Visceral Debranching Thoracic Endovascular Aneurysm Repair for Chronic Dissecting Thoracoabdominal Aortic Aneurysm

Type II chronic dissecting thoracoabdominal aortic aneurysms are a surgically challenging disease. The conventional thoracoabdominal aortic aneurysm repair technique using cardiopulmonary bypass is a high-risk procedure. However, a recently developed endovascular technique may be an alternative treatment for the disease, but faces the obstacle of lesional restriction. This new technique uses a hybrid strategy to overcome the limits of endovascular thoracoabdominal aortic aneurysm repair. Herein, we report on a successful outcome after performing the hybrid visceral debranching procedure.

Surgical Experience of the Remnant Thoracoabdominal Aortic Replacement after Aortic Surgery / 대한흉부외과학회지

BACKGROUND: Aortic diseases tend to involve the entire aorta. Hence, there is the constant possibility of the need for a secondary operation at the remnant aorta. This study analyzed our cases of secondary aortic surgery in order to determine its characteristics and problems. MATERIAL AND METHOD: Between April 2003 and June 2007, 12 patients (6 male and 6 female) underwent thoracoabdominal aortic replacement as a secondary aortic operation. Their clinical courses were analyzed. Four of the patients underwent lower thoracobadominal aortic replacement under the normothermic femorofemoral bypass, and the others underwent an entire thoracobdominal aortic replacement under deep hypothermic circulatory arrest. RESULT: There was no death or paraplegia. As local complications, there were 3 cases of wound infection and 2 cases of an immediate reoperation caused by bleeding and one case of delayed wound revision for a contaminated perigraft hematoma. As a systemic complication, there was one case of renal insufficiency, which required hemodialysis and one case of respiratory insufficiency that needed prolonged ventilator care. The mean admission period was 30+/-21 days. All the patients were followed up for 626+/-542 days without reoperation or other problems. CONCLUSION: Using properly selected patients and a careful approach, thoracoabdominal aortic replacement can be performed safely as a secondary aortic surgery.

Independent Prognostic Value of the Fascin Expression in Patients with Esophageal Cancer / 대한흉부외과학회지

Backgrond: Fascin is an actin-bundling protein that induces membrane protrusions and it increases cell motility in various transformed cells. Esophageal cancer is one of the most lethal malignancies, and it exhibits extensive local invasion or frequent regional lymph node metastasis even after curative surgery. We investigate the expression of fascin by performing immunohistochemistry to evaluate the clinical characteristics and prognostic significance of its expression in esophageal cancer patients. MATERIAL AND METHOD: Immunochemistry for fascin was performed on 76 tumor samples from 76 patients who underwent esophageal cancer operations. The expression levels of fascin in the 76 esophageal cancer tissues were compared with those in the corresponding normal esophageal epithelium. The fascin-positive samples were defined as those showing more than 75% of fascin-positive cells. RESULT: Overall, a fascin positive expression was detected in 39 (51.3%) out of the total 76 cases. The tumors with positive fascin expression tended to more frequently show a higher stage (p=0.030), and a higher T-factor (p=0.031). The prognosis of the fascin negative group was significantly better than that of the fascin positive group (p=0.004). Multivariate analysis revealed that lymphovascular invasion and the fascin expression were independent prognostic factors. CONCLUSION: Fascin was expressed in 51.3% of the esophageal cancer tissues, and a positive expression of fascin was associated with more advanced tumor progression and recurrence. Our study suggests that the fascin expression may be an independent prognostic factor for an unfavorable clinical course for those patients suffering with esophageal cancer.

Comparison of the Mid-term Changes at the Remnant Distal Aorta after Aortic Arch Replacement or Ascending Aortic Replacement for Treating Type A Aortic Dissection / 대한흉부외과학회지

BACKGROUND: Replacing the ascending aorta is a standard surgical option for treating acute type A aortic dissection. But replacing the aortic arch has recently been reported as an acceptable procedure for this disease. We compared the effects of aortic arch replacement for treating acute type A aortic dissection with the effects of ascending aortic replacement. MATERIAL AND METHOD: From 2002 to 2006, 25 patients underwent surgical treatment for acute type A aortic dissection. 12 patients underwent ascending aortic replacement and 13 patients underwent aortic arch replacement. Among the aortic arch group, an additional distal stent-graft was inserted during the operation in 5 patients. 19 patients (11 arch replaced patients and 8 ascending aortic replaced patients) were followed up at the out patient clinic for an average of 756+/-373 days. All the patients underwent CT scanning and we analyzed their distal aortic segments. RESULT: 4 patients who underwent ascending aortic replacement died, so the overall mortality rate was 16%. Among the 11 long term followed-up arch replacement patients, 2 patients (18.1%) developed distal aortic dilatation and one of them underwent thoracoabdominal aortic replacement later on. However, among the 8 the ascending aortic replaced patients, 5 patients (62.5%) developed distal aortic dilatation. CONCLUSION: Aortic arch replacement is one of the safe options for treating acute type A aortic dissection. Aortic arch replacement for treating acute type A aortic dissection could contribute to a reduced distal aortic dilatation rate and fewer secondary aortic procedures.

Clinical Analysis of Pleuropneumonectomy for Chronic Inflammatory Lung Disease / 대한흉부외과학회지

BACKGROUND: Pneumonectomy for inflammatory lung disease has been of major concern because of its associated morbidity and mortality, particularly with respect to pleuropneumonectomy. The purpose of this study is to evaluate the surgical outcomes, and identify the risk factors contributing to postoperative complications in patients undergoing pleuropneumonectomy. MATERIAL AND METHOD: Ninety-eight patients underwent pneumonectomy for benign inflammatory lung disease were retrospectively analyzed. Pleuropneumonectomy (Group A) was done in 48 patients and standard pneumonectomy (Group B) was done in 50 patients. Clinical characteristics, postoperative complications were examined and compared between 2 groups. In pleuropneumonectomy group, postoperative risk factors affecting morbidity were evaluated. RESULT: There was one in-hospital death. Twenty-three major postoperative complications occurred in 21 patients (21.4%). The common complications were empyema and bronchopleural fistula (BPF) in 8 (8.4%), re-exploration due to bleeding in 8. At least one postoperative complication occurred in 14 of 48 patients from Group A (29.2%) and in 7 of 50 patients from Group B (14%). In Group A, empyema and BPF encountered in 6 and re-exploration for bleeding in 6 were the most common complication. In univariate analysis, right pneumonectomy, completion pneumonectomy, large amount of blood loss (>1,000 mL), and intrapleural spillage were risk factors contributing to postoperative complications in Group A. In multivariate analysis, intrapleural contamination during operation was a risk factor of postoperative complication. CONCLUSION: The morbidity and mortality rates of pneumonectomy for chronic inflammatory lung disease are acceptably. However, we confirm that pleuropneumonectomy is a real technical challenge and a high-risk procedure and technically demanding. Meticulous surgical techniques are very important in preventing serious and potentially lethal complications.

Surgical Management of Coarctation of the Aorta with a Ventricular Septal Defect and Coexisting Partial Anomalous Pulmonary Venous Connection: A case report / 대한흉부외과학회지

A newborn girl with a partial anomalous pulmonary venous connection, coarctation of the aorta, and ventricular and atrial septal defects underwent a complete repair successfully at 19 days of age. In this case, the left upper pulmonary vein was connected to the left innominate vein via an atypical vertical vein.

Surgical Treatment of the Ruptured Abdominal Aortic Aneurysm Complicated with Abdominal Compartment Syndrome and Colon Ischemia

A 76-years old man with a ruptured abdominal aortic aneurysm underwent an emergency abdominal aortic replacement with artificial graft. The patient developed abdominal compartment syndrome at the day of the operation and he received secondary decompression operation the next day. At 45 hours after the second operation the patient was returned to operation room to close the abdominal fascia, and sigmoid colon necrosis was found so we performed sigmoid colectomy with colostomy. After 22 days from the last operation, the abdominal wound was closed completely and the patient was discharged at the 42nd postoperative day with a colostomy state. We report here on this complex case together with a review of the recent articles.

Surgical Treatment of Anastomotic Pseudoaneurysm after the Aortic Replacement / 대한흉부외과학회지

An anastomotic pseudoaneurysm after the aortic replacement surgery is a rare complication which could be lethal when it ruptures. So it should be corrected whenever it is found after the aortic surgery. The authors performed three surgical corrections in 2 cases. The first case is type B chronic aortic dissection with abdominal aortic aneurysm. After an abdominal aortic replacement, the patient developed an anastomotic pseudoaneurysm. We treated him with a thoracoabdominal aortic replacement. The second case is ruputred throacoabdominal aortic aneurysm. After a thoracoabdominal aortic replacement, the patient developed an anastomotic pseudoaneurysm in the proximal anastomosis. We treated her with aortic arch replacement. But She developed another pseudoaneurysm in the aortic root anastomotic site. So we performed secondary operation to reinforce the anastomosis. They all recovered from the operations without any complication and are being followed up.

The Thracoabdominal Aortic Replacement Using Deep Hypothermic Circulatory Arrest Technique / 대한흉부외과학회지

BACKGROUND: Thoracoabdominal aortic replacement is an extensive operation that opens both the pleural cavity and abdominal cavity, which has high mortality and morbidity rate. The authors have reported 9 cases of the thoracoabdominal aortic replacement in 2001. Since 2003 we have applied the deep hypothermic circulatory arrest to the Crawford type I and II thoracoabdominal aortic replacement. Therefore, we analysed the effect of the changes in operative techniques. MATERIAL AND METHOD: Between 1996 and 2005, we have performed 20 cases of thoracoabdominal aortic replacement. The underlying diseases were 8 cases of atherosclerotic aneurysm with 4 cases of ruptured aneurysm and 12 cases of aortic dissection with 10 cases of a previous operations. According to Crawford classification, there were 2 cases of type I, 7 cases of type II, 1 case of type III, 7 cases of type IV, and 3 cases of type V. We compaired the results of the patients who underwent thoracoabdmoninal replacement before 2001 which already has been reported and after then. RESULT: Before 2001 we have performed 9 cases of thoracoabdominal replacement and 5 patients were died of the operation. All three patients with type I and II were died. There was no case of thoracoabdominal replacement between 2001 and 2002, but after 2003 we have performed 11 cases of thoracoabdominal replacement which involved 1 case of type I, 5 cases of type II, 1 case of type III, 2 cases of type IV and 2 cases of type V. There was no mortality and no fetal complications. CONCLUSION: The deep hypothermic circulatory arrest is a safe method of extended thoracoabdominal aortic replacement.

The Clinical Effect of Administration of Magnesium Sulfate in Cardiac Surgery / 대한흉부외과학회지

BACKGROUND: Hypomagnesemia is a common complication after cardiac surgery with cardiopulmonary bypass. The purpose of this study was to assess the clinical beneficial effect of administration of magnesium sulfate in cardiac surgery. MATERIAL AND METHOD: Thirty five patients scheduled for elective cardiac surgery were randomly assigned to magnesium group (n=20) which received magnesium sulfate in priming solution (1 g) and cardioplegic solution (1 g) or control group (n=15) which did not receive it. Arterial blood samples were drawn for measuring Mg++ and electrolytes contents, blood gas analysis, CBC, total protein, albumin, blood urea nitrogen (BUN), creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), interleukin-10 (IL-10), creatine phosphokinase (CpK), creatine kinase-MB (CK-MB), lactate dehydrogenase(LDH), troponin-I (TNI), prothrombin time (PT) and activated pratial thromboplastin time level (aPTT). Venous blood samples were drawn before and after the operation for measuring activated clotting time level (ACT). RESULT: Mg++ levels in magensium group were higher than those of control group at intraoperative and postoperative periods (p<0.05). dysrhythmias were lower in magnesium group (8 cases out of 17 patients, 46.4%) than in control group (10 cases out of 10, 100%, p=0.050). CONCLUSION: These results showed that administration of low dose magnesium sulfate during cardiac surgery prevented hypomagnesemia and lowered incidence of dysrhythmia.

A Recent Overview of Varicose Vein in the Legs

Varicose vein is one of the ancient diseases, which has its evidence in Greek sculpture. Nowadays varicose vein has become a popular disease because of the media, so that many people want to treat their varicose vein and many medical doctors from a variety of fields seek a varicose clinic, accordingly. Since the introduction of the great saphenous vein stripping, the treatment of varicose vein has not been changed very much for about 100 years. Recently, however, many doctors in the outpatient varicose clinic prefer less invasive treatment and some innovative techniques that have become available recently. Endovascular treatment or transilluminated powered phlebectomy is one of them. Some dermatologists try to treat all kinds of varicose vein with sclerotherapy. But the long-term results of the treatment reveal that the gold standard of the treatment of typical varicose vein is a groin-to-knee inversion stripping of the great saphenous vein with stab avulsion of the varicose cluster. The application of the color Doppler duplex ultrasonogram to the leg vein has made it possible to evaluate the reflux of axial veins and perforator veins more thoroughly and less invasively. Therefore ultrasonography is the method of choice for the diagnosis of varicose vein preoperatively and postoperative follow-up studies for recurrent cases. The recurrence of varicose vein after treatment is mostly from the remnant reflux in the saphenofemoral junction and its tributary. Thus more meticulous treatment of the tributaries of saphenofemoral junction is needed.

Report of Nation-wide Questionnaire Survey for Abdominal Aortic Aneurysm Treatment in Korea

While endovascular aneurysm repair (EVAR) is prevailing for the treatment of abdominal aortic aneurysm (AAA) in modern vascular practice, PURPOSE: we conducted nationwide questionnaire survey to investigate the current status of AAA treatment and their results in Korea. METHOD: We reviewed the replies from 28 hospitals (33 departments) to the questionnaire inquiring annual number, clinical features, mode of treatment and results of AAA patients during the period from Jan. 2000 to Jul. 2004. Results: 980 AAA patients were reported including 292 ruptured AAA (29.8%) and 688 non-ruptured AAA (70.2%). For treatment of AAA, 834 (85.1%) surgical repairs (SRs) and 111 (11.3%) endovascualr aneurysm repairs (EVARs) were performed while 35 patients (3.6%) died of AAA rupture before operation. The locations of AAA were infrarenal in 889 (90.7%), juxtarenal in 62 (6.3%), and suprarenal in 29 patients (3.0%). Among 834 patients undergoing SR, 577 patients (69.2%) had non-ruptured AAAs and 257 patients (30.8%) had ruptured AAAs. Mean operative mortality rate was 4.1% after elective SRs, 30.7% after SR for ruptured AAAs, and 2.3% after EVARs. The reported brand name of stent graft devices were various including domestic custom-made in 56 (50.5%), imported brand in 18 (16.2%) while 37 (33.3%) stent grafts were not reported their brand name. The frequencies of type I and III endoleaks after EVAR were reported 5.8% and 5.8% respectively in 86 patients with an available data. CONCLUSION: SR has been used as a major treatment option in Korea for the treatment of AAA patients while EVAR is increasing. The mortality rate of SR of AAA was comparable to western multi-center trial reports but mortality or morbidity rates of EVAR were unable to know in this questionnaire survey.

A Case of Total Aortic Arch Replacement with Root Plasty with Right Coronary Artery Bypass and Distal Open Stent-graft Insertion in Acute Type I Aortic Dissection / 대한흉부외과학회지

Since the operative mortality rate of the Acute aortic dissection has been reducing, a more extensive primary repair of the dissected aorta is preferred for acute aortic dissection to reduce the needs of secondary procedures. We performed a total aortic arch replacement with distal stent-grafting in acute type A aortic dissection. The patient was a 50-years old man. He recovered from the operation and was followed up for 7 months. The pseudolumen in the descending aorta was obliterated with the stent.

The Short Term Results of the Total Aortic Arch Replacement with Arch First Technique / 대한흉부외과학회지

BACKGROUND: The total aortic arch replacement is one of the most difficult operations with high mortality rate. But the arch first technique with subclavian arterial perfusion has been reported to be a safe methods for arch replacement. MATERIAL AND METHOD: Between Feb 2003 and July 2004, 18 patients, 10 men and 8 women, underwent total aortic arch replacement with arch first technique. Their mean age was 59.3+/-12.9 years. The patietns received 11 acute aortic dissections, 3 chronic aortic dissectiong aneurysms, and 4 ruptured aortic arch aneurysms. RESULT: The mean admission period was 20.2+/-7.4 days. There was one early mortality case which died of low cardiac output syndrome and another late mortality case which died of cerebral hemorrhage. The others were discharged without any sequelae and they were followed up for an average period of 180+/-156.3 days. CONCLUSION: The total aortic arch replacement with arch first technique and subclavian arterial perfusion is a good method that will reduce the surgical mortality and the possibility of secondary late reoperation from the remnant distal aortic problems.

The Short Term Results of the Total Aortic Arch Replacement with Arch First Technique / 대한흉부외과학회지

BACKGROUND: The total aortic arch replacement is one of the most difficult operations with high mortality rate. But the arch first technique with subclavian arterial perfusion has been reported to be a safe methods for arch replacement. MATERIAL AND METHOD: Between Feb 2003 and July 2004, 18 patients, 10 men and 8 women, underwent total aortic arch replacement with arch first technique. Their mean age was 59.3+/-12.9 years. The patietns received 11 acute aortic dissections, 3 chronic aortic dissectiong aneurysms, and 4 ruptured aortic arch aneurysms. RESULT: The mean admission period was 20.2+/-7.4 days. There was one early mortality case which died of low cardiac output syndrome and another late mortality case which died of cerebral hemorrhage. The others were discharged without any sequelae and they were followed up for an average period of 180+/-156.3 days. CONCLUSION: The total aortic arch replacement with arch first technique and subclavian arterial perfusion is a good method that will reduce the surgical mortality and the possibility of secondary late reoperation from the remnant distal aortic problems.

A Case of Surgical Treatment of the Abdominal Aortic Graft Infection with Bilateral Superficial Femoral Vein / 대한흉부외과학회지

The graft infection within the abdomen is a notorious condition, which usually develops serious complications of anastomotic rupture or distal embolism that ended in death. There has been many controversies in the treatment of an aortobiiliac graft infection and varying results have been reported. The authors treated a case of aortobiiliac graft infection after abdominal aortic aneurysm surgery. The operation was performed with re-aortobiiliac bypass using bilateral superficial femoral veins. The result was successful.

The Clinical Experience of the Aortic Arch Replacement in Acute Type A Aortic Dissection / 대한흉부외과학회지

BACKGROUND: The aortic arch replacement in an acute aortic dissection is technically demanding procedure that has a lot of postoperative morbidity and high mortality. The authors have applied several techniques of aortic arch replacement to overcome the risks of the procedure. Therefore we analysed the results of these techniques. MATERIAL AND METHOD: From March of 1996 to July of 2002, we performed 31 cases of the aortic arch replacement in the Stanford type A acute aortic dissection. There were 12 male and 19 female patients with 59.6+/-9.4 years of mean age. Among them 18 cases were treated with the hemiarch replacement and 13 cases with the total arch replacement. We approached the aortic arch through median sternotomy in all but 3 cases of Clamshell incision and applied the deep hypothermic circulatory arrest with retrograde cerebral perfusion. The associated procedures were 2 Bentall's procedures, an axillobifemoral bypass, a femorofemoral bypass and a carotid artery bypass. RESULT: The postoperative morbidities were 8 acute renal failures, 3 CNS complications, 2 low cardiac output syndromes, 2 malperfusion syndromes, and 2 deep wound infections. There were 4 cases of early hospital mortality which were from an acute renal failure, a postoperative bleeding, a low cardiac output syndrome, and a reperfusion syndrome. There were 3 cases of late hospital mortality which were from an acute renal failure, and 2 multiorgan failures. So the total mortality rate was 22.5%. There were 4 cases of late mortality after the discharge, which were form 2 cases of distal anastomotic rupture and 2 cases of intracranial hemorrhage. CONCLUSION: The hemiarch replacement has relatively shorter operative time and lower hospital mortality but higher late mortality than the total arch replacement. The total arch replacement needs more technically demanding procedure.

Surgical Treatment of the Graft Infection after Abdominal Aortic Aneurysm Repair 2 Cases

Infection is one of the most feared complications in vascular surgery, especially when it involves the aortoiliac segment. There are many controversies in the treatment of aortoiliac graft infection with varying results reported. The author treated 2 cases of graft infection after an aortobiiliac bypass. These patients had an abdominal aortic aneurysm with aortoenteric fistula before or after the bypass surgery. Both developed graft infection within about 1 year after the first operation. One was treated with an extra-anatomic bypass after complete removal of the infected graft; and the other was treated with a re-aortobifemoral bypass with bilateral femoral vein graft. Both patients showed no recurrence of infection nor limb loss.

The Clinical Experience of The Descending Thoracic and Thoracoabdominal Aortic Surgery / 대한흉부외과학회지

BACKGROUND: The thoracic and thoracoabdominal aortic surgery is a complicated procedure that has various method of approach and protection. The authors have performed several methods to treat these diseases. Therefore, we attempt to analyze their results and risks. MATERIAL AND METHOD: From June of 1992 to August of 2001, we performed 26 cases of thoracic aortic surgery and 10 cases of thoracoabdominal aortic surgery. There were 17 aortic dissections, 17 aortic aneurysms, one coarctation of aorta and one traumatic aortic aneurysm. The thoracic aortic replacement was performed under a femorofemoral bypass, an LA to femoral bypass, or a deep hypothermic circulatory arrest. The thoracoabdominal aortic replacement was performed under a femorofemoral bypass or a pump assisted rapid infusion. RESULT: There were 7 renal failures, 11 hepatopathies, 7 cerebral vascular accidents, 2 heart failures, 5 respiratory insufficiencies, and 2 sepsis in postoperative period. There were 9 hospital mortalities which were from 2 bleedings, 2 heart failures, 2 renal failures, a sepsis, a respiratory failure, and a cerebral infarction. There were 3 late deaths which were from ruptured distal anastomosis, cerebral infarction, and pneumonia. CONCLUSION: Deep hypothermic circulatory arrest was not good supportive methods for thoracic aortic replacement. Total thoracoabdominal aortic replacement was a high risk operation.

Clinical Experiences of Transilluminated Powered Phlebectomy in Varicose Vein

PURPOSE: The removal of varicose vein using a minimally invasive, transilluminated vein-extracting device (TriVex system) with cutaneous transillumination and tumescent anesthesia technique was newly developed and became popular in USA. This study was performed to evaluate its efficacy and safety. METHOD: The author performed TIPP (Transilluminated powered phlebectomy) procedure in 90 patients 118 legs from Feb 2001 to March 2002. The patients were 26 men and 64 women and their age ranged in from 19 to 65 (46.3 +/- 10.7) years. The preoperative evaluation was performed with Dupplex Doppler ulatrasound scan. All patients were admitted before the day of the surgery and discharged on the day or the next day of the surgery. The operation was performed under spinal or general anesthesia. The greater saphenous vein was ligated and in the saphenofemoral junction and stripped out to the knee with stripper under inguinal incision and then the varicose vein was removed with TriVex system. After the operation the patients were discharged at the day of the surgery and followed up at OPD for an average of 43 16 days. RESULT: The mean operative time was 61.6 +/- 25.7 min, the average numbers of small incision per leg were 3.4 +/- 1.3, and the average admission period was 1.6 +/- 0.8 days. These data were far different from those of conventional varicosectomy in previous periods. There were 2 cases of subcutaneous infection at medial calf and one case of remnant varicsoe vein which need reoperation with the TIPP. There was no permanent complication like paresthesia or skin changes. The pain and cosmetic outcome were so excellent that all patient had no limitation in daily life in a week after the procedures. CONCLUSION: The transilluminated powered phlebectomy in varicose vein is safe, efficacious and cosmetically satisfactory.