A Surgical Case of Stanford Type A Acute Aortic Dissection Concomitant with Paraplegia / 日本心臓血管外科学会雑誌

A 76-year-old man who suffered from consistent back pain was admitted for anti-hypertensive therapy to strictly manage the early thrombosed acute type A aortic dissection (AAAD). On admission, his blood pressure could not be controlled well ; soon he complained of recurrent severe back pain. The second thoracoabdominal enhanced computed tomography revealed the progression of AAAD from DeBakey type II to type I with thrombosed pseudolumen at the descending thoracic aorta ; therefore, emergent surgical intervention by primary central repair was conducted. Paraplegia was diagnosed eight hours after surgery, then cerebrospinal fluid drainage and intravenous administration of Naloxone were started immediately followed by keeping the systemic blood pressure more than 120 mmHg. However, paraplegia had never improved and been persistent with neurological deficit of the lower extremities. We herein report a complicated surgical case of an AAAD patient with paraplegia and review the complex clinical settings.

Three Cases of Ascending Aorta-Abdominal Aorta Bypass for Atypical Coarctation with Takayasu's Aortitis / 日本心臓血管外科学会雑誌

We report 3 cases of ascending aorta-abdominal aorta bypass for atypical coarctation with Takayasu's aortitis. We performed an extra-anatomical bypass from the ascending aorta to the terminal abdominal aorta. The graft was arranged to pass through the diaphragm from the pericardium, behind the left lobe of the liver and the stomach, to the front side of the pancreas to the terminal abdominal aorta. Although the graft was exposed in the abdominal cavity in part behind the stomach, it was completely covered with the great omentum thus avoiding direct contact between the graft the abdominal organs. Decrease in the pressure gradient between the ascending aorta and the abdominal aorta was achieved using a large prosthetic graft 14-16 mm in diameter. There are several advantages with this technique. (1) Positional change during surgery can be avoided. (2) Anastomosis can be performed in non-diseased vessels. (3) This bypass graft can be branched off to visceral arteries if necessary. Reduction of the after load on the left ventricle and long-term graft patency by using a large diameter prosthetic graft were anticipated. The postoperative courses of all cases were satisfactory. Case 1 died of another disease 11 years and 11 months postoperatively, but the graft to was still patent.

Change of Oxidative Stress in Cases of Cardiac and Aortic Surgeries / 日本心臓血管外科学会雑誌

We measured oxidative stress and antioxidative stress in clinical cases of cardiac and aortic surgery, especially in extracorporeal circulation cases. From June to October 2007, 18 cases who underwent cardiac and aortic surgery with extracorporeal circulation (ECC group) and 8 cases with an infra-renal abdominal aortic aneurysm (AAA group) were studied. We measured reactive oxygen metabolites (d-ROM) in oxidative stress for the operative time, after the operation endpoint, and at one day postoperatively, one, two, and three weeks postoperatively, and one, two, three, and four months postoperatively. Regarding d-ROM, the level in the ECC group was significantly higher than that in the AAA group (<i>p</i><0.0001). Peak values were observed 3 weeks postoperatively in the ECC group and 2 weeks postoperatively in the AAA group. Although the oxidative stress increased in both groups, the peak value in the ECC group was more marked than that in the AAA group. We concluded that oxidative stress under surgical stress in cardiovascular surgery with extracorporeal circulation was higher than that under surgical stress in cardiovascular surgery for infra-renal abdominal aortic aneurysms.

Long-Term Results of Patchplasty for True Thoracic Aortic Aneurysm and the Effectiveness of Open Stents in Recurring Cases / 日本心臓血管外科学会雑誌

We reviewed 24 cases of patchplasty for true thoracic aortic aneurysm performed in our hospital up to July 2001. The size of the aneurysm in the ascending aorta was 6.0cm (1 case), and the mean size in the aortic arch was 2.5±0.5cm (4 cases), that in the distal arch was 4.7±1.7cm (11 cases), and that in the descending aorta was 3.7±0.5cm (8 cases). The hospital mortality rate was 12.5% (3 patients out of 24). The causes of death were multiple organ failure, cerebral bleeding and sepsis. In the long-term results, 2 patients had recurrence, but there were no late deaths in relation to the aneurysmal recurrence. We performed open stent operations for severe adhesion and pulmonary dysfunction in the aneurysmal recurrence cases. The postoperative course of these cases was uneventful. The open stent was useful for the treatment of the aneurysmal recurrence in the distal arch.

A Case of Tumor-Like Thrombus in the Distal Aortic Arch / 日本心臓血管外科学会雑誌

We report a 65-year-old man with a mobile thrombus in the distal aortic arch with no previous history of thromboembolic events. There was no evidence of either aneurysmal changes or aortic dissection. Transesophageal echocardiography revealed the presence of a mobile tumor in the distal arch. The patient underwent elective resection. The mobile tumor was attached to the aortic wall, approximately 3cm distal to the left subclavian artery. Histological examination revealed an old thrombus containing calcification. He was discharged on the 22nd postoperative day with no thromboembolic complications. This is the first report of a case of mobile thrombus in the distal aortic arch in Japan.

A Case of Infected Type IIIb Aortic Dissection / 日本心臓血管外科学会雑誌

A 62-year-old man was admitted to our hospital because of acute aortic dissection (DeBakey type III b). Inflammatory findings were detected and methicillin-resistant staphylococcus aureus (MRSA) was detected by blood culture. Appropriate antibiotic therapy was begun but was ineffective. Repeated CT scans revealed dilation of the false lumen with thrombus and perianeurysmal inflammatory change in the lung. A diagnosis of infected aortic dissection was made. The patient was treated by resection of the descending aorta and placement of an <i>in situ</i> Dacron graft covered with a pedicled omental flap. An infected thrombus in the false lumen was confirmed by a positive MRSA culture. Computed tomography was found to be more sensitive in the diagnosis of infected aortic dissection. When the infection is not controlled with antibiotics, prompt surgical treatment should be performed.

A Case of Popliteal Artery Stenosis due to Blunt Sports Trauma / 日本心臓血管外科学会雑誌

A 26-year-old man was suffered a tendon injury in the left knee when playing American football 3 years previously and was treated consevatively. He was admitted to our hospital because of coldness and paresthesia in the left leg since 2 months previously. Femoral angiogram revealed severe stenosis of left popliteal artery and occlusion of the anterior and posterior tibial artery. CT and MRI examination revealed a tumor which protruded into the lumen of the left popliteal artery or dissection of left popliteal artery. Operation was performed by a posterior approach. The left popliteal artery was not compressed from the lateral side and there was a white thrombus in the popliteal artery. Thromboendartherectomy and autologus venous patch plasty was done. Histopathological findings of the stenotic lesion revealed an organizing thrombus, chiefly consisting of fibrin, and intima both of which were infiltrated by granuration tissue. It was suggested that the stenotic lesion was caused by arterial wall hyperplasia or thrombus formation during the healing process after blunt arterial injury. The post-operative course was uneventful.

Surgical Treatment of Carotid Occlusive Disease / 日本心臓血管外科学会雑誌

Twenty-two patients who underwent vascular reconstruction for carotid occlusive disease by April 1998 were examined in terms of long-term results. The cause of disease was atherosclerosis in 16, and aortitis in 6. The operation method included CEA in 11 and bypass in 5 cases in the atherosclerosis cases, and CEA in 2 and bypass in 6 cases in aortitis. Cases of occlusive disease included 1 early occlusion (atherosclerosis) and 4 late occlusion (atherosclerosis 2, aortitis 2). The cause of early occlusion was considered to be due to technical factors, but late occlusion was thought to be related to progression of disease, anastomotic intimal thickening, and recurrence of inflammation. It is important to enforce strict operative indications, accurate intraoperative monitoring, and perioperative drug control.

Treatment of Vascular Graft Infection after Operation for Thoracic Aortic Aneurysms / 日本心臓血管外科学会雑誌

During 23 years, 224 cases underwent graft replacement of thoracic aortic aneurysms at our institution. Of these, 14 cases suffered postoperative vascular graft infection. Out of the 14 cases, 13 cases had sternal or mediastinal infections, and one case showed sepsis without these deep wound infections. Six cases were positive by blood culture. We thought that sternal or mediastinal infections had a high possibility of contamination of vascular grafts and that cases with these deep wound infections should be treated as cases of graft infection. Reoperation was done urgently soon after the diagnosis of infection was made. When the wound was not so deep, only debridement was performed. In addition to debridement, continuous irrigation through a chest tube and, recently, pedicled omental flap placement were done, when the wound was deep. Except for the one case without deep wound infection, 13 cases were reoperated. There were 4 hospital deaths; 3 operated cases and the nonoperated case, due to lack of control of their infection. Blood culture were positive in all these four cases. The other 10 cases were discharged from hospital without infection. Infection of vascular grafts after operation for thoracic aortic aneurysms is a serious complication and urgent reoperation should be done. However it should be noted that the mortality rate of cases with positive blood culture is high.

A Case of Marfan's Syndrome Associated with Ruptured Abdominal Aortic Aneurysm Following Bentall's Operation / 日本心臓血管外科学会雑誌

A 27-year-old man had received Bentall's operation for annuloaortic ectasia with Marfan's syndrome 4 years previously. He was admitted to our hospital because of sudden abdominal pain and lumbago. The abdominal pulsatile mass with tenderness was palpated and dilatation of abdominal aorta was revealed by abdominal ultrasonography. An emergency operation was performed under a diagnosis of ruptured abdominal aortic aneurysm. At operation, the infrarenal abdominal aorta formed a fusiform aneurysm of which maximum diameter was 6cm. The aneurysm had a thin wall, and ruptured opening about 2cm in diameter at the posterior wall, but no thrombus inside. Graft replacement was done from the infrarenal abdominal aorta to the bilateral common iliac artery using knitted Dacron vascular prosthesis, and reconstruction of inferior mesenteric artery with wrapping of the proximal anastomosis were performed. Histopathological examination of the aneurysmal wall revealed medial necrosis and degeneration, by which Marfan's syndrome was diagnosed. Although abdominal aortic aneurysm is rarely associated with Marfan's syndrome, it often shows rapid development and has a high risk of rupture. Therefore, we suggest that strict observation and early operation are important for abdominal aortic aneurysm associated with Marfan's syndrome.

Therapeutic Results of Critical Leg Ischemia in Aged Patients with Arteriosclerosis Obliterans / 日本心臓血管外科学会雑誌

We treated 261 arteriosclerosis obliterans cases with critical leg ischemia since 1976. Those patients aged 75 years and older were designated as the elderly group and were compared with those under 75 years of age. Among the elderly patients with critical leg ischemia, the percentages of women and Fontaine scale IV cases were higher. The condition of those who had to undergo an initial major amputation was often complicated by cerebrovascular diseases, resulting in a higher early death rate after operation. Therefore, the necessity of early diagnosis and immediate treatment must be emphasized. There were no differences in patency and limb salvage rates between the two groups. In cases of arterial reconstruction however, graft occlusion in the elderly group immediately after operation was frequently observed. It is important to include drug therapy in follow-up to prevent occlusion of the graft following surgery in elderly patients.