Multiple Re-entry Closures After TEVAR for Ruptured Chronic Post-dissection Thoraco-abdominal Aortic Aneurysm.

INTRODUCTION: Although thoracic endovascular aortic repair (TEVAR) has become a promising treatment for complicated acute type B dissection, its role in treating chronic post-dissection thoraco-abdominal aortic aneurysm (TAA) is still limited owing to persistent retrograde flow into the false lumen (FL) through abdominal or iliac re-entry tears. REPORT: A case of chronic post-dissection TAA treatment, in which a dilated descending FL ruptured into the left thorax, is described. The primary entry tear was closed by emergency TEVAR and multiple abdominal re-entries were closed by EVAR. In addition, major re-entries at the detached right renal artery and iliac bifurcation were closed using covered stents. To close re-entries as far as possible, EVAR was carried out using the chimney technique, and additional aortic extenders were placed above the coeliac artery. A few re-entries remained, but complete FL thrombosis of the rupture site was achieved. Follow-up computed tomography showed significant shrinkage of the FL. DISCUSSION: In treating post-dissection TAA, entry closure by TEVAR is sometimes insufficient, owing to persistent retrograde flow into the FL from abdominal or iliac re-entries. Adjunctive techniques are needed to close these distal re-entries to obtain complete FL exclusion, especially in rupture cases. Recently, encouraging results of complete coverage of the thoraco-abdominal aorta with fenestrated or branched endografts have been reported; however, the widespread employment of such techniques appears to be limited owing to technical difficulties. The present method with multiple re-entry closures using off the shelf and immediately available devices is an alternative for the endovascular treatment of post-dissection TAA, especially in the emergency setting.

[Left atrial myxoma with extramedullary hematopoiesis and ossification].

A 65-year-old female with palpitation was referred to our hospital for a further examination. Trans-esophageal and thoracic echocardiogram demonstrated a left atrial tumor with a patchy calcification, arising from the lower portion of the interatrial septum. It was completely extirpated together with its sessile pedicle and the related disc of interatrial septum. The tumor showed the extensive extramedullary hematopoiesis and ossification around scanty clusters of myxoma cells on light microscopy. These findings indicated further support to the belief that the primitive mesenchymal cell is the origin in cardiac myxoma.

Rupture in a mitral papillary muscle following blunt chest trauma.

The successful surgical repair of an uncommon case of blunt chest trauma is described. A 28-year-old man was involved in a motorcycle accident during which the victim struck a pole at high speed. Extracorporeal membrane oxygenation was required with a tentative diagnosis of traumatic respiratory distress syndrome, but he nevertheless continued to show progressive deterioration. In the preoperative evaluation, transesophageal echocardiography clearly demonstrated an injury involving of mitral regurgitation secondary to total rupture of a papillary muscle. Mitral valve replacement was performed seven days after the accident. The importance of the diagnostic process and surgical treatment are emphasised.

[The combined resection of left atrium for advanced lung cancer on cardiopulmonary bypass: a case report].

We successfully treated surgically using cardiopulmonary bypass an elderly patient, a seventy-six-year-old man, with primary advanced lung cancer (rt. S6) with left atrial extension. He had intermittent episodes of bloody sputum. A preoperative chest roentogenogram revealed an abnormal mass shadow in S6 of the right lower lobe of the lung. MRI findings of the chest and a right heart catheterization with levophase demonstrated the extension of the tumor into the left atrium. A distant metastatic work-up was negative. By use of the full lateral thoracotomy and cardiopulmonary bypass, the tumor was removed en bloc through a combined left atrial resection and right middle and lower lobectomy. The patient has been well without and symptoms 8 months after surgery. An advanced lung cancer invading the left atrium can be safety and completely resected with the use of cardiopulmonary bypass if the extent of left atrial involvement is recognized preoperatively.

[Extralobar sequestration presenting increased serum CA19-9 and associated with lung aspergillosis--an unusual case].

In a thirty-four-year old man, an asymptomatic abnormal mass shadow was detected in S10 of the left lower lobe on chest X-ray film. The serum CA19-9 was abnormally elevated 395 U/ml). The definitive histological diagnosis was not obtained by both transbronchial and percutaneous lung biopsy preoperatively. Surgery demonstrated that an abnormal mass was separated from S10 of the left lower lobe by a fibrous tissue, and it contained severe inflammatory changes and abscess. Extralobar pulmonary sequestration was diagnosed, but aberrant arteries were not conformed. Sequestered lung and a part of the lower lobe were resected en bloc. The serum CA19-9 level returned to normal postoperatively. Aspergillus was only detected in the sequestered lung by postoperative cultre. Moreover, CA19-9 level in the fluid of this sequestered lung was markedly high, 50,000 U/ml. Production of CA19-9 was demonstrated in bronchial epithelium of the sequestered lung immunohistochemically. Extralobar pulmonary sequestration associated with aspergillosis and high serum CA19-9 is very rare. To our knowledge, this is the first reported case in the literatures.

An in vitro evaluation of venous cannula in a simulated partial (femoro-femoral) cardiopulmonary bypass circuit.

We designed a study to evaluate three factors (siphon gradient [PH], the right atrial pressure [RAP], and the inferior vena caval flow [IVCF]) to be optimized to maximize the venous drainage flow (DF) during partial cardiopulmonary bypass using eight venous cannulas of three different types and an original model circuit. The relationship between venous DF and the three factors is indicated by the multiple regression equation DF2 = alpha PH + beta RAP + gamma IVCF2 + C, where alpha, beta, and gamma are regression estimates and C is a constant. Multiple regression analysis results showed that DF was positively correlated with PH and RAP and negatively correlated with IVCF. A long cannula with 12 side holes and 60 cm long was considered to be useful to yield the optimal venous drainage flow under the condition of maintenance of the flow balance (DF and ICVF) and the pressure balance (RAP and IVCP) at the zero point. Moreover, this model may allow extensive research in flow dynamics of venous cannula without involving human subjects.

[A two staged extending graft replacement for dissecting aortic aneurysm with Marfan's syndrome].

We experienced four cases of dissecting aortic aneurysms with Marfan's syndrome, in which two staged operations were performed with satisfactory results. The operations performed in the four patients were the replacement of the ascending aorta, transverse aortic arch and the entire descending thoracic aorta in DeBakey type I dissecting aortic aneurysm, replacement of the entire descending thoracic and abdominal aorta in type IIIb, replacement of the aortic valve, ascending aorta, transverse aortic arch, the entire descending thoracic and upper abdominal aorta in type I, and replacement of the total aorta including the aortic valve in type II + IIIb, respectively. There were no operative deaths, but a 42-year-old woman with DeBakey type IIIb died suddenly 2 years 11 months after the second operation. The cause of death was presumed to be due to rupture of a dissecting aneurysm (DeBakey type II). Dissecting aortic aneurysm with Marfan's syndrome must be observed carefully and corrected surgically, because the lesion is progressive and the residual dissecting aneurysm usually dilates eventually. In view of our clinical results, we conclude that the operation for dissecting aortic aneurysm with Marfan's syndrome should be performed as extensively as possible.

[Angiographic evaluation of reconstructed spinal arteries in thoracic aortic aneurysm surgery].

Revascularization of the spinal arteries with thoracic aortic aneurysm were performed on nineteen patients using partial extracorporeal bypass. They were 16 men and 3 women. Age range were from 33 to 70 years (mean 49.9 +/- 10.3 years). There were eleven patients of dissecting aneurysm (DeBakey type IIIb in eight patients, type I in two patients and type IIIa in one patient), and eight patients of non-dissecting thoracoabdominal aneurysm (including two patients with ruptured aneurysm). The number of revascularized spinal arteries were 60 pairs (average 3.2 pairs per each patient). The revascularized spinal arteries were localized between levels T4 and L5.36 pairs of the 60 existed between levels T8 and L2 from where the artery of Adamkiewicz arises. Seven patients (eleven spinal arteries) underwent selective angiography of the revascularized spinal arteries postoperatively, and the anterior spinal artery and the artery of Adamkiewicz was identified in three patients. Two patients died within one month, one from MOF and the another from intestinal perforation respectively (operative mortality 11.1%). One patient, with ruptured thoracoabdominal aortic aneurysm showed paraparesis postoperatively, but no paraplegia was found in any patients. We recommend that not only the artery of Adamkiewicz but also the spinal arteries at the midthoracic area from T4 to T8 should be revascularized, to prevent postoperative paraplegia. Replacing of extended thoracic aneurysm, our method (using partial extracorporeal circulation and segmental aortic clamping) was thought to prevent spinal cord ischemia.

[Bochdalek diaphragmatic hernia in the elderly: a case report].

We successfully treated surgically an elderly patient, a 80-year-old woman, with Bochdalek diaphragmatic hernia. She had intermittent episodes of intestinal obstruction. A preoperative chest roentgenograph revealed a loop of gas-filled bowel in the left chest and elevation of the left diaphragm. CT scanning of the thorax revealed the bowels filled with gastrografin in the left thoracic cavity. She was treated surgically, through transabdominal and then transthoracic approaches. The herniated large bowel was reduced from the thoracic cavity and the hernial sac was excised. The posterolateral defect of the diaphragm, 5 x 6 cm in size was closed with interrupted mattress sutures. The patient has been well without any symptoms 6 months after the surgery. Bochdalek diaphragmatic hernia is the most common problem in infants with risky respiratory distress and high mortality, however it is preferable to carry out surgical treatment for adult patients because of good postoperative results. As a surgical route in the management of Bochdalek diaphragmatic hernia in adults, a transthoracic approach is preferable since it provides easy separation and reduction of herniated bowels from the thoracic cavity and easy closure of the diaphragmatic defect, furthermore there are no other serious gastrointestinal complications which are required specific repair.

Clinical studies on the vasodilating and anti-platelet effects of OP-41483, a prostacyclin derivative.

The vasodilating and anti-platelet actions of OP-41483 was studied to determine the effective dose of this drug for the treatment of ischemic lower limbs. The compound was given to 11 patients intravenously at rates of 2.5, 5.0 and 10.0 ng/kg/min. Infusion at a rate of 10 ng/kg/min increased the mean flow rate of the tibial arteries from 3.15 +/- 1.77 ml/min before the infusion, to 7.89 +/- 2.51 ml/min (p less than 0.001) and to 6.38 +/- 3.19 ml/min (p less than 0.001), at the time of, and 60 minutes after the cessation of the infusion, respectively. The peripheral flow resistance of the tibial arteries was reduced from 2.1 +/- 1.12 X 10(5) dyne.sec/cm5 before the infusion to 0.9 +/- 0.33 X 10(5) dyne.sec/cm5 (p less than 0.001) and to 1.2 +/- 0.78 X 10(5) dyne.sec/cm5 (p less than 0.05), at the time of, and 60 minutes after the cessation of the infusion. ADP-induced platelet aggregation was reduced from 73.3 +/- 17.6% before the infusion to 50.7 +/- 24.5% (p less than 0.01) and to 64.0 +/- 23.5% (p less than 0.05), at the time of, and 60 minutes after the cessation of the infusion, respectively. Collagen-induced platelet aggregation was also reduced from 71.4 +/- 24.0% to 66.6 +/- 21.5% before and after the infusion (p less than 0.05).