (OR = 0.81, 95% CI: 0.26 to 2.48). All patients in the training group were discharged home without the need for deglutition diets and tube feeding. CONCLUSIONS: Preoperative training with simple tongue exercises may increase tongue pressure and support clinical outcomes in patients with low tongue pressure.

Objective: This study aimed to investigate the operative and short-term clinical outcomes of total arch replacement using the partial frozen elephant trunk (FET) technique. Methods: Sixteen patients with aortic arch disease were treated with partial FET at six institutions between August and December 2023. The primary endpoint of our study was the technical success of partial FET implantation. The secondary endpoints included death and the occurrence of aortic events, such as the distal stent graft–induced new entry. Numerical values are presented as mean ± standard deviation. Results: The mean age of the patients was 62 ± 10 years, with eight being female. The indications for the operation included acute aortic dissection in 10 patients, chronic aortic dissection in 5, and anastomotic pseudoaneurysm in 1. Total arch replacement with partial FET was successfully performed on all patients. The duration of circulatory arrest, aortic cross-clamping, and cardiopulmonary bypass were 62 ± 17, 176 ± 66, and 271 ± 65 min, respectively. No symptomatic postoperative pressure gradient between the upper and lower extremities was observed. The 30-day and in-hospital mortality rates were both 0%. There were no cases of new postoperative stroke, paraplegia, or paraparesis. Additionally, no aorta-related complications were reported. An excellent surgical view of the distal unstented portion of the partial FET was achieved through left thoracotomy during the thoracoabdominal aortic replacement performed 3 months after the initial surgery. Conclusions: The clinical outcomes of total arch replacement using the partial FET technique were satisfactory. However, surgeons must exercise caution when employing this method for chronic aortic dissection due to its weak radial and spring back forces. Graphical

Lower limb malperfusion for type A acute aortic dissection (ATAAD) is a challenging complication, particularly when it occurs suddenly during the operation. We report a 76-year-old female with ATAAD having thrombosed false lumen who underwent emergency hemiarch replacement with primary tear resection on the ascending aorta. After distal anastomosis, a sudden and severe drop in bilateral lower limb oxygen saturation was observed, indicating malperfusion. Subsequent angiography revealed significant stenosis of the descending aorta and iliac arteries. To avoid the additional risk of curative total arch replacement, we planned to insert stent grafts instead, restoring the flow. Follow-up computed tomography confirmed complete resolution of malperfusion. Early intraoperative diagnosis and prompt intervention were crucial in this complex situation. This case underscores the importance of prompt management for intraoperative malperfusion.

Primary tumors arising from within the arterial wall are extremely uncommon and often present at advanced stages, making timely intervention challenging. Surgeons need to be aware of these rare conditions, as early detection and treatment can significantly improve patient outcomes. Angiosarcoma of the abdominal aorta is a particularly rare and aggressive malignancy, often resembling an aneurysm at risk of rupture. A 59-year-old woman presented with sudden onset of severe abdominal pain and was diagnosed with a 42 mm saccular abdominal aortic aneurysm, which was urgently repaired under the presumption of impending rupture. Intraoperatively, we found the aneurysm to be notably more fragile than a typical abdominal aortic aneurysm, while the rest of the aorta appeared healthy. This discrepancy raised suspicion of an atypical lesion, prompting us to resect the aneurysm and submit it for pathology. Subsequent immunohistochemical staining confirmed angiosarcoma, enabling timely referral for oncological management. Angiosarcoma is often difficult to diagnose based on computed tomography findings alone, so any atypical appearance of the aorta should raise suspicion of this malignancy, even in emergent surgery. This case shows the important role of careful intraoperative assessment and pathological examination in guiding definitive management.

Background: The mechanical complications associated with acute myocardial infarction can be fatal. We report a life-saving case of a very elderly patient with consecutive mechanical complications of acute myocardial infarction. Case presentation: A 90-year-old woman was transferred to our hospital for emergency care due to chest pain. She underwent emergency percutaneous coronary intervention of the left anterior descending branch and was diagnosed with acute myocardial infarction and intra-aortic balloon pumping insertion was performed. After returning to the intensive care unit, she experienced chest pain and went into shock. Echocardiography showed left ventricular free wall rupture, and percutaneous cardiopulmonary support was established. Emergency left ventriculoplasty was performed for the left ventricular free wall rupture. A ventricular septal perforation was observed on postoperative day 9, and its closure through right ventriculotomy was performed on postoperative day 10. On the 128th postoperative day, the patient was transferred to the hospital for rehabilitation. Conclusions: A 90-year-old patient with consecutive left ventricular free wall rupture and ventricular septal perforation after acute myocardial infarction was successfully managed with two surgeries.