Résumé
A 68-year-old man suffered a pain in his right groin and was diagnosed with deep vein thrombosis at a previous medical clinic, two months earlier. He was referred to our hospital to treat deep vein thrombosis. However, adventitial cystic disease of the femoral vein was suspected from findings of preoperative contrast CT and ultrasonography. Under general anesthesia, the operation was performed. The venous wall was resected including an adventitial cyst, which was followed by the venous reconstruction using an autologous vein patch. Anticoagulant therapy was continued after the operation for one year. He was followed for 18 months after the surgery without a recurrence of the adventitial cystic disease. Venous adventitial cystic disease is extremely rare and may be misdiagnosed as deep vein thrombosis. Careful follow-up is mandatory, because the postoperative recurrence rate is reported to be substantially high.
Résumé
A 39-year-old man was found to have left iliac artery rupture, and was transferred to our department. Emergency surgical repair was done, however, his intra- and postoperative condition precluded primary abdominal closure. On the 8th postoperative day, temporary abdominal closure (TAC) was performed using Composix Mesh TM and negative pressure wound therapy (NPWT). On the 19th day after the first surgery, an emergency reoperation was needed because of the rupture of the common hepatic artery aneurysm, of which there was no finding on admission. After the reoperation of the hepatic artery aneurysm, TAC was again performed using new Composix Mesh. On the 43rd day after the first surgery, the abdominal wall reconstruction without Composix Mesh was done using components separation and the anterior rectus abdominis sheath turnover flap method. On the 106th day after the first surgery, he had recovered well and was discharged. The genetic testing revealed COL3A1 mutation, which is specific for vascular type Ehlers-Danlos syndrome. When long-term open abdominal management is necessary after the abdominal aortic surgery, TAC with Composix Mesh and NPWT may be a useful alternative. Artery rupture in young people is a finding that should be considered suspicious for vascular type Ehlers-Danlos syndrome, which is difficult to treat.
Résumé
A 77-year-old woman with previous aortic grafting for abdominal aortic and iliac artery aneurysms developed a blue toe in her left foot. Enhanced CT showed a high density area around the vascular graft of the left iliac artery, which partially protruded into the graft. Because of the elevated <i>β</i>-D glucan level, fungal infection of the vascular graft was strongly suspected. Her general condition precluded the graft removal. Instead, thrombectomy was performed. Microbial examination of the removed clot revealed infection by <i>Aspergillus fumigatus</i>. Voriconazole was administered for 3 months. The <i>β</i>-D glucan level was normalized. Only thrombectomy and Voriconazole administration can be an alternative in case with vascular graft infection by <i>Aspergillus</i>.
Résumé
Because changes in the Medical Practitioners’ Act in 2001 allowed persons with impaired hearing to obtain a physician’s license, medical education for hearing–impaired students has become necessary.<br> The Shiga University of Medical Science provided learning support for a student with severely impaired hearing who entered our university in 2001.<br> For class sessions, consideration was given to seating location, devices for taking notes, and distributed educational materials. However, difficulties often occurred in small–group sessions. Clinical training was made possible by taking measures in advance to compensate for the hearing impairment. Classmates viewed positively their learning with a severely hearing–impaired student.<br> We believe that a good understanding of hearing impairment by teachers and classmates and the selection of communication tools compensating for the impairment are essential for the medical education of hearing–impaired students.
Résumé
A 65-year-old woman with a history of chronic atrial fibrillation was admitted for treatment of progressively worsening pain in the right forearm, which had begun several days before presentation. She did not have a palpable right brachial pulse, but her axillary pulse was palpable. We suspected acute thromboembolism of the brachial artery, and tried emergency thrombectomy via the brachial artery. However, her brachial artery was completely occluded with white organized thrombi, which was the cause of the chronic occlusion. Vasodilative drugs were administered, but her symptoms remained. Preoperative angiography showed the right brachial artery to be occluded and the ulnar artery could be partially visualized via the collateral arteries. We performed bypass grafting between the right axillary and ulnar artery, using an autologous saphenous vein graft. Her symptoms improved, and postoperative angiography revealed the bypass graft to be patent. The possibility of acutely worsening chronic ischemia should be considered, even if symptoms indicate acute thromboembolism of the extremities.
Résumé
An 84-year-old woman was brought to our hospital with cardiogenic shock. Ischemic changes of the ST segment were observed on the electrocardiogram in broad leads, but Q waves were not. Echocardiography revealed severe mitral regurgitation due to prolapse of the posterior leaflet, and coronary angiography showed 2-vessel disease involving left coronary arteries accompanied by a hypoplastic right coronary artery, so the coronary lesion seemed to be equivalent to 3-vessel disease. Preoperative tracheal intubation and intraaortic balloon pump (IABP) were required to maintain the hemodynamics. Emergency surgical procedures of combined coronary artery bypass grafting with mitral valve replacement were performed successfully. After 18 days, the patient was discharged, classified as NYHA class II. The prognosis for acute ischemic mitral regurgitation presenting shock in an octogenarian is extremely poor. Although the clinical symptoms were serious in this case, partial rupture of the papillary muscle and subendocardial infarction contributed to the favorable surgical result.
Résumé
We report 18 cases of thoracoabdominal aortic aneurysm repair. Most causes of the thoracoabdominal aortic aneurysm were atherosclerotic lesions (56%) or inflammatory changes (39%), such as Takayasu's aortitis and Behçet's disease. The Crawford procedure was performed in 13 patients, patch aortoplasty in 3, the Hardy procedure in 1 and extra-anatomic bypass in 1. As an adjunct, temporary bypass was employed in 8 patients and F-F bypass in 7 patients. Visceral arteries were perfused selectively during aortic cross-clamp. A total of 39% of all patients required emergency surgery for rupture, and among inflammatory aneurysms 86% of them ruptured. The early mortality rate was 0% in non-ruptured thoracoabdominal aneurysms, 42.9% in ruptured and 16.7% overall. There were 3 severe post-operative complications including one each of paraplegia, non-occlusive intestinal ischemia and rupture. All of them turned resulted in in-hospital death and the in-hospital mortality rate was 33.3%. There was no late death among atherosclerotic thoracoabdominal aortic aneurysms. However both Behçet's disease cases required re-operation for rupture at the anastomotic site in the late postoperative period and one patient died. One Marfan's syndrome patient also died 3 years postoperatively. We conclude that the Crawford procedure with F-F bypass is an effective and safe approach to thoracoabdominal aortic aneurysm repair and yields good clinical results.
Résumé
Nine patients with type IIIb dissecting aortic aneurysm underwent graft replacement of the thoracic and abdominal aorta between 1988 and 1992. The spiral opening method was used to expose the thoracic and abdominal aorta. Temporal bypass was employed in 2 patients and F-F bypass in 7 patients. Visceral arteries were perfused selectively during aortic cross-clamp. The entire descending thoracic aorta and abdominal aorta was reconstructed in 6 patients and the proximal descending thoracic aorta to renal arteries in 3 patients. The Crawford graft inclusion technique was used in all cases. Three patients required emergency surgery for rupture in one and impending rupture in 2. Operative deaths occurred in 2 patients (22.2%). Morbidity included renal failure (2), bleeding requiring reoperation (2), arrythmia (1), paraplegia (1), paraparesis (1), respiratory failure (1) and ileus (1). In the past two years, we operated on 5 cases of type IIIb dissecting aneurysms and there was neither operative death nor paraplegia.