Evaluation of Catheter-Directed Thrombolysis for Acute Deep Vein Thrombosis / 日本心臓血管外科学会雑誌

We report the efficacy of catheter-directed thrombolysis (CDT) for acute deep vein thrombosis. Between January 2003 and August 2004, 20 patients were treated with CDT for occlusive femoral, ilio-femoral and vena caval thrombosis, for less than 2 weeks from onset. Average age was 56.4 years (range 30-78 years), 11 patients were male, and the duration of leg symptoms was 4.4 days (range 1-12 days). Routine temporary inferior vena caval filters were used, and a multi-lumen catheter was inserted from the popliteal vein. Urokinase was used via the catheter by the combination drip infusion method and pulse-spray method. All patients received heparin and stasis of venous flow was prevented with intermittent pneumatic compression. If thrombus remained, mechanical thrombolysis was necessary. Metallic stents were implanted for iliac vein compression syndrome and organized thrombus. Venographic severity score (VS score) and extremity circumference were used to evaluate the effects of treatment. The duration of the treatment was 5.0±0.28 days (range 2-9 days) and the total dosage of urokinase was 1, 025, 000±57, 000 units (range 360, 000-1, 680, 000 unit). One (5%) iliac vein compression syndrome and two (10%) organized thrombi were treated by implanted metallic stents. Giant thrombi was captured by temporary inferior vena caval filters in two patients, but there was no pulmonary embolism. Two patients had thrombophilia, one was antiphospholipid syndrome and one was protein S deficiency. There was an early recurrence in one patient and re-CDT was needed. The VS score deteriorated to 6.2±2.5 (post CDT) significantly (<i>p</i><0.0001) from 26.2±6.3 (pre CDT). CDT for acute deep vein thrombosis was effective and its early outcome was acceptable.

Experience of Popliteal Arterial Aneurysm / 日本心臓血管外科学会雑誌

In general the incidence of peripheral arterial aneurysm is said to be low. We focussed on popliteal aneurysm and enrolled 18 legs in 14 patients with popliteal aneurysm who visited us during the period from 1974 to January 1998 in our study. Acute arterial occlusion was observed as a complication in 6 of the 14 patients (42.9%) and rupture developed in 4 patients (28.6%), and on those occasions this disease was frequently detected and treated for the first time. Although this disease is said to scarcely affect prognosis, we encountered patients for whom amputation of the leg was unfortunately required. This disease was thus considered to require sufficient care. Popliteal arterial aneurysm is frequently palpable from the body surface and increased recognition of this disease should enable more appropriate treatment.

The Role of Systemic Inflammatory Response Syndrome for Acute Arterial Occlusion of the Lower Limb / 日本心臓血管外科学会雑誌

Reperfusion injury occasionally occurred after revasculization of acute arterial occlusion (AAO). The most common reason of death is myonephropatic metabolic syndrome due to reperfusion injury. This paper focusses on the criterion of systemic inflammatory response syndrome (SIRS). From January 1987 to April 1996, we treated 89 patients (male 59/female 30) with lower limb AAO. The mean age was 68.5 (ranging from 16 to 94) years old. There were 59 cases of thrombosis, 25 of embolism, 2 trauma and 3 dissecting aneurysm of the aorta. These patients were divided into two groups according to whether or not they fulfilled the criterion of SIRS. Of these patients, 46 cases met the criterion of SIRS (SIRS group) but the other 43 did not (non-SIRS group). We compared the two groups. The mortality of the SIRS group (23.9%) was higher than the non-SIRS group (2.3%). The ischemic time of the SIRS group (83.1±113.3 hours) was longer than the non-SIRS group (37.5±38.2 hours). Complications of MNMS were more common in the SIRS group (15.3%) than in the non-SIRS group (2.3%). The ischemic area in the SIRS group was remarkably less than in the non-SIRS group. Conclusion: The criterion of SIRS as indicated by the measurement of interleukin 8 (IL-8) was a useful prognostic parameter for limb salvage rate and mortality of AAO patients.

Recurrent Suprarenal Abdominal Aortic Aneurysm(AAA) after Repair Infrarenal AAA / 日本心臓血管外科学会雑誌

We encountered a recurrent suprarenal abdominal aortic aneurysm (AAA) patient with coronary artery disease and hyperlipidemia after repair of infrareanal AAA. A 72-year-old woman complaining of an abdominal throbbing mass was admitted. Computed tomography (CT) and aortography revealed infrarenal AAA which was totally removed and Dacron graft was replaced. The patient was followed as an outpatient. At the time of initial graft replacement there was no remarkable aneurysmal change in suprarenal abdominal aorta. Five years after the initial operation, a suprarenal AAA 5cm in diameter was detected by ultra sonographic examination. CT scan and aortography confirmed suprarenal AAA involving the celiac trunk of the supramesenteric artery and renal artery. Redo AAA operation with reconstruction of these branches was performed under V-A bypass support in a thoracoabdominal approach. Slight renal and liver dysfunction occurred postoperatively. However, serum creatine GOT and GPT values normalized by the ninth postoperative day. Postoperative aortography revealed patency of all branches.

A Case of Pseudoaneurysm of the External Iliac Artery after Total Hip Arthroplasty / 日本心臓血管外科学会雑誌

A case of pseudoaneurysm of the external iliac artery after a total hip arthroplasty is reported. A 48-year-old man had undergone a total left hip arthroplasty 5 years previously. Acute arterial occlusion (AAO) of the left lower extremity occurred 3 times. AAO was due to pseudoaneurysm of the external iliac artery, which was detected by rotating digital subtraction angiography (DAS). Aneurysmectomy and reconstruction were carried out. Rotating DSA was useful for the diagnosis of this unusual case of pseudoaneurysm of the external iliac artery after a total hip arthroplasty is unusual.

Two Cases of Cystic Adventitial Disease of the Popliteal Artery / 日本心臓血管外科学会雑誌

Cystic adventitial disease of the popliteal artery is a rare cause of lower extremity occlusive disease. We report 2 cases of this disease. Two male patients aged 27 and 59 year old complaining of intermittent claudication visited our vascular service. Angiography showed a smooth sharp defect of the popliteal artery. Postcontrast computed tomography (CT) scanning and magnetic resonance image (MRI) showed a cystic lesion around the popliteal artery. One patient underwent resection of the cyst, which in the other patient endscopic surgery was performed with the aid of intravascular ultrasonograpy and intravascular endscope. Fifty three cases of this disease have been reported in Japan so far. These patients included 45 men and 8 women with a mean age of 47.7, ranging from 19 to 76 years old. Chief complaints were commonly intermittent claudication and sensory disturbance. In all cases, angiography revealed a smooth sharp defect. Recently 3D-CT scan, ultrasonography and magnetic resonance angiography (MRA) also are accurate for cystic lesions around the popliteal artery and these new technologies easily distinguish such cases from arteriosclerosis obliterans, Buerger disease and popliteal entrapment syndrome. Treatment consist resection of the cyst, in 27 cases reconstruction of the popliteal artery using a saphenous vein graft or artificial graft in 19 cases, percutaneus aspiration under the guide of CT and endscopy in 2 cases and 1 with spontaneous resolution, was seen in 1 case. In conclusion, we encountered 2 cases of cystic adventitial disease of the popliteal artery. 3D-CT scan, ultrasonography and MRA were useful for preoperative diagnosis and evaluation of postoperative condition.