Purpose To describe the efficiency of the candy-plug technique using an Excluder aortic extender and obtain optimal aortic remodeling. Case A 46-year-old male patient had a history of acute type B aortic dissection and progressive dilation of the descending aorta (53 mm diameter) with a patent false lumen. He was treated with the candy-plug technique, using an Excluder aortic extender of 32-45 mm was placed and a 16-mm Amplatzer Vascular Plug II. No technical complications were observed in the patient. Good aortic remodeling was observed after 6 months, CT showed complete thrombosis of the false lumen and reduction of the maximum perpendicular diameter of the descending aorta from 53 to 47 mm. The diameter of the other proximal zones of the descending aorta was 45-47 mm, and the Excluder aortic extender changed into an elliptical shape. This is the first report of good aortic remodeling with an elliptical shape by performing the candy-plug technique. Discussion The candy-plug technique using an Excluder aortic extender is an improved method for occluding the false lumen as it provides improved aortic remodeling. The 2 indications for this surgery are limited. A large entry point in the descending abdominal aorta that is more peripheral than the candy-plug position must be visible on contrast-enhanced CT and the false lumen is not too large. We consider candy-plug placement in the true lumen central to the TEVAR to avoid occluding the artery of Adamkiewicz, since we have to avoid the thrombosis of the peripheral false lumen where a candy-plug was placed. Since it is unclear whether long-term results are satisfactory, we must continue to study chronic aortic type B dissection.

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Background Although there have been many reports concerning the normal position of the umbilicus, the measurements were performed from the surface of the body in all cases. We examined computed tomography (CT) images to determine the accurate position of the umbilicus in children. Methods We retrospectively examined the CT data of 120 Japanese children (60 boys, 60 girls). The angle between both iliac crests to the umbilicus (IU angle), the angle between both anterior superior iliac spines and the umbilicus (AU angle), and the ratio of the length from the xiphoid process to the umbilicus and length from the umbilicus to the pubic symphysis were measured. Results The mean AU angle was 33.7° ± 5.1°, showing the least data variations. A significant difference was noted in the AU angle between boys and girls (32.7° ± 4.6° and 34.6° ± 5.4° respectively; p = 0.04). When we defined the position of the umbilicus as an AU angle of 33° in boys and 35° in girls, 115 children (95.8%) fell within ±10°. Conclusions The AU angle is the preferable predictor of the umbilicus position in children.

We read with interest the article by Orihashi and colleagues 1 concerning axillary artery cannulation pitfalls. We present another possible drawback of axillary artery cannulation. A 69-yearold woman was admitted to the Department of Cardiac Surgery for a type A acute aortic dissection involving the innominate artery. After the usual cannulation of the right axillary artery, with a prosthetic side graft, and the right atrium, cardiopulmonary bypass (CPB) was established with no perfusion problems. At 26 C core temperature, CPB was arrested and the aorta was opened longitudinally. The entry tear was located in the ascending aorta. The innominate artery was clamped, and brain perfusion was begun through the axillary artery cannulation. The dissected aorta was excised, and a 30-mm prosthetic vascular graft was sutured to the distal aortic stump, just proximal to the innominate artery. The vascular graft was clamped, and, always via the axillary artery, systemic perfusion was restored. Near-infrared spectroscopy revealed poor cerebral perfusion, whereas the arterial line inflow pressure increased significantly. Suspecting an obstruction in the axillary artery or innominate artery, we directly cannulated the vascular graft and continued CPB antegradely. This allowed an uneventful completion of the procedure.In aortic dissections involving the innominate artery, there may be a reentry

We can safely treat mitral valve disease with mitral annular calcification using Sapien 3 valve through the incision of the right side of the left atrium under direct visualization preventing atrio-ventricular disruption and left ventricular outflow tract obstruction.