Long-Term Outcome of Ultrasonic Scalpel Coronary Artery Bypass Grafting Using Bilateral Internal Thoracic Arteries / 日本心臓血管外科学会雑誌

It seems obvious that artery grafts improve the long-term prognosis of coronary artery bypass grafting (CABG). Besides, the superiority of using bilateral ITAs compared with a single ITA has been reported. An ultrasonic scalpel was introduced in our hospital in April 2001, and since then, we have harvested bilateral ITAs with it in a full skeletonized fashion, and as a result, we have been using bilateral ITAs for CABG routinely. In this study, we reviewed the surgical outcomes in 256 patients who underwent CABG alone, using bilateral ITAs harvested with ultrasonic scalpel between April, 2001 and December, 2012. Of these patients, 194 underwent off-pump CABG (8 were converted to on-pump CABG), and 38 required emergency surgery. One patient died from cerebral infarction within 30 days after the operation. Of all 256 patients, 234 underwent graftograms within 2 weeks after surgery, and 10 patients (4.3%) needed re-intervention including redo CABG or PCI in the early stage. None of these suffered mediastinitis. We also studied long-term outcomes. The follow-up rate was 100% and the mean follow-up period was 2.97±2.6 years. The survival rate was 81.8%, and 72.6% at 5 years, and 10 years, respectively. The freedom from redo CABG was 99.5%, and 99.3% at 5 years, and 10 years, respectively. The freedom from PCI was 96.3%, and 95.2% at 5 years, and 10 years, respectively. The freedom from MACE was 90.3%, and 81.2% at 5 years, and 10 years, respectively. Bilateral ITAs harvested with an ultrasonic scalpel can be used for CABG safely and with satisfactory long-term results.

Finger Lifting Resternotomy Technique / 日本心臓血管外科学会雑誌

We describe a novel method for repeat median sternotomy. We have successfully used ‘finger’ lifting resternotomy technique and achieved zero major cardiovascular injury/catastrophic hemorrhage events at reoperation. After general anesthesia, all patients were placed in the supine position and two external defibrillator pads were placed on the chest wall. We perform a median skin and subcutaneous incision along the previous sternotomy incision extending 3 cm distal to the sternum. The sternal wires that had been used for the previous closure were left in place but untied. Using a long electric cautery, right thoracotomy was performed under the right costal arch approach. Then, the operator could approximate the sternal wires in the retro-sternal space. At the same time, the operator could confirm the retro-sternal adhesion status which by touching with a finger. Resternotomy was performed using an oscillating saw pointed toward the operator's finger, which allowed safe re-median sternotomy from the lower to the upper part of the sternum. This technique of finger-lifting resternotomy has been employed in 50 cardiovascular reoperations and resulted in 0 incident of major cardiac injury or catastrophic hemorrhage. The finger-lifting resternotomy technique is safe and simple in reoperation procedures and yield excellent early outcomes.

A Successful Case of Selective Intercostal Arterial Perfusion in a Patient with Ruptured Thoraco-Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 61-year-old man underwent thoracic aortic graft replacement and abdominal aortic graft replacement because of a dissecting aneurysm. He presented with a ruptured residual dissecting thoraco-abdominal aortic aneurysm and underwent emergency thoraco-abdominal aortic graft replacement in February 2007. An inverted bifurcated graft was fashioned by cutting one of the two graft legs and creating an elliptical patch, like a cobra-head. In order to prevent paraplegia after the operation, it was necessary to shorten the duration of spinal cord ischemia. Once the elliptical patch was sutured to the orifices of the internal costal arteries with running sutures, selective intercostal arterial perfusion was initiated by using a cardiopulmonary bypass. After the operation, he did not suffer paraplegia.

Endovascular Repair of Chronic Aortic Dissection Expansion from Distal Fenestration in Previous Graft Replacement / 日本心臓血管外科学会雑誌

A 58-year-old man was admitted because of enlargement in diameter of the descending thoracic aorta. Six years previously, he had undergone graft replacement of the proximal descending aorta due to a chronic dissecting aneurysm. During that surgery, distal fenestration involving resection of the intimal flap of the distal anastomotic site and graft replacement with distal anastomosis of the true and false lumen were performed. Our preoperative enhanced computed tomography (eCT) revealed a thoracic aortic aneurysm 58mm in diameter at the site of distal fenestration. Graft replacement through left lateral thoracotomy was considered difficult because of previous occurrence of methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) empyema after the previous operation: hence, endovascular repair was done using a handmade stent graft to interrupt blood flow into the false lumen. The postoperative course was uneventful. Postoperative eCT showed the thrombosed false lumen and the shrinkage of the aneurysm from 58 to 38mm in diameter over a period of 18 months.