Debranching and Endovascular Repair of a Saccular Aneurysm of the Aortic Arch with Preoperatively Devised, Fenestrated and Branched Stent Grafts (Surgeon-Modified Fenestrated and Retrograde Branched Technique) / 日本心臓血管外科学会雑誌

An 85-year-old man being treated for idiopathic interstitial pneumonia underwent chest CT 6 months prior to the current admission and was diagnosed as having an expanding saccular aneurysm of the aortic arch. Due to the patient's advanced age and the anatomical position of the aneurysm, it was difficult to perform total aortic arch replacement or hybrid arch repair with a commercially available device. After ethical approval had been obtained from the institutional review board, a commercially available stent graft (Relay Plus®) was fenestrated with a 12-mm hole. Under general anesthesia, bypass grafting was performed between the bilateral axillary arteries and the right common carotid artery with a T-shaped ring-supported e-PTFE prosthesis. The fenestrated stent graft was advanced through the left femoral artery and deployed with the device fenestration located at the bifurcation of the brachiocephalic artery. Then, a branched stent graft was deployed through the right common carotid artery in a retrograde manner between the brachiocephalic artery and the ascending aorta through the fenestration to complete the procedure. The patient had an uneventful postoperative course, with no detectable endoleak on postoperative digital subtraction angiography. The current technique, involving the use of an easy-to-make device，is effective for endovascular aneurysm repair, especially when a proximal neck needs to be created in the ascending aorta.

Debranching and Endovascular Repair for Kommerell's Diverticulum Involving Right-Sided Aortic Arch with Mirror Image Branching / 日本心臓血管外科学会雑誌

A 71-year-old man with an abnormal shadow on chest x-ray was given a diagnosis of Kommerell's diverticulum involving the right-sided aortic arch with mirror image branching. Furthermore, mild funnel chest had been seen on CT scan more than 10 years earlier. The patient was followed up because there were no symptoms ; the Kommerell's diverticulum expanded to reach 63 mm in diameter. To eliminate the risk of rupture, we performed thoracic endovascular aortic repair (TEVAR) with a commercially available device, consisting of bypass grafting of the supra-aortic branches. The patient was discharged from the hospital in good clinical condition, with no signs of endoleak and currently shows no indications of device migration. We thus concluded that debranching TEVAR for Kommerell's diverticulum with right-sided aortic arch is minimally invasive, safe, and effective. Availability of this device that has a new performance feature is expected to improve treatment results and lead to advances in minimally invasive endovascular repair.

Traumatic Ulnar Artery Aneurysm: A Case Report / 日本心臓血管外科学会雑誌

A 42-year-old man noted a left hypothenar mass about one week after hitting the palm of his left hand. Although he did not seek treatment, numbness and cyanosis of the left 2nd, 3rd, 4th, and 5th digits appeared suddenly about one year later. A computed tomography scan revealed an ulnar artery aneurysm with a mural thrombus, with a maximal diameter of 20mm, at the site where the ulnar artery passed near the hamate bone. The aneurysm was excised, and the ulnar artery was reconstructed with direct end-to-end anastomosis. Traumatic ulnar artery aneurysm is commonly seen in workers who use the hypothenar eminence of their hands as a hammer, and is usually accompanied by finger ischemia.

A Case of Pseudo-False Aneurysm of the Left Ventricle with Ventricular Septal Perforation / 日本心臓血管外科学会雑誌

We report here a case of pseudo-false aneurysm of the left ventricle with ventricular septal perforation following myocardial infarction. An 85-year-old man was treated for acute inferior myocardial infarction three months previously. He was admitted due to an acute posterior myocardial infarction. Since a cardiac catheter study showed three diseased coronary arteries, a left ventricular aneurysm and a ventricular septal perforation, he underwent emergency surgery. The ventricular aneurysm was located on the right side along the posterior descending branch, and was 4×1.5cm in size. We ruled out a false aneurysm because there was no adhesion between the epicardium and the pericardium. The communication between the aneurysm and the left ventricle was then closed with a Gore-Tex patch, and the perforation of the right ventricle was closed directly. CABG was performed for the left anterior descending artery using a vein graft. The postoperative course was uneventful, and he was discharged on the 27th postoperative day. The pathological findings showed a pseudo-false aneurysm of the ventricle.

Acute High Aortic Occlusion with Aplastic Anemia / 日本心臓血管外科学会雑誌

A 67-year-old man had been diagnosed as having aplastic anemia three years ago. He had taken anabolic steroids continuously. He suddenly complained of the ischemic signs of the lower extremities. Aortography showed the total occlusion of the abdominal aorta with encroachment upon the left renal artery. The right renal artery and superior mesenteric artery were intact. Laboratory data showed acute renal failure. We selected an axillo-femoral bypass because of aplastic anemia and acute renal failure. Throughout the intraoperative and post-operative periods the patient showed a bleeding tendency, then disseminated intravascular coagulation (DIC) has occurred. He required much blood transfusion, anti-coagulant drugs and hemodialysis post-operatively and finally recovered from acute renal failure and DIC.

Clinical Experiences of Dissecting Aortic Aneurysm with Organ Ischemia / 日本心臓血管外科学会雑誌

We studied 6 surgical cases of dissecting aortic aneurysm with organ ischemia, consisting of 4 cases of DeBakey type I dissection and 2 cases of DeBakey type III b dissection and the average age was 62 years old. The ischemic organs were, the brain and upper extremities, intestine and kidney, kidney, kidney and lower extremity, and bilateral lower extremities, respectively. We performed the graft replacements of the ascending aorta or ascending aorta and arch for DeBakey type I dissection, and bypass or Y-graft replacement for DeBakey type III b dissection. In one case of DeBakey type I dissection we performed a second Y-graft replacement two days after the first operation. MNMS (myonephropathic metabolic syndrome) developed in two cases of 3 lower extremity ischemia. The results were unsatisfactory because 3 patients died. To improve of the outcome of surgical treatment in case of dissecting aortic aneurysm with organ ischemia, preoperative appropriate diagnosis and appropriate surgical planning are necessary.

Three Operations Following Conservative Therapy in Patients with Stanford A Type Acute Thrombosed Aortic Dissection / 日本心臓血管外科学会雑誌

We performed 3 operations for Stanford A type aortic dissections which were confirmed as acute thrombosed type by contrast chest CT. Initially conservative therapy was chosen in all patients. In case 1, a 64-year-old woman received ascending aortic replacement with a Hemashield^® vascular prosthesis 3 days after admission, because of increasing diameter of the ascending aorta and sustained back pain. In case 2, a 54-year-old woman, we replaced the total aortic arch with Hemashield^® graft, on an emergency basis since recanalization of the false lumen was revealed by contrast CT and D.S.A. 3 days after admission. In case 3, a 52-year-old woman, cardiac tamponade occured on the 30th admission day even though anti-hypertensive treatment had been effectively performed immediately after onset. Emergency D.S.A. revealed an“ulcer like projection” in the ascending aorta, so following pericardiocentesis, we resected and directly anastomosed the ascending aorta at the entry site 34 days after onset. Generally, acute thrombosed aortic dissections should be treated conservatively. Here we reported 3 operations for acute thrombosed Stanford A type aortic dissections even under good B.P. control, suggesting the importance of careful and long term observation for acute thrombosed aortic dissections.

Surgical Experience of Localized Abdominal Aortic Dissections / 日本心臓血管外科学会雑誌

Six surgical cases of localized abdominal aortic dissections experienced from 1977 to August, 1992 comprised 1.1% of all true aneurysms of the abdominal aorta (563 cases) and 2.5% of all aortic dissections (242 cases) for the same period. The mean age of the 6 patients at operation was 70 years (range from 62 to 74 years, 2 males, 4 females). All dissections were localized at the infrarenal abdominal aorta and one case showed three-channeled dissection. All cases were diagnosed preoperatively and prosthetic graft replacement was performed. Localized abdominal aortic dissection was reported in only 30 cases, including our cases, in the Japanese literature. Compared to thoracic aortic dissection, the development of symptoms is slow, age is high and the condition is often accompanied by hypertension and atherosclerosis.

Renal aneurysm in solitary kidney. A successful case and surgical consideration / 日本心臓血管外科学会雑誌

A 57-year old woman with a left renal aneurysm in a solitary kidney was successfully treated by <i>in situ</i> aneurysmectomy under careful renal preservation (intermittent perfusion combined with topical cooling). In our knowledge, 219 cases of renal aneurysms have been reported in the Japanese literatures by 1987. Among those cases, only 9 cases including our case were noted to have a solitary kidney. Surgical repair was recommended for renal aneurysm, especially, in a solitary kidney because of the high incidence of nephrectomy when ruptured.