Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A.

OBJECTIVE: Total arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury. METHODS: We evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA. RESULTS: The surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow. CONCLUSIONS: FeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

[Surgical repair for ascending aortic pseudoaneurysm derived from the proximal anastomotic site of saphenous vein graft after coronary artery bypass grafting; report of a case].

A 61-year-old male had undergone coronary artery bypass grafting (CABG) using a saphenous vein. Postoperative angiography represented an ascending aortic pseudoaneurysm derived from the proximal anastomotic site of the saphenous vein graft( SVG) which was connected to the obtuse marginal branch and left posterior descending branch sequentially. We performed the closure of tear and the plication of pseudoaneurysmal wall through median sternotomy on the 56th postoperative day. A 7mm length longitudinal tear in the ascending aorta close to the proximal anastomotic site of the SVG was observed. This tear was considered to be caused by the intimal injury during the anastomosis of SVG to ascending aorta. Aortic pseudoaneurysm formation close to the proximal anastomotic site of SVG is a rare and potentially lethal complication requiring urgent operation. Postoperative angiography or enhanced 3 dimensional computed tomography after CABG should be performed before hospital discharge.

Expression of thrombomodulin in human aortic smooth muscle cells with special reference to atherosclerotic lesion types and age differences.

Expression of thrombomodulin (TM) in atherosclerotic lesions of the human aorta (8 cases of diffuse intimal thickening, 4 fatty streaks, 11 atheromatous plaques, and 5 fibrous plaques) as well as in undiseased aortas of 5 infants obtained at autopsy was studied immunohistochemically using a novel polyclonal antibody against human TM. TM was expressed in intimal smooth muscle cells (SMC) besides endothelial cells and foamy macrophages in almost all patients (26/28). In addition, medial SMC in adult cases over 27 years of age expressed TM. In young adults with diffuse intimal thickening under 26 years of age, medial SMC showed no TM expression whereas intimal SMC did show it. Both intimal and medial SMC in infants showed no TM expression. An immunofluorescence method showed TM expression in cultured adult human SMC. These findings indicate that TM expression in SMC may depend on patient age as well as lesion type of atherosclerosis.

Nasal-type NK/T cell lymphoma of the orbit with distant metastases.

A case of a nasal-type NK/T cell lymphoma of the orbit with distant metastases is reported. The orbital lymphoma was angiodestructive with prominent necrosis and frequent apoptosis. Lymphoma cells were positive for CD56, cytotoxic molecules (granzyme B and TIA-1), and EBV. Despite local radiotherapy, the patient had a highly aggressive clinical course. A postmortem examination revealed distant metastases to the heart and lungs exhibiting angiocentric growth. TCR and Ig genes of a cardiac lesion were in germ line configuration. This case demonstrated that nasal-type NK/T cell lymphomas with a poor prognosis can occur in the orbit.

Leiomyosarcoma arising from soft tissue tumor of the mediastinum.

The occurrence of a leiomyosarcoma (LMS) in soft tissue of the mediastinum is rare. We report a 60-year-old woman with an LMS in mediastinal soft tissue who died 8 months after surgical removal. Pathological, immunohistochemical, and electron microscopic features of this rare tumor are described.

Case of primary malignant hemangiopericytoma of the heart expressing basement membrane-degradable enzymes.

An echocardiogram demonstrated a large tumor in the left atrium of a 47-year-old woman with sudden heart failure. Emergent cardiotomy showed that the tumor arose from the left atrial wall, and almost entirely occupied the left atrium. Grossly, the tumor had partly undergone necrosis. Histologically, the tumor consisted predominantly of round to polygonal cells with ill-defined cell borders surrounding 'stag horn'-shaped blood vessels. Mitosis was frequently seen with abnormal mitotic figures. Immunohistochemically, the tumor cells diffusely expressed vimentin and focally expressed factor XIIIa and human leukocyte antigen-DR. A few tumor cells expressed S-100 protein or alpha-smooth muscle actin. Histopathological diagnosis was malignant hemangiopericytoma of the left atrium. Most tumor cells expressed matrix metalloproteinase (MMP)-2 and MMP-3, and several cells expressed MMP-9, all of which are capable of degrading a major component of basement membrane (i.e. type IV collagen). Furthermore, tumor cells expressed membrane type 1 MMP and tissue inhibitor of metalloproteinase-2, both of which are required for activation of proMMP-2. Fourteen months after the surgical removal, she died of systemic recurrent tumors.

Anaplastic large-cell lymphoma (Ki-1 lymphoma): ultrastructural and immunohistochemical studies.

We report an autopsy case of a malignant neutrophil-rich anaplastic large cell lymphoma (ALCL), which was reactive to the monoclonal antibody Ki-1 (CD30). This subtype of Ki-1 ALCL containing many neutrophils was named by Mann and colleagues in 1995, and its clinical and pathological characteristics have not been well described. In our case, the patient died 2 months after he first noticed an abdominal skin tumor. It was difficult to make the exact diagnosis of malignant lymphoma because the histological examination showed very poorly differentiated tumor cells. Ultrastructural observations revealed nuclei with convoluted contours and, sometimes, deep indentations, which suggested ALCL. Immunohistologically, most neoplastic cells were reactive with Ki-1 (CD30), leukocyte common antigen (LCA), and CD45RO (UCHL-1), and we confirmed Ki-1 ALCL. When we encounter poorly differentiated tumors on light microscopy, we should perform immunohistochemistry for hematological markers, such as LCA and Ki-1.

Synovial sarcoma arising from the pleura: a case report with ultrastructural and immunohistological studies.

Synovial sarcoma commonly occurs in the para-articular regions of the extremities, and rarely in the pleura. We report a 46-year-old woman with primary synovial sarcoma of the pleura. She was admitted with a complaint of left-sided chest pain and exertional dyspnea. She had previously undergone two operations for pleural neoplasm, at the ages of 33 and 36 years. A computed tomography scan revealed an expanded mass in the left thoracic cavity, involving the surrounding tissue. Macroscopic findings demonstrated a 25 x 25 x 15-cm grayish-white mass with hemorrhage beneath the pleura. Both epithelial and spindle cells were observed microscopically. Ultrastructural microscopy of the epithelioid cells demonstrated short, blunt microvilli on the luminal surface, and desmosomes between the neoplastic cells. Immunohistochemically, the tumor cells of the epithelial component were positive for embryonal membrane antigen (EMA), carcinoembryonic antigen (CEA), human mesothelial cells (HBME)-1, and cytokeratin, and the spindle cells were positive for vimentin. These findings led us to a diagnosis of primary synovial sarcoma of the pleura. She had no evidence of recurrence or metastasis after the third operation.