Aortic Patch Repair and Bronchial Stenting for a Giant Thoracic Aortic Aneurysm with Airway Obstruction / 日本心臓血管外科学会雑誌

A 62-year-old woman with severe breathlessness was admitted to the emergency department. Computed tomography revealed nearly complete airway obstruction by a giant thoracic aortic aneurysm, measuring 90 mm in diameter. Previously, she had undergone hemiarch replacement for acute aortic dissection and was not attending follow-up consultations for personal reasons. Owing to the excessive adhesion of the aorta, the aorta and aneurysm could not be detected. We decided to remove the hematoma inside the aneurysm and perform aortic patch repair instead of total arch replacement. After cardiopulmonary bypass and deep hypothermic circulatory arrest with antegrade selective cerebral perfusion, a hall of 30 mm diameter through the intimal wall was found at the aortic distal arch. The hall was a neck of the aneurysm. A dacron patch was attached to the intimal wall covering the hall after removal of the hematoma to reduce the volume of the aneurysm. After surgery, her airway was not completely relived yet owing to the remaining hematoma. Subsequently, bronchial stenting was performed. Bronchial compression was successfully resolved. She underwent tracheotomy and safely withdrew from the respirator. Aortic patch reconstruction is an alternative technique for thoracic aortic disease in the case of incapability of graft replacement or endovascular therapy. Additionally, although bronchial compression from an aortic aneurysm is not common, it could be life threatening. Endobronchial stenting is indicated not only for unresectable malignancy but also for benign lesions like an aortic aneurysm.

Incidental Diagnosis of a Giant Coronary Artery Pseudoaneurysm / 日本心臓血管外科学会雑誌

Coronary artery pseudoaneurysms are rare, and usually present as long-term complications of percutaneous coronary intervention or coronary artery bypass grafting, or as a side effect of systemic vasculitis, including Behçet disease. A 60-year-old man was admitted to our hospital due to a hemorrhagic duodenal ulcer. As a mucosal bulge at the fornix was detected on upper gastrointestinal endoscopy, the patient underwent a further examination of other organs using computed tomography. Coronary computed tomography and coronary angiography revealed a right coronary artery aneurysm with a maximum diameter of 43 mm and 90% stenosis in the left anterior descending artery. The patient successfully underwent coronary artery aneurysmectomy and coronary artery bypass grafting of the left anterior descending artery using the left mammary artery. The pathological findings were consistent with those of a pseudoaneurysm. In the present case, the coronary pseudoaneurysm may have been due to traumatic because he had experienced neither coronary treatments nor systemic vasculitis, although he had suffered blunt trauma that involved splenectomy 30 years earlier.

Disruption of a Dacron Graft Caused by the Vertebral Body of the Lumbar Vertebrae after Reconstruction of the Thoracoabdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

We report an extremely rare case of early disruption of a woven Dacron graft by the mechanical force of the lumbar vertebral body after a thoracoabdominal aortic aneurysm repair. A 75-year-old man with thoracoabdominal aortic aneurysm of Crawford type III underwent replacement of the thoracoabdominal aorta using a Gelweave thoracoabdominal graft (Vascutek) and a Gelweave bifurcate graft (Vascutek). His postoperative course was uneventful and discharged on postoperative day 20. On the 22nd postoperative day, he was re-hospitalized with low back pain. Computed tomography scanning showed a massive hematoma around the region of the graft-to-graft anastomosis. He underwent an emergency operation. At laparotomy, the Gelweave thoracoabdominal graft had a 2-mm hole which had been caused by the mechanical force of lumbar vertebral body, which was not related to the anastomosis. The graft was repaired with a 4-0 polypropylene buttress suture and a new prosthesis graft was used to wrap around the disrupted graft.

A Case Report of Acute Thrombotic Obstruction of the On-X Mitral Valve Prosthesis / 日本心臓血管外科学会雑誌

A 39-year-old woman underwent aortic valve replacement (AVR) with a 21 mm St Jude Medical prosthesis and mitral valve replacement (MVR) with a 27/29 mm On-X valve prosthesis when she was 38-year-old, and she was discharged uneventfully. Five months after the operation, she was admitted with aggravated dyspnea. Upon admission she went into serious heart failure, followed by cardiogenic shock. Cineradiography showed a restricted opening of the On-X mitral valve prosthesis and transesophageal echocardiography demonstrated thrombus formation on the mitral valve annulus. We diagnosed thrombosed valve and reoperated urgently. Intraoperatively we found a large amount of fresh thrombus extending from the sewing cuff that restricted valve motion. The valve was cleaned and left in place. Although the heart recovered well, she lost some neurologic functions and was transferred to another hospital for rehabilitation. We also investigated the opening angle of the On-X mitral prosthesis in other patients who had clinically normal valve function.

Mid-Term Results of the Use of Radial Artery Graft for Coronary Artery Bypass (Radial Artery Graft Versus Saphenous Vein Graft) / 日本心臓血管外科学会雑誌

The use of the radial artery (RA) for coronary artery bypass grafting (CABG) is increasing. This study describes mid-term results of the use of RA for CABG. Between March 1996 and March 1999, we performed 134 CABGs using RA or saphenous vein graft (SVG) for the left circumflex branch area or diagonal branch area. The mean age was 62.6±9.6 years in the RA group and 65.0±7.8 years in the SVG group. The average number of anastomoses was 2.7per patient. RA was anastomosed with the postero-lateral branch (PL) in 69 cases, with the obtuse marginal branch (OM) in 29 cases and with the diagonal branch (DB) in 10 cases. SVG was anastomosed with PL in 26 cases, with OM in 14 cases and with DB in 2 cases. The proximal anastomosis was made with the ascending aorta in all cases. No sequential bypass anastomosis was used in any case. The early patency rate of the grafts was 97.9% (93/95) in RA and 91.7% (33/36) in SVG. The clinically negative rate in the treadmill test (TMT) performed later was 99.0% (102/103) in RA and 90.9% (30/33) in SVG. The late patency rate of the grafts was 92.9% (13/14) in RA and 50.0% (3/6) in SVG. Perioperative death occurred in 5 cases. Late cardiac death occurred in 2 cases (0.02%) of the RA group and 1 case (0.03%) of the SVG group. The 3 year-survival rate free of cardiac events was 92.8% in the RA group and 80.9% in the SVG group. The use of RA for CABGs is not only effective for myocardial revascularization, but also can be expected to bring about good patency as a late result.