Surgical strategy of IgG4-related inflammatory abdominal aortic aneurysm with preoperative steroid therapy: A case report.

Immunoglobulin G4 (IgG4)-related disease, characterized by high serum IgG4 concentrations and IgG4-positive plasma cell infiltration, often presents as an inflammatory aneurysm. We herein report the case of a 78 year-old man, presenting with elevated inflammatory markers and IgG4 concentrations, who was diagnosed with IgG4-related inflammatory abdominal aortic aneurysm with dense perianeurysmal fibrosis. Before the surgical intervention, steroid therapy was administered to resolve his perianeurysmal inflammatory fibrosis. Half a year after the initiation of steroid therapy, there was an improvement in serum inflammatory markers and IgG4 concentrations, and the perianeurysmal fibrosis had regressed. Thus, we performed a surgical intervention including resection of the aneurysm and interposition with a prosthetic graft. Histopathological examination demonstrated few IgG4-positive plasma cells were distributed in the adventitia, which was suspected to be associated with the preoperative steroid therapy. This case study suggests preoperative steroid therapy is a useful therapeutic strategy for IgG4-related abdominal aortic aneurysm because it allows the use of open surgical procedures with reduced surgical risk.

Surgical Management of Incidental Profunda Femoris Artery Aneurysm: A Case Report.

Profunda femoris artery aneurysm is a rare vascular disorder, which is often diagnosed incidentally on identification of synchronous aneurysms. Herein, we report the case of a 63-year-old man, presenting with a hepatic cyst, who had left profunda femoris artery and left internal iliac artery aneurysms. We performed surgical intervention, including resection of the aneurysm and reconstruction of the profunda femoris artery using a prosthetic graft. The postoperative course was uneventful, and computed tomography revealed good graft patency. We believe surgical reconstruction of the profunda femoris artery should be completed except in complicated cases, such as rupture or aneurysm in the distal segment of the profunda femoris artery.

Undifferentiated intimal sarcoma mimicking a mycotic aneurysm.

Intimal sarcoma of arteries is a rare malignant tumor, which often mimics other vascular disorders; therefore, preoperative diagnosis is often challenging. We herein report a 71-year-old man who presented with fever and elevated inflammatory markers who had a mass in the left internal iliac artery with rapid growth. Based on clinical findings, a diagnosis of mycotic aneurysm was made. We performed surgical intervention, including resection of the affected vessels with omentopexy, although intraoperative findings were not typical of a mycotic aneurysm. Microscopic and immunohistochemical examination demonstrated undifferentiated intimal sarcoma. The patient died of multiorgan failure two months after the surgery. The vascular surgeon should consider the possibility of a diagnosis of intimal sarcoma for patients with atypical findings and the importance of histological and immunohistochemical examination for precise diagnosis in surgical vascular cases.

The Risk Factor Analysis for the Late Graft Failure of Radial Artery Graft in Coronary Artery Bypass Grafting.

OBJECTIVE: The aim of this retrospective study was to investigate the early operative results and detect the factors influencing the fate of radial artery grafts (RAGs) by evaluating the mid-term patency. METHODS: We retrospectively reviewed 410 patients who underwent isolated coronary artery bypass grafting using RAG. RAGs were anastomosed to 526 coronary arteries. Mid-term angiography was performed in 214 patients at an average 4.9 years after the operation. RESULTS: The early patency of RAGs was 97.6%. Cumulative 5-year patency was 86.5% for RAG, 94.1% for LITA graft, and 81.0% for saphenous vein graft (SVG). RAG was significantly superior to SVG in mid-term patency. Individual grafting (not sequential grafting) (hazard ratio [HR]: 2.535; 95% confidence interval [CI]: 1.293-5.281; p = 0.006) and grafting to the target coronary artery with ≤75% proximal stenosis (HR: 1.947; 95% CI: 1.090-3.484; p = 0.025) were found to be independent risk factors influencing late RAG patency. CONCLUSIONS: The patency of RAGs was superior to that of SVGs in the studied population. When using RAGs, grafting to the target vessel with severe proximal stenosis is favorable. The RAG is suitable for sequential grafting.

Efficacy and Safety Evaluation of Tolvaptan on Management of Fluid Balance after Cardiovascular Surgery Using Cardiopulmonary Bypass.

Background: Tolvaptan is an orally administered selective vasopressin 2 receptor antagonist that promotes aquaresis. This study aimed to evaluate the efficacy and safety of tolvaptan on management of systemic fluid balance after cardiovascular surgery using cardiopulmonary bypass. . Methods: Sixty-four patients who underwent cardiovascular surgery using cardiopulmonary bypass in our hospital were enrolled for this prospective, randomized study. These patients were divided into three groups: tolvaptan 15 mg+furosemide 20 mg (TH group), tolvaptan 7.5 mg+furosemide 20 mg (TI group), and furosemide 40 mg+spironolactone 50 mg (C group). The endpoint was safety management of systemic fluid balance using tolvaptan without renal dysfunction and electrolyte imbalance. Results: The mean daily urine output in the TH and TL groups (2656±767 and 2505 ±684 mL) was significantly higher than that in the C group (1956±494 mL, TH vs C: p<0.01 and TL vs C: p=0.03). The lowest serum sodium level during medication in the TH group (139.3 ±2.3 mEq/L) was significantly higher than that in the C group (137.1±2.9 mEq/L, p=0.03) The lowest serum osmolality during medication in the TH group was significantly higher than that in the C group (284.8 ±4.3 vs 279.5± 6.3 mOsm/kg, p<0.01). None had critical hypernatremia, hyperosm6lality, or renal dysfunction in any. of the groups. Conclusions: Tolvaptan exerts, a strong diuretic effect compared with conventional diuretics (furosemide and spironolactone) during the postoperative period after an operation using cardiopulmonary bypass without adverse effects on electrolyte balance and renal function.

[Surgical treatment for pseudoaneurysm of the sinus of valsalva ruptured into the right atrium after mycotic right coronary artery aneurysm repair;report of a case].

A 67-year-old man was admitted to our hospital by ambulance after syncope due to complete A-V block. He had received surgical treatment for mycotic aneurysm of the right coronary artery 3 months before, with patch plasty of the right sinus of Valsalva and bypass grafting to the right coronary artery (RCA) as well as the left anterior descending branch. Computed tomography revealed pseudoaneurysm of the right Valsalva sinus of about 8 cm in diameter and a shunt flow to the right atrium. The previous bypass graft to RCA had been occluded due to compression by the aneurysm. As he was in a shock state, emergency operation was performed. Cardiopulmonary bypass was first established, and after the rectal temperature reached to 26 degrees centigrade, the chest was opened. The pseudoaneurysm burst out when the sternum was re-opened. Under circulatory arrest, the ascending aorta was clamped, and then the circulation was resumed. The previous bovine pericardium patch repairing the Valsalva sinus was detached due to infection, and mural thrombus and pus were observed in the aneurysm. At the bottom of the aneurysm, a fistula connected to the right atrium was found. Debridement around the aneurysm was performed as much as possible. The defect of the Valsalva sinus was repaired with a Dacron patch immersed in gentian violet. The postoperative course was uneventful without any recurrence of infection.

Successful surgical treatment of traumatic transection of the innominate artery: a case report.

Blunt traumatic injury to the innominate artery is relatively rare. We present the case of a 40-year-old woman who fell from a fourth-floor window and was transferred to our hospital with multiple injuries, hemodynamic shock, and disturbance of consciousness. Computed tomography with image reconstruction revealed transection of the innominate artery near its origin. Emergent surgery required establishment of cardiopulmonary bypass before sternotomy in preparation for uncontrollable hemorrhage. Proximal aortic arch replacement with a branch to the right axillary artery was successfully performed using circulatory arrest and selective cerebral perfusion.

Preoperative increasing C-reactive protein affects the outcome for active infective endocarditis.

PURPOSE: This study aimed to determine if preoperative time course changes in serum C-reactive protein (CRP) levels can predict clinical outcome of surgical intervention for active infective endocarditis. METHODS: Surgically treated patients (n = 109) with active infective endocarditis were reviewed retrospectively. We divided the patients into 2 subgroups according to preoperative transition of increasing or decreasing serum CRP levels, and performed a comparative study. The increasing CRP group included 29 patients and the decreasing CRP group included 80 patients. RESULTS: There were more patients with methicillin-resistant Staphylococcus aureus and New York Heart Association functional class IV in the increasing CRP group. Hospital mortality was significantly higher in the increasing CRP group (34.5%) than that in the decreasing CRP group (5.0%) (p <0.05). In multivariate analysis, 3 significant risk factors of surgical outcome were identified: a tendency for increasing preoperative CRP levels (odds ratio [OR]: 18.15, 95% confidence interval [CI]: 1.03-320.78), nosocomial infective endocarditis (OR: 18.73, 95% CI: 1.57-223.60), and dialysis (OR: 1025.46, 95% CI: 2.89-363587.12). CONCLUSION: The outcome of operations for patients with increasing preoperative CRP levels is poor. For treatment of active infective endocarditis, a better operative result is expected when preoperative CRP levels are decreasing.

Aortoesophageal fistula after endovascular repair for aberrant right subclavian artery aneurysm.

A 76-year-old woman with malignant rheumatic arthritis developed dysphagia and hoarseness secondary to an aberrant right subclavian artery aneurysm. We performed a hybrid endovascular repair with concomitant surgical treatment for the aberrant right subclavian artery aneurysm. One month after discharge, she was emergently admitted to our hospital because of chest pain and fever. We diagnosed aortoesophageal fistula and stent graft infection based on computed tomography, gallium scintigraphy, and esophagoscopy results. Esophagectomy, elimination of the infected stent graft, and muscle plombage were performed during several surgeries. However, she died of hemorrhagic shock secondary to an aortobronchial fistula.

Does rich coronary collateral circulation distal to chronically occluded left anterior descending artery compete with graft flow?

OBJECTIVES: In coronary artery bypass grafting (CABG), graft flow distal to a mild stenosis can compete with relatively preserved native flow through the stenosis and the competition can result in graft stenosis. In chronic total occlusion (CTO), coronary collateral circulation, which is essential to maintain myocardial viability distal to CTO, varies in extent among patients and the extent can be scored by Rentrop grade in coronary angiography. We investigated whether rich collateral circulation distal to CTO competes with distally anastomosed graft flow in association with Rentrop grade. METHODS: Of 666 patients who underwent CABG from January 2001 to December 2012, 70 patients whose left internal thoracic artery (ITA) was grafted distal to CTO in the left anterior descending artery (LAD) were divided into three groups: Poor collaterals (Rentrop grades 0 and 1, Group P, n = 22), Moderate collaterals (grade 2, Group M, n = 23) and Rich collaterals (grade 3, Group R, n = 25). The intraoperative measurements of mean graft flow (MGF) and pulsatility index (PI) of left ITA grafts, early graft patency and long-term clinical outcomes were compared. RESULTS: The MGF and PI of left ITA grafts differed significantly among the three groups (P = 0.025 and P = 0.046, respectively). Lower Rentrop grade was associated with preferable results of higher MGF and lower PI. The graft flow pattern in Group P showed a significantly higher MGF (P = 0.020) and lower PI (P = 0.041) than those in Group R. All early postoperative coronary angiograms showed patent left ITA grafts. Serial echocardiographic evaluations, survival rates and cardiac event-free rates were comparable with the follow-up of 5.00 ± 3.11 years. CONCLUSIONS: Rich collateral circulation distal to CTO in LADs can potentially compete with graft flow, although the competition seems not to affect clinical outcomes probably due to the regression of collaterals surmounted by the graft flow. Rentrop grade is shown to certainly reflect the degree of collateral haemodynamic circulation distal to CTO and especially important to evaluate intraoperative graft flow appropriately, considering the possible phenomenon of graft flow competition.

Is elimination of cardiotomy suction preferable in aortic valve replacement? Assessment of perioperative coagulation, fibrinolysis and inflammation.

OBJECTIVES: Guidelines recommend the avoidance of direct return of pericardial blood based on evidence from coronary surgery. A continuous auto-transfusion system (CATS) can be a good alternative to cardiotomy suction by reinfusing aspirated pericardial blood without the necessity of intermittent collection. To clarify the effects of direct return of pericardial blood in aortic valve replacement (AVR), we compared the effects of cardiotomy suction and an alternative CATS on perioperative coagulofibrinolysis and inflammation systems, and clinical outcomes. METHODS: In 40 AVR operations between April 2009 and April 2011, the retransfusion method of pericardial blood during cardiopulmonary bypass (CPB) was allocated to the use of cardiotomy suction (non-Cell-Saver group, n = 20) or CATS (Cell-Saver group, n = 20) under identical protocols of anticoagulation and transfusion. The blood from the left ventricular vent was returned to the venous reservoir. We obtained blood samples at nine points up to the morning after surgery. RESULTS: Perioperative values for coagulofibrinolysis markers, such as thrombin-antithrombin III complex, fibrinogen degeneration products, D-dimer and plasmin-α2 plasmin inhibitor complex, were significantly lower in the Cell-Saver group than those in the non-Cell-Saver group from 1 h after the initiation of cardiopulmonary bypass to 3 or 6 h after termination of cardiopulmonary bypass (P < 0.05 for all markers). A fibrinolysis inhibition marker of plasminogen activator inhibitor-1 and the inflammation markers of interleukin-6, 8 and 10 as well as tumour necrosis factor-α were not significantly different. The amount of packed red blood cells required after the termination of CPB was significantly less in the Cell-Saver group compared with that in the non-Cell-Saver group (P = 0.004). There were no significant differences in the other clinical outcomes between the two groups. CONCLUSIONS: In AVR, the avoidance of direct return of pericardial blood induced considerable suppressions of coagulofibrinolysis responses. A CATS is a favourable alternative for managing pericardial blood during cardiopulmonary bypass. Our results support the published guidelines and could help to establish ideal strategies for eliminating the use of cardiotomy suction, thus facilitating less-invasive valve surgeries with marked suppression of coagulofibrinolysis responses.

[Axillo-axillary bypass for coronary-subclavian steal syndrome].

We describe a case of coronary-subclavian steal syndrome in a 77-year-old man who presented with progressive coronary ischemia 8 years after coronary artery bypass grafting with an in-situ left internal thoracic artery graft. Coronary and left subclavian artery angiogram revealed completely patent internal thoracic artery graft and 90% stenosis in the proximal left subclavian artery. We performed axilloaxillary artery bypass using expanded polytetrafluoroethylene (ePTFE)[8 mm] graft. No coronary ischemia was noted postoperatively. Axillo-axillary artery bypass grafting was effective for coronary subclavian steal syndrome.

Adding coronary artery bypass grafting to aortic valve replacement increases operative mortality for elderly (70 years and older) patients with aortic stenosis.

OBJECTIVE: This retrospective study aimed to determine the effect of simultaneous aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) on operative outcomes and long-term survival in elderly patients with a high prevalence of comorbidity. METHODS: One hundred and fifty-seven elderly patients (70 years old or older) undergoing isolated AVR (n = 120) or combined AVR/CABG (n = 37) were evaluated. Operative outcomes were compared between the two surgical groups. Long-term survival was also compared between the groups using the Kaplan-Meier method and long-rank (Mantel-Cox) test. RESULTS: Operative mortality was 0.8 % for the isolated AVR group and 5.4 % for the combined AVR/CABG group (p = 0.076). The length of the intensive care unit stay for the combined AVR/CABG group was significantly longer than that for the isolated AVR group (median: 40 vs. 21 h, p = 0.008). However, the occurrence rate of hospital complications, such as reoperation for bleeding, deep sternal infection, supra-ventricular arrhythmia, and neurological complications, was similar between the two groups. Actuarial survival at 3 and 5 years was 82.3 and 80.9 % for the isolated AVR group, and 88.3 and 73.0 % for the combined AVR/CABG group, respectively (p = 0.637). CONCLUSIONS: The satisfactory operative and long-term results in our study support a more aggressive simultaneous coronary revascularization combined with AVR for aortic valve stenosis in elderly patients.

Risk factors for late valve-related mortality after aortic valve replacement in elderly patients.

PURPOSE: Few recent studies have examined the long-term outcomes after aortic valve replacement (AVR), and independent predictors for long-term survival and valve-related mortality have not been elucidated. METHODS: From January 1993 to December 2009, 132 elderly patients (≥70 years old) with aortic stenosis underwent AVR in our hospital. The patients comprised 61 men and71 women with a mean age of 76.1 ± 3.7 years. Patients with acute or old myocardial infarction, mitral valve disease, and re-do surgery were not included in this study. Risk factors for late valve-related mortality were examined. RESULTS: The 5-year freedom from valve-related mortality rate was 89.6%. The following significant independent risk factors for late valve-related mortality were identified:increase in the preoperative left ventricular mass index (hazard ratio, 1.10 [per 10 g/m(2)];p = 0.040); lack of sinus rhythm (hazard ratio, 7.11; p = 0.005); peak transvalvular pressure gradient of <60 mmHg (hazard ratio, 7.48; p = 0.008). CONCLUSION: In the elderly, AVR should be performed at an early stage of aortic stenosis, before an increase in the left ventricular mass index has occured, and while the heart rhythm is in sinus rhythm and the peak transvalvular pressure gradient is high.

Efficacy of landiolol hydrochloride for prevention of atrial fibrillation after heart valve surgery.

The goal of this prospective study was to examine the effects of landiolol hydrochloride on prevention of atrial fibrillation and on hemodynamics in the acute postoperative phase after heart valve surgery. The subjects were 60 patients who underwent valve surgery at our hospital from April 2008 to July 2010. The patients were randomly divided into two groups: the landiolol group (30 patients) and the control (no landiolol) group (30 patients). In the landiolol group, continuous intravenous landiolol was initiated immediately on admission to the intensive care unit at a dose of 10 µg/kg/ minute. Occurrence of atrial fibrillation was compared between the groups over an observation period of 72 hours after surgery. Atrial fibrillation occurred in 6 patients (20%) in the landiolol group and 16 (53.3%) in the control group during the observation period. Landiolol hydrochloride significantly reduced the occurrence of atrial fibrillation in the acute postoperative phase after heart valve surgery. Heart rate was significantly decreased by landiolol, but aggravation of hemodynamics was not observed. These results suggest that landiolol is a useful drug for prevention of atrial fibrillation after valve surgery.

Mitral bioprosthetic valve stenosis in a patient with antiphospholipid antibody syndrome and systemic lupus erythematosus.

A 45-year-old woman with antiphospholipid antibody syndrome (APS) and systemic lupus erythematosus was admitted because of severe dyspnea. She had undergone mitral valve replacement (MVR) using a Mosaic bioprosthesis for infective endocarditis 9 years previously. She developed congestive heart failure secondary to mitral bioprosthetic valve stenosis resulting from relatively early structural valve deterioration. She underwent a second MVR using a mechanical valve prosthesis. The explanted bioprosthesis showed marked pannus formation and mineralization with fibrin thrombus formation, especially on the outflow surfaces of the leaflets. After the second operation, she was discharged without APS-related thromboembolic events under meticulous anticoagulant and antiplatelet therapies.

Very-low-dose continuous drip infusion of landiolol hydrochloride for postoperative atrial tachyarrhythmia in patients with poor left ventricular function.

Three patients with poor left ventricular function (left ventricular ejection fraction <30 %) developed postoperative atrial tachyarrhythmia in intensive care. Case 1 was a 64-year-old man who underwent a modified Bentall procedure and mitral valve annuloplasty. Case 2 was a 63-year-old woman who underwent quintuple coronary artery bypass grafting. Case 3 was a 65-year-old man who underwent mitral valve replacement. Preoperative intra-aortic balloon pumping was required in Cases 2 and 3. Excellent heart rate control with no hemodynamic deterioration was achieved in all three cases by very-low-dose continuous drip infusion of landiolol hydrochloride (2-5 µg/kg/min). Very-low-dose continuous drip infusion of landiolol hydrochloride is a safe and useful alternative for the control of perioperative atrial tachyarrhythmias in patients with poor left ventricular function.

Evaluation of risk factors for hospital mortality and current treatment for poststernotomy mediastinitis.

PURPOSE: Poststernotomy mediastinitis (PSM) following cardiovascular surgery remains an intractable complication associated with considerable mortality. It is therefore necessary to assess the risk factors associated with hospital mortality and evaluate the surgical treatment options for PSM. METHODS: We identified 59 (2.2%) patients who developed PSM after cardiovascular surgery between January 1991 and January 2010. PSM was defined as deep sternal wound infection requiring surgical treatment. In all, 31 patients were infected with methicillin-resistant Staphylococcus aureus (MRSA); and 14 patients died in hospital from PSM. A total of 51 patients were treated by simple closure or tissue flap reconstruction after débridement (traditional treatment), and 8 underwent closure or reconstruction after negative-pressure wound therapy (NPWT). The risk factors for in-hospital mortality due to PSM were analyzed by comparing the characteristics of survivors and nonsurvivors. The available surgical treatments for mediastinitis were also assessed. RESULTS: Univariate analysis identified age, sex, pulmonary disease, MRSA infection, prolonged mechanical ventilation and prolonged intensive care unit stay as risk factors for in-hospital mortality (P < 0.05). Multiple logistic regression analysis identified MRSA infection (odds ratio 20.263, 95% confidence interval 1.580-259.814; P = 0.0208) as an independent risk factor for hospital mortality. NPWT was associated with significantly less surgical failure than traditional treatment (P = 0.0204). There were no deaths as a result of PSM in patients who underwent NPWT irrespective of the presence of MRSA infection. CONCLUSION: MRSA infection was an independent risk factor for PSM-related in-hospital mortality. NPWT may improve the prognosis for patients with MRSA mediastinitis.

[Hybrid repair of thoracoabdominal aortic aneurysm in high-risk patients using a quadrifurcated graft].

Surgical treatment for thoracoabdominal aortic aneurysm is still challenging and is associated with a high risk of paraplegia. Hybrid repair with stent graft insertion for the thoracoabdominal aorta excluding the branches of the lumbar and visceral arteries and bypass grafting to the visceral branches has been introduced as a less invasive treatment that reduces the risk of paraplegia. For hybrid repair, it is important to have appropriate management of the revascularized grafts to the 4 visceral arteries with sufficient inflow. We have recently adopted a knitted quadrifurcated graft applied inversely from the abdominal aorta or the iliac artery to the 4 visceral arteries; the celiac, superior mesenteric, and bilateral renal arteries. To date, we have used the graft in hybrid repair of thoracoabdominal aortic aneurysm in 2 high-risk elder patients who had disseminated intravascular coagulopathy and severe renal failure, respectively. We found that a knitted quadrifurcated graft was easy to handle and useful for reducing the number of anastomoses, which were expected to shorten the operation time. Postoperative courses were uneventful without paraplegia in either patient. Postoperative computed tomography showed excellent patency of the inversely applied quadrifurcated graft without any endoleak or migration in the thoracoabdominal stent. In conclusion, revascularization of 4 visceral arteries using a quadrifurcated graft should be considered a preferable option in hybrid treatment for thoracoabdominal aortic aneurysm.