Operative Results and Clinical Features of Chronic Stanford Type B Aortic Dissection: Examination of 234 Patients Over 6 Years.

OBJECTIVE/BACKGROUND: Recently, the indications for thoracic endovascular aortic repair (TEVAR) have been expanding, and the applicability of TEVAR for acute type B aortic dissection (TBAD) is proposed with regard to the high mortality of open surgery for chronic TBAD. TEVAR in the acute phase may lead to remodeling of the false lumen (FL), but it is controversial whether it completely resolves the aortic expansion in the chronic phase. In this study, operative results and the relationship between FL status and the time before surgical intervention were retrospectively analyzed. METHODS: From January 2008 to September 2013, 234 patients underwent open surgery for chronic TBAD. Most patients were on left heart bypass. By considering Japanese aortic disease treatment guidelines and the smaller physique of Japanese patients, operative indications were aneurysm >50 mm in diameter or rapid aneurysm enlargement of >5 mm in a 6 month period. RESULTS: In 180 cases, the FL was patent. The mean interval between onset of TBAD and operation was 61 ± 54 months. There was no significant difference between patients in the patent FL group and those in the thrombosed FL group (p = .44). Mean ratio of FL diameter to maximum aortic diameter (FL/AD) was 0.64 ± 0.21. There was no correlation between FL and AD before the operation (r = .12). Descending thoracic aortic replacement (DTAR) was performed in 127 cases and thoracic ascending aortic replacement (TAAR) in 107 cases (Crawford type I, n = 9; Crawford type II, n = 65; Crawford type III and IV, n = 22, respectively; Safi type V, n = 11). The overall operative mortality was 6.8%: 3.9% (5/127) for DTAR and 10.3% (11/107) for TAAR. The three year survival was 86.7, and the freedom from re-intervention rate was 97.0%. CONCLUSION: Enlargement of uncomplicated TBAD in the chronic phase was poorly related to FL status and the results of open repair have improved. However, further prospective study is necessary.

Indocyanine green angiography for intra-operative assessment in vascular surgery.

OBJECTIVES: Indocyanine green (ICG) angiography is used for the intra-operative assessment of the graft vessel in coronary artery bypass grafting to enable immediate revision if necessary. We report the feasibility and implications of an ICG colour imaging system, HyperEye Medical System (HEMS), in surgeries for arteriosclerosis obliterans (ASO) and abdominal aortic aneurysm (AAA) which carry risk of mesenteric ischaemia. METHODS: HEMS ICG angiography was used for the intra-operative assessment of 12 ASO patients and 10 AAA patients. RESULTS: In the ASO patients, HEMS angiography enabled visualisation of the graft and native artery. The fluorescent lucent region in the artery distal to the anastomosis was shown in 1 of 12 ASO patients. There was a 3-s time lag in the increase of intensity between the proximal artery and distal stenotic region. In AAA patients, HEMS angiography clearly showed the perfusion in the mesenteric arteries and intestinal wall as opaque. One AAA patient had segmental ischaemia due to thromboembolism and another one had diffuse ischaemia due to systemic malperfusion. The ischaemic region of the intestine was visualised as a fluorescent lucent area by HEMS angiography. CONCLUSION: HEMS angiography can accurately assess peripheral arterial perfusion in surgical cases with ASO and AAA.

[Insertion and removal of the intraaortic balloon pumping].

Intraaortic balloon pumping (IABP) is the most popular circulatory assist device. Although insertion and removal of IABP has proved to be a safer technique, a significant number of pitfalls have been seen. On the basis of our experience, we make several recommendations that may facilitate safer insertion and removal of IABP. Careful insertion and removal by experienced hands of cardiovascular surgeons should minimize complications.

Dielectric behavior of pulmonary edema induced in the rat lung.

The dielectric properties (conductivity, kappa and relative permittivity, epsilon) of excised rat lung are modified by lung air and water content. The measurements of these quantities were made over the frequency range of 10 kHz to 100 MHz with an open-ended coaxial probe. The following relationships were analyzed in an oleic acid-induced pulmonary edema model using 18 animals: the spectra of kappa, epsilon and the loss tangent as a function of lung air and water content. Secondly, an isolated-perfused lung system was produced to induce a gradual increase in lung water. The time course of kappa, epsilon and the loss tangent for one excised lung was analyzed. The principal findings were: (i) a decrease in kappa and epsilon with increasing air content, (ii) an increase in kappa and epsilon with increasing water content, and (iii) a good correlation between lung water content and maximum loss tangent that was insensitive to changes in air content. We conclude that this technique could provide a quantitative assessment of lung water during pulmonary edema formation.

Protective effect of a radical scavenger, MCI-186 on islet cell damages induced by oxidative stress.

Oxidative stress generated during islet isolation and transplantation causes islet cell damage. These oxidative injuries are mediated by reactive oxygen species (ROS) and reactive nitrogen species (RNS). MCI-186 is an antioxidant used for clinical treatment of cerebral infarction in Japan. We examined a possible protective effect of MCI-186 on islet cells against oxidative stress. Islets isolated from Sprague-Dawley rats by collagenase P digestion were purified by density gradient centrifugation with Ficoll. Islets were treated with hydrogen peroxide (H(2)O(2); 5 to 250 micromol) in the presence or absence of MCI-186. Cell death was measured by an LDH release assay. Maximum islet cell death was observed at 250 micromol of H(2)O(2). MCI-186 inhibited islet cell death in a dose-dependent manner with significant reduction above 30 micromol. From the results observed we suggest that the antioxidant effects of MCI-186 may prove beneficial to improve the preservation of islet cells.

[Surgery for aneurysms of the aortic arch in elderly patients].

Surgery for aneurysms of the aortic arch in octogenarians can be performed with increased but operative mortality remains high. Minimally invasive operation may be required for further improvement of the outcome of surgery for aneurysms of the aortic arch in octogenarians. Aged patients with life-threatening events have excessive mortality and morbidity. We think that sugery for aneurysms of the aortic arch in octogenarians should not be withheld on the basis of age alone, but should be based on careful assessments of the relative medical risks and benefits, as well as the wishes of the patients and family.

Insufficient effect of p27(KIP1) to inhibit cyclin D1 in human esophageal cancer in vitro.

The cell cycle is controlled by protein complexes composed of cyclins and cyclin-dependent kinases. p27KIP1 (p27) is one of the Kip/Cip family cyclin-dependent kinase inhibitory proteins which negatively regulate cell cycle progression, and have been proposed as candidate tumor suppressor genes. To examine the role of p27 in the development of human esophageal squamous cell carcinoma (ESCC), we performed Western blot and immunoprecipitation analyses of the levels of expression of p27 protein in a series of ESCC cell lines. This protein was expressed at various levels in these cell lines during exponential growth. p27 level was significantly associated with that of cyclin D1, but not of cyclin E. Further cell cycle synchronization studies demonstrated that p27 was free or bound with affinity to cyclin E-CDK2 more than to cyclin D1-CDK4 or cyclin D1-CDK6. It is known that overexpression of cyclin D1 rather than cyclin E is involved in the pathogenesis of ESCC. Our findings indicated that high expression of p27 throughout the G1 to S phase may inhibit more likely cyclin E, than cyclin D1, which promotes tumor growth of esophageal squamous cell carcinoma.

Anteroaxillary thoracotomy facilitates the use of retrograde cerebral perfusion in distal aortic arch reconstruction.

Anteroaxillary thoracotomy in a 45-degree position provides an ideal view of the distal aortic arch and also makes direct superior vena caval cannulation possible for retrograde cerebral perfusion. This approach is especially useful in cases in which retrograde cerebral perfusion is indicated as an adjunct to deep hypothermic circulatory arrest in repair of the distal aortic arch.

Immunohistochemical characterization of p57KIP2 expression in human esophageal squamous cell carcinoma.

Functional defects in the CIP/KIP family of cyclin-dependent kinase inhibitors (CDKIs) have been shown to be associated with human malignancies. We immunohistochemically examined p57KIP2 (p57) expression in 92 patients with human esophageal squamous cell carcinoma (SCC) to determine the relationship between this expression and those of cyclin D1 and E. The p57 labeling index (LI) (defined as the percentage of p57-positive cells) in esophageal SCC was 43.3 +/- 3.2% (mean +/- standard error of the mean). In non-neoplastic esophageal epithelium, p57 staining was more frequently observed in the basal and parabasal cells than in surface layer cells. Immunostaining for cyclin D1 and E was observed in 28.2% (28/92) and 32.6% (30/92) of tumors, respectively. The median p57 LI in cyclin D1-positive cases was 66.2, and significantly higher than that in negative cases (31.9%) (p = 0.0009). There was no significant relationship between p57 LI and cyclin E expression (p = 0.147). As determined using Kaplan-Meier's method, loss of p57 immunoreactivity was not a prognostic factor for esophageal SCC (p = 0.548). Our in vivo findings suggested that p57 protein expression was positively correlated with cyclin D1 expression and that loss of p57 protein expression alone does not affect progression of esophageal SCC.

A soft dual-port trocar for endoscopic subcutaneous surgery.

BACKGROUND: We developed a new trocar for endoscopic subcutaneous surgery and tested it in subfascial endoscopic perforator surgery (SEPS) for varicose veins of the lower leg. METHODS: The soft trocar is a y-shaped polyvinyl chloride bag equipped with two ports at one end and a flexible ring at the other end. We performed SEPS on 12 patients through a 2-cm incision below the knee. After dissection of the subfascial plane, the ring of the trocar was inserted beneath the fascia, and the subfascial cavity was inflated with CO2 gas. The perforating veins were divided with UltraShears (Autosuture, USSC, Norwalk, CT, USA) inserted through the second port of the trocar with an endoscope. RESULTS: There were no major device-related difficulties or wound complications. CONCLUSION: The soft trocar allowed both an endoscope and a surgical instrument to be inserted simultaneously in the tissue space through a single incision. This useful instrument may have applications in other endoscopic surgical procedures.

Retrograde cerebral perfusion through antero-axillary thoracotomy in the aortic arch surgery.

OBJECTIVE: We have recently found that left antero-axillary thoracotomy provides an ideal view of aortic arch and makes the direct cannulation to superior vena cava possible for retrograde cerebral perfusion during circulatory arrest. METHOD: Twelve patients with distal aortic arch aneurysm or aortic dissection underwent the repair of aortic arch through this approach. Mean duration of retrograde cerebral perfusion was 41 min. RESULTS: Two hospital deaths occurred due to respiratory failure and stroke. The remaining patients survived without any neurological deficits. CONCLUSION: Antero-axillary thoracotomy may be an ideal approach which combines the advantages of median sternotomy and postero-lateral thoracotomy.

Epidermal growth factor and insulin inhibit cell death in pancreatic beta cells by activation of PI3-kinase/AKT signaling pathway under oxidative stress.

Production of reactive oxygen species (ROS) during islet purification by enzymatic digestion as well as during warm and cold ischemia causes islet cell damage. Recent reports have shown that activated Akt, the downstream protein after phosphatidylinositol (PI) 3-kinase, is involved in cell survival by phosphorylating several proteins that mediate apoptosis. We analyzed the role of PI3-kinase/Akt pathway activation using insulin or epidermal growth factor (EGF) on islet beta cell survival during oxidative stress. Canine islets and murine beta cell line (BTC) were cultured in the presence of hydrogen peroxide (H(2)O(2)) for 12 to 20 hours. Viability and cell death were measured by MTT assay. Maximum cell damage was observed with as little as 100 micromol/L of H(2)O(2). Pretreatment with 100 ng/mL of insulin significantly decreased cell damage. Meanwhile, the protective effect of insulin was partially blocked with an inhibitor of PI3-kinase, LY294002, suggesting the utilization of PI3-kinase/Akt signaling pathway for the observed cytoprotective effect. Similar to insulin, EGF also protected beta cells from oxidative stress. Our results suggest that PI3-kinase/Akt activation by insulin or EGF is beneficial for islet beta cell protection.

Study of the diagnostic difference between the clinical diagnostic criteria and results of immunohistochemical staining of multiple primary lung cancers.

AIM: When multiple synchronous or metachronous lung cancer lesions are identified, discrimination of multicentric lung cancers from intrapulmonary metastases by clinical findings is often difficult. When tissue types have the same pathological features, such as combinations of squamous cell carcinoma (SCC), adenocarcinoma (AD) or bronchiolo-alveolar cell carcinoma (BAC), it is especially difficult to distinguish a 2(nd) primary lung cancer from a metastatic lesion. A new strategy for accurate diagnosis of multiple synchronous or metachronous lung cancer is needed because of the difficulty of histological discrimination. METHODS: Of 363 patients with primary lung cancer for which surgeries were conducted at our hospital, 7 cases were diagnosed as synchronous multiple lung cancer (BAC-BAC in 4 cases and SCC-BAC in 3 cases) and 8 cases (BAC-BAC in 2 cases, AD-BAC in 1 case, AD-AD in 1 case, SCC-AD in 1 case and SCC-SCC in 3 cases) were diagnosed as metachronous multiple lung cancer according to the clinical diagnostic criteria. This study focused on 8 cases with the combinations AD-AD, AD-BAC, or BAC-BAC. For immunohistochemical staining, we used the antibodies to 6 antigens as follows: CK-19, p53, CEA, Hup-1, PE-10, and Ki-67. RESULTS: Of 4 cases diagnosed as synchronous lung cancer according to the clinical diagnostic criteria, differing immunohistochemical stained images of the lesions were observed in 3 cases, while in the 4th case almost identical immunohistochemical stained images were obtained, which indicated the 2 lesions were the primary and metastatic focuses. Of 4 cases diagnosed as metachronous lung cancer according to the clinical diagnostic criteria, almost identical stained images were seen in 3 cases, which indicated the 2 lesions were the primary and metastatic focuses. CONCLUSION: In general, Type A and Type B in Noguchi's BAC classification, tended to be multiple synchronous or metachronous lung cancer lesions, while AD and Type C in Noguchi's BAC classification tended to be the metastatic focus. For the focuses with tissue type of BAC-BAC, the staining using CK-19, PE-10, and Ki-67 was useful in distinguishing multiple primary lung cancer from pulmonary metastasis in cases with a combination of AD and BAC.

What is the safe time limit for retrograde cerebral perfusion with hypothermic circulatory arrest in aortic surgery?

Retrograde cerebral perfusion technique has been used recently for the protection of the brain during circulatory arrest in aortic surgery. However, the safe time limit for retrograde cerebral perfusion has not been known. From July 1993 to April 1995, 20 patients underwent thoracic aortic operations using retrograde cerebral perfusion technique with hypothermic circulatory arrest. Retrograde cerebral perfusion was used to repair the aortic dissection in seventeen patients, aortic arch aneurysm in two patients and annuloaortic ectasia with severely calcified ascending aorta in one patient. The mean duration of retrograde cerebral perfusion was 74 minutes (19-135 min). There were six patients in whom retrograde cerebral perfusion exceeded 90 minutes, however no patients except one who had preoperative cerebral infarction showed any neurological deficits. There were two operative deaths and three hospital deaths, neither of which was related to postoperative neurological complications. Retrograde cerebral perfusion safely may provide a longer period of circulatory arrest at least up to 90 minutes.

Time limitation of postural retrograde cerebral perfusion during cerebral hypothermic circulatory arrest. A report of an unsuccessful case.

We report an unsuccessful case with ruptured aortic arch aneurysm using deep hypothermia with postural retrograde cerebral perfusion by simply elevating central venous pressure in the Trendelenburg position. Ninety-three minutes of cerebral circulatory arrest by this method caused irreversible global cerebral damage. Ninety minutes may be over the time limit of this method.

Immunohistochemical study with antibody to glycoprotein GCDFP-15 for metastatic lung cancer from breast cancer.

Even when gross pathologic specimens are available, evaluation is always complicated due to the difficulty in distinguishing the pathologic diagnosis of an adenocarcinoma as a pulmonary metastasis of the breast or lung. In this paper, we describe the usefulness of a preoperative immunohistochemical study using gross cystic disease fluid protein-15 (GCDFP-15). A 50-year-old woman, who had undergone a right radical mastectomy due to an infiltrating ductal carcinoma 4 years previously, was admitted because of an abnormal shadow on chest roentgenography. A chest CT scan showed a nodule 20 mm in diameter with an irregular margin and vascular involvement in the S3 region of the right lung. Though the specimen from a percutaneous CT guided needle biopsy revealed characteristic pathologic findings of a primary lung adenocarcinoma under H.E. stain, which was recommended for lobar resection, we re-examined that specimen immunohistochemically, which disclosed that the tumor cells were negative for the antibody to pulmonary surfactant apoprotein and were positive for GCDFP-15 antibody. Therefore, the diagnosis of a metastatic breast carcinoma in the lung was established. Upon her request, a wedge resection of the right upper lobe including the tumor was performed under video-assisted thoracoscopic surgery (VATS). Her postoperative course was uneventful.

Coronary artery bypass grafting. Late result of actual 10-years follow-up in 376 patients.

OBJECTIVES: The aim of this study was to analyze the long-term results of coronary artery bypass grafting in Japanese patients who were followed more than 10 years after surgery, and, without resorting to actuarial methods, to determine the factors that influence long-term survival. SUBJECTS AND METHODS: From January 1984 through December 1986, 376 patients received coronary artery bypass grafting at the Department of Cardiothoracic Surgery of Juntendo University; it is these patients who comprise the subject of this study. Of the 376 patients, 328 were males (87.2%) and the mean patient age was 58.5 years (range: 32 to 78 years). Single vessel disease was present in 36 patients (10.8%), double vessel disease in 89 patients (26.7%), triple vessel disease in 150 patients (45.0%) and 58 patients (17.4%) with 50% of more stenosis of the left main coronary artery. The mean number of grafts used was 2.3 grafts per patient, while internal thoracic artery conduits were used in 66 patients (17.6%). RESULTS: The 10-year survival rate for the entire series of patients was 81.4%. Patients receiving internal thoracic artery grafts had a 10-year survival rate of 94.0%, superior to the 78.0% rate found in patients who received only saphenous vein grafts. Other risk factors associated with reduced survival rates, besides non-use of internal thoracic artery, were: advanced age, diabetes mellitus, hypertension, presence of left main coronary artery disease, and severely impaired left ventricular function. The 10-year cardiac event free rate in the total group was 80.4%. Of 70 patients who died during the follow-up period, 19 deaths were due to cardiac causes (27.1%), 19 due to malignant neoplasm (27.1%) and 13 due to the cerebral vascular accident (18.6%). CONCLUSIONS: Univariate analysis revealed that: the use of only saphenous vein grafts (P = 0.0055), advanced age (P < 0.0001), diabetes mellitus (P < 0.0001), hypertension (P = 0.0282), presence of left main coronary artery disease (P = 0.0140), and severely impaired left ventricular function (P = 0.0075) are associated with reduced survival in patients undergoing coronary artery bypass grafting in this cohort of patients.

Is diabetes mellitus a major risk factor in coronary artery bypass grafting? The influence of internal thoracic artery grafting on late survival in diabetic patients.

OBJECTIVE: The presence of diabetes could possibly have an adverse influence on the late results of coronary artery bypass grafting (CABG). A retrospective observational risk-unadjusted estimation study was conducted to clarify the magnitude of this unfavorable influence of diabetes based on our experience at Juntendo University. METHODS: Between January 1984 and December 1995, 1,618 primary CABG operations were performed and 99.0% of these patients were followed up for a mean period of 81.2 months with a maximal follow-up of 14 years. Among the 1,610 patients who were successfully followed up, 523 patients (32.5%) were diabetic and this cohort was compared with 1,087 nondiabetic patients regarding the patient profiles, perioperative outcome, and the long-term outcome. RESULTS: Diabetic patients included a higher proportion of females, a greater preoperative presence of renal insufficiency, a higher rate of three vessel disease, and reception of a greater number of grafts (mean: 2.5 versus 2.4) and an internal thoracic artery graft (68% versus 58%). Hospital mortality was not significantly different (2.1% vs 1.0%: ns). An actuarial analysis revealed a significantly unfavorable long-term survival in the diabetic group (59.6%) at 14 years, compared with the nondiabetic group (73.4%), however diabetic patients with an internal thoracic artery graft had a favorable long-term survival (82.0%) at 13 years, and this finding was almost identical to that of nondiabetic patients with an internal thoracic artery graft (88.5%). CONCLUSION: We conclude that the presence of diabetes appears to be a major risk factor in patients undergoing CABG. However, diabetic patients with an internal thoracic artery graft had a survival almost identical to that of nondiabetic patients with an internal thoracic artery graft.

Left antero-axillary thoracotomy as an alternative approach for aortic arch reconstruction.

Antero-axillary thoracotomy--a new approach for the reconstruction of the aortic arch--provides a wide view of the arch and makes accessible the superior vena cava for retrograde cerebral perfusion as well as the coronary sinus for retrograde infusion of cardioplegia. This procedure has been used over 22 months for 26 patients with aortic arch aneurysm or aortic dissection, and the surgical results were evaluated. The distal arch was replaced in 16 patients, the total arch in 9 patients, and the proximal arch in 1 patient, using this technique. The mean duration of deep hypothermic circulatory arrest was 38 min, and the hospital mortality was 15.4%. Antero-axillary thoracotomy may be an excellent approach for the reconstruction of the aortic arch, minimizing the duration of hypothermic circulatory arrest.

[Study of the difference between the clinical diagnostic criteria and results of immunohistochemical staining].

If more than 2 lesions of cancer are observed in the lung, differences in the histology or in situ component is the basic criterion for multicentricity. In addition, remote lung mass with same histology in the absence of both distant metastasis and mediastinal lymphadenopathy is also regarded as multicentricity. We have studied the difference between the clinical diagnostic criteria and the results of immunohistochemical staining. Thirteen patients who were diagnosed as double lung cancers under the clinical of Martini et al or Cortese et al were reviewed. Of them, clinically 6 patients had synchronous double lung cancers and 7 patients had metachronous double lung cancers. Four patients in each group with combination of adenocarcinoma (AD) and bronchiolo-alveolar cell carcinoma (BAC) were studied by immunohistochemical staining. As the result, 3 patients in the former group were defined as the synchronous double lung cancers, however in the latter group, only 1 patients was defined as the metachronous double lung cancers. As for from the histological findings, if either of multiple lung cancer lesion were Noguchi's A or B typed BAC, the patients are prone to have double lung cancers. Subsequently if the histology of the both lesions were the same as AD-AD or Noguchi's C typed BAC-BAC, then the patients are prone to have the metastatic lung cancers.