Extracranial internal carotid fibromuscular dysplasia associated with successfully treated hyperacute cerebral infarction

Fibromuscular dysplasia [FMD] is a segmental non-atheromatous and non-inflammatory stenosing angiopathy of unknown cause and the cervico-cephalic [cc] FMD is relatively uncommon. The big majority of the ccFMD patients are Caucasians and there have been several reports in Japan up to the present, the greatest number of which were associated with intracranial aneurysms or discovered post-mortem. The association with cerebral infarction has been rarely described in Japanese patients. We report a case of hyperacute cerebral ischemia caused by embolism, originating in the internal carotid artery. We performed super-selective thrombolysis of a middle cerebral artery embolic ooclusion by a microcatheter with excellent result. Although ccFMD can be associated with a range of vascular pathology and cerebral ischemia is only one of the possibilities, it should be considered as a cause in these young patients where there is no evidence of other embolic sources. Early intervention in these cases can prevent ischemic brain damage

Treatment of severe subarachnoid haemorrhage -440 cases clipping versus coiling

We reviewed the ruptured cerebral aneurysm treatment in Fujita Health University Hospital with multimodalities of treatment. Form 1996 to 2002, cerebral aneurysms were treated by two methods: direct microsurgical clipping and endovascular coiling. Both were selected based on definite guidelines of clinico-radiological criteria as follows: endovascular therapy comprised of GDC embolisation and CSF washout with UK or TPA performed in cases with Hunt and Kosnik grade 4 [GCS 7,8], and grade 5 [without hydrocephalus or intracranial haemorrhage], age > 70 years, subacute stage [4-14 days of vasospasm], basilar aneurysm and peripheral MCA/PCA aneurysms. Microsurgical clipping with drainage procedure was performed in cases with Hunt and Kosnik grade 0-3, grade 4 [GCS 9-12], age less than 70 years, grade 5 with hydrocephalus or intracerebral haematoma and acute stage [0-3 days after bleed]. The patient's outcome was measured using Glasgow Outcome Score [GOS] at the time of discharge. In our series of severe [poor grade] SAH cases, 120 cases underwent clipping and 59 cases underwent coiling. Though they accounted for 37.8% and 48% of total SAH cases respectively, the outcome was satisfactory. In each treatment modality, a favourable outcome [good recovery/moderate disability] was found in 75.4% of clipping cases and 55.2% of coiling cases clipping had a better outcome than coiling in cases of acute severe SAH in our series and is in contrast to ISAT results

Clinical Results of Ascending Aorta-Abdominal Aorta Bypass / 日本心臓血管外科学会雑誌

Ascending aorta-infrarenal abdominal aorta bypass was performed in 8 patients: 4 patients with dissecting aortic aneurysm, 3 patients with thoracic aneurysm and 1 patient with stenosis of the thoracic aorta after grafting for congenital thoracic aneurysm. Four patients who had aortic dissection underwent the thromboexclusion method, but thromboexclusion of the thoracic aorta occured in only one patient after additional clamp to the distal thoracic aorta. He is the only long-term survival in this series. The thromboexclusion method was also performed in two patients with infectious thoracic aortic aneurysm, but they died of aneurysmal rupture within 13 months after operation. One patient who undewent resection of a thoracic aneurysm with extra-anatomic bypass, developed respiratory insufficiency and paraplegia, and died of pneumonia. The patient with thoracic aortic stenosis is alive and well 11 years after operation. The indications of the thromboexclusion method for thoracic aneurysm should be limited only to very poor-risk patients who seem to be inaccessible to a direct approach. Ascending aorta-abdominal aorta bypass is recommended in cases of thoracic aortic stenosis.

Long-term Results of Direct Surgical Approach to Left Main Coronary Artery / 日本心臓血管外科学会雑誌

Five patients with isolated stenosis of the left main coronary artery or stenotic ostial lesions underwent direct coronary artery surgery. These surgical approaches included vein patch angioplasty in 2 cases, punch out endarterectomy in 1 case, and resection of the thickened aortic wall and transaortic endarterectomy in 2 cases. Early results were satisfactory, except for one case who died due to severe LOS and MOF. In the late postoperative period, one case of vein patch angioplasty died due to cerebral bleeding, and in the other case, stenosis existed in position of distal patch anastomosis. Since direct coronary artery surgery was successful in both early and late postoperative fidings, it is believed to be useful and safe technique if the candidates are selected properly.

Clinical Experience of Right Heart Bypass Using Heparin-coated Tube and Roller Pump System / 日本心臓血管外科学会雑誌

A 47 year-old man with frequent attacks of ventricular tachycardia (VT) due to arrhythmogenic right ventricular dysplasia (ARVD) developed severe right heart failure following cryoablation of the multiple VT focuses. Inotropic support and intraaortic balloon pumping failed to maintain the systemic circulation, so that we performed the right heart bypass (RHB) using a heparin-coated tube and roller pump. With the use of RHB, systemic circulation improved. We attempted to wean the patient off after 14 days RHB support. However this was unsuccessful because of poor RV function, and RHB was recommenced. The patient finally died of multiple organ failure on the 21st postoperative day, but the major organ function was well maintained for at least two weeks. The heparin-coated tube and roller pump system is easy to handle, and is suitable as a short term lifesaving adjunct for severe right ventricular failure.

An Experimental Evaluation for Blood Compatibility of Mock Cardiopulmonary Bypass Systems / 日本心臓血管外科学会雑誌

To estimate the blood compatibility during extracorporeal circulation, we designed mock circulation system consisted of a membrane oxygenator and vinyl circuit with roller pump. Primed with 200ml Ringer's acetate and 200ml of fresh whole human blood, mock circulation was worked at flow rate 0.5<i>l</i>/min for 6hr. Heparin was not primed, oxygenator did not fill any gases and circulation was keeping at 37°C. The thrombin-antthrombin complex and fibrinopeptide-A showed progressive increase and fibrinogen correspondingly decrease. Nevertheless, the plasmin α2 plasmin inhibitor complex and D-dimer showed minimal changes within normal range in spite of increasing fibrinopeptide B β 15-42. We can not find any signs of secondary fibrinolytic activity. On the other hand, the platelet was persistently activated as shown statistically significant increase in β-thrombogloblin and platelet factor IV. Significant elevations of complement 3a and 4a were seen with increase of complement 5a and activated oxygen productivity by neutrophilic leucocytes. In conclusion, moderate and limited blood alterations occurred in mock cardiopulmonary bypass circuit.