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Objective: Isolated abdominal aortic dissection (IAAD) co-occurring with an abdominal aortic aneurysm (AAA) is rather rare. The objective of this report was to discuss the adequate timing and method of surgery for this condition.Patients: We encountered two operative cases, for which we carefully considered the timing and method of surgery. One patient underwent open repair 1 month after the onset, and the other patient underwent endovascular aneurysm repair (EVAR) 3 years after the onset.Results: Both patients had a good postoperative recovery and are doing well 8 months after the surgery.Conclusion: The presence of symptoms or an increase in the diameter of an AAA is important in determining the timing of intervention.
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Objective: Deep femoral artery (DFA) aneurysms are extremely rare cases of aneurysms that are difficult to diagnose. The objective of this report was to discuss the timing and method of surgery for this disease.Patient: We encountered an asymptomatic left DFA aneurysm that was discovered along with a symptomatic aneurysm of the right superficial femoral artery (SFA). Both sides of the aneurysm were resected with Dacron knitted artificial vascular grafts (Gelsoft™ Plus, Vasctek, UK) simultaneously.Result: After the operation, the right SFA had good blood flow, but the graft of the left DFA was occluded. The occlusion was considered to be caused by insufficient blood flow in the graft. The patient was discharged without any complications.Conclusion: The coexistence of DFA aneurysms should be examined if other aneurysms are found. DFA aneurysms are at a high risk of rupture. Careful follow-up is required, and intervention is recommended when the diameter exceeds 35 mm.
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Cystic adventitial disease (CAD), a rare arterial disorder, can cause localized arterial stenosis or obstruction. A 55-year-old man presented with a 2-month history of left lower leg pain and paleness when bending the left knee. The patient was diagnosed with CAD of the left popliteal artery based on imaging examinations. Surgery was performed with the patient placed in the prone position using an S-shaped skin incision, and the left popliteal artery was exposed. A simple incision of the cyst wall was made. There was no sign of recurrence at 1 year postoperatively.
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Background: Older pacemaker systems, which are magnetic resonance imaging (MRI) incompatible, require replacement with compatible systems when patients are in need of MRI. Replacement involves extraction of the pacing lead, which is usually done with a laser sheath under general anesthesia.Case presentation: We report two cases of complete pacing system replacements allowing patient access to MRI. Both replacements were made under local anesthesia and without the use of special devices over 6 years after the initial surgery. Both replacements used retractable screw-in leads with a cut-down of cephalic or external jugular veins performed during the initial surgeries. Case 1 involved a 79-year-old man with cerebral ischemia, and case 2 involved a 70-year-old man with spinal canal stenosis.Conclusion: With careful management, it is possible to replace an entire pacing system under local anesthesia without additional devices.
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An 85-year-old malnourished man was admitted with ischemia-induced necrosis of the right leg and high-risk factors, including chronic obstructive pulmonary disease, pneumonia, and infection of the necrotic leg. We controlled the infection and provided proper nutrition. Using light general anesthesia and a nerve block, we amputated the leg above the knee. The patient could eat and drink the same day following the surgery, and respiratory rehabilitation was begun the next day. His postoperative course was uneventful. Our case suggests that maintenance of good nutrition may play a key role for high-risk elders undergoing leg amputation.
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<b>Objective:</b> The aim of the present study was to consider the importance of medical information obtained via the Internet for difficult cases in hospitals, especially in those located in rural areas. We report here a case of congenital arteriovenous fistula (AVF) in the upper extremities. <br><b>Patient:</b> A 30-year-old lady was transported to our hospital by ambulance due to massive bleeding in her left hand. She was seen by our current cardiovascular surgery team for the first time, although she had been diagnosed with congenital AVF of the left arm 9 years previously. Because it was asymptomatic, she was followed up by observation. During 5 years of observation, symptoms such as cyanosis, pain, and refractory ulcers gradually developed. When she was 26 years old, she was referred to a university hospital in Akita, but surgery had already been judged to be impossible. When she was 30 years old, traumatic bleeding in her left hand and hemorrhagic shock led her to be taken to our hospital by ambulance. Using the Internet, we found an institution that had treated a large number of cases of AVF. After controlling the bleeding, we referred her to that institution. However, she could not be treated without an above-elbow amputation. <br><b>Conclusion:</b> Congenital AVF in the upper extremities is a rare vascular anomaly and has been generally accepted to be an extremely difficult disease to treat. Treatment should be started as early as possible before the presence of any symptoms. When a specialist is not available near the hospital, precise information must be found using the Internet and the patient should be referred without any delay.
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An 85-year-old malnourished man was admitted with ischemia-induced necrosis of the rightleg and high-risk factors, including chronic obstructive pulmonary disease, pneumonia, andinfection of the necrotic leg. We controlled the infection and provided proper nutrition.Using light general anesthesia and a nerve block, we amputated the leg above the knee. Thepatient could eat and drink the same day following the surgery, and respiratoryrehabilitation was begun the next day. His postoperative course was uneventful. Our casesuggests that maintenance of good nutrition may play a key role for high-risk eldersundergoing leg amputation.
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<b>Objective:</b> The aim of this report was to discuss the type, timing, and surgical techniques of permanent pacemaker implantation in a juvenile patient. <br><b>Patients:</b> A 17-year-old girl with Down syndrome and congenital heart defects comprised of ventricular septal defects (VSD) and patent ductus arteriosus (PDA) suffered from postoperative complete atrioventricular block (AVB) when she was 7 months old. <br><b>Methods and Results:</b> An epicardial pacemaker was implanted just after the occurrence of complete AVB. Due to the pacing threshold of a ventricular lead not being good, the battery showed rapid depletion. Her generator had to be exchanged under general anesthesia every 2–3 years. When she was 10 years old, we implanted a permanent pacemaker transvenously by using cutdown, screw-in and subpectoral pocket techniques. She has shown a satisfactory outcome since then. <br><b>Conclusion:</b> Transvenous pacemaker implantation was safe and effective in our young patient without any complications. The timing of surgery and surgical technique are quite important for pacemaker implantation in juvenile patients.
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<b>Objective:</b> The aim of the present study was to consider the importance of medical information obtained via the Internet for difficult cases in hospitals, especially in those located in rural areas. We report here a case of congenital arteriovenous fistula (AVF) in the upper extremities. <br><b>Patient:</b> A 30-year-old lady was transported to our hospital by ambulance due to massive bleeding in her left hand. She was seen by our current cardiovascular surgery team for the first time, although she had been diagnosed with congenital AVF of the left arm 9 years previously. Because it was asymptomatic, she was followed up by observation. During 5 years of observation, symptoms such as cyanosis, pain, and refractory ulcers gradually developed. When she was 26 years old, she was referred to a university hospital in Akita, but surgery had already been judged to be impossible. When she was 30 years old, traumatic bleeding in her left hand and hemorrhagic shock led her to be taken to our hospital by ambulance. Using the Internet, we found an institution that had treated a large number of cases of AVF. After controlling the bleeding, we referred her to that institution. However, she could not be treated without an above-elbow amputation. <br><b>Conclusion:</b> Congenital AVF in the upper extremities is a rare vascular anomaly and has been generally accepted to be an extremely difficult disease to treat. Treatment should be started as early as possible before the presence of any symptoms. When a specialist is not available near the hospital, precise information must be found using the Internet and the patient should be referred without any delay.
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<b>Objective:</b> The aim of this report was to discuss the type, timing, and surgical techniques of permanent pacemaker implantation in a juvenile patient.<br><b>Patients:</b> A 17-year-old girl with Down syndrome and congenital heart defects comprised of ventricular septal defects (VSD) and patent ductus arteriosus (PDA) suffered from postoperative complete atrioventricular block (AVB) when she was 7 months old.<br><b>Methods and Results:</b> An epicardial pacemaker was implanted just after the occurrence of complete AVB. Due to the pacing threshold of a ventricular lead not being good, the battery showed rapid depletion. Her generator had to be exchanged under general anesthesia every 2–3 years. When she was 10 years old, we implanted a permanent pacemaker transvenously by using cutdown, screw-in and subpectoral pocket techniques. She has shown a satisfactory outcome since then.<br><b>Conclusion:</b> Transvenous pacemaker implantation was safe and effective in our young patient without any complications. The timing of surgery and surgical technique are quite important for pacemaker implantation in juvenile patients.
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<b>Objective:</b> The aim of this report was to discuss validity of pacemaker surgery for elderly individuals over 90 years old.<br><b>Patient:</b> We operated on 12 individuals over 90 years old who had syncope or congestive heart failure in association with bradycardia, between January 2005 and November 2012.<br><b>Methods:</b> All 12 patients were referred to us by the cardiology department of our hospital for pacemaker surgery. We applied our routine technique: cutdown of the cephalic vein, creation of a subpectoral pocket, use of screw-in leads, and use of generators with an automatic output control system.<br><b>Results:</b> All of the patients received a dual chamber system with atrial and ventricular leads and recovered uneventfully. The follow-up period was between 1 month and 7 years.<br><b>Conclusion:</b> An advanced age over 90 years old is not a contraindication for pacemaker surgery.
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We report a case of massive, life-threatening from a varicose lesion of the right lower extremity. An 81-year-old lady was brought to the emergency room at our hospital because of massive bleeding from her right leg. She had had high ligation of the right saphenous vein at another hospital 2 years ago. After hemostat and transfusion, she recovered from hemorrhagic shock. Three-dimensional enhanced computed tomography angiography revealed a residual right great saphenous vein and recurrent varicose lesion. We performed high ligation of the great saphenous vein and closed all of the residual perforators. The patient was discharged hospital 10 days after the surgery and experienced no bleeding episodes within 8 months after the surgery. Certain high ligation and elimination of perforators of the great saphenous vein in surgery for varicose vein of leg is necessary to prevent lethal bleeding.
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Objective: To report that screw-in type pacing leads can be removed by screw retraction even after a significant anchoring period. Patient: A 78-year-old woman who visited our hospital for skin erosion over a pacemaker that had been implanted 3 years previously and had migrated from the subclavicular area to the axilla. Methods: Culture revealed a local staphylococcus infection. We placed a new pacemaker system in the contralateral (right) side, removed the old one, inserted a straight type stylet into the leads, and turned the rotator counterclockwise. Results: An image monitor confirmed complete retraction of the ventricular lead screw and partial retraction of the atrial lead screw, and we were able to pull out both leads without any resistance. The patient was given antibiotics and discharged 2 days after the surgery. No wound infection was evident at a 3-month follow-up examination. Conclusion: When a screw-in type pacemaker with a retractor must be removed long after its implantation, screw retraction should be tried before resorting to a removal kit or open heart surgery.
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Objective: To asses the risk of acquired antithrombin III (AT III) deficit before heart surgery and consider countermeasures. Patient: A 50-year-old gentleman who suffered from congestive heart failure due to mitral valve regurgitation. Methods: We replaced the mitral valve with cardiopulmonary bypass. Activated clotting time (ACT) was not long enough even after general heparinization (300 U/Kg) for cardiopulmonary bypass. We measured the activity of antithrombin III and added a total 50000 units of heparin until ACT was over 400 sec. We noted low AT III activity (36.8%) and transfused 4 U of fresh frozen plasma (FFP) during surgery. Results: After administration of protamine (0.3 ml/Kg), ACT reached 137 sec. The hemostasis procedure was uneventful and the patient recovered well without a bleeding incident. Conclusion: Measurement of AT III activity just before the initiation of cardiopulmonary bypass is necessary to avoid insufficient anticoagulation such as antithrombin III deficit.
Subject(s)
Mitral Valve , Cardiopulmonary Bypass , Antithrombin IIIABSTRACT
Objective: To reduce the length of hospital stay for patients undergoing pacemaker surgery. Patient and Methods: We prevented the leads from dislodging by anchoring a screw-in type pacing lead in the right atrium/ventricle through a cephalic vein that was cut down. We retrospectively compared the cost and duration of the hospital stay for the subpectoral technique (35 cases; January 2005-March 2006) and conventional technique (subcutaneous pocket and subclavian vein puncture) (18 cases; October 2003-December 2004) groups. Results: The mean (± SD) duration of hospital stay was 5.1 ± 2.1 days for the subpectoral technique group and 22.2 ± 15.2 days for the conventional technique group (P < 0.001), and the cost was 2,167,883 ± 147,549 yen in the subpectoral technique group and 2,528,053 ± 217,810 yen in the conventional technique group (P < 0.001). We noted no major complications such as bleeding, lead dislodgement, or wound infection. Conclusion: Our novel subpectoral technique helped reduce the length and cost of the hospital stay associated with pacemaker surgery.
Subject(s)
Hospitals , Pacemaker, Artificial , Congresses as TopicABSTRACT
Our strategy for treatment of thoracic aortic aneurysms with severely stenotic or occluded cerebral vessels is as follows. 1) The status of cerebral vessels and brain is assessed in detail by a team of neurologists and neurosurgeons, 2) cerebral surgical treatment is performed prior to aortic arch surgery, and 3) reconstruction of the total arch is performed using the arch-first technique through a median sternotomy. We successfully performed artificial graft replacement of the total aortic arch in two patients with old cerebral infarcts and severely stenotic cerebral vessels. In both cases, the operation was performed through median sternotomy under circulatory arrest by feeding the blood to the ascending aorta and draining it from the right atrium. Cerebral protection during reconstruction of the aortic arch was provided by profound hypothermia and retrograde cerebral perfusion (RCP). Prior to the incision of the aneurysm, cerebral branches were dissected to avoid escape of debris into cerebral vessels. The graft replacement was completed in 4 steps: 1) anastomosis of each of the 3 arch vessels, 2) distal anastomosis of another graft for the elephant trunk procedure, 3) anastomosis of the arch graft and the graft for the elephant trunk, and 4) proximal anastomosis. Just after cerebral branches were anastomosed to the 3 branches of the graft, the blood was supplied to the brain through the side branch of the graft instead of RCP. No signs of neurological deficit occurred postoperatively. The above protocol provided protection of high-risk patients with old cerebral infarcts from possible postoperative brain damage.
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We developed a new double-lumen balloon catheter for retrograde cerebral perfusion (RCP) via jugular vein cannulation. Between November 1996 and September 2000, 34 of 73 patients treated with surgical procedures for thoracic aortic aneurysms underwent RCP using the new catheter during circulatory arrest under deep hypothermia. Nine patients underwent a median sternotomy, and 25 underwent a left thoracotomy. In all cases, the new catheter installation under fluoroscopy was easy, and it took about 15min. The mean RCP time, pressure, and flow rate were 26.8min, 20.0mmHg, and 202.6ml/min, respectively. Our procedure using the new catheter was safe and easy in RCP during circulatory arrest in aortic arch replacement regardless of surgical approaches such as a left thoracotomy or median sternotomy.