Multiple Infected Aneurysms of the Aortic Arch and Thoraco-abdominal Aorta Caused by <i>Bacteroides fragilis</i> / 日本心臓血管外科学会雑誌

A 67-year-old man who had undergone robot-assisted laparoscopic radical prostatectomy 16 days before suffered from high fever. A screening CT showed an aortic arch aneurysm was 40 mm in diameter, and <i>Bacteroides fragilis </i>was identified from blood culture. A few days after the first CT, the size of the aneurysm increased rapidly to 50 mm in diameter, subsequently an urgent procedure of total arch replacement using rifampicin-soaked Dacron graft was performed. Although the postoperative course was unremarkable, pyrexia recurred on the ninth post operative day. The third CT showed a new aneurysm in the thoraco-abdominal aorta just below the celiac artery. The second urgent procedure of graft replacement of the thoraco-abdominal aorta with the reconstruction of the celiac artery was performed. Preoperative FDG-PET/CT was useful to decide the level of the resection and the suture. The intravenous administration of the antibiotics continued for six weeks after surgery. The patient is doing well without any signs of infection on oral antibiotics at 7 months after the second surgery.

A Case of Infected Brachiocephalic Pseudoaneurysm with Fistulation to the Skin 11 Years after Radical Mastectomy and Irradiation for Right Breast Cancer / 日本心臓血管外科学会雑誌

A 57-year-old woman was admitted with intermittent bleeding and pus discharge from her right anterior chest. She had undergone radical mastectomy (Halsted operation) and irradiation for breast cancer 11 years previously. Skin ulcer with a bleeding fistula had appeared at the right clavicular region 6 months previously. An emergency operation was performed, since angiography revealed brachiocephalic pseudoaneurysm with fistulation to the skin. The brachiocephalic artery was exposed through a right cervical and middle sternal incision. The brachiocephalic artery was interposed with two segments of the great saphenous vein joined to make a proper graft in size. The infected area was filled by the greater omentum. A pedicle flap was used to close the large skin defect after removing the fistula. The postoperative course was uneventful and infection improved soon after the operation. The patient was discharged about one month after the operation. We reported a rare case of infected brachiocephalic pseudoaneurysm with fistulation to the skin after radical mastectomy and irradiation for breast cancer.

Coronary Artery Bypass Grafting without Cardiopulmonary Bypass and Percutaneous Coronary Angioplasty in a Patient with Cerebrovascular Stenosis / 日本心臓血管外科学会雑誌

Complete revascularization of the coronary artery was performed in a 73-year-old man who had severe stenosis of the bilateral subclavian and left vertebral arteries and severe calcification of the ascending aorta. At first, we performed CABG (coronary artery bypass grafting) on the LAD (left anterior descending artery) and the RCA (right coronary artery) without cardiopulmonary bypass. <i>In-situ</i> GEA (gastroepiploic artery) was anastomosed to the LAD and SVG (saphenous vein graft) was anastomosed to 4 PD (4 posterior descending artery) of the RCA. The right brachiocephalic artery was selected as the site of the proximal anastomosis of the SVG. A Palmaz-Schatz stent was then held in place in the LCX (left circumflex artery) postoperatively. The combination of CABG without cardiopulmonary bypass and PTCA was a safe method for preventing cerebrovascular complications in a patient with a severely calcified artery.

The Extended Retroperitoneal Approach for Treatment of Abdominal Aortic Aneurysms / 日本心臓血管外科学会雑誌

From July 1984 to June 1998, 159 patients with infrarenal abdominal aortic aneurysms (AAA) were surgically treated in our hospital by the extended retroperitoneal (ERP) approach described by Williams et al. There were 132 men and 27 women, with a mean age of 69.3 years. Of the 159 patients, 82 (52%) had hypertension, 62 (39%) had coronary artery disease, of which 20 cases had previously received coronary artery bypass grafting, 17 (11%) had diabetes, 16 (10%) had thoracic aortic disease, 15 (9.4%) had cerebrovascular disease, and 14 (8.8%) had chronic renal dysfunction, including 6 cases on hemodialysis. Among these patients treated with this approach, 67 cases underwent tube grafting and 92 received Y-grafting. Patent inferior mesenteric arteries were ligated in all cases except one. Postoperative morbidity was observed in 54 cases (34%); lower extremity ischemia including microembolism or acute graft occlusion in 13, abdominal complication including paralytic ileus, liver dysfunction, or gastrointestinal hemorrhage in 11, wound complication in 9, pulmonary in 7, cardiac in 6, cerebral in 4, and the others in 4. No patient suffered ischemic colitis. There was hospital mortality in 4 cases (2.5%). Two patients died because of myonephropathic metabolic syndrome on second postoperative day. Two patients with combinations of several co-existing diseases died because of respiratory failure or multi-organ failure on the 48th and 141st postoperative day. Oral feeding was restarted at a mean of 2.7 days after the operation, and 64% of the cases did not require blood products. The mean postoperative hospital stay of survivors was 16.9 days (range, 7-63 days). Based on our clinical experience, we believe that the ERP approach is a safe and useful procedure for elective surgery for AAA to enable fast recovery and short hospital stay, especially in older and high-risk patients.