Preventive Innominate Artery Transection for a High-Risk Case of Tracheo-Innominate Artery Fistula / 日本心臓血管外科学会雑誌

An 18-year-old man with hypoxic encephalopathy was admitted because of recurrent minor bleeding a tracheal stoma, which was suspected as a tracheo-innominate artery fistula (TIF). He had undergone tracheostomy and gastrostomy 2 years prior and had mild opisthotonos and scoliosis. Although tracheal endoscopy showed no tracheal mucosal erosion, necrosis, or granulation tissue formation, contrast-enhanced computed tomography (CT) revealed a close contact between the innominate artery and the anterior wall of the trachea, and an equal height between the innominate artery and the tip of the tracheal cannula. Magnetic resonance angiography of the head showed dominant intracranial blood flow from the left internal carotid and vertebral arteries. Preventive innominate artery transection through the supra-sternal approach without sternotomy or reconstruction of the innominate artery was performed for this high-risk case of TIF. The patient's postoperative course was uneventful. Postoperative CT revealed that the innominate artery was transected and isolated from the site of tracheostomy. The preserved connection between the right common carotid and subclavian artery at the distal sutured stump helped maintain blood flow in the right internal and middle cerebral arteries. The patient was discharged on postoperative day 9 without any new neurological complications or bleeding from a tracheal stoma. TIF is a rare but fatal complication after laryngotracheal separation or tracheostomy. It is important to prevent the onset of TIF, however, there are no criteria for preventive innominate artery transection. Our preventive innominate artery transection through the supra-sternal approach is considered as one of the useful surgical treatment for high-risk cases of TIF accompanied by severe neuromuscular disorders.

Treatment Strategy for Leriche Syndrome Complicated with Ischemic Heart Disease / 日本心臓血管外科学会雑誌

Leriche syndrome is often complicated with ischemic heart disease (IHD). In such cases, as the internal mammary artery (IMA) supplies blood to the lower-limbs through a collateral network, coronary artery bypass grafting (CABG) using IMA is considered to worsen the lower-limb ischemia and use of intra-aortic balloon pumping prior to lower limb revascularization is not possible. Recent advances in endovascular technology enable us to perform endovascular treatment (EVT) even in Leriche syndrome. In 3 patients diagnosed with Leriche syndrome associated with IHD, tailor-made treatments were performed as one-stage or two-stage surgeries. Various techniques such as percutaneous coronary intervention (PCI), CABG, and open surgical revascularization or EVT of lower limbs were employed. EVT is a less invasive and more attractive alternative to open surgical revascularization, it led to new treatment options in patients with this particular circumstance. Considering the severity of pathophysiology, treatment strategy should be determined on a case-by-case basis.

Abdominal Vacuum-Assisted Closure for Secondary Abdominal Fascial Closure into Open Abdomen after Surgical Repair for Ruptured Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

Secondary abdominal fascial closure by abdominal vacuum-assisted closure (VAC) therapy is required for abdominal organ protection and prevention of infection due to abdominal compartment syndrome (ACS) developing after the surgery. In this paper, we present our experience with abdominal VAC therapy for two cases that required open abdominal management after surgical repair for ruptured abdominal aortic aneurysm, with favorable outcomes. Case 1 involved a 72-year-old man who underwent endovascular aortic repair for ruptured abdominal aortic aneurysm. Abdominal VAC therapy was started after decompression laparotomy because he developed ACS immediately after surgery. Secondary abdominal fascial closure was performed on day 4 postoperatively, and he had no complications. Case 2 involved a 71-year-old man who underwent emergency Y-graft replacement for ruptured abdominal aortic aneurysm. We considered secondary abdominal fascial closure necessary because of prominent intestinal edema and massive retroperitoneal hematoma, and performed abdominal VAC therapy. We changed the VAC system on day 4, postoperatively and performed secondary abdominal fascial closure on day 7, postoperatively. Abdominal VAC therapy is considered effective and safe for patients requiring secondary abdominal fascial closure after abdominal surgery.

Sartorius Muscle Flap Coverage in Patients with Groin Wound Complications Subsequent to Vascular Surgical Procedure / 日本心臓血管外科学会雑誌

<p>After vascular surgical procedures, complications of the wounds in the groin region may sometimes lead to prosthetic graft infections or prolonged hospital stays. While some wounds heal completely during re-suture and VAC therapy, healing of other wounds that involve refractory graft infection, lymphorrhea, or a dead space, is extremely difficult. We performed tissue coverage using a Sartorius muscle flap for such difficult cases. The muscle is twisted onto itself to fill the dead space with some blood supply. Tissue coverage using a Sartorius muscle flap with adequate blood flow was effective in improving lymphorrhea and infection. We report four such cases where complications in the groin region were managed using a Sartorius muscle flap for wounded coverage.</p>

Aortic Arch Aneurysm 7 Years after Aortic Root Replacement in a Patient of Loeys-Dietz Syndrome / 日本心臓血管外科学会雑誌

<p>A 14-year-old women who had a history of aortic root replacement at 7 years old admitted our hospital due to dilatation of aortic arch aneurysm. Loeys-Dietz syndrome was diagnosed when she was 10 years old. Computed tomography showed 70 mm proximal arch aneurysm. Operative findings revealed brachiocephalic artery and left common carotid artery branched from aneurysm. Partial arch replacement was performed and distal anastomosis was made between left common carotid artery and left subclavian artery. Close observation by CT regularly is necessary and undergo aortic repair not to miss the timing of surgery.</p>

Plasma Levels of D-dimer and Fibrin Degradation Product Could Be Predictors of Endoleaks after Endovascular Abdominal Aortic Aneurysm Repair / 日本心臓血管外科学会雑誌

<b>Objective</b> : Although an endoleak is the most common complication after endovascular abdominal aortic aneurysm repair (EVAR), the proper and noninvasive method for the detection of endoleaks is not established. The purpose of this study is to investigate whether plasma levels of D-dimer and fibrin degradation product (FDP) could be predictors of endoleaks after EVAR. <b>Methods</b> : Between June 2011 and January 2014, 65 consecutive patients underwent EVAR at our institution. We evaluated 55 patients excluding 10 patients pre-existing conditions such as aortic dissection, arterial or venous thrombosis, conversion to open surgery, and difficulties in making outpatient visits. Enhanced computed tomography (CT) examination was performed during 12 months after EVAR. Persistent endoleaks and maximum aneurysmal diameter were evaluated at each follow-up time. Patients were divided into groups according to CT findings at 12 months after EVAR. There were 26 patients with endoleaks vs. 29 non-endoleak patients, 34 with unchanged aneurysm findings vs. 21 with shrinkage. No patient showed aneurysmal enlargement. Plasma levels of D-dimer, FDP, counts of platelet, prothrombin time (PT), and activated partial thromboplastin time (APTT) were also measured at the time of CT examinations. <b>Results</b> : There was no operative death and no major complication. Endoleaks in all patients were identified as type II. None of them required re-intervention. In the endoleak group, plasma levels of D-dimer and FDP were significantly higher than in the non-endoleak group in each postoperative period. In addition, postoperative counts of platelet were significantly lower in the endoleak group. PT and APTT test results showed no significant difference in the two groups. In the unchanged aneurysm group, postoperative D-dimer and FDP tended to be higher compared with the shrinkage group. Postoperative counts of platelet also tended to be lower in the unchanged group. There were no differences in PT and APTT test results. <b>Conclusion</b> : Plasma levels of D-dimer and FDP are potentially useful predictors of endoleaks after EVAR.

Surgical Treatment of Proximal Aortic Dissection in Patients with Stanford Type A Acute Aortic Dissection / 日本心臓血管外科学会雑誌

<b>Objective</b> : Although dissection extending to the aortic root is a common finding, it is potentially fatal in patients with acute type A aortic dissection. The purpose of this study was to evaluate surgical results of acute type A aortic dissection with proximal involvement. The proximal extension of dissection, types of aortic root procedure and its feasibility were investigated. <b>Methods</b> : Between 1997 and 2011, 80 patients with acute type A aortic dissection underwent emergent operation. <b>Results</b> : Dissection reaching around the coronary artery orifice was observed in 28 patients. In 11 patients, both left and right coronary arteries were involved with aortic dissection. Aortic root replacement was performed in 4 patients. In 7 patients, the dissected aortic root was reinforced by GRF glue and proximal aorta was replaced with a graft. Among these patients, postoperative aortic root redissection with severe aortic regurgitation was observed in 5 patients during postoperative long-term periods. All of them required surgical re-intervention of the aortic root. In 17 patients, dissection was extended to the right coronary artery. Aortic root reconstruction was performed in 2 patients due to pre-existing annulo-aortic ectasia. The remaining 15 patients underwent proximal reinforcement with GRF glue. No patient showed dissection extending to the left coronary artery alone. Operative mortality was 11% and other types of complications concerning the aortic root was not observed. <b>Conclusion</b> : An acceptable outcome was demonstrated with our surgical strategy of proximal aortic dissection. For patients, in particular, with proximal involvement to both the left and right coronary arteries, redissection of the aortic root should be noticed as a late complication with considerable frequency. Special care should be taken for precise recognition of the proximal extension of dissection and appropriate surgical procedure including simultaneous aortic root replacement.

Surgical Experience of Superior Mesenteric Venous Aneurysm / 日本心臓血管外科学会雑誌

Superior mesenteric venous aneurysm (SMVA) is rare and no standard treatment protocol has yet been established. We report our experience in performing surgical treatment for SMVA. A 64-year-old man was found to have a SMVA by computed tomography which had been performed during follow-up for gastrectomy. The SMVA was observed to gradually increase in diameter, and surgical treatment was therefore indicated. We successfully resected the aneurysm and then closed the defect with a bovine pericardial patch. Considering the potential risk of rupture, venous aneurysms that present with a saccular shape and an expanding tendency should be immediately surgically treated.

Port-Access Minimally Invasive Cardiac Surgery for Patent Foramen Ovale Complicated with Paradoxical Cerebral Embolism / 日本心臓血管外科学会雑誌

The patient was a 63-year-old man, who had developed cerebral infarction during treatment for sleep apnea syndrome. He also presented typical features of deep venous thrombosis of the right lower extremity. Transesophageal echocardiography clearly showed the blood flow passing through the patent foramen ovale (PFO) followed by Valsalva maneuver. Paradoxical cerebral embolism caused by a PFO was diagnosed. Several procedures were considered to prevent recurrence of cerebral infarction, he underwent PFO closure by minimally invasive procedure, so-called port-access cardiac surgery. He started walking on the day of surgery, and postoperative echocardiography showed no residual shunt flow. Currently, no catheter-based PFO closure device is allowed in Japan, the PFO closure by the port-access technique should be considered as a feasible alternative.

A Case Of Anemia and Thrombocytopenia with Myelodysplastic Syndrome Successfully Treated with Juzentaihoto and Malt Sugar / 日本東洋医学雑誌

We report the case of a 76-year-old woman diagnosed with refractory anemia arising from myelodysplastic syndrome. Vitamin K 2 was administered, but pancytopenia continued to progress. At the initial visit to our department, her white blood cell count was 2150/μL, hemoglobin (Hb) was 9.6 g/dL and platelet count was 2.3×10⁴/μL. Juzentaihoto was administered for <i>Qi</i> and blood deficiency. A dosage of shimotsuto was increased from 3 to 5 g, and juzentaihoto was changed to ogikenchuto go shimotsuto, but the anemia did not improve. Juzentaihoto was again administered, and the dosage of shimotsuto was increased to 6 g. Malt sugar, 10 g, was added to the decoction, after which her Hb and platelet count markedly increased. There was no significant difference between pre- and post-treatment bone marrow findings. It is possible that malt sugar enhances the hematopoietic function of juzentaihoto.

Treatment for Eradication of Helicobacter pylori Infection among Chronic Hepatitis C Patients

BACKGROUND/AIMS: Helicobacter pylori infection causes gastritis, peptic ulcers and gastric malignancies, and its eradication has been advocated by many groups. We determined the H. pylori carrier status and eradication rates of patients with chronic hepatitis C virus (HCV) infection. METHODS: In total, 76 chronically HCV-infected patients were enrolled for comparison with 228 HCV-noninfected, age- and sex-matched controls. H. pylori infection was confirmed by H. pylori antibody and urea breath testing. RESULTS: The H. pylori infection rate was significantly higher for HCV-infected patients (67 of 76, 88.2%) than for HCV-noninfected controls (158 of 228, 69.3%). Endoscopic findings showed that the rates of gastric ulcers and gastritis were significantly higher for the 67 HCV-infected patients with H. pylori infection (34.3% and 77.6%) than for the 158 HCV-noninfected controls with H. pylori infection (15.2% and 57.6%). Treatment to eradicate H. pylori had a significantly higher success rate for HCV-infected patients (61 of 67, 91.0%) than for HCV-noninfected controls (115 of 158, 72.8%). CONCLUSIONS: The markedly high H. pylori eradication rate observed in this study shows that eradication of H. pylori holds promise for the improvement of the long-term health condition of patients with chronic HCV infection.

Efficacy of Intravenous Glycyrrhizin for the Treatment of Chronic Hepatitis C : A Comparison of the Original and Generic Drugs / General Medicine

The utilization of generic drugs in medical practice has been promoted in Japan for the purpose of minimizing drug costs. In order to determine the clinical efficacy of the original preparation of glycyrrhizin, in comparison to its generic drug, a controlled longitudinal study was done of 82 consecutive patients with chronic hepatitis C receiving the original preparation of glycyrrhizin for 6 months. Patients treated with the original preparation of glycyrrhizin for 6 months at two hospitals were separated into two groups for study: Patients who changed from the original preparation of glycyrrhizin to a generic drug and then changed back from the generic drug to the original preparation of glycyrrhizin (Group A, n=46) ; and, patients who were continuously treated with the original preparation of glycyrrhizin (Group B, n=36) . HCV RNA levels were serially determined by Cobas Amplicor HCV Monitor assay. In Group A, the ALT level significantly elevated 3 months after switching treatment from the original preparation of glycyrrhizin to the generic drug (from 65.1 ±22.7 IU/L to 1 12.4±39.9 IU/L) (P<0.05), then significantly decreased 3 months after the change back to the original preparation of glycyrrhizin (from 112.4±39.9 IU/L to 62.1±23.0 IU/L) (P<0.05) . In Group B, however, the ALT level did not significantly change during the same observation period. The serum HCV RNA level did not significantly change in either group, even in Group A patients whose ALT levels significantly changed. The efficacy on ALT of the original preparation of glycyrrhizin and the generic drugs differed in patients with chronic hepatitis C.