[Open stent-grafting applied with the Matsui-Kitamura stent to a distal arch aneurysm].

An open stent-grafting applied with the Matsui-Kitamura (MK) stent to a distal arch aneurysm is presented herein. The graft using the MK stent at its distal end was successfully inserted into the descending thoracic aorta through a J-shaped sheath-introducer. The major advantages of this stent-graft include its flexibility, shape memory, and small profile when compressed, compared with other devices. This technique may be feasible and clinically effective in the treatment of distal arch aneurysm.

[Off-pump coronary artery bypass grafting for restenosis after coronary angioplasty in the patient with left main shock syndrome].

A case of left main shock syndrome due to total occlusion of left main trunk was reported. A 65-year-old man with acute myocardial infarction developed cardiogenic shock shortly after admission. An emergency coronary angiogram revealed total occlusion of the left main trunk without collaterals. Immediately, a stent was implanted in the left main trunk and the lesion was successfully improved. However, the left coronary angiogram revealed 90% restenosis of the left main trunk in a coronary angiogram examined 6 months after stent placement. Since the patient suffered from poor cardiac function, off-pump coronary artery bypass grafting (left internal thoracic artery to left descending coronary artery) was successfully performed using an intracoronary shunt. No complications were observed.

[Application of transluminally place endoluminal prosthetic grafts for the treatment of multiple aortic aneurysms].

We have 5 cases with multiple aortic aneurysms who have undergone conventional abdominal aortic replacement with transluminally placed endoluminal prosthetic grafts (TPEGs) into the descending thoracic aorta. Simultaneous operation was done in one patient. A 2-stage operation was done in 4 patients, and the abdominal aortic aneurysm was performed on the first. One patient required urgent surgical intervention to treat migration of a stent-graft. However, there was no hospital death. The mean follow-up interval was 34 months and there were no complications correlated with the procedures. Application of TPEGs for the treatment of multiple aortic aneurysms may be a valuable treatment option.

Results of 256 consecutive abdominal aortic aneurysm repairs using extraperitoneal approach.

Two hundred and fifty-six consecutive abdominal aortic aneurysms were repaired using three approaches for extraperitoneal exposure of the aorta and iliac vessels from February 1990 through September 1998. The perioperative mortality rate was 3.1% in 228 elective repairs and 14.3% in 28 ruptured cases. The initial 23 cases were repaired using Sicard's method. The duration of endotracheal intubation was 1.0+/-2.8 h, alimentation initiation was 2.7+/-1.6 days, and narcotic requirements were 1.2+/-1.1 times. Following these initial cases, we employed Williams' method for 192 abdominal aneurysms, however; repeated incisional pain and three cases of deforming bulge led us to avoid dividing muscles. In the last 13 cases, our approach was performed without muscle dividing. The narcotic requirements decreased to 0.3+/-0.7 times. As for postoperative complications, the larger skin incision approach had no shower embolism. However, the shorter skin incision had four cases of shower embolisms, one lymphorrhea and one vascular trauma by the aortic clamp. The extraperitoneal approach offers certain physiologic advantages with minimal disturbance of gastrointestinal and respiratory function. We believe that this method is useful for rapid approach to the proximal aorta in case of emergency. Postoperative wound complications could be prevented via an oblique incision without muscle dividing.

Severe subarachnoid hemorrhage with pulmonary edema successfully treated by intra-aneurysmal embolization using Guglielmi detachable coils--Two case reports.

A 48-year-old male and a 39-year-old female presented with subarachnoid hemorrhage (SAH) due to ruptured anterior communicating artery aneurysms. Both patients were comatose on admission. Chest radiography disclosed pulmonary edema. They were conservatively treated under controlled ventilation, but cardiopulmonary dysfunction persisted over 2 days. The patients were then treated by intra-aneurysmal embolization with Guglielmi detachable coils (GDCs) 2 days after the onset. The postoperative courses were uneventful, and the patients showed full recovery from pulmonary edema and were discharged without neurological deficits. Neurogenic pulmonary edema is one of the serious complications of SAH, and is a leading cause of poor clinical outcome. The favorable outcomes of the present cases suggest that intra-aneurysmal embolization with GDCs is an excellent choice for the patients with severe aneurysmal SAH complicated with pulmonary edema, in whom conventional surgical treatment under general anesthesia is difficult to perform in the acute stage.

Intravascular Imaging Methods for Venous Disorders.

The purposes are to assess the problems associated with intravascular imaging methods such as angioscopy and intravascular ultrasound (IVUS) and to evaluate their efficacy through the results of our observations. A total of 54 limbs in 53 patients, 50 patients with chronic venous insufficiency and 3 patients with deep vein thrombosis, were diagnosed and operated on using angioscopy (Olympus OES, order made type) and IVUS (Endosonics, model 82700). The imaging catheters were inserted through a branch of the long saphenous vein and the valves and the intraluminal views were observed. By angioscopy, intraluminal views were clearly observed in 98% of all lesions. However, observation became more difficult in iliac veins compared to in femoral and in long saphenous veins (p < 0.01). Venous wall and thrombus were detected more by IVUS than by angioscopy (p < 0.01), but only 21 valves (24%) were visualized by IVUS among the 88 valves observed by angioscopy. The intravascular imaging method of angioscopy is more suitable for observing valves and intraluminal views compared with IVUS, whereas IVUS is more suitable for observing the cross-sectional venous wall.

Prevention of paraplegia in transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms.

OBJECTIVE: To evaluate the efficacy of a temporary balloon occlusion test for the prevention of paraplegia following transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms. SUBJECTS AND METHODS: Two occlusion balloons were inserted via the brachial and femoral arteries and positioned in the proximal and distal neck of the descending thoracic aortic aneurysms using fluoroscopy. After temporary occlusion of the thoracic aorta by inflation of both the proximal and distal balloons, the evoked spinal potential was measured for 15 mins. A maximum amplitude during temporary balloon occlusion test decreasing by more than 20% of the pre-balloon occlusion level was considered to be significant, enough to not perform transluminally placed endoluminal prosthetic grafts, but instead an open repair. The test was applied in 12 cases (9 males and 3 females, 50-86 years old). All aneurysms were located between the Th6 and Th12 with a maximum diameter of 40-70 mm, and average of 56 mm. RESULTS: The changes in maximum amplitude of evoked spinal potential remained within 20% of the value before balloon occlusion in 11 cases. Transluminally placed endoluminal prosthetic grafts were performed in these 11 cases and no instance of paraplegia or other complication relating to the test was observed. Deployment of stent-grafts was successful in 10 cases (91%). CONCLUSION: It is suggested that the preoperative measurement of evoked spinal potential during temporary balloon occlusion is clinically useful for the assessment of the risk to paraplegia occurring in transluminally placed endoluminal prosthetic grafts.

Preoperative cerebrovascular screening before cardiovascular surgery in a high risk area of cerebrovascular events in Japan.

BACKGROUND: Cerebrovascular disease and cervical artery diseases are potentially treatable conditions that are associated with an increased incidence of stroke after cardiac surgery. This prospective study was designed to determine the prevalence of cerebrovascular diseases in the high risk population of cerebrovascular event including some young patients in Japan and establish the strategy for cardiac surgery of patients with cerebrovascular disease. METHODS: 100 (71 male, 29 female) of 126 consecutive patients undergoing cardiac surgery under cardiopulmonary bypass were screened for the presence of cerebrovascular disease by intra-arterial angiogram. RESULTS: In seven patients angiographic evaluation disclosed some evidence of cerebrovascular disease for 50% or greater stenosis or cerebral aneurysm. Preoperative 99mTc-Hexamethyl propylene amino oxime (99mTc-HMPAO) single emission computed tomography (SPECT) with combination of balloon arterial occlusion test provided detailed information of cerebral ischemic tolerance and reliable decision making for surgical repair of cerebrovascular disease. No deaths were recorded and a small stroke in one patient. CONCLUSIONS: We concluded that cerebrovascular screening in patients with cardiovascular disease may be requested in a high risk population of cerebrovascular events.

[Transluminally placed endovascular graft indications: thoracic aortic aneurysm and abdominal aortic aneurysm].

In 1991, Parodi et al described the first clinical use of a new technique for abdominal aortic aneurysm (AAA) repair using transluminally placed endovascular grafts (TPEG). Subsequently, in 1994 Dake et al reported the use of this new technique for the treatment of patients with aneurysms of the descending thoracic aorta. Since then, TPEG for the treatment of aneurysms have been clinically investigated in a number of centers. Initially, TPEG appeared to be an attractive alternative to standard surgical open repair, since they are less invasive and thereby reduce the operative risk in high-risk patients. The effectiveness and safety of TPEG have been reported by many investigators, and indications for this technique are increasing. However, the placement of TPEG within the artery by insertion via a remote site and fixation by attachment systems, such as various types of expandable stents, is completely different from conventional graft replacement. The long-term durability of TPEG is not yet known, and therefore we must remain cautious in patient selection. The cause and morphology of each aortic aneurysm determine whether TPEG are indicated. At present, TPEG is used to treat patients with aneurysms below the distal arch, and infrarenal abdominal aorta. However, indications in patients with aortic dissections are not clearly defined, because though the procedure is technically feasible, the effectiveness is not yet known and further investigation is required.

Graft-wall endoleak 18 months after successful endoluminal AAA repair.

PURPOSE: To describe a case of graft-wall endoleak 18 months after successful endoluminal repair of an abdominal aortic aneurysm (AAA). METHODS AND RESULTS: A 71-year-old man with infrarenal AAA was successfully treated with an endoluminal aortomonoiliac graft and femorofemoral crossover bypass with surgical ligation of the right external iliac artery. The stent-graft was made from 2 Gianturco Z-stents and a tapered thin-walled (0.1-mm) Dacron graft. Eighteen months after endografting, the patient complained of a pulsatile abdominal mass. Angiography and computed tomography showed graft-wall endoleak. Aneurysmectomy was performed, and the aneurysm was successfully replaced with a Y-shaped knitted Dacron graft. A hole in the graft wall was found 3 cm from the proximal edge of the stent-graft. CONCLUSIONS: This case suggests that the use of thin-walled graft material in endografts may not be sufficiently durable.

Vascular backache and consideration of its pathomechanisms: report of two cases.

We experienced two cases whose low back pain was improved after vascular reconstructive surgery for arteriosclerosis obliterans in the abdominal cavity. Based on these observations, we propose the term "vascular backache" and we discuss possible pathomechanisms underlying this condition. One patient had a stenotic lesion in the lower abdominal aorta and was operated transluminally; the other patient had a diffuse stenotic lesion from the abdominal aorta to the femoral arteries and had an axillofemoral bypass operation. After surgery, they experienced a reduction of backache along with an improvement of the vascular intermittent claudication. It is suggested that one factor leading to low back pain in some cases might be various degrees of ischemia of the extensor muscles in the lumbar spine.

[Partial median sternotomy for pediatric cardiac surgery].

In order to minimize scar appearance and thereby improve postoperative cosmetic appearance for pediatric cardiac surgery patients, we performed partial median sternotomy incisions. A short midline incision, from 1 to 2 cm below the articular notch of the 2nd rib to the xiphoid process, was made. The sternum was divided from the xiphoid process to the articular notch of the 2nd rib. The thymus was mobilized and the pericardium incised longitudinally. The aorta and superior and inferior vena cava were mobilized to facilitate direct cannulations. Cardiopulmonary bypass was instituted in the usual fashion. From June to December 1997, 14 patients between the ages of 4 days and 12 years have undergone cardiac repair using this technique. Cases included 7 VSD (including 4 pulmonary hypertension and 1 DCRV), 5 ASD, 1 ECD and and 1 DORV with mitral atresia. All patients were extubated within 3 hours after surgery, and there were no wound infections or hospital mortalities (except one 4 day old baby who died by LOS on the 16th postoperative day). In our experience, this approach is safe and provides good exposure with excellent cosmetic results.

Anti-angiogenic effect of TGFbeta in aqueous humor.

Neovascularization is mediated by various factors in ocular tissues. Recent studies have emphasized the role of vascular endothelial growth factor in the induction of angiogenesis. We have previously reported that aqueous humor (AH) suppressed vascular endothelial cell growth and angiogenesis. We speculated that the anti-angiogenic effect of AH is mediated by transforming growth factor beta (TGFbeta). In order to clarify the presence of TGFbeta in bovine AH, we applied it on the heparin-sepharose affinity column and prepared two fractions (bound and unbound fractions). We measured TGFbeta concentration in each fraction and examined how the anti-TGFbeta antibody decreased the inhibitory effect of AH on human umbilical vein endothelial cell growth and on in vitro angiogenesis. We found the presence of TGFbeta2, but not TGFbeta1, in the heparin bound fraction, and the inhibitory effect was detected in the heparin-bound fraction. Anti-TGFbeta antibody completely and dose-dependently extinguished the inhibitory effect of AH. We propose that the inhibitory effect of AH on endothelial cell growth and in vitro angiogenesis are both mediated by TGFbeta2. Our results indicate TGFbeta2 is normally present in AH and protects the eye tissue against abnormal neovascularization.

Regional cerebral blood flow evaluated by 99mTc-HMPAO-SPECT in patients with axillo-axillary bypass for subclavian steal syndrome.

BACKGROUND: Clear evidence of cerebral blood circulation has not been shown after axillo-axillary bypass surgery in patients with subclavian steal syndrome. METHODS: We investigated the cerebral circulation and blood flow in 3 patients receiving axillo-axillary bypass by RI angiography using 99mTc-dl hexamethyl propylene amine oxime (99mTc-HMPAO). Two patients had vertebral basilar cerebral symptoms which were related to decreased cerebral blood flow evidenced by 99mTc-HMPAO. RESULTS: After the correction, cerebral symptoms disappeared and improved cerebral blood circulation detected by 99mTc-HMPAO-SPECT. CONCLUSIONS: We concluded that axillo-axillary bypass was a fairly effective procedure to improve cerebral blood circulation evidenced by 99mTc-HMPAO-SPECT.

[Superselective angiographic findings of ipsilateral middle meningeal artery of chronic subdural hematoma in adults].

The authors reported the results of continuous superselective angiography of the ipsilateral middle meningeal artery (MMA) in cases of chronic subdural hematoma (CSH) in adults. MMA angiography was performed twice, at an interval of approximately two weeks, in 3 cases of conservative and 1 case of surgical treatment. The features of MMA angiographic findings were diffuse dilatation of MMA and visualization of scattered abnormal vascular networks (VN), which seemed to be macrocapillaries in the outer membrane of the CSH. In two out of the three cases of conservative treatment, these VN revealed a dynamic change temporarily and spatially, i.e. either enlargement or reduction. In one case with a long clinical course a stable MMA angiogram was seen. The operated case showed dramatic change on the second (postoperative) MMA angiogram. The VN around burr hole portion was huge and dark, and several newly visualized small arteries penetrated the enlarged VN, which was thought to have been caused by the operation. The mean blood pressure in the MMA was 103 mmHg. The reason for the acute enlargement of the CSH might be explained as arterial bleeding into the hematoma cavity, caused by rupture of thin walled macrocapillaries by direct arterial pressure.

[Case performed: simultaneous surgery for left coronary ostial stenosis and gastric cancer].

This report describes a case in which a 68-year-old male underwent two operations simultaneously for left coronary ostial stenosis and gastric cancer. Successfully performed procedures were a single coronary artery grafting with the saphenous vein to the left anterior descending artery, and a subtotal gastrectomy using the Billroth II method. The postoperative course was uneventful and the patient was discharged from the hospital in good condition after 42 days. At present, one-year postoperative, the patient has been visiting the outpatient clinic in healthy condition.

[Quantitative evaluation of response at acetazolamide test using 99mTc-ECD SPECT; a trial of production of the response map].

In the method by Matsuda and Takeuchi et al. for easy regional cerebral blood flow (rCBF) measurements at pre- and post-acetazolamide tests using 99mTc-ECD, a study was done for producing the increase rate of rCBF as a response map after acetazolamide administration. To prepare the response map calculated from the arithmetic operation of [(rCBF image at administration--rCBF image at rest)/rCBF image at rest x 100], the images were preprocessed by combination of matrix size conversion and smoothing techniques and then areas outside the brain were masked to remove amplified noises. The response map seemed helpful for visual evaluation of the response after acetazolamide administration, and also for understanding the disease conditions and clinical courses.

Apolipoprotein E Sendai (arginine 145-->proline): a new variant associated with lipoprotein glomerulopathy.

Lipoprotein glomerulopathy (LPG) is a novel disease characterized by proteinuria, lipoprotein thrombi in the glomeruli, and increased concentration of plasma apolipoprotein (apo) E. It is believed that a genetic disorder of apo E may be present and associated with the disease. Three patients with LPG were examined in this study. The patients' DNA sequences were analyzed, and a nucleotide G to C point mutation in exon 4 of the apo E gene was confirmed in each patient. This missense mutation denotes amino acid substitution of the proline residue for arginine residue at position 145 of apo E. This variant (apo E Sendai) may cause a marked molecular conformational change of the apo E. These findings suggest that a novel variant is etiologically related to LPG.

Human arterial smooth muscle cell proliferation in diabetes.

In the present study, we focus on the proliferation of human arterial smooth muscle cells (SMCs) from NIDDM patients (DM-SMCs) to clarify the reactivity to the growth factor(s) in fetal calf serum (FCS) and the factor(s) secreted by T-cells. The proliferation of DM-SMCs was significantly greater than SMCs from nondiabetic patients (nonDM-SMC). DM-SMC conditioned medium (DM-condMed) increased the growth of nonDM-SMCs. These results suggest that the growth factor is secreted from DM-SMCs as an autocrine system, which increases the proliferation of nonDM-SMCs. T-cells increased DNA synthesis of SMCs, and DM-SMCs strikingly reacted to T-cells. The present results support a function of T-cells in stimulating SMC growth. In conclusion, human arterial SMC proliferation is increased in diabetes in the same fashion as in experimentally induced diabetes in animals through responses to growth factors and an increased autocrine system. These results provide a mechanism for the increase in atherosclerotic disease in diabetes.