Posterior Tibial Artery Aneurysm Caused by Trauma: A Case Report.

In this study, we present a case of 59-year-old man with a posterior tibial artery (PTA) aneurysm. Mostly, PTA aneurysm is caused by trauma, infection, and iatrogenic injury. The patient had a history of ankle trauma that occurred 2 years ago. Computed tomography and ultrasonography showed a 7×14 mm PTA aneurysm. The aneurysm was resected and primary end-to-end anastomosis was performed. So far, there are only few reported cases of PTA aneurysm. Herein, we describe the surgical strategy and provide detailed intraoperative images.

[Total Arch Replacement with Open Stent Grafting for Chronic Dissecting Aortic Aneurysm with Aberrant Right Subclavian Artery:Report of a Case].

A 59-year-old man was referred to our hospital for surgery for a dissecting aortic aneurysm with an aberrant right subclavian artery( ARSA). He had a history of surgery for atrial septal defect at the age of 3 and developed Stanford type B aortic dissection at the age of 53. The maximum diameter of the aortic aneurysm was 68 mm, and the entry was located close to the ARSA origin. We established cardiopulmonary bypass using the femoral artery and vein and performed a median re-sternotomy. We performed total arch replacement with the open stent-grafting technique. The ARSA was ligated from the right thoracic cavity. Three arch branches were reconstructed in situ, and the right axillary artery was bypassed with a 9 mm Dacron graft. Six months after that operation, reduction of the false lumen was observed. This strategy is considered to be effective for chronic aortic dissection with ARSA.

[A Novel Virtual-reality Imaging System in Cardiovascular Surgery:a Potentially Promising Technology for Surgeons].

Adequate preoperative planning may facilitate successful procedures in cardiovascular surgery. We have developed a system named the Vesalius 3D suite, combining three-dimensional (3D) image-processing software with an optic-tracking spatial navigation, allowing quick, accessible 3D image interpretation for virtual reality (VR) exploration and measurement from one or more of a range of imaging modalities. We present a novel method of virtual imaging analysis for preoperative planning and simulation in cardiovascular surgery using this 3D-VR system. Based on unimodal or multimodal medical imaging data, digital imaging and communication in medicine (DICOM) data sets can be reconstructed for 3D visualization. Virtually reconstructed images can be viewed on flat-screen or stereoscopic display, revealing each patient's specific anatomy and the internal structures in exquisite detail. Highly accessible 3D interpretation promptly permits precise measurements of repair-relevant anatomical parameters including geometrically complex shapes. This technology may promote understanding of form and function in the cardiovascular system, and facilitate operative procedures in more challenging cases, and it seems especially valuable for any surgeon to gain experience in practicing for rarely-performed procedures or uncommon patient-specific preoperative surgical rehearsal.

Ex-vivo aortic root and coronary artery cast measurement to validate the accuracy of virtual imaging.

BACKGROUND AND AIM OF THE STUDY: To investigate the accuracy of two methods of measuring features in cardiac anatomy, using an objective standard cast model. METHODS: We made a silicone cast using a swine heart. Computerized tomography data of the solidified cast were processed through virtual reality (VR) software and through two-dimensional multiplanar-reconstruction (2D-MPR), and all measurements were compared against physical measurements of the cast. RESULTS: The cast perfectly demonstrated the fine detail of the aortic valve and the proximal parts of coronary arteries. Anatomical features were measured by 3D-VR, 2D-MPR, and directly on the cast. Measurement differences between 2D-MPR and the cast were on average at least 3.6 times larger than those between 3D-VR and the cast. CONCLUSIONS: Based on the observed accuracy, 3D-VR measurements seem considerably more accurate than the current standard 2D-MPR, and 3D-VR may be considered as the next gold standard for 3D measurement of cardiac anatomy in vivo.

Validation of Virtual Imaging of a Dynamic, Functioning Aortic Valve Using an Ex Vivo Porcine Heart.

PURPOSE: To investigate a virtual reality imaging system in terms of visualization accuracy and appropriate orientation when displaying cardiac anatomy, we used an ex vivo model enabling direct comparison between reconstructed 3-dimensional visualization of intracardiac structures and real-time visual images. DESCRIPTION: We established a systole-diastole platform using a swine heart activated by an external mechanical pump and reservoir, allowing simultaneous acquisition of endoscopic visual and computed tomography images of the aortic valve. Virtual images were processed from computed tomography data using 3-dimensional software (the Vesalius 3D suite; PS Medtech, Amsterdam, Netherlands) and compared with visual images seen through a fiberoptic scope. EVALUATION: An endoscope gave a fine view of the aortic valve, whereas the virtual images elucidated the valve structures. Superimposition of the images from the 2 different modalities showed the virtual reality images precisely matching the visual images in both systole and diastole, confirming the validity of this virtual reality application. CONCLUSION: In view of this demonstrated fidelity of virtual imaging, this technology may be of sufficiently high quality to be considered a gold standard for cardiac anatomy.

A Virtual-Reality Imaging Analysis of the Dynamic Aortic Root Anatomy.

PURPOSE: To measure and explore complex cardiac anatomy in research and preoperative simulation, a virtual imaging technology-the Vesalius 3D suite (PS Medtech, Amsterdam, Netherlands)-combines Vesalius three-dimensional (3D) image-processing software with an optic-tracking navigation system running PST-Client software. We present a novel method of evaluating dynamic aortic root geometry in vivo using this visualization system. DESCRIPTION: Based on electrocardiography-gated cardiac computed tomography data in systole and diastole, images of the aortic root in a healthy adult were reconstructed for 3D visualization. Virtual interaction tools were used to explore and measure the aortic root structures. EVALUATION: Virtually reconstructed images revealed the aortic root internal structures in exquisite detail. Highly accessible 3D interpretation promptly permitted precise measurements of repair-relevant anatomic parameters, including geometrically complex curves of the aortic root wall and dynamic changes in the aortic valves. Measurement accuracy examined against a known prosthesis showed within 1 mm of error (less than 0.5%). CONCLUSIONS: This technology may promote understanding of aortic root form and function, and facilitate valve-sparing surgery, and seems valuable for 3D exploration and measurement of cardiac anatomy in vivo.

Infected Aortic Aneurysm Caused by Streptococcus zooepidemicus: A Case Report and Literature Review.

A 66-year-old Japanese male working at a stable developed abdominal pain and fever and was brought to the emergency department. The computed tomography scan revealed an aneurysm of approximately 70 mm in diameter, with an irregular border, at the infrarenal abdominal aorta. Emergency surgery was performed with a bifurcated Dacron graft. Streptococcus zooepidemicus was observed on the aneurysm wall. He was discharged in good condition and was prescribed oral amoxicillin/clavulanic acid for 4 months. He has remained well and did not develop inflammation. Evaluation of patient history and data, including the consumption of unpasteurized dairy food, occupation, and direct contact with animals, is important for an early diagnosis, a prompt surgery, and an appropriate antibiotic therapy.

Carcinosarcoma of the liver with mesenchymal differentiation.

We report an extremely rare case where a mesenchymal differentiation, especially embryonal sarcoma, was demonstrated in cholangiocarcinoma. At autopsy, a yellowish-white tumor (15 cm x 12 cm) was found in the right hepatic lobe, and there were several daughter nodules in both hepatic lobes. Histologically, most of the main tumor and all of the daughter nodules examined showed sarcomatous changes (spindle cells, pleomorphic cells and hyalization). Histologic examination of a part of the main tumor disclosed a focus of adenocarcinoma within the tumor. The frequent transitions between the adenocarcinomatous areas and the sarcomatous areas suggested that sarcomatous transformation occurred in the cholangiocarcinoma and then spread rapidly. Immunohistochemically, the adenocarcinomatous elements were positive for cytokeratin, carcinoembryonic antigen (CEA) and epithelial membrane antigen, and negative in the sarcomatous cells. Vimentin was positive only in the sarcomatous elements. The findings of the present case support the view that carcinosarcomas represent carcinomas that develop sarcomatous elements via metaplasia of the epithelial element.

Appendix is a priming site in the development of ulcerative colitis.

AIM: The role of the appendix has been highlighted in the pathogenesis of ulcerative colitis (UC). The aims of this study were to elucidate the immuno-imbalances in the appendix of UC patients, and to clarify the role of the appendix in the development of UC. METHODS: Colonoscopic biopsy specimens of the appendix, transverse colon, and rectum were obtained from 86 patients with UC: active pancolitis (A-Pan; n = 15), active left-sided colitis (A-Lt; n = 25), A-Lt with appendiceal involvement (A-Lt/Ap; n = 10), inactive pancolitis (I-Pan; n = 14), and inactive left-sided colitis (I-Lt; n = 22), and from controls. In the isolated mucosal T cells, the CD4/CD8 ratio and proportion of activated CD4+ T cells were investigated, and compared with controls. RESULTS: In the appendix, the CD4/CD8 ratio significantly increased in A-Lt and A-Lt/Ap. The ratio in the appendix also tended to increase in A-Pan. In the rectum, the ratio significantly increased in all UC groups. In the appendix, the proportion of CD4+CD69+ (early activation antigen) T cells significantly increased in all UC groups. In the rectum, the proportion of CD4+CD69+ T cells significantly increased only in A-Pan. The proportion of CD4+HLA-DR+ (mature activation antigen) T cells significantly increased only in the rectum of A-Pan, but not in the other areas of any groups. CONCLUSION: The increased CD4/CD8 ratio and predominant infiltration of CD4+CD69+ T cells in the appendix suggest that the appendix is a priming site in the development of UC.

Handcrafted two-channel colonoscope for grasping-forceps-assisted resection of giant pedunculated polyps.

BACKGROUND: Colonoscopic polypectomy of giant pedunculated polyps has an increased risk of bleeding and is technically difficult. To facilitate the removal of the polyps, we handcrafted a two-channel colonoscope and applied it for grasping-forceps-assisted resection. METHODS: We easily handcrafted a two-channel colonoscope by taping a plastic tube along the shaft of a standard colonoscope and used it for the technique in 10 patients with 12 giant pedunculated polyps. OBSERVATIONS: The colonoscope with forceps assistance proved to be satisfactory for handling detachable and polypectomy snares. Immediate bleeding occurred in one patient because the detachable snare could not be maneuvered over the polyp. In 3 patients, the plastic tube became mobile during the procedure because the tape that attached the tube became loose. No other complications occurred. CONCLUSIONS: A handcrafted two-channel colonoscope for grasping-forceps-assisted resection of giant pedunculated polyps is effective for the prevention of postpolypectomy bleeding and the reduction of technical difficulties.

[A case of effective weekly paclitaxel administration for primary lesion of schirrous gastric cancer].

We report a case of advanced schirrous gastric cancer with carcinomatous peritonitis. Chemotherapy with TS-1 was applied during the first 4 weeks, but the tumor did not respond to this therapy. Next, paclitaxel (TXL) was administered at a weekly dose of 90 mg/body/day for 3 weeks followed by a week interval of rest. Remarkable mass reduction of primary tumor was observed after 3 courses of treatment, and the symptom derived from primary tumor was relieved without significant side effects. The clinical course for schirrous gastric cancer with carcinomatous peritonitis is still miserable for patients, although many attempts have been made to improve its prognosis. A weekly paclitaxel regimen appears to be one of the promising treatment for schirrous gastric cancer.