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Journal of Cardiothoracic Surgery Jun 2024The surgical treatment strategy for aortic arch pathology with a shaggy aorta must be determined on a case-by-case basis because of the risk of catastrophic...
BACKGROUND
The surgical treatment strategy for aortic arch pathology with a shaggy aorta must be determined on a case-by-case basis because of the risk of catastrophic complications, such as brain infarction and spinal cord injury.
CASE PRESENTATION
This report describes the surgical case of two saccular aneurysms of the arch and abdominal aorta associated with a shaggy aorta in a 63-year-old man who underwent total arch replacement and secondary thoracic endovascular aortic repair. Considering the risk of embolization during endovascular therapy, graft replacement for the abdominal aortic aneurysm was initially performed. On postoperative day 28, total arch replacement with the conventional elephant trunk was performed using the functional brain isolation technique, which involves manipulating places far from the atherosclerotic burden, such as arterial inflow for cardiopulmonary bypass and unclamping of neck vessels. On postoperative day 7 after total arch replacement, thoracic endovascular aortic repair was performed across the conventional elephant trunk in the nondiseased descending aorta. No postoperative complications, such as cerebrovascular failure, paraplegia, or embolization to abdominal viscera or lower extremities, occurred. The patient remained asymptomatic.
CONCLUSIONS
The present case suggests that total arch replacement with the conventional elephant trunk and secondary thoracic endovascular aortic repair may be an effective alternative for aortic arch pathology with a shaggy aorta. The strategy for surgical treatment in patients with aortic arch pathologies with a shaggy aorta must be judged on a case-by-case basis, considering patient characteristics, comorbidities, and preoperative evaluation using transesophageal echocardiography and computed tomography angiography, to eliminate potential determinants of intraoperative stroke.
Topics: Humans; Male; Middle Aged; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Endovascular Procedures; Blood Vessel Prosthesis Implantation; Tomography, X-Ray Computed
PubMed: 38890739
DOI: 10.1186/s13019-024-02841-5 -
Journal of the American Heart... Jun 2024Recent studies suggest that immune-mediated inflammation of perivascular adipose tissue of abdominal aortic aneurysms (AAAs) contributes to disease development and...
BACKGROUND
Recent studies suggest that immune-mediated inflammation of perivascular adipose tissue of abdominal aortic aneurysms (AAAs) contributes to disease development and progression. Whether the perivascular adipose tissue of AAA is characterized by a specific adaptive immune signature remains unknown.
METHODS AND RESULTS
To investigate this hypothesis, we sequenced the T-cell receptor β-chain in the perivascular adipose tissue of patients with AAA and compared it with patients with aortic occlusive disease, who share the former anatomical site of the lesion and risk factors but differ in pathogenic mechanisms. Our results demonstrate that patients with AAA have a lower repertoire diversity than those with aortic occlusive disease and significant differences in variable/joining gene segment usage. Furthermore, we identified a set of 7 public T-cell receptor β-chain clonotypes that distinguished AAA and aortic occlusive disease with very high accuracy. We also found that the T-cell receptor β-chain repertoire differentially characterizes small and large AAAs (aortic diameter<55 mm and ≥55 mm, respectively).
CONCLUSIONS
This work supports the hypothesis that T cell-mediated immunity is fundamental in AAA pathogenesis and opens up new clinical perspectives.
Topics: Humans; Aortic Aneurysm, Abdominal; Male; Aged; Female; T-Lymphocytes; Adipose Tissue; Receptors, Antigen, T-Cell, alpha-beta; Middle Aged; Aorta, Abdominal
PubMed: 38888318
DOI: 10.1161/JAHA.123.034096 -
Vascular Specialist International Jun 2024
PubMed: 38887877
DOI: 10.5758/vsi.230075.e -
Cureus May 2024A Type IV endoleak is a very rare complication following endovascular aneurysm repair (EVAR) and differential diagnosis can be difficult. Reported here is a case that...
A Type IV endoleak is a very rare complication following endovascular aneurysm repair (EVAR) and differential diagnosis can be difficult. Reported here is a case that showed the development of a Type IV endoleak after an EVAR procedure, for which a novel software was useful to differentiate that from Type I based on visual confirmation. The 89-year-old man was diagnosed with a large abdominal aortic aneurysm, sized 70 mm, as shown by computed tomography (CT). EVAR was performed in a routine fashion using an Endurant II stent graft. Postoperative CT revealed a massive endoleak around the neck that was difficult to differentiate between Types I and IV. The use of the novel software Viewtify (SCIEMENT, Inc., Tokyo, Japan) to visualize the endoleak with surrounding tissues as real-time three-dimensional computer graphics (3DCG) resulted in confirmation that the endoleak was not from the proximal end but rather the stent graft body. CT findings obtained one week later showed that the endoleak had diminished and no additional procedures were needed. Following a diagnosis of endoleak after EVAR, images viewed with Viewtify helped to confirm the appropriate diagnosis. This novel software was found useful to clarify the position and mechanism of a Type IV endoleak.
PubMed: 38887348
DOI: 10.7759/cureus.60527 -
BMC Infectious Diseases Jun 2024Q fever, caused by the zoonotic pathogen Coxiella burnetii, exhibits a worldwide prevalence. In China, Q fever is not recognized as a notifiable disease, and the disease...
BACKGROUND
Q fever, caused by the zoonotic pathogen Coxiella burnetii, exhibits a worldwide prevalence. In China, Q fever is not recognized as a notifiable disease, and the disease is overlooked and underestimated in clinical practice, leading to diagnostic challenges.
CASE PRESENTATION
We present a case series of three patients diagnosed with persistent Q fever between 2022 and 2023. The average age of our three cases was 63.33 years old, consisting of two males and one female. The medical history of the individuals included previous valve replacement, aneurysm followed by aortic stent-graft placement and prosthetic hip joint replacement. At the onset of the disease, only one case exhibited acute fever, while the remaining two cases were devoid of any acute symptoms. The etiology was initially overlooked until metagenomic next-generation sequencing test identified Coxiella burnetii from the blood or biopsy samples. Delayed diagnosis was noted, with a duration ranging from three months to one year between the onset of the disease and its confirmation. The epidemiological history uncovered that none of the three cases had direct exposure to domestic animals or consumption of unpasteurized dairy products. Case 1 and 2 resided in urban areas, while Case 3 was a rural resident engaged in farming. All patients received combination therapy of doxycycline and hydroxychloroquine, and no recurrence of the disease was observed during the follow-up period.
CONCLUSION
Q fever is rarely diagnosed and reported in clinical practice in our country. We should be aware of persistent Q fever in high-risk population, even with unremarkable exposure history. Metagenomic next-generation sequencing holds great potential as a diagnostic tool for identifying rare and fastidious pathogens such as Coxiella burnetii.
Topics: Q Fever; Humans; Male; Middle Aged; Female; China; Coxiella burnetii; Aged; Delayed Diagnosis; Anti-Bacterial Agents; Doxycycline; High-Throughput Nucleotide Sequencing
PubMed: 38886677
DOI: 10.1186/s12879-024-09484-w -
EJVES Vascular Forum 2024Diagnosing non-occlusive mesenteric ischaemia (NOMI) in patients is complicated, due to poor signs and symptoms and non-specific laboratory tests, leading to a high...
INTRODUCTION
Diagnosing non-occlusive mesenteric ischaemia (NOMI) in patients is complicated, due to poor signs and symptoms and non-specific laboratory tests, leading to a high mortality rate. This case study presents the rare case of a patient who developed mesenteric ischaemia after an emergency thoracic endovascular aneurysm repair (TEVAR) for a type B aortic dissection (TBAD) and peri-operative cardiogenic shock. Study outcomes revealed that intestinal fatty acid binding protein (I-FABP) identified early mucosal damage two days before the clinical presentation.
REPORT
A 43 year old male patient was admitted to the emergency department with an acute TBAD and a dissection of the superior mesenteric artery (SMA), for which TEVAR was performed with additional stent placement in the SMA. Peri-operatively, the patient went into cardiogenic shock with a sustained period of hypotension. Post-operatively, the plasma I-FABP levels were measured prospectively, revealing an initial increase on post-operative day five (551.1 pg/mL), which continued beyond day six (610.3 pg/mL). On post-operative day seven, the patient developed a fever and demonstrated signs of peritonitis and bowel perforation. He underwent an emergency laparotomy, followed by an ileocaecal resection (<100 cm) with a transverse ileostomy. Pathological analysis confirmed the diagnosis of mesenteric ischaemia.
DISCUSSION
The diagnosis of NOMI in critically ill patients is often complicated, and the currently available diagnostic markers lack the specificity and sensitivity to detect early intestinal injury. This case report highlights that elevated I-FABP in plasma levels may indicate the presence of early mesenteric injury. Further research needs to be conducted before I-FABP can be applied in daily practice.
PubMed: 38884076
DOI: 10.1016/j.ejvsvf.2024.04.004 -
EJVES Vascular Forum 2024Primary aorto-enteral fistula (PAEF) is a connection between the gastrointestinal tract and the aorta that occurs without previous aortic surgery. The aetiological...
OBJECTIVE
Primary aorto-enteral fistula (PAEF) is a connection between the gastrointestinal tract and the aorta that occurs without previous aortic surgery. The aetiological factors include, but are not limited to, aneurysm, infection, and tumours. It is a life threatening condition if untreated and requires emergency vascular surgical repair. A secondary aorto-enteric fistula (AEF) can occur to a previously reconstructed aorta. This case report presents a unique case of a male patient who developed a primary AEF and subsequent secondary AEF with successful surgical outcomes, suggested to be due to tuberculous aortitis.
REPORT
The patient was diagnosed and treated for tuberculosis and developed a saccular aneurysm within six months. The PAEF was surgically corrected with a tube graft using a bovine pericardial patch, the defect in duodenum was sutured, and a retrocolic omental flap was created between the duodenum and aorta. He developed a small stable pseudoaneurysm during follow up, and then a secondary AEF two and a half years later, in which a connection between the pseudoaneurysm and duodenum was corrected using a new bovine aorto-aortic interposition graft using a bovine pericardium patch. The defect in the duodenum was also sutured in two layers and a new omental flap was created.
DISCUSSION
The mortality rate of AEF is high and it is very unlikely that a patient will survive two AEFs without major complications. It is believed that there are extremely few double AEF cases described in the literature. The aetiological factor in the development of PAEF in this case was most likely the patient's aortic aneurysm, which was most likely of mycotic origin due to tuberculosis. The patient developed a pseudoaneurysm during follow up and it is uncertain whether the pulsatile pressure of the pseudoaneurysm led to the recurrence of the AEF.
PubMed: 38884073
DOI: 10.1016/j.ejvsvf.2024.05.005 -
Research Square Jun 2024Loeys-Dietz syndrome (LDS) is an aneurysm disorder caused by mutations that decrease transforming growth factor-β (TGF-β) signaling. Although aneurysms develop...
Loeys-Dietz syndrome (LDS) is an aneurysm disorder caused by mutations that decrease transforming growth factor-β (TGF-β) signaling. Although aneurysms develop throughout the arterial tree, the aortic root is a site of heightened risk. To identify molecular determinants of this vulnerability, we investigated the heterogeneity of vascular smooth muscle cells (VSMCs) in the aorta of LDS mice by single cell and spatial transcriptomics. Reduced expression of components of the extracellular matrix-receptor apparatus and upregulation of stress and inflammatory pathways were observed in all LDS VSMCs. However, regardless of genotype, a subset of -expressing VSMCs predominantly located in the aortic root intrinsically displayed a less differentiated, proinflammatory profile. A similar population was also identified among aortic VSMCs in a human scRNAseq dataset. Postnatal VSMC-specific deletion reduced aortic root dilation in LDS mice, suggesting that this factor sensitizes the aortic root to the effects of impaired TGF-β signaling.
PubMed: 38883722
DOI: 10.21203/rs.3.rs-4420617/v1 -
Journal of Thoracic Disease May 2024Despite improvements in management, infective endocarditis (IE) is still associated with high mortality and morbidity. The outcome of patients with IE remains unclear in...
Postoperative follow-up of 221 patients with infective endocarditis from Gaoligong mountain area of Yunnan in China: a retrospective, single-center, observational cohort study.
BACKGROUND
Despite improvements in management, infective endocarditis (IE) is still associated with high mortality and morbidity. The outcome of patients with IE remains unclear in high-altitude areas of China. To characterize the epidemiological features and surgical outcomes, a retrospective analysis was conducted to 221 patients diagnosed with IE from a single center. In addition, to assess the prognosis of patients, a multivariate logistic regression model was performed to analyze the affecting risk factors.
METHODS
A retrospective analysis was conducted on the clinical data of 221 patients with IE who underwent surgical treatment at the Department of Cardiac Surgery of Yan'an Hospital Affiliated to Kunming Medical University from January 2013 to December 2019. The analysis evaluated patient demographics, pathogenic bacterial composition, echocardiography results, and surgical treatment outcomes. After a 1-year follow-up period, the mortality rate was statistically analyzed. The patients were divided into two groups based on their survival status: those who survived and those who did not. Relevant factors were compared between the two groups, and a multivariate logistic regression model was used to analyze the risk factors that affect the prognosis of patients with IE.
RESULTS
Out of the 221 patients diagnosed with IE, 164 were male and 57 were female, with an average age of 39.25±14.36 years. The most common underlying heart diseases were bicuspid aortic valve disease (24.9%), congenital heart disease (19.5%), rupture of aortic sinus aneurysm (5.0%) and rheumatic valvular disease (2.3%). The blood culture had a positive rate of 48.42% (107/221), with (29.9%) and (13.1%) being the main specifically pathogenic bacteria identified. Transthoracic echocardiography produced positive results in 89.6% (198/221) of cases. The findings included vegetation formation (100%), valve perforation or tear (21.7%), and perivalvular abscess formation (5.6%). Out of the patients, 174 underwent elective surgery, 47 received emergency surgery, and 11 died within 1 year after surgery, resulting in a mortality rate of 5.0%. However, the death group had longer operation time, cardiopulmonary bypass (CPB) time and higher EuroSCORE II compared to the non-death group (P<0.05). Logistic regression analysis identified preoperative hematocrit decrease, prolonged operation time and CPB time, high New York Heart Association (NYHA) cardiac function grade, and liver diseases as risk factors for 1-year mortality in patients with IE (OR =1.003, 0.000, 1.006, 1.026, 1.624 and 4.746).
CONCLUSIONS
IE primarily affects young and middle-aged men with rheumatic heart valvular disease as the main underlying heart disease and as the main pathogen. Surgical intervention significantly reduces early mortality in IE patients. To improve postoperative prognosis, clinicians should remain vigilant, especially in high-risk groups with preoperative hematocrit, prolonged operation time, and CPB time, high NYHA cardiac function grade, EuroSCORE II, and vegetation formation.
PubMed: 38883629
DOI: 10.21037/jtd-24-470 -
Journal of Thoracic Disease May 2024Although aortic aneurysm is associated with vascular aging and atherosclerosis, carotid and intracranial vascular disease prevalence in patients with aortic arch...
Prevalence of carotid artery stenosis and intra-cranial lesions in patients with aortic arch aneurysm and its association with intraoperative regional cerebral oxygen saturation and postoperative neurological outcomes.
BACKGROUND
Although aortic aneurysm is associated with vascular aging and atherosclerosis, carotid and intracranial vascular disease prevalence in patients with aortic arch aneurysm remains unclear. Similarly, the effect of carotid and intracranial lesions on postoperative outcomes is unknown. This study aimed to investigate the prevalence of carotid artery stenosis and intracranial lesions in patients with aortic arch aneurysm and its association with intraoperative regional cerebral oxygen saturation (rScO2) and postoperative neurological outcomes, including delirium and cerebral infarction.
METHODS
This retrospective observational study included 133 patients with true aortic arch aneurysm who underwent preoperative magnetic resonance imaging (MRI). We evaluated the prevalence of carotid and intracranial arterial lesions. Symptomatic cerebral infarction and delirium, defined by the confusion assessment method for the intensive care unit, were evaluated for their association with preoperative cerebrovascular lesions. Additionally, changes in regional saturation of the cerebral tissue at different surgical phases were evaluated for patients with and without cerebrovascular lesions.
RESULTS
Fifteen (11.3%) patients experienced symptomatic cerebral infarction, and 64 (48.1%) had postoperative delirium. Preoperative MRI showed old infarction, microbleeds, significant carotid artery stenosis, and intracranial lesions in 21.1%, 14.3%, 10.5%, and 7.5% of the patients, respectively. White matter hyperintensities with Fazekas scale 2 were observed in 40.6% of the patients, while Fazekas scale 3 were observed in 18.8% of the patients. Preoperative MRI findings and postoperative neurological outcomes were not significantly different. Seventy-six patients underwent rScO2 monitoring intraoperatively. Changes in rScO2 in patients with and without carotid/cerebrovascular lesions were not significantly different. However, rScO2 was significantly lower in patients who developed cerebral infarction.
CONCLUSIONS
Significant carotid artery stenosis and intracranial lesions were observed in 10.5% and 7.5% of the patients, respectively. Although preoperative MRI findings and changes in rScO2 or postoperative outcomes showed no significant association, patients with postoperative cerebral infarction showed significantly lower rScO2 intraoperatively.
PubMed: 38883627
DOI: 10.21037/jtd-24-78