Management of Inguinal Vascular Graft Infection by Lateral Femoris Axillo-Popliteal Bypass / 日本心臓血管外科学会雑誌

A 81-year-old man was referred to our hospital for treatment of a skin ulcer of the right anterior crus. After 2 months left common femoral artery-right popliteal artery bypass, graft infection was occurred and methicillin-sensitive <i>Staphylococcus aureus</i> was found in the bacterial culture. The wound was extended in order to decide the extent of graft infection, but graft healing was totally insufficient. All of the graft was excised, and right axillo-popliteal bypass using 8mm Bionit graft was performed. The graft was passed through lateral femoral. Thus, in this case the graft excision was necessary, but major amputation could be avoided by successful revascularization.

A Case of Impending Rupture of an Infected Thoracoabdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 50-year-old woman who had received hemodialysis for 8 years was admitted due to lumbago, fever and leukocytosis. Computed tomography and angiography revealed a supraceliac saccular aneurysm and right pleural effusion. Impending rupture of an infected supraceliac aneurysm was strongly suspected, and an emergency operation was performed. The aneurysm was almost completely resected and replaced by a 24mm Hemashield graft with reconstruction of visceral and intercostal arteries using partial bypass and deep hypothermia. <i>Staphylococcus aureus</i> infection was diagnosed based on the culture of the aneurysmal wall. The postoperative course was uneventful without any adverse neurological symptoms. After surgery, antibiotics were administered for 4 weeks intravenously. The patient is well 22 months after the operation.

Surgery for Subclavian Artery Occlusion / 日本心臓血管外科学会雑誌

Three patients with subclavian artery obstruction caused by arteriosclerosis underwent surgical reconstruction based on their specific anatomic characteristics. Subclavian artery transposition was performed in a patient with a short segmental occlusion of the proximal subclavian artery. The patient with a long segmental occlusion, from the origin of the internal thoracic artery to the origin of the thoracoacrominal artery, underwent bypass-grafting between common carotid artery and axillary artery. The graft was passed lateral to the anatomical tract to prevent compression by the scalenus and subclavian muscles. Because the branchial plexus also can be compressed in the thoracic outlet, the scalenus muscles were detached at the first rib in both methods. It is important to consider the specific cause of subclavian artery occlusion when planning corrective surgery. Ischemic and neurologic symptoms improved using both techniques.

Pulmonary Complications Following Myocardial Revascularization Using Internal Thoracic Artery Harvested under Pleurotomy / 日本心臓血管外科学会雑誌

A recent study evaluated the effect of pleurotomy for harvesting internal thoracic arteries (ITAs) on pulmonary complications after coronary artery bypass grafting (CABG). Fifty consecutive patients with pleurotomy (group I) were studied retrospectively and compared with a control group of fifty patients undergoing CABG without pleurotomy during ITA harvest (group II). Group I was divided into two groups; forty patients using left ITAs with left open pleurotomy (group Ia), and ten patients using bilateral ITAs with bilateral open pleurotomy (group Ib). On the other hand, group II includes 22 patients without pleurotomy (group IIa) and 28 patients with closed pleurotomy (group IIb). In group I, ITAs were dissected from the chest wall with mediastinal pleura and then isolated from the pleura by pleurotomy. Before sternal closure, an L-shaped pleural tube was inserted into the deep costophrenic sinus and the pleurotomy remained open. In group II, ITAs were simultaneously dissected from the chest wall and mediastinal pleura, and if the pleura was damaged, the pleurotomy was approximated before sternal closure. There was no significance in the number of bypass grafts, aortic crossclamp time, cardiopulmonary bypass time and temperature. ITA harvest time with open pleurotomy was shorter than that of closed pleura (15min versus 25min). Postoperatively, the ventilation time and duration of chest drainage also showed no significance, however group Ia and Ib showed significantly more fluid accumulation removed by chest drainage (Ia, 288±193ml; Ib, 285±198ml, versus IIb, 169±98ml). On postoperative day 30 no pleural effusion was observed in group I but it was seen in one case in group IIb which had diaphragm paralysis. In conclusion, open pleurotomy results in minimal pulmonary complications with optimal chest drainage and offers significant advantages for harvesting ITAs.