Hybrid endovascular stent-grafting technique for patent ductus arteriosus in an adult.

A 51-year-old man was referred to our institution for patent ductus arteriosus (PDA) complicated by left ventricular dysfunction and pulmonary hypertension. Surgical closure of a PDA is usually carried out via a small posterior thoracotomy. However, thoracoscopic procedures are probably not appropriate in adults because of the frequency of calcification and the greater risk of rupture while ligating the ductus. To minimize surgical trauma, we used hybrid endovascular stent grafting combined with revascularization of the left subclavian artery, which enabled us to eliminate shunt flow to the pulmonary artery. At 11-month follow-up, the patient was asymptomatic and showed no complications.

The history and current status of thoracic endovascular aneurysm repair in Japan.

Japan has a long and successful history of performing thoracic endovascular aneurysm repair (TEVAR). While commercial endovascular grafts were being used worldwide, Japan developed and distributed custom and semi-order made triple-branched one-piece grafts and fenestrated devices for the treatment of arch aneurysms. Historically, Japan also innovated and proposed hybrid procedures such as debranching with stent grafting to treat arch aneurysms and thoracoabdominal aneurysms. Since its introduction, Japan has been at the forefront of performing TEVAR for complicated acute aortic dissection and uncomplicated chronic aortic dissection for patients with predicted aortic enlargement. In this review, the authors discuss the many issues surrounding successful TEVAR, focusing on devices, operative methods, and prevention of complications.

[Surgical treatment for distal aortic arch aneurysm using stent grafting].

To alleviate the invasiveness of surgical treatment for distal aortic aneurysm or dissection, we have been using a stented graft to replace the distal anastomotic suture of the descending aorta. We also developed a new stent graft implanting method for distal aortic aneurysm or dissection which uses cervical branch bypasses from the ascending aorta and requires no extracorporeal circulation. These new surgical treatments for distal arch aneurysm result in low surgical mortality (3.8%) and low surgical morbidity rates (stroke, 7.7%; respiratory complications, 7.7%; no renal complications). These results indicate that these new graft implanting methods using stent graft should be considered as a less-invasive surgical treatment for distal aortic aneurysm or dissection.

Outcomes of stent-graft treatment of false lumen in aortic dissection.

BACKGROUND: Stent-graft treatment for aortic disease promises to lead to a less invasive therapy than conventional surgical therapy. However, this treatment has not been established as a therapy for aortic dissection. The aim of this study was to examine the effect of stent-graft treatment of aortic dissection, as measured by follow-up data on entry site closure, clotting in the false lumen, and the outcome of the false lumen from the acute to chronic phase after operation. METHODS AND RESULTS: We used a stent-graft of our own design to close the entry site of aortic dissection in 21 cases: 9 were acute (< 14 days), 8 subacute (< 6 months), and 4 chronic (> 6 months). Nine were type A and 12 were type B. In 15 cases, the stent-graft was inserted through the transverse arch, which had been surgically opened under median sternotomy. In the other 6 cases, the stent-graft was inserted by means of a transcatheter through a femoral artery. Using computed tomographic scans, we followed and examined clot formation in the false lumen and reduction in size of the false lumen at 3 levels: at the level of maximum aortic diameter, at the distal end of the stent-graft, and 50 mm distal to the stent-graft. The entry sites were successfully closed in 19 cases (90.4%); in the remaining 2 (both treated with a transcatheter) there was perigraft leakage into the false lumen. The hospital mortality rate of these stent-graft treatments was 14.3% (3 of 21). At 2 weeks after operation, the false lumen had completely clotted, respectively, in 100%, 77%, and 38% of cases at the 3 measurement levels. Substantial shrinkage (> 50% in diameter) of the false lumen at 6 months after the operation was observed in 72%, 60%, and 38% of cases at the respective levels. Shrinkage of the false lumen was particularly enhanced in patients treated within 6 months from the onset of dissection: The false lumen shrank by > 50% in 93%, 75%, and 50% of patients. CONCLUSIONS: In cases of aortic dissection, the stent-graft is an effective tool for closing the entry site and promoting clot formation in the false lumen and for reducing the size of the false lumen within 6 months of the onset of dissection if the entry site has been closed.

Induction of abundant osteoclast-like multinucleated giant cells in adjuvant arthritic rats with accompanying disordered high bone turnover.

The development of an in vivo system for investigating osteoclast differentiation is important because molecular events occurring in vivo can be observed during the differentiation of the authentic osteoclasts. In adjuvant arthritic rats, an experimental model of human rheumatoid arthritis, extensive bone resorption is observed in the distal diaphysis of the tibia. In the area of extensive bone resorption, it is always accompanied with clusters of numerous multinucleated giant cells (MGCs) as well as bone-resorbing osteoclasts. Here we characterized the morphological properties of these MGCs with the use of enzymehistochemical and immunohistochemical techniques. Extensive destruction but also a marked formation of the inner and outer bone surfaces were the predominant features in the tibiae of such arthritic rats 4 weeks after the adjuvant injection. Numerous MGCs were frequently clustered in the bone marrow spaces located apart from the bone matrices. Although the MGCs lacked ruffled borders, these cells were rich in mitochondria and vacuoles. These multinucleated cells revealed a positive reaction for tartrate-resistant acid phosphatase but a negative reaction for non-specific esterase staining. Most of these MGCs expressed the Kat 1-antigen, an immunological marker specifically expressed on the cell surface of rat osteoclasts. In a dentin resorption experiment using a cluster of MGCs excised from the bone marrow tissues of the tibial distal diaphyses of rats with adjuvant arthritis, many resorption lacunae were formed on dentin slices after a 3-day culture. These results suggest that the majority of the MGCs are osteoclasts but not macrophage polykaryons.

[Transcatheter stent-graft implantation for the treatment of acute aortic dissection--rupture of aneurysm because of perigraft leakage].

An 82-year-old woman was diagnosed as having acute type B aortic dissection. At bed rest, her systolic blood pressure was kept less than 120 mmHg. Four days later the aneurysm threatened to rupture. Because she presented a high operative risk for open-chest surgery, a stent-graft was implanted across the dissection site via transcatheter. The entry site to the aneurysm was closed by the stent-graft, and postoperative aortograph demonstrated that contrast medium did not enter the false lumen except for a trivial projection. A CT scan 6 days after the stent-graft implantation unexpectedly demonstrated the false lumen not only had not thrombosed, but had expanded. As a result, 8 days after the operation the aneurysm ruptured into the left pleural cavity, and the patient died. An autopsy revealed the stent-graft was exactly implanted across the entry site, but that the diameter of the graft was slightly larger than that of the aorta. Consequently, a portion of the rim of the graft had been wraped after implantation, causing perigraft leakage. Leakage is one of the gravest complications of the stent-graft implantation, to prevent it, a new design for stent-graft device is essential.

Osteoclasts in normal and adjuvant arthritis bone tissues express the mRNA for both type I and II interleukin-1 receptors.

Osteoclasts are known to play a crucial role in both physiologic and pathologic bone resorption. Moreover, it is generally agreed that IL-1 has powerful effects on osteoclastic bone resorption, although the precise cellular sites and mechanisms by which IL-1 mediates osteoclastic bone resorption remain unclear. In particular, it is still controversial whether osteoclasts can respond to IL-1 directly. The expression of mRNA for type I IL-1 receptor (IL-1RI) and type II IL-1 receptor (IL-1RII) in osteoclasts was investigated in normal and inflammatory bone tissues by in situ hybridization to determine whether osteoclasts are the target cells for IL-1 and to elucidate the mechanism by which IL-1 induces osteoclastic bone resorption. For this study, normal tibiae were obtained from newborn, young, and adult mice and rats, and inflammatory bone tissues with bone destruction were obtained from adjuvant arthritis rat models. The results showed that (a) both IL-1 receptors (IL-1RI and -II) mRNA were expressed by osteoclasts in all tissue sections of normal tibiae; (b) at the stage of the adjuvant arthritis studied, the IL-1RI mRNA was the most predominant message in osteoclasts present in the area with serious cartilage and bone destruction, whereas the expression level of IL-1RII mRNA in these osteoclasts was weak; and (c) both IL-1RI and -II mRNA were expressed by osteoblasts, as well as by osteocytes localized in the osteoid. In addition, these messages were also expressed by chondrocytes, but the signals were not detected in the chondrocytes in the zones of hypertrophy and provisional calcification. Our present study demonstrates for the first time that mouse and rat osteoclasts express IL-1RI and -II mRNA, which suggest that a primary effect of IL-1 on osteoclasts may be one of the mechanisms by which IL-1 mediates normal bone remodeling and pathologic bone resorption in chronic inflammatory diseases.

Injury to a duplicated cystic duct during laparoscopic cholecystectomy.

Duplication of the cystic duct is a rare variation of the biliary system. It is important to pay attention to this variation to avoid intraoperative biliary system injury, especially during laparoscopic cholecystectomy. In a 66-year-old woman with gallstones, endoscopic retrograde cholangiopancreatography (ERCP) revealed no anomaly of the biliary system. At laparoscopic cholecystectomy, although intraoperative cholangiography demonstrated the second cystic duct, we misdiagnosed the duplication of cystic duct because preoperative ERCP had demonstrated normal anatomy. It was thought that the second cystic duct was dissected during the operation and the patient suffered from postoperative bile leakage. After reoperation, the patient recovered well. The diagnostic and therapeutic problems of such an anomaly are discussed below with the review of the literature.

Leukocyte depletion attenuates reperfusion injury in patients with left ventricular hypertrophy.

BACKGROUND: Reperfusion injury can occur after a long period of aortic cross-clamping in patients with left ventricular hypertrophy during open-heart surgery, even with the most up-to-date techniques of myocardial protection. In the present study, we examined whether leukocyte depletion as an adjunct to terminal blood cardioplegia (LDTC) attenuates reperfusion injury in patients with left ventricular hypertrophy (LV mass, >300 g; left ventricular end-systolic volume index, >100 mL/m2) in a group of 30 patients undergoing aortic valve replacement. METHODS AND RESULTS: We used basic cold potassium crystalloid cardioplegic solution. Terminal blood cardioplegic solution (TC) or LDTC was accomplished by mixing a cold potassium crystalloid cardioplegic solution with warm arterial blood obtained through cardiopulmonary bypass and administered to the aortic root for the first 10 minutes of reperfusion. During delivery of LDTC, warm arterial blood was passed through a leukocyte-removal filter. Patients were randomized into one of three groups for reperfusion: whole blood (WB) (n=10), TC (n=10), and LDTC (n=10). Left ventricular biopsies were obtained before ischemia, at the end of ischemia, and 15 minutes after reperfusion. Semiquantitative scoring for ultrastructural alterations indicated that the LDTC group achieved significantly better recoveries of both scores at reperfusion for myocyte damage and for endothelial cell damage of capillaries than did the WB and TC groups. The LDTC group had significantly fewer neutrophils adhering to endothelial cells at reperfusion and a lower level of malondialdehyde derived from myocardium than did the WB and TC groups. Regarding the clinical data, the LDTC group had a lower maximum creatine kinase-MB, a higher percentage of spontaneous defibrillation, a lower pulmonary capillary wedge pressure, and a lower requirement for dopamine that did the WB group, whereas the TC group failed to do better than the WB group. CONCLUSIONS: These results demonstrate that leukocyte-depleted reperfusion is potentially beneficial as an adjunct to terminal cardioplegia during cardiac surgery to attenuate reperfusion injury in patients with left ventricular hypertrophy.

Experimental assessment of newly devised transcatheter stent-graft for aortic dissection.

Despite recent advances, surgical results for Stanford type B dissection are not yet satisfactory because the procedure is so highly invasive. The aim of this study was to devise a new intraaortic (IA) graft that would offer less invasive treatment for type B dissection. To close the entry of type B dissections using transcatheter placement, we devised an IA graft (inner diameter, 15-20 mm; length, 40 to 60 mm) in which a self-expandable stent was covered with a thin, open-cell-structured polyurethane jacket. In acute animal experiments in which type B aortic dissections were prepared in 4 mongrel dogs, IA grafts were implanted to close the entry using a transfemoral catheter sheath, and closure of all the entries was confirmed by aortography. In chronic experiments, five IA grafts for normal descending aortas and one IA graft for an experimentally dissected aorta were implanted to observe histologic biocompatibility for up to 8 months. Histopathologic examination conducted at the projected sacrifice periods revealed that endothelialization of the luminal surface of the IA graft had begun as early as 1 month after implantation and was completed within 4 months. The prototype device that we developed may be promising as an effective, minimally invasive therapeutic intervention for closure of the entry site of type B dissection.

Myocardial protective effect and its mechanism of leukocyte-depleted reperfusion in neonatal rabbit hearts.

Thirty-six isolated blood-perfused hearts from newborn rabbits (age range, birth to 2 days) were subjected to 2 hours of cold global ischemia (15 degrees C), with an initial infusion of cold crystalloid cardioplegic solution, followed by 30 minutes of reperfusion (37 degrees C). The hearts were divided into two groups: those reperfused with whole blood (n = 18) and those reperfused with leukocyte-depleted blood (n = 18) obtained by the passage of blood through a leukocyte removal filter. At 30 minutes of reperfusion, the group of hearts reperfused with leukocyte-depleted blood showed significantly higher percentages of recovery in terms of the left ventricular developed pressure, the maximum rate of increase of left ventricular pressure, the rate pressure product, coronary sinus flow, and the adenosine triphosphate content in myocardium than did the group of hearts reperfused with whole blood. The hearts reperfused with leukocyte-depleted blood also showed significantly lower levels of malondialdehyde, chemiluminescence in the coronary sinus effluent, and counts of intracapillary neutrophils in myocardium than did the group of hearts reperfused with whole blood. The ultrastructural semiquantitative assessment in the myocardium showed that the mitochondrial and endothelial cell damages after 30 minutes of reperfusion were significantly less in the hearts reperfused with leukocyte-depleted blood than those in the hearts reperfused with whole blood.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrastructural assessment of postoperative lung injury--the effect of bronchial blood flow during cardiopulmonary bypass].

On the basis of the hypothesis that pulmonary blood flow during cardiopulmonary bypass (CPB) is related to postoperative pulmonary dysfunction, we divided following two groups in 17 patients with congenital cardiac disease; A group: bronchial blood flow (BF) during CPB < 10%, B group: BF during CPB > 25%. Lung specimens taken immediately after CPB were reviewed for ultrastructural changes using semi-quantitative grading of epithelial cell injury, endothelial cell injury, and measuring thickness of basement membrane (BMT) as the index of interstitial edema. And postoperative pulmonary function using AaDO2 were assessed. Ultrastructural grading of epithelial cell injury, BMT, and AaDO2 of A group (BP < 10) were higher than those of B group (BP > 25%). These results indicate that pulmonary blood flow during CPB somewhat may reduce pulmonary impairment for CPB.

Primary plasmacytoma of the thyroid: a case report and comparative literature study between Western nations and Japan.

A 52 year old man presented with primary thyroid plasmacytoma. The patient was initially followed up for thyroid dysfunction. The histological examination of the removed thyroid revealed a proliferation of mature and immature plasma cells indicative of plasmacytoma with Hashimoto's disease. After radiotherapy (40 Gy) to the neck following right hemi-thyroidectomy, the patient is currently alive and well 3 years after diagnosis without any evidence of tumor. The immunohistological examination of the removed thyroid showed monoclonality for immunoglobulin G-Kappa light chains. Sixty-six literature cases of primary thyroid plasmacytoma were reviewed and comparison of the clinical and histological characteristics between Japanese and Western cases noted. The incidence of the patients with antithyroid antibody was significantly lower (P < 0.01) in Western patients (42.9%) than in Japanese patients (87.5%). The higher incidence of thyroid dysfunction and Hashimoto's disease in Japan in comparison with Western nations was well reflected in the incidence of antithyroid antibody.

Myocardial protective effect of deep hypothermic cardiac arrest without aortic cross clamp in neonatal hearts: comparison with cardioplegic arrest in a rabbit model.

Using an isolated perfusion model of neonatal rabbit hearts aged 3 to 6 days, cardioplegic arrest (CPA) using crystalloid cold cardioplegia with aortic cross clamp (AXC: 60 min, n = 15) and continuous deep hypothermic perfusion (DHP) at 15 degrees C without AXC (n = 15) were compared. The hearts were divided into two subgroups: intact hearts (n = 18) and with preceding 40 min warm ischemia (stressed hearts, n = 22). In the intact hearts, there were no significant differences between the CPA and DHP groups in left ventricular function, myocardial water content, and myocardial mitochondrial score after reperfusion. In the stressed hearts, recovery of cardiac output and left ventricular work was significantly higher in the DHP group than in the CPA group. The post-reperfusion myocardial mitochondrial score was significantly better in the DHP group than in the CPA group. These results suggest that non-AXC DHP may be advantageous in the setting of stressed hearts with preceding ischemic injury where conventional CPA cannot provide adequate myocardial protection.

[Experimental study on heparin-free cardiopulmonary bypass using nafamostat mesilate (FUT-175) and heparin-coated circuit].

We investigated whether the combination of a new synthetic protease inhibitor, nafamostat mesilate (FUT-175), and heparin-coated cardiopulmonary bypass (CPB) circuit can achieve heparin-free CPB in rabbits. Nine rabbits underwent 2 hours of CPB with heparin-coated circuits. In 4 rabbits (FUT-Group), FUT was administered before (2 mg/kg in bolus) and during (5 mg/kg/hr continuously) CPB. In 5 rabbits (Heparin-Group), heparin was given before (4 mg/kg) and at 1 hour (2 mg/kg) of CPB. Activated clotting time, activated partial thromboplastin time and fibrin degradation products showed no significant differences between the two groups during CPB. However, prothrombin time was significantly (p < 0.05) shorter in FUT-Group than in Heparin-Group. Platelet counts in FUT-Group was significantly lower than Heparin-Group. Massive clots were observed in all of the venous reservoirs of FUT-Group after CPB, whereas there were no major clots in Heparin-Group. The occlusion rate of hollow fibers of the oxygenators was significantly higher in FUT-Group (55 +/- 25%, mean +/- SD) than in Heparin-Group (14 +/- 12%). We concluded that heparin-free CPB with FUT and heparin-coated circuit is difficult in rabbits because activation of the extrinsic coagulation cascade cannot be sufficiently suppressed by FUT.

Development of a chronic endothelialized transcatheter implantable intra-aortic graft.

The authors developed a new intraluminal aortic prosthesis (IA graft) for internal obliteration of Stanford type B dissection. The newly devised intraluminal aortic graft is a self-expandable metallic stent (Gianturco stent) outer-jacketed with a thin open-cell structured microporous film made of segmental polyurethane (0.2 mm thick, 0.1 mm pore size). Through the femoral artery, the intraluminal aortic grafts (14-20 mm diameter-, 4 cm long) were inserted into a 12 Fr catheter sheath by compression, were implanted into the descending thoracic aortas of five mongrel dogs; they were removed at the projected times of death ranging from 1 to 6 months after implantation. Histopathologic examination revealed that an elastic fiber layer had regenerated and that on the inner surface of the graft adherent and proliferating endothelial cells were observed, even at 1 month after graft implantation. Complete epithelialization was observed over the entire inner surface of the graft within 4 months after implantation. This healing process suggests that the intraluminal aortic graft is highly biocompatible and might be stable in chronic use after the obliteration of acute Stanford type B dissections.

Development of an expandable intra-aortic prosthesis for experimental aortic dissection.

To achieve transcatheter entry obliteration for Stanford type B dissection, the authors devised and developed a self-expandable intra-aortic prosthesis (IA graft). This graft consisted of a microporous polyurethane graft (wall thickness: 0.2 mm; average pore size: 0.1 mm) and an expandable metallic stent (Gianturco double stent) attached to the lumen surface of the polyurethane graft. Experimental dissections in the descending aorta of mongrel dogs were prepared. An IA graft was inserted through a femoral artery by a catheter sheath into which a compressed IA graft was installed and expanded at the entry site. After 30 min of graft implantation, closure of all the entry sites in four dogs was confirmed by aortography. The results suggest that the newly devised IA graft is extremely useful as a non invasive treatment for Stanford type B dissection.

Experimental study in a rabbit model of ischemia-reperfusion lung injury during cardiopulmonary bypass.

Adult white rabbits were subjected to 2 hours of partial cardiopulmonary bypass (flow rate 90 ml/min/kg) at 32 degrees C, and unilateral pulmonary artery occlusion was used to simulate total cardiopulmonary bypass in the lung subjected to arterial occlusion, with the other side used as the control lung. The lung subjected to arterial occlusion was reperfused by one of the following methods: (1) by whole blood (WB group), (2) by leukocyte-depleted blood (LD group), and (3) by whole blood with protease inhibitor (nafamostat mesilate, FUT group), expecting its anticomplement action. In the fourth group, the lung was inflated with oxygen during pulmonary artery occlusion followed by whole blood reperfusion (OXY group). As a result, lungs subjected to pulmonary artery occlusion showed significant decreases in tissue concentrations of adenosine triphosphate and regional tissue blood flow during cardiopulmonary bypass. Furthermore, recovery of adenosine triphosphate was depressed in the WB group and recovery of regional tissue blood flow in the WB and OXY groups. Ultrastructural findings in alveolar epithelial cells and capillary endothelial cells showed worsening at reperfusion in only the WB group. Transpulmonary gradients of C5a and leukocyte showed significant increases at reperfusion in the WB and OXY groups. Alveolar-arterial oxygen difference was significantly higher in the WB group than in the others. Results indicate that complete cessation of pulmonary artery flow in normothermic cardiopulmonary bypass may cause ischemia of the lung followed by reperfusion injuries with the no-reflow phenomenon, with possible involvement of activation of leukocytes and complement.