Graft Replacement and Reconstruction of the Celiac, Superior Mesenteric and Both Renal Arteries in a Patient with Primary Dissection of Juxtarenal Abdominal Aorta / 日本心臓血管外科学会雑誌

Primary abdominal aortic dissection occurs infrequently. We experienced aortic dissection originating at the level of the right renal artery, for which graft replacement and reconstruction of the aorta and also the celiac, superior mesenteric and both renal arteries were performed. A 44-year-old woman with severe back pain was admitted to our hospital. CT and aortogram revealed primary abdominal aortic dissection. The abdominal aorta was replaced with a trunk prosthetic graft, to which were connected smaller grafts for the four abdominal visceral and also lumbar arteries. The intercostal artery was preserved by a diagonal trasection at the upper end of the graft site. To prevent ischemia of the visceral organs, we used a selective perfusion technique to the superior mesenteric artery and both renal arteries. The postoperative course was uneventful. The postoperative aortogram demonstrated good patency and function of the trunk graft and reconstructed visceral arteries

A Case of Reoperation for Budd-Chiari Syndrome after the Occlusion of a Cavoatrial Bypass Graft / 日本心臓血管外科学会雑誌

A 42-year-old man with Budd-Chiari syndrome was admitted to our institute for reoperation. The patient had undergone a cavoatrial bypass 9 years previously, but early occlusion of the bypass graft was suspected as there was reappearance of dilated abdominal veins. Preoperative cavography showed occlusion of the bypass graft and well-developed collateral veins. The patient underwent direct reconstruction with endo-venectomy and patch angioplasty of the obstructed vena cava and hepatic veins using a ringed ePTFE graft. The markedly dilated tortuous subcutaneous veins of abdominal wall disappeared immediately after reoperation. Postoperative cavography showed the patency of the IVC and three hepatic veins, IVC-right atrium mean pressure gradient decreased from 16mmHg to 6.5mmHg. Direct reconstruction should be the first choice in surgical treatment for Budd-Chiari syndrome, and is also useful as a reoperative procedure.

A Case of Ruptured Dissecting Aortic Aneurysm Involving a Right-sided Aortic Arch / 日本心臓血管外科学会雑誌

A case of ruptured dissecting aortic aneurysm (DeBakey IIIa) involving a right-sided aortic arch is reported. A 54-year-old man was admitted to our hospital with a complaint of severe back pain. Roentgenogram and enhanced computed tomography of the chest revealed a right-sided aortic arch, right descending thoracic aorta and right pleural effusion. Thoracocentesis of the right thoracic cavity revealed bloody fluid. The ruptured dissecting aortic aneurysm was suspected. The enhanced CT of the chest revealed leakage of the contrast medium at the level of the bifurcation of the trachea so aortography wasn't performed. There was a 2cm intimal tear in the descending aorta. Resection and grafting of the aneurysm via right thoracotomy was performed. The patient made an uneventful recovery and was discharged 4 weeks later. It is pointed out that the operative method and/or decision of the method of approach for the aneurysm involving a right arch are difficult because of the aberrant left subclavian artery and/or tortuous descending thoracic aorta. Impeccable judgement is needed for emergency operation of ruptured dissecting aneurysms like the present case.

A Case of Ruptured Coronary Arteriovenous Fistula with Cardiac Tamponade / 日本心臓血管外科学会雑誌

A 59-year-old female case with cardiac tamponade due to rupture of the coronary arteriovenous fistula is described. Preoperative coronary arteriography showed bilateral coronary-pulmonary fistulae not associated with significant atherosclerotic stenosis. On opening the pericardium after establishing F-F bypass, the pericardial sac contained 300 grams of partially clotted blood. There was subepicardial hematoma along the area of the left anterior descending artery and the left circumflex artery without any other abnormal findings of the heart. The operation consisted of hemostasis with several mattress sutures along the left anterior descending artery and the left circumflex artery, closure of multiple fistulous openings from within the pulmonary artery, and ligation of abnormal dilated vessels originating from bilateral coronary arteries. The coronary arterio-venous fistula with aneurysmal dilatation should be operated on aggressively, whether symptomatic or asymptomatic, to prevent the rupture of fistulae.

Aortic Valve Replacement in Patients with Pulmonary Hypertension / 日本心臓血管外科学会雑誌

During the last 15 years, isolated aortic valve replacement was performed in 122 patients, 12 of whom had severe elevated pulmonary systolic pressure (PAS) of 50mmHg or over. A comparative study of preoperative and postoperative data was done between two groups; group I (<i>n</i>=12), with a pulmonary systolic pressure 50mmHg or over, and group II, with a value of under 50 mmHg (<i>n</i>=45). On preoperative evaluation, cardiomegaly and constrictive pulmonary dysfunction were found in group I and also PAWP, mean pressure of PA, PAS, LVEDP and RVEDP were of a higher value in group I than group II. The LVEDP was high in group I and correlated well with PAS preoperatively, suggesting that pulmonary hypertension was a consequence of severe LV dysfunction. There was no difference in the operative mortality and postoperative complication between these two groups. CTR, PAWP, mPA and PAS decreased to within the normal range postoperatively. It was concluded that pulmonary hypertension does not adversely effect the operative mortality and postoperaive complications of AVR, and the cause of the elevated pulmonary pressure was thought to be due to the impaired LV function.