Delayed bowel necrosis due to inferior mesenteric artery occlusion in Stanford type A acute aortic dissection.

Although inferior mesenteric artery occlusion due to acute aortic dissection sometimes occurs, it is usually not considered an important finding. Herein, we present an extremely rare case of delayed bowel ischaemia due to inferior mesenteric artery occlusion in Stanford type A acute aortic dissection that highlights the need for cardiac surgeons to be mindful of inferior mesenteric artery occlusion in patients with superior mesenteric artery dissection or vascular anomalies in the mesenteric arteries.

A Modified Modular Stem in Primary Total Hip Arthroplasty for Developmental Dysplasia of the Hip: Average 11-year Follow-Up in Cases With Previously Reported 3-year Clinical Results.

BACKGROUND: Modular stems require careful follow-up, especially after any design modification. This study investigated the mid- to long-term outcomes of total hip arthroplasty in patients with developmental dysplasia of the hip using the S-ROM-A stem, a modified S-ROM stem for Asians. METHODS: We previously reported short-term outcomes for all 220 dysplastic hips that underwent primary total hip arthroplasty with the S-ROM-A stem. Here, we followed the clinical and radiological outcomes of 201 of the 220 hips (91%) for a mean 11.4 years postoperatively. We also performed multivariate analysis to determine whether large anteversion angle adjustment was associated with increased osteolysis. RESULTS: The cumulative survival rate of the stem at 168 months postoperatively was 97.4%. Two hips underwent revision surgery, including 1 due to neck trunnionosis. Characteristic distal stem fracture occurred in 3 hips (1.5%). Most partial radiolucent lines observed around the sleeve early postoperatively disappeared by 7 years, postoperatively. Mild osteolysis occurred relatively frequently (20%), but a multivariate model adjusted for polyethylene type showed no significant association between the occurrence of osteolysis and anteversion adjustment of the modular stem (stem anteversion decreased ≤-20°, P = .829; stem anteversion increased ≥+20°, P = .619). CONCLUSION: Partial radiolucent lines early postoperatively do not affect long-term outcomes. The clinical benefits of actively adjusting the stem anteversion angle outweigh the mechanical risks. Mild osteolysis, stem fracture, and trunnionosis were relatively frequent complications. Analysis with longer follow-up and more cases are necessary to clearly determine if these complications are associated with the design modification.

Surgical glue-induced left main trunk stenosis removed by directional coronary atherectomy.

A 55-year-old man underwent aortic repair for acute aortic dissection. The pseudolumen of the Valsalva sinus was reapproximated with BioGlue by placing a sponge inside of it to prevent the BioGlue from entering. Postoperative contrast-enhanced computed tomography showed stenosis of the left main trunk. Directional coronary atherectomy was performed; complete release of the stenosis was achieved. Various fragments retrieved from the left main trunk were pathologically consistent with BioGlue. When we reapproximated the dissected aortic wall, inserting a sponge into the aorta did not prevent the surgical glue from entering. Directional coronary atherectomy was a good therapeutic option to treat glue-induced coronary artery stenosis.

Revision Total Hip Arthroplasty Using the Modular Proximal Stem Modified for Asians: Medium-Term Clinical Results and Perioperative Complications.

BACKGROUND: This study aimed to examine the medium-term clinical and radiological outcomes of revision THA using the S-ROM-A stem, a modification of the S-ROM stem intended for Asians. METHODS: Femoral reconstruction using the S-ROM-A stem was performed in 126 hips that underwent revision THA. All patients were followed for perioperative complications. In addition, clinical and radiographic outcomes at a mean of 8 (range 5-14) years postoperatively were evaluated in 96 hips of 86 patients (76%). RESULTS: The most common perioperative complication was a femoral fracture, occurring in 16 hips (13%), including 11 intraoperative and 5 postoperative fractures. Dislocation occurred in five hips (4.0%), infection in three hips (2.4%), and trunnionosis in two hips (1.6%), including late complications. The total second stem revision was performed in two hips while stem only second revision preserving the bone ingrown sleeve was performed in four hips. With a second revision for aseptic loosening as the endpoint, the 13-year stem survival rate was 100%. Hip function as assessed by the Japanese Orthopedic Association score improved from a mean of 48 points preoperatively to 87 points 8 years postoperatively (P < .05). Radiological evaluation at the final follow-up showed that 95 hips (99%) achieved bone ingrowth fixation and one hip (1%) achieved fibrous stable status. CONCLUSION: Revision THA using the S-ROM-A stem resulted in good medium-term outcomes. Although modifications of the stem length and shape may be effective in preventing fractures in Asians with relatively small body sizes, attention should be paid to the occurrence of trunnionosis, which may be associated with the decreased taper size.

Results of off-pump coronary artery bypass grafting with off-pump first strategy in octogenarian.

BACKGROUND AND AIM: Ischemic heart disease is the leading cause of death around the world. Coronary artery bypass grafting offers efficient surgical revascularization for ischemic disease. Both on- or off-pump coronary artery bypass methods provide promising results to octogenarians, once complete vascularization is achieved. However, off-pump bypass requires a certain level of experience to achieve sufficient results. We have applied an off-pump coronary artery bypass-first strategy to all generations since 2008. This study investigated early and long-term results of surgical revascularization for octogenarians by a team with an off-pump-first strategy. METHODS: All cases of isolated coronary artery bypass grafting performed since 2008 were identified and divided into a young group (age < 80 years) and an old group (age ≥ 80 years). Peri-operative results were investigated retrospectively in both groups and long-term results for the old group were assessed. RESULTS: Among the 707 patients, 97% underwent off-pump bypass, and 94 cases were classified to the old group. Distal anastomoses and ventilator time were identical between groups (young vs. old: 3.3 vs. 3.2; 3.7 h vs. 3.7 h). In-hospital death rates were 0.5% and 0% in the young and old groups, respectively. With a mean follow-up of 1318 days, actual 1-, 3-, and 5-year survival rates for octogenarians were 92.1%, 81.2%, and 68.3%, respectively. Nearly half of the patients reached their nineties, which was close to the life expectancy of the national general octogenarian. CONCLUSIONS: An experienced team with an off-pump-first strategy could provide valid therapeutic options for octogenarians.

A Five-Year-Old Slipped Capital Femoral Epiphysis Treated With Dynamic Single Screw Fixation.

Slipped capital femoral epiphysis (SCFE) commonly occurs during puberty. Onset of SCFE at either less than 10 years old or over 16 years is defined as atypical. As in our patient, atypical onset at less than 10 years occurred in 9%, and the age of onset has been decreasing in recent years and that the probability of concomitant obesity is particularly high in young patients without obvious underlying disease or background factors. In the treatment of SCFE, preventing further slipping and permitting femoral bone growth by physeal closure is difficult, especially for young patients. We adopted 'dynamic single screw fixation' using SCFE short thread screw for continuous fixation without disturbing the growth of proximal femur or damaging to growth plate. Refixation was necessary once. The screw worked for 7 years 4 months while physeal closure was avoided. At the 10-year follow-up, her growth had stopped. She had no problem clinically, no increase in the posterior sloping angle (PSA), and no obvious growth disturbance of the femur.

Clinical results of a short stem with flat tapered wedge design in primary total hip arthroplasty for hip dysplasia in Asians.

BACKGROUND: Cementless femoral reconstruction is challenging in hip dysplasia due to deformity of the proximal femur causing insufficient stem fixation and/or inadequate neck anteversion. Strategies to address these problems include the use of a modular stem or a distal fixation stem, but both stems have some characteristic disadvantages. METHODS: We studied the postoperative clinical outcomes in primary total hip arthroplasty in 257 hips using the flat tapered wedge short femoral stem for hip dysplasia in an Asian population (postoperative follow-up period: 2 years to 6 years and 11 months; mean 4 years and 5 months). We took advantage of the characteristic of high flexibility in stem placement because of its low volume, positioning it while performing some varus/valgus and rotational alignment adjustments. RESULTS: Favorable clinical functional outcomes were obtained, including the radiographic outcome of biological fixation achieved in all stems. Regarding complications, there was no case of split fracture of the femoral calcar region during stem insertion, and the rate of postoperative dislocation was also low at 0.4% (1 case). In the pre- and postoperative computed tomography measurements, the variability in stem anteversion postoperatively was significantly reduced compared to preoperative anatomical anteversion. CONCLUSION: This flat-shaped short low-volume stem likely has high flexibility in positioning in cases of hip dysplasia and can be easily positioned to avoid fractures while still achieving secure fixation.

Surgical repair of thoracoabdominal aortic aneurysm accompanied by Leriche syndrome using a quadrifurcated graft without a distal anastomosis.

BACKGROUND: The coexistence of Leriche syndrome and thoracoabdominal aortic aneurysm is rare and challenging for surgeons especially if there are no distal anastomosis sites. CASE REPORT: A 56-year-old man with past medical histories of coronary artery bypass grafting and total arch replacement was planned to the surgery for thoracoabdominal aneurysm. His abdominal aorta was occluded just below the renal arteries and his terminal aorta, iliac and femoral arteries were hypoplastic. Right internal thoracic artery and visceral arteries provided collateral blood supply to the legs. The aneurysm was successfully repaired using a quadrifurcated graft without distal anastomoses. CONCLUSION: A quadrifurcated graft can be a therapeutic option for repair of thoracoabdominal aneurysm accompanied by Leriche syndrome without distal anastomosis sites.

[Cardiac Surgery for Mitral Regurgitation Associated with Essential Thrombocythemia].

An 80-year-old woman with essential thrombocythemia was diagnosed with severe mitral regurgitation and moderate tricuspid regurgitation. Preoperatively, she had been treated with hydroxycarbamide and low-dose aspirin since her platelet count was high( 96.2×104/µl). After the platelet count was reduced to 46.2×104/µl, she underwent mitral valve repair and tricuspid valve annuloplasty. Atypical heparin resistance was noted intraoperatively. After initial heparin infusion, the activated clotting time(ACT) increased as expected. However, it decreased after initiation of cardiopulmonary bypass, despite additional heparin infusion and heparin concentration maintenance. A correlation between platelet factor 4 and heparin resistance was suggested. On discharge, she had no complications. We should consider the possibility of heparin resistance in essential thrombocythemia even when platelet count is adequately controlled.

Aortic Valve Replacement by a Transaxillary Anterior Minithoracotomy Approach.

A modified transaxillary approach for aortic valve disease to obtain the same exposure as the anterior minithoracotomy approach and to preserve the pectoralis major muscle is presented. When the patient's right shoulder is adducted horizontally, or the right arm is flexed anteriorly 90 degrees and adducted to the left, the right axilla comes close to the chest midline. That means that a right anterior thoracotomy can be made through the right axilla when the arm position is adjusted appropriately. The modified new approach is safe and faster than the conventional transaxillary approach, and it provides cosmetic advantages to the patient.

Thoracic endovascular aneurysm repair to treat recurrent lower limb ischemia secondary to occlusion of axillofemoral bypass.

INTRODUCTION: A case of malperfusion in which the patient presented with aortic dissection is presented. PRESENTATION OF CASE: A 69-year-old man with an acute aortic dissection (Stanford type B) had lower limb ischemia. Axillary-femoral bypass was performed, and his lower limb ischemia improved. Eight months after the onset of acute aortic dissection, he again had lower limb ischemia. Contrast-enhanced computed tomography showed axillary-femoral bypass occlusion and true lumen collapse, compressed by the increased false lumen pressure in the aorta. Thoracic endovascular aortic repair (TEVAR) was performed for entry closure. His lower limb ischemia was improved by TEVAR. DISCUSSION: One of the complications of type B aortic dissection is malperfusion. Endovascular therapy is a first step in treating the malperfusion of type B aortic dissection. It is important to seal the entry for the treatment of malperfusion. CONCLUSION: If there is an entry, it is important to seal it for the treatment of malperfusion.

How to anastomose a patch to avoid residual leak in the infarct exclusion method.

BACKGROUND AND AIM: Postinfarction ventricular septal defect is a potentially lethal complication of acute myocardial infarction for which surgical repair is mandatory. The infarct exclusion method has contributed to improving surgical outcomes, but a certain percentage of residual leakage continues to be reported. We considered possible mechanisms of residual leakage and modified the sewing method to overcome these mechanisms. METHOD: A bovine pericardial patch and a Teflon felt strip between the patch and endocardium to achieve good fit were used. The patch and felt were anchored with U stay sutures and reinforced with a running suture. RESULTS: Use of the modified method in seven cases showed improved outcomes. Only one patient had trivial leakage, compared to nine cases using the older method; six of nine patients had residual leaks, including three minor ones. CONCLUSIONS: Our method is a rational approach that effectively reduces residual leakage.

Early and long-term results of surgery for secondary mitral regurgitation with a damaged heart.

BACKGROUND: Surgery for secondary mitral regurgitation is still controversial, especially when the left ventricle is damaged. The Mitra Clip has been shown to be safe and effective for certain patient groups but does not offer superior control of mitral regurgitation compared with the surgery. If performed safely, the surgery can provide greater benefits over the long-term. The objective of this study was to retrospectively investigate the early and long-term results of mitral valve surgery for secondary mitral valve regurgitation with a damaged, dilated left ventricle. METHODS: Patients with ejection fraction <40% and left ventricular end-diastolic/systolic diameter >50/40 mm who underwent mitral valve surgery for secondary mitral regurgitation were investigated retrospectively. RESULTS: The mean age of the 80 identified cases was 65.7 years, and 63 patients were male. Preoperative echocardiograms showed a mean ejection fraction of 25.2% and mean left ventricular diameters in diastole/systole of 64.5/56.9 mm, respectively. Mitral valve replacement was performed in 39 cases, and mitral valve plasty in 41 cases. The most common concomitant procedures were coronary artery bypass grafting and tricuspid valve surgery (41.3% each). Mitral regurgitation improved significantly from 3.5 to 0.83, and no operative or in-hospital deaths were encountered. Long-term results showed actual 1-, 3- and 5-year survival rates of 93.1%, 80.0%, and 64.7%, respectively (mean follow-up, 1264 days). CONCLUSIONS: Early results of this study were good and long-term results were acceptable. Our results suggest that mitral valve surgery is feasible for secondary mitral valve regurgitation even in dilated, damaged hearts.

A drainage catheter tangled around a closed left atrial appendage.

A 70-year-old man underwent cardiac surgery including left atrial appendage closure. A pigtail catheter was inserted into the pericardial sac because of delayed tamponade. Removal of the catheter was planned for 2 days after drain insertion. However, the resistance was high and pulsatile. The patient was transferred to the catheterization laboratory and a guide wire was inserted through the catheter, revealing the catheter route around the left atrial appendage. The wire was exchanged for a stiff wire to uncurl the catheter as much as possible, then the catheter was removed. The left atrial appendage does not usually represent an obstacle to catheter removal because it is soft and shrinkable. However, once the left atrial appendage becomes closed off, it can become hard, unshrinkable and an obstacle that might be caught by the drainage catheter.

Treatment of periprosthetic hip infection with retention of a well-fixed stem: six to 13-year outcomes.

BACKGROUND: Treatment of periprosthetic joint infection (PJI) is challenging, generally requiring complete implant removal. However, recently reported treatments involve partial retention of implants because of the severe local and systemic burden on the patients and difficulties in functional preservation. Long-term results should be evaluated because of the risk of residual biofilm on the retained implant and late infection recurrence. We evaluated 6 to 13-year clinical outcomes of two-stage treatment of chronic PJI retaining well-fixed cementless stems. METHODS: Among 36 surgeries for deep infection following hip arthroplasty performed from 2004 to 2011, six hips had a well-fixed and well-functioning cementless stem. These six hips were all chronic PJI and were treated without stem removal. The first-stage surgery involved acetabular cup removal and reconstruction by filling the acetabular defect with antibiotic-loaded acrylic cement, creating a socket-like hemispherical dent, and reducing the retained femoral head to this dent. After confirming infection eradication the second-stage acetabular reconstruction was performed. One patient died of an unrelated noninfective cause 1 year after the operation. Clinical outcomes of the remaining five patients were followed for 6 to 13 years. RESULTS: Between the two surgeries (range; 2-5 months), patients underwent active range-of-motion and ambulation exercises. No dislocation was found during the interval. No recurrence of infection was found and good functional outcomes and radiographic findings were observed during the average follow-up of 109 months in all five patients. CONCLUSIONS: Two-stage treatment with retention of a well-fixed stem may minimize local and systemic burden of the patient and enhance functional preservation while obtaining long-term infection control. Although further study could establish the effectiveness and indications for this treatment option, currently used indications should be carefully evaluated considering factors including local and systemic conditions of the patient, implant fixation status, and type of bacteria.

Treatment for unstable slipped capital femoral epiphysis: Current status and future challenge in Japan.

BACKGROUND: Treatment for unstable slipped capital femoral epiphysis (SCFE) is challenging and controversial. For many years, the debate centered around closed treatments and especially the pros and cons of manual reduction and its concrete procedure. However, recent studies reported on open treatments such as open reduction through an anterior approach and modified Dunn procedure. Being in a period of such transition, we investigated the current status and future challenge of treatment for unstable SCFE. METHODS: A questionnaire survey of medical institutions specializing in pediatric hip disorders across Japan was conducted. Survey items were the accurate diagnosis of physeal stability, the pre- and intra-operative evaluation of epiphyseal hemodynamics, and current treatment strategy. RESULTS: Survey responses returned from 29 out of 40 participant institutions (response rate: 73%) revealed that 55% of the institutions evaluated physeal stability based on clinical findings of ambulation capability in accordance with the Loder classification. Another 38% diagnosed physeal stability comprehensively by combining the Loder classification and imaging findings. Epiphyseal hemodynamics was assessed preoperatively in 18% of the institutions, effectively using angiography, contrast-enhanced magnetic resonance imaging (MRI), and bone scintigraphy. Intraoperative assessment was performed in 13% based on the bleeding through a drilling hole on the articular surface and observation of the cancellous bone color during open surgeries. As a treatment strategy, 52% of the institutions used in-situ fixation, while another 38% used manual reduction and internal fixation. On the other hand, open reduction was used at 3 institutions (the remaining 10%): the modified Dunn procedure at 2 institutions and arthrotomy at 1 institution. CONCLUSION: Treatment for unstable SCFE remains controversial, but closed treatments without hemodynamic monitoring is no longer the center of the controversy. Today, the topic of the discussion is shifting toward how to correlate hemodynamic findings with treatment procedures and the indications for open treatments.

[Myocardial Ischemia in Acute Type A Aortic Dissection; Coronary Artery Dissection and Functional Ischemia].

Myocardial ischemia due to acute type A dissection is a fatal complication. This study was undertaken to evaluate the surgical results of acute type A aortic dissection with myocardial ischemia. Between 1986 and 2014, 364 patients were treated for acute type A dissection in our hospital. Twenty-four patients were underwent myocardial revascularization. Preoperative coronary artery stent placement was involved in 2, coronary-artery bypass grafting (CABG) 18 (right 12, left 4, both 2), reCABG 2, and Carrel patch with coronary orifice restoration 2. Seven of CABG group had no symptom of myocardial ischemia, but right coronary artery was circumferentially detached from the intimal ostia. Hospital mortality was 20.1% in patients who underwent CABG. Sixteen patients with significant electrocardiogram ischemic change were not undertaken with CABG, because coronary artery was not involved by dissection. In these cases, acute aortic valve regurgitation, loss of backward pressure from distal aorta, or valve formation by intimal tear in ascending aorta might decrease diastolic pressure at aortic root and make myocardial ischemia.

A modified S-ROM stem in primary total hip arthroplasty for developmental dysplasia of the hip.

This study examined the clinical outcome of 220 hips in 196 Asian patients who underwent primary total hip arthroplasty (THA) for treatment of developmental dysplasia of the hip (DDH) using a modified S-ROM modular (S-ROM-A) stem designed for Asians, after 2-5 years (mean, 3.3 years) of follow-up. The stem was placed so that the anteversion angle of the neck was decreased against the sleeve in 56% of the hips and increased in 18% of the hips. Bone ingrown fixation was achieved in 99.5% of the hips on X-ray at final follow-up. There were 2 (0.9%) dislocations postoperatively. In primary THA for treatment of DDH accompanied by femoral rotational deformity, the freely-rotatable modular stem provided favorable short-term outcomes by affording both morphological and functional advantages.