RESUMO
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.
Assuntos
Implante de Prótese Vascular/métodos , Permeabilidade do Canal Arterial/cirurgia , Procedimentos Endovasculares/métodos , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Permeabilidade do Canal Arterial/diagnóstico por imagem , Permeabilidade do Canal Arterial/fisiopatologia , Procedimentos Endovasculares/instrumentação , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Circulação Pulmonar , Radiografia Intervencionista , Stents , Artéria Subclávia/cirurgia , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
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.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Prótese Vascular , Implante de Prótese Vascular/história , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/tendências , Difusão de Inovações , História do Século XX , Humanos , Japão , Desenho de Prótese , Stents , Resultado do TratamentoRESUMO
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.
Assuntos
Ponte Cardiopulmonar/efeitos adversos , Isquemia/etiologia , Pulmão/irrigação sanguínea , Traumatismo por Reperfusão/etiologia , Reperfusão/efeitos adversos , Trifosfato de Adenosina/análise , Animais , Benzamidinas , Sangue , Constrição , Guanidinas , Isquemia/fisiopatologia , Leucócitos , Pulmão/química , Pulmão/patologia , Pulmão/fisiopatologia , Modelos Biológicos , Inibidores de Proteases , Artéria Pulmonar , Coelhos , Fluxo Sanguíneo Regional , Reperfusão/métodos , Traumatismo por Reperfusão/prevenção & controleRESUMO
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.
Assuntos
Artrite Experimental/patologia , Osso e Ossos/patologia , Células Gigantes/patologia , Osteoclastos/patologia , Animais , Antígenos de Superfície/metabolismo , Modelos Animais de Doenças , Feminino , Ratos , Ratos Endogâmicos LewRESUMO
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)
Assuntos
Animais Recém-Nascidos , Traumatismo por Reperfusão Miocárdica/prevenção & controle , Reperfusão Miocárdica/métodos , Animais , Sangue , Parada Cardíaca Induzida , Hemodinâmica , Contagem de Leucócitos , Traumatismo por Reperfusão Miocárdica/metabolismo , Traumatismo por Reperfusão Miocárdica/patologia , Traumatismo por Reperfusão Miocárdica/fisiopatologia , Miocárdio/metabolismo , Miocárdio/patologia , CoelhosRESUMO
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.
Assuntos
Aneurisma Aórtico/terapia , Dissecção Aórtica/terapia , Prótese Vascular/instrumentação , Stents , Animais , Aorta/fisiologia , Cães , Microscopia Eletrônica de Varredura , Desenho de Prótese , RegeneraçãoRESUMO
A new cyclic adenosine monophosphate phosphodiesterase inhibitor, DN-9693, was examined to see whether myocardial reperfusion injury could be reduced in a setting of cardioplegic arrest through its antiaggregation effect on leukocytes. Isolated rabbit heart models with whole blood perfusion were used, and 18 hearts were divided into three groups according to the reperfusion method: control (G-1, n = 5), DN-9693 (G-2, n = 7), and leukocyte depletion (G-3, n = 6). The hearts were subjected to 120 minutes of cold global ischemia under crystalloid cardioplegia followed by 30 minutes of reperfusion. A dose of 20 micrograms.kg-1.min-1 of DN-9693 was administered in G-2, and a leukocyte removal filter was used in G-3 during reperfusion. Ultrastructural changes in mitochondrial injuries, intracellular edema, and capillary injuries of the myocardium showed worse changes in G-1 than in G-2 and G-3. Under microscopic study, the intracapillary leukocyte count was significantly higher in G-1 than in G-2 and G-3. Recovery of rate-pressure product, left ventricular developed pressure, and coronary flow were significantly better in G-2 and G-3 than in G-1. There were no significant differences between G-2 and G-3 for all these indices. These results indicate that reperfusion with leukocyte-depleted blood attenuates reperfusion myocardial injury and DN-9693 has a comparable myocardial protective effect with possible inhibition of leukocyte aggregation.
Assuntos
3',5'-AMP Cíclico Fosfodiesterases/antagonistas & inibidores , Traumatismo por Reperfusão Miocárdica/prevenção & controle , Inibidores de Fosfodiesterase/uso terapêutico , Quinazolinas/uso terapêutico , 3',5'-AMP Cíclico Fosfodiesterases/uso terapêutico , Animais , Circulação Coronária/efeitos dos fármacos , Miocárdio/patologia , CoelhosRESUMO
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.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Prótese Vascular , Stents , Dissecção Aórtica/patologia , Animais , Aorta Torácica/patologia , Aneurisma da Aorta Torácica/patologia , Aortografia , Cães , Desenho de PróteseRESUMO
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.
Assuntos
Aneurisma da Aorta Torácica/terapia , Dissecção Aórtica/terapia , Prótese Vascular , Stents , Dissecção Aórtica/patologia , Animais , Aneurisma da Aorta Torácica/patologia , Cateterismo Periférico/instrumentação , Cães , Endotélio Vascular/patologia , Células Gigantes de Corpo Estranho/patologia , Microscopia Eletrônica de Varredura , Desenho de Prótese , Propriedades de Superfície , Cicatrização/fisiologiaRESUMO
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.
Assuntos
Dissecção Aórtica/cirurgia , Ruptura Aórtica/cirurgia , Complicações Pós-Operatórias , Implantação de Prótese/métodos , Stents , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , HumanosRESUMO
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.
Assuntos
Aneurisma Aórtico/cirurgia , Implante de Prótese Vascular , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , StentsAssuntos
Aneurisma da Aorta Torácica/terapia , Dissecção Aórtica/terapia , Artérias Carótidas/cirurgia , Stents , Artéria Subclávia/cirurgia , Dissecção Aórtica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aortografia , Feminino , Humanos , Pessoa de Meia-Idade , Polietilenotereftalatos , Politetrafluoretileno , Tomografia Computadorizada por Raios XRESUMO
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.
Assuntos
Brônquios/irrigação sanguínea , Ponte Cardiopulmonar , Pulmão/ultraestrutura , Criança , Pré-Escolar , Endotélio/ultraestrutura , Feminino , Cardiopatias Congênitas/fisiopatologia , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Masculino , Fluxo Sanguíneo RegionalRESUMO
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.
Assuntos
Plasmocitoma/patologia , Neoplasias da Glândula Tireoide/patologia , Autoanticorpos/sangue , Europa (Continente) , Feminino , Humanos , Imunoglobulina G/sangue , Cadeias kappa de Imunoglobulina/sangue , Imuno-Histoquímica , Japão , Masculino , Pessoa de Meia-Idade , Plasmocitoma/imunologia , Plasmocitoma/fisiopatologia , Plasmocitoma/terapia , Testes de Função Tireóidea , Glândula Tireoide/imunologia , Neoplasias da Glândula Tireoide/imunologia , Neoplasias da Glândula Tireoide/fisiopatologia , Neoplasias da Glândula Tireoide/terapia , Tireoidite Autoimune/complicações , Estados UnidosRESUMO
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.
Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Ducto Cístico/anormalidades , Ducto Cístico/lesões , Idoso , Colangiopancreatografia Retrógrada Endoscópica , Colelitíase/cirurgia , Feminino , Humanos , ReoperaçãoRESUMO
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.
Assuntos
Ponte Cardiopulmonar , Guanidinas/administração & dosagem , Heparina , Animais , Benzamidinas , Testes de Coagulação Sanguínea , Contagem de Plaquetas , Coelhos , Trombose/prevenção & controleRESUMO
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.
Assuntos
Parada Cardíaca Induzida/métodos , Coração/fisiologia , Traumatismo por Reperfusão Miocárdica/prevenção & controle , Animais , Animais Recém-Nascidos , Débito Cardíaco/fisiologia , Constrição , Circulação Coronária/fisiologia , Frequência Cardíaca/fisiologia , Hemodinâmica , Hipotermia Induzida , Mitocôndrias , Modelos Biológicos , Miocárdio/ultraestrutura , Coelhos , Função Ventricular Esquerda/fisiologiaRESUMO
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.