Simultaneous Left Ventricular and Deep Vein Thrombi Caused by Protein C Deficiency.

Protein C deficiency is a risk of venous thrombosis because of poor fibrinolytic activity. It remains controversial whether protein C deficiency causes arterial thrombosis. A 21-year-old woman was referred with a chief complaint of right leg pain and numbness. Contrast-enhanced computed tomography revealed a low-density mass in the left ventricle (LV), splenic infarction, and peripheral arterial obstructions in her right leg. Thrombosis extending from the renal vein to the inferior vena cava was also detected. Electrocardiography revealed ST depression in leads II, III, and aVF. Transthoracic echocardiography revealed hypokinesis of the apex and interventricular septum and a hypoechoic mass in the LV (26 × 20 mm). She was diagnosed with acute arterial obstruction caused by the LV thrombus, which might have resulted from previous myocardial infarction. Protein C activation turned out to be low (41%) 5 days after admission. The anticoagulant therapy was switched from heparin to rivaroxaban 16 days after admission. The LV thrombus disappeared 24 days after initial treatment, and she has had no thrombotic episodes for 2.8 years under rivaroxaban therapy. Thrombophilia should be investigated for cases of simultaneous left ventricular and deep venous thrombi. Rivaroxaban can be effective in prevention of further thrombotic events.

Neoadjuvant imatinib treatment and laparoscopic anus-preserving surgery for a large gastrointestinal stromal tumor of the rectum.

BACKGROUND: Resection of a gastrointestinal stromal tumor (GIST) of the rectum can be difficult because of the particular location in the pelvis, and a large rectal GIST often requires abdominoperineal resection. Recent reports demonstrate that neoadjuvant imatinib treatment improves surgical outcomes in patients with a rectal GIST, and there are only a few reports of the effectiveness of laparoscopic surgery for a rectal GIST. CASE PRESENTATION: A 46-year-old man was found to have a rectal GIST that measured 80 mm and was located on the anterior wall of the lower rectum. After 6 months treatment with imatinib, the tumor decreased in size to 37 mm, and laparoscopic low anterior resection was performed. The patient is currently alive without any evidence of recurrence 37 months after surgery. CONCLUSIONS: Neoadjuvant imatinib should be a treatment of choice for a large rectal GIST. When marked tumor shrinkage is achieved, laparoscopic surgery may be the preferred procedure.

Laparoscopic resection of adult colon duplication causing intussusception.

Gastrointestinal duplications are uncommon congenital malformations that can occur anywhere along the gastrointestinal tract. Most cases are recognized before the age of 2 years, and those encountered in adults are rare. We describe here a case of ascending colon duplication in a 20-year-old male that caused intussusception and was treated laparoscopically. Although computed tomography revealed a cystic mass filled with stool-like material, the preoperative diagnosis was a submucosal tumor of the ascending colon. We performed a laparoscopic right colectomy, and the postoperative pathological diagnosis was duplication of the ascending colon, both cystic and tubular components. We conclude that gastrointestinal duplications, although rare, should be considered in the differential diagnosis of all abdominal and submucosal cystic lesions and that laparoscopy is a preferred approach for the surgical treatment of gastrointestinal duplications.

Transabdominal approach assisted by thoracoscopic drainage for lower esophageal perforation.

The effectiveness of use of thoracoscopy for esophageal perforation has not been fully evaluated. We herein report a case of esophageal perforation for which a transabdominal approach assisted by thoracoscopic drainage was performed.

A case of paraspinal arteriovenous fistula in the lumbar spinal body assessed with time resolved three-dimensional phase contrast MRI.

A 93-year-old female with a paraspinal arteriovenous fistula (AVF) occurred within the lumbar spinal vertebral body was assessed with time resolved three-dimensional (3D) phase-contrast MRI (4D-Flow) on 1.5 Tesla MR scanner (GE Healthcare). The 3D vector field, streamlines, and pathlines analyses demonstrated uni-directional flow from the aorta to the large vascular cavity in the lumbar vertebral body by means of the lumbar artery as well as dilated paravertebral veins as drainers, which confirmed AVF, not aortic pseudoaneurysm. The 4D-Flow also showed an added value in planned endovascular surgery concerning localization of the precise shunting point and the shunting volume quantification.

Assessment of pelvic hemodynamics during an open repair of an infrarenal abdominal aortic aneurysm.

PURPOSE: To assess the pelvic circulation during abdominal aortic aneurysm (AAA) repair by measuring the inferior mesenteric artery stump pressure (IMA-SP), penile blood flow, and gluteal blood flow. METHODS: Twenty males were selected for this study. An aorto-bi-common iliac arteries (CIA) graft replacement was performed in ten patients (Group Bi-CIA). An aorto-right-CIA/left-external iliac artery (EIA) graft replacement was performed in five (Group Lt-EIA). The other five underwent an aorto-right-EIA/left-CIA anastomosis (Group Rt-EIA). The right graft limb was anastomosed first, followed by the left limb in all of the patients. Pelvic circulation was monitored during aortic reconstruction, including the IMA-SP index (IMA-SPI), penile brachial pressure index (PBI) by pulse-volume plethysmography, and gluteal tissue oxygenation metabolism with near-infrared spectroscopy by monitoring the gluteal tissue oxygenation index (TOI) bilaterally. RESULTS: The PBI and bilateral gluteal TOI became depressed in all patients during proximal aortic clamping. However, there was no significant change in IMA-SPI in each group. The PBI and bilateral gluteal TOI in all groups recovered to the baseline values after completion of bilateral graft limb anastomosis. CONCLUSIONS: IMA-SPI is likely to reflect collateral circulation mainly from the superior mesenteric artery. The penile blood flow and bilateral gluteal blood flow therefore seem to be supplied via the bilateral hypogastric arteries or the profunda femoris arteries.

A novel method of measuring human lymphatic pumping using indocyanine green fluorescence lymphography.

OBJECTIVES: Lymph transportation through the body is partly controlled by the intrinsic pumping of lymphatic vessels. Although an understanding of this process is important for medical application, little is currently known because it is difficult to measure. Here, we introduce an easy, safe, and cost-effective technique for measuring lymphatic pumping in leg superficial lymphatic vessels. Readings obtained with this technique were compared with values obtained with dynamic lymphoscintigraphy. Differences in lymphatic pumping between healthy volunteers and patients with lymphedema were also investigated. METHODS: Indocyanine green (ICG) fluorescence lymphography was performed by subcutaneously injecting 0.3 mL of ICG (0.5%) into the dorsum of the foot. Real-time fluorescence images of lymph propulsion were obtained with an infrared-light camera system with the individual supine or sitting. A custom-made transparent sphygmomanometer cuff was wrapped around the lower leg and connected to a standard mercury sphygmomanometer. The cuff was inflated to 60 mm Hg and then gradually deflated at 5-minute intervals to lower the pressure by 10-mm Hg steps until the fluorescence contrast agent exceeded the upper border of the cuff, indicating that the lymphatic contraction had overcome the cuff pressure. Lymph pumping pressure (P(pump)) was defined as the value of the cuff pressure when the contrast agent exceeded the upper border of the cuff. We measured P(pump) among healthy volunteers who maintained a supine position and compared these values with measurements obtained from lymphoscintigraphy. P(pump) values while sitting were also compared between 30 legs from healthy volunteers and 30 legs from lymphedematous patients. RESULTS: Among healthy, supine participants, P(pump) was 25.2 ± 16.7 mm Hg (mean ± standard deviation [SD]) when measured by ICG fluorescence lymphography. These values were significantly correlated with values taken using dynamic lymphoscintigraphy (r(2) = 0.54, p < .01), while 2 SDs of the mean were approximately 20 mm Hg, suggesting a substantial disagreement between the two methods (Bland-Altman plots). In the comparison of seated measurements, readings for healthy participants (P(pump) = 29.3 ± 16.0) were higher than those for lymphedematous participants (13.2 ± 14.9). CONCLUSION: ICG fluorescence is an accurate-as well as a safe, easy, and economical-method of measuring lymphatic pumping. Therefore, it may develop as a vital tool for diagnosing lymphatic malfunctions even when they are only in their formative stages. Studies that use this technique may increase our knowledge of the lymphatic system as a whole, allowing us to develop better treatments for lymphatic disorders.

Trans-Serosal Leakage of Proinflammatory Mediators during Abdominal Aortic Aneurysm Repair: Role of Phospholipase A2 in Activating Leukocytes.

Gut barrier failure and the resultant translocation of luminal bacteria and bacterial products into the systemic circulation have been proposed as pathogenic mechanisms of multiorgan dysfunction syndrome (MODS) in open repair of abdominal aortic aneurysm (AAA). Our study aimed to demonstrate the direct release of gut-derived inflammatory mediators via the trans-serosal route in humans. Fifteen patients who underwent elective infrarenal open repair of AAA were randomized into two groups. In Group I patients (n = 10), the small intestine was exteriorized into a bowel bag. In Group II patients (n = 5), the small intestine was packed within the peritoneal cavity using large gauzes. We collected the bowel bag fluid in Group I and the ascites fluid, squeezed out from the gauzes at the end of surgery, in Group II. Leukocytes were collected from patients' blood samples. Incubation with the bowel bag fluid and ascites fluid caused a significant increase in both granulocyte pseudopod formation and CD11b expression compared to that with control fluid (p < 0.01). The addition of phospholipase A2 (PLA2) inhibitor quinacrine abolished leukocyte activation by the bowel bag fluid. Based on these results, we consider that trasns-serosal leakage of gut-derived mediators occurred during the open repair of AAA; further, sPLA2 may be the most potent mediator in the activation of leukocytes among such gut-derived mediators in AAA surgery.

Elastic stocking-induced foot necrosis in a patient with severe pneumonia.

Elastic stockings (ES) are widely used for the prevention of venous thromboembolism. Here we report a case of foot ulcers induced by ES in patients with pneumonia and hypoxia. A 94-year-old woman was admitted for the treatment of pneumonia. The patient had been wearing an ES because of a history of deep vein thrombosis of the leg. Multiple foot ulcers occurred within 24 hours after the admission despite the absence of peripheral arterial occlusive disease. The ulcers took almost 5 months to heal. For patients with hypoxia, ES may further deteriorate local tissue hypoxia and thus should be used carefully.

Impaired lymphatic function recovered after great saphenous vein stripping in patients with varicose vein: venodynamic and lymphodynamic results.

OBJECTIVES: Venodynamics and lymphodynamics may interact as an inseparable and mutually dependent dual outflow system. This study investigated the effect of surgical treatment on lower limb lymph flow in patients with varicose veins. METHODS: Thirty-nine patients with varicose veins in the lower limb (28 patients with unilateral limb, 11 patients with bilateral limb), who demonstrated great saphenous vein reflux, were investigated with air-plethysmography and indocyanine green (ICG) fluorescence lymphography before surgical treatment and 6 months later. Fifteen healthy volunteers participated in this study as a control. With air-plethysmography, venous volume (VV) and venous filling time were measured. Venous filling index (VFI) was calculated. For ICG lymphography, 0.3 mL of ICG (0.5%) was subcutaneously injected at the dorsum of the foot. After the injection, fluorescent image of ICG dye was traced on real-time video images using a near-infrared camera system. The interval until the dye reached the knee was measured (transit time [TT]) in a standing position, which was previously demonstrated to correlate with the interval measured using dynamic isotope lymphoscintigraphy. RESULTS: In CEAP clinical stage venous disease, TT in patients with C4 approximately 6 and C2 approximately 3 was significantly longer than that in the control group (587 +/- 97 seconds, 484 +/- 82 seconds, 252 +/- 29 seconds, respectively, mean +/- SD, P < .01). Among all limbs with varicose veins, there were correlations between TT and VV (Pearson r = 0.31, P < .01), between TT and VFI (Pearson r = 0.48, P < .01). All patients underwent great saphenous vein stripping. Six months later, the venous clinical severity score significantly improved with significant reductions in both VV and VFI values. TT 6 months postoperatively was also significantly shorter than that before surgical treatment (501 +/- 67 seconds, 340 +/- 38 seconds, respectively, mean +/- SD, P < .01). CONCLUSIONS: Varicose veins could affect lymphatic function and delay lymphatic flow in the lower limbs. Derangement of lymph flow may correlate with the severity of clinical venous disease and/or the magnitude of venous reflux, which could be reversible with surgical treatment of venous incompetence.

Two-stage Surgery for Endovascular Repair and Laparoscopic Colectomy for a Patient with Abdominal Aortic Aneurysm and Concomitant Colon Cancer: Report of a Case.

Surgical management of abdominal aortic aneurysm (AAA) with concomitant malignancy remains controversial. Commercial availability of a stentgraft may change the treatment strategy for such patients. We present a case of AAA with concomitant colon cancer, in which two-stage surgery consisting of EVAR and subsequent laparoscopic colectomy was performed with an interval of six days. The patient's postoperative course was uneventful. For high-risk patients, application of endovascular AAA repair and laparoscopic surgery may decrease the risk of surgical morbidity and mortality.

Effect of hyperbarically oxygenated-perfluorochemical with University of Wisconsin solution on preservation of rat small intestine using an original pressure-resistant portable apparatus.

BACKGROUND: Perfluorochemicals (PFC) are chemical substances that have a higher oxygen solubility under hyperbaric oxygen (HBO) pressure. This study investigated the effect of cold HBO-PFC/University of Wisconsin (UW) solution on preservation of rat small intestinal graft. METHODS: We manufactured an air-tight, pressure-resistant tank made of stainless steel with high thermal conductivity. Rat ileal grafts were placed in a custom-made silicon-gum bag with UW solution, which was immersed in 5 atm HBO-PFC solution in the tank (Group P-5). The tank was kept at 4 degrees C. We compared the ATP concentration and mucosal permeability in Group P-5 with grafts preserved in 1 atm oxygenated-PFC/UW solution (Group P-1) and simple cold storage in UW solution (Group C). Histologic study was also performed. RESULTS: PO(2) in UW solution after 48 h preservation were 1852 +/- 37, 499 +/- 13, and 173 +/- 3 mmHg (Group P-5, P-1 and C, respectively, mean +/- SD). At 48 h of preservation, graft ATP concentration was significantly greater in Group P-5 compared to that in Group P-1 and Group C. Mucosal hyperpermeability as well as mucosal morphologic changes were also ameliorated in Group P-5. CONCLUSION: HBO-PFC can supply a greater amount of oxygen to UW solution. Indirect measures of oxygen metabolism such as ATP content and lactate production suggested improvement in maintaining graft oxygen metabolism.

Hemorrhagic shock with delayed retroperitoneal hemorrhage after deployment of an inferior vena cava filter: report of a case.

Although inferior vena cava (IVC) filter placement has demonstrated an excellent therapeutic efficacy in preventing pulmonary embolism, several filter-related complications have been reported. Among them, retroperitoneal hemorrhage due to IVC perforation is one of the most serious complications. We report herein a female patient who underwent TrapEase IVC filter placement with anticoagulation and thrombolytic therapy for treatment of pulmonary embolism, and later demonstrated hemorrhagic shock 5 days after filter placement. The patient's blood pressure stabilized after the anticoagulant therapy was stopped and she received a blood transfusion. We should therefore carefully observe patients after IVC filter placement, particularly those receiving simultaneous anticoagulation therapy.

Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema.

BACKGROUND: Lymphoscintigraphy has largely been performed to diagnose lymphedema. It is, however a time-consuming and expensive technique, which has not been covered by Japanese medical insurance since the year 2002. In this report we introduce a new imaging technique of fluorescent lymphography to diagnose lymphedema. METHODS: Fluorescence images of subcutaneous lymphatic drainage after subcutaneous injection of indocyanine green (ICG) at the foot were obtained using a newly developed near-infrared camera system. ICG fluorescent lymphography was performed in 12 patients with secondary lymphedema and 10 healthy volunteers. The 12 patients were diagnosed with secondary lymphedema according to the medical history and lymphoscintigram, of which 11 had a history of hysterectomy with extended lymph node dissection and local radiation therapy for uterine cancer. Lymphedema developed in one patient after femorotibial artery bypass for peripheral artery occlusive disease. RESULTS: Four abnormal fluorescent patterns of the lymph drainage were observed in lymphedema: dermal backflow (an abnormal filling of the lymph capillaries), extended fluorescent signal at the dorsum and plantar region of the foot, dilated lymph channels with proximal obliteration, and diffuse glittering of fluorescent signals with scattered twinkling of the dye. Continuous lymph channels from the injection site of the foot to the groin were observed along the medial aspect of thigh in healthy subjects. CONCLUSION: ICG fluorescence lymphography is safe, simple, and minimally invasive. The device is portable and easy to use. The technique may be useful in clinical practice to identify presence of lymphatic disorder.