Pulmonary blastoma in an adult. A case with rapid progression.

A case of biphasic type pulmonary blastoma in a 59-year-old man is reported. Although the tumour was radically resected, there was rapid metastasization to the neck, mediastinum, liver and multiple bones. Despite radiotherapy, the patient died about 14 months postoperatively. Close follow-up and aggressive chemotherapy should be considered for such tumours.

A sweat-gland tumor metastasizing to the axilla: report of a case.

Sclerosing sweat-duct carcinoma is a rare malignancy of the skin. We herein present the case of a 68-year-old Japanese man who developed sclerosing sweat-duct carcinoma 2 years after undergoing local excision of a primary tumor in his right arm. Firm nodules appeared in the right axilla, which were revealed by surgical resection to be metastases. This rare tumor grows slowly but usually metastasizes to the regional lymph nodes, whereupon they are often associated with a poor prognosis. As the effectiveness of chemotherapy and radiotherapy against this neoplasm remains unclear, we recommend that the disease should initially be aggressively treated by surgery, which would also be indicated for any metastatic lesions.

Eicosapentanoic acid reduces the intimal thickening of autogenous vein grafts and enhances endothelium-derived relaxing factor.

The present study examined the effect of purified eicosapentanoic acid (EPA) on intimal thickening of an autogenous vein graft. In addition, experiments were performed to determine whether EPA supplementation would alter the endothelium-dependent responses of the reversed vein graft. Segments of femoral veins were grafted into the femoral arteries of dogs. Six dogs received regular chow (control group) and six other dogs regular chow with 1500 mg/day 90.0% pure EPA (EPA group). At 6 weeks after surgery, the vein grafts were removed from the dogs, cut into rings, and suspended in organ chambers for isometric tension recording. In some rings, the endothelial cells were removed. When the rings taken from the control group were contracted with norepinephrine, adenosine diphosphate (ADP) and A23187 caused endothelium-dependent relaxations. In the EPA group, the endothelium-dependent responses to ADP were significantly augmented, while A23187 caused comparable endothelium-dependent relaxations. Direct relaxation in response to sodium nitroprusside was comparable between the two groups. Intimal thickening of the grafts in the control group (29.0 +/- 1.8 microns) was significantly (P < 0.05) greater than in the EPA group (12.5 +/- 1.8 microns). These results suggest that EPA enhances the release of endothelium-derived relaxing factor in autogenous vein grafts. This may be one of the effects of EPA in reducing the intimal thickening of autogenous vein grafts.

Endothelium-dependent relaxation in response to adenosine diphosphate is impaired under poor runoff conditions in the canine femoral artery.

To examine whether poor distal runoff conditions of the canine femoral artery modulates endothelium-dependent relaxations, we developed a poor distal runoff limb in the canine right femoral artery (poor runoff group). The left femoral artery was used as a control. Endothelium-dependent responses were examined in vitro. The rings of femoral artery were obtained from dogs pretreated with 6 weeks of poor distal runoff. In the control, flow rate and tau-variation were 79.1 ml/min and 214.2 dynes/cm2, respectively. In the poor runoff group, the flow rate and tau-variation were 27.4 ml/min and 52.7 dynes/cm2. There were significant differences between the two groups. In the rings taken from the control group contracted with norepinephrine, adenosine diphosphate (ADP) and A23187 caused endothelium-dependent relaxations. In the poor runoff group, the endothelium-dependent relaxations in response to ADP were impaired, while A23187 caused comparable endothelium-dependent relaxations. Direct relaxations in response to sodium nitroprusside were comparable between the two groups. These experiments indicate that under poor runoff conditions, the endothelium-dependent relaxations to ADP are impaired without changing the properties of the smooth muscle cells. This dysfunction of the endothelium under conditions of abnormal flow may accelerate a loss of late patency of the reconstructed arteries.

Comparison of endothelial function between in situ and reversed vein graft: differences in endothelium-dependent responses.

BACKGROUND: The endothelium releases endothelium-derived relaxing factors that are potent vasodilators and inhibitors of platelet aggregation. Experiments were performed to determine whether the endothelium-dependent responses differed between in situ and reversed vein grafts. The influence of valve disruption or of dissection of the adventitia was also examined. METHODS: Segments of canine jugular veins were grafted into the carotid arteries during procedures such as reversed grafting, in situ grafting with valve disruption, in situ grafting without valve disruption, and in situ grafting with dissection of adventitia. After 4 weeks the endothelium-dependent responses of the grafts were examined by isometric tension recording. RESULTS: In the reversed and in situ vein graft with valve disruption, acetylcholine caused endothelium-independent contractions, whereas in the in situ vein graft without valve disruption acetylcholine-induced endothelium-dependent relaxations were preserved. Adenosine diphosphate (ADP) caused comparable endothelium-dependent relaxations in the in situ vein graft irrespective of valve disruption. In the reversed vein graft ADP-induced relaxations were significantly impaired. In the in situ vein graft with dissection of the adventitia, relaxations in response to acetylcholine and ADP were significantly reduced. CONCLUSIONS: These results suggest that endothelial function, in terms of endothelium-derived relaxing factors in the in situ vein graft, can be preserved and that adventitial dissection in the in situ vein graft should be minimized to preserve endothelial function.

Do patients with intermittent claudication need surgical treatment?

To determine whether surgical intervention is of therapeutic significance for patients with intermittent claudication (IC), 315 patients with IC followed in our outpatient clinics for the past 8 years 3 months (mean of 3 years 10 months), including 142 non-operated and 173 operated patients, were investigated as to changes in symptoms and the prognosis. Changes in symptoms in both groups were analyzed according to the variable distances of claudication and location of the diseased artery. To examine the degree of association between surgery and improvement of symptoms, Goodman and Kruskal's gamma was used. For all subgroups with a variable claudication distance (group A; distance < 100 m, B: 100-500 m, C: > 500 m), surgery inversely correlated with improvement in symptoms (group A; gamma = -0.378, group B; gamma = -0.651, group C; gamma = -0.828). According to location of the diseased artery, surgery correlated with improvement in symptoms in aorto-iliac (gamma = -0.811), aorto-ilio-superficial femoral (gamma = -0.641), and superficial femoral-distal (gamma = -0.533) groups but not in superficial femoral (gamma = -0.427) or infrapopliteal (gamma = -0.194) alone groups. Concerning the prognosis, no significant difference was noted between operated and non-operated groups (p = 0.35). These computed data show that surgical intervention has therapeutic significance for patients with IC, except for cases of claudication with segmental occlusion of the superficial femoral or infrapopliteal artery alone.

Persistent sciatic artery: two case reports and a review of the literature.

Persistent sciatic artery (PSA) sometimes shows variant vascular symptoms such as chronic or acute limb ischaemia and a pulsatile mass in the buttocks caused by aneurysmal dilatation. This report presents two cases of surgically treated PSA that caused lower-limb ischaemia. The first patient, a 58-year-old man, showed acute limb ischaemia in the chronic clinical course, and thrombectomy and patch angioplasty were performed. The second patient, a 70-year-old woman, had an incomplete type of PSA without development of the femoral artery while complaining of a 10-year history of coldness and numbness in the left lower limb. A left common iliac to profunda femoris arterial bypass was performed. This is the second case of symptomatic incomplete PSA reported in the literature. This report also reviews 45 cases of PSA published since 1977. The diagnosis of PSA requires arteriography that includes the bilateral iliac systems. Femoropopliteal bypass and, in the case of sciatic artery aneurysm, a ligature of the sciatic artery are recommended for the surgical treatment of PSA.

Correlation of long-term results of extra-anatomic bypass and flow waveform analysis.

To investigate the correlation between the long-term results of an extra-anatomic bypass and operative flow waveform analysis, we retrospectively reviewed 32 axillofemoral and 21 femorofemoral bypasses for between 1 and 5 years after surgical repair. For the grafts with a type O or I flow waveform pattern, the patency at 3 years (83%) and at 5 years (83%) was superior to grafts with a type II flow waveform (69 and 60%). For the axillofemoral bypass grafts with a type O or I waveform, the patency rate was 92% at 5 years. In contrast with the type II flow, the patency rate was 70% at 5 years. For the femorofemoral bypass with a type O or I and a II flow waveform, the patency at 4 years was 67 and 46%, respectively. In cases with concomitant superficial femoral artery occlusion, the flow waveform was type O or I in 23% and type II in 77%. The patency rate at 5 years was 85% for cases with a patent superficial femoral artery, and 51% for an occluded superficial femoral artery (p < 0.05). These results suggest that the long-term outcome of extra-anatomic bypass correlates with the operative flow wave analysis. In addition, good long-term results and an accurate flow wave pattern depend on the distal run-off, particularly the presence of a patent superficial femoral artery.

Impaired endothelial prostacyclin production of the canine vein graft in a poor distal runoff limb.

BACKGROUND: Because blood flow modulates endothelial prostacyclin production, the extent of this production in autologous vein grafts implanted in poor distal runoff limbs needed to be examined. METHODS: Endothelial prostacyclin production in canine autologous vein grafts was measured in poor distal runoff limbs (poor runoff group) and compared with findings in normal runoff limbs (control group). Vein grafts were perfused in a closed circuit at 3 days and 1, 2, 3, and 4 weeks after implantation; after perfusion for the first 30 minutes in a steady flow (basal prostacyclin production), the grafts were exposed to arachidonic acid (stimulated prostacyclin production) for the following 30 minutes. Prostacyclin, as the metabolite 6-keto-PGF1 alpha, was radioimmunoassayed. RESULTS: Basal and stimulated prostacyclin production increased in both groups during a period of time after implantation. At 2 weeks when endothelialization was complete, prostacyclin production in the poor runoff group was impaired, compared with the findings in the control group, and this difference increased with time. At 4 weeks the stimulated prostacyclin production was 18.91 +/- 4.03 ng/cm2 in the control group and 11.60 +/- 1.67 ng/cm2 in the poor runoff group (p < 0.05). CONCLUSIONS: We propose that the impaired capacity of the vein graft to produce prostacyclin in a poor distal runoff may lead to loss of graft patency in reconstructed arteries.

Natural course of endothelium-dependent and -independent responses in autogenous femoral veins grafted into the arterial circulation of the dog.

We examined the natural course of endothelium-dependent and -independent responses in reversed autogenous vein grafts during regeneration and tissue repair processes after vein grafting in dogs. Vein grafts implanted in the canine femoral artery were removed, cut into rings, and suspended in organ chambers for isometric tension recording at 3 days and 1, 2, 4, and 6 weeks after implantation. Endothelial cells were denuded from some rings. Control veins were taken from nonsurgically treated femoral veins. Acetylcholine caused endothelium-dependent relaxations in the control veins, whereas in the vein grafts there was no evidence of endothelium-dependent relaxations to acetylcholine 3 days after the operation. Acetylcholine caused endothelium-independent contractions throughout the study. The endothelium-dependent responses to ADP and calcium ionophore A23187 were constantly maintained. Three days after the operation, the amplitude of norepinephrine-induced contractions of the vein grafts was impaired, and at 1 week the amplitude was recovered, although it was significantly smaller than the amplitude of contractions of the control veins at any postoperative period. Endothelium-independent relaxations to sodium nitroprusside were maintained throughout the study. Thus, there was a selective loss of acetylcholine-mediated relaxation in vein grafts in the early postoperative stage, a time when the intima is not thickened. These altered responses in vein grafts in the early postoperative period may have a role in graft failure.

Simultaneous resection of abdominal aortic aneurysms and early gastric cancer by retroperitoneal and transperitoneal approach.

The surgical approach to patients with abdominal aortic aneurysm and gastrointestinal malignancy remains controversial. We experienced two cases with abdominal aortic aneurysm and gastric cancer, which were treated by a one-stage operation using a different approach. At first, the operation for the aneurysm was done through a retroperitoneal approach and then, a partial gastrectomy for gastric cancer was done through a transperitoneal approach. The postoperative course of both cases was uneventful. The patients were discharge on the 19th and 21st postoperative days, respectively. This one-stage operation using different isolated approaches, such as the retroperitoneal approach for abdominal aortic aneurysm and transperitoneal approach for gastric cancer, was useful for the patients with abdominal aortic aneurysm and particularly early gastric cancer in terms of preventing an infection of the prosthetic graft.

High aortic occlusion associated with lupus anti-coagulant.

Lupus anti-coagulant (LAC) has been recognised in association with venous and arterial thrombotic events. We retrospectively investigated the relationship between LAC and 21 patients with juxtarenal high aortic occlusion. Four of the 21 patients were LAC positive (19%), one of whom was a woman suffering from systemic lupus erythematosus (SLE). The three men had neither SLE nor any other connective tissue disease. The mean age of the four patients was 43.5 years and three of them (75%) were younger than 50 years of age. By contrast, the mean age of the 17 patients without LAC was 59.9 years and 14 of them (82.4%) were older than 50 years. The postoperative courses in all four patients with LAC undergoing arterial reconstructions were uneventful. Two patients were treated by either anti-coagulation or anti-platelet agents, postoperatively. The present paper demonstrates for the first time that, in patients with juxtarenal high aortic occlusion, the incidence of LAC positivity is higher in younger patients (below 50) than in older patients (above 50). In addition, our results show that a preoperative evaluation of the presence of LAC is required in cases with juxtarenal high aortic occlusion, particularly when the partial thromboplastin time (PTT) is prolonged and the patients are younger than 50 years old.