Thoracic Endovascular Aortic Repair for Chronic Aortic Dissection with an Isolated Left Vertebral Artery / 日本心臓血管外科学会雑誌

Thoracic endovascular aortic repair (TEVAR) is valuable in the treatment of type B aortic dissection. An isolated left vertebral artery (ILVA) is a common anomaly of the aortic arch. The ILVA is covered during TEVAR in specific cases; however, whether the ILVA should be reconstructed in all cases remains controversial. We report a case of TEVAR performed for chronic aortic dissection in a patient with an ILVA. A 57-year-old woman with an ILVA had a type B acute aortic dissection one year prior to presentation and underwent TEVAR owing to dilation of an ulcer-like projection. We performed ILVA-left common carotid artery (LCCA) anastomosis and LCCA-left axillary artery bypass prior to TEVAR using our usual procedure. The postoperative course was favorable without any major complication. ILVA reconstruction may reduce the incidence of postoperative stroke and spinal cord injury. Usually, an ILVA is easily accessible through the supraclavicular approach, and the anatomical position of the vessel facilitates ILVA-LCCA anastomosis. ILVA reconstruction requires additional features and further consideration.

Distal Perfusion in Open Stent-Grafting / 日本心臓血管外科学会雑誌

<p><b>Objective</b> : We examined the utility of distal perfusion (DP) in open stent grafting (OSG) for the treatment of thoracic aortic aneurysm. <b>Methods</b> : Fifty patients who underwent OSG were categorized into two groups (the Non-DP group and the DP group) based on the presence or absence of distal perfusion in OSG. There was no statistically significant difference between the two groups with regard to patient characteristics. <b>Results</b> : There was no statistically significant difference between the two groups with regard to operation time, but, cardiopulmonary bypass time (178±22 min vs. 193±18 min ; <i>p</i> <0.01) and aortic cross clamp time (84±23 min vs. 106±19 min ; <i>p</i><0.01) were significantly longer in the DP group. Lower-body circulatory arrest time (46±11 min vs. 20±5 min ; <i>p</i><0.001) was significantly longer in the Non-DP group. Postoperative paraplegia and paraparesis occurred in one case each in the Non-DP group, whereas permanent spinal cord ischemia did not occur in the DP group. Postoperative intubation time (72.6±40.1 h vs. 40.1±34.7 h ; <i>p</i><0.05) was significantly longer in the Non-DP group. There were two in-hospital deaths due to stroke and respiratory failure in the Non-DP group, and one in-hospital death due to respiratory failure in the DP group. The postoperative maximum value of BUN (38.5±15.6 mg/dl vs. 30.8±9.8 mg/dl ; <i>p</i><0.05) and s-Cr (1.9±1.0 mg/dl vs. 1.3±0.4 mg/dl ; <i>p</i><0.01) were significantly higher in the Non-DP group. <b>Conclusion</b> : DP in OSG was an effective method for prevention of spinal cord ischemia, and for protection of respiratory and renal function.</p>

A Rare Complication after Tricuspid Annuloplasty / 日本心臓血管外科学会雑誌

We report a rare case of severe aortic regurgitation after mitral valve replacement (MVR) and tricuspid annuloplasty (TAP). An 83-year-old woman underwent MVR and TAP for mitral regurgitation and secondary tricuspid regurgitation. The early postoperative course was not eventful until 6 days after surgery. However, 7 days after surgery, she suffered from acute heart failure and transthoracic echocardiography showed severe aortic regurgitation. We performed a second operation 13 days after the first surgery. Intraoperatively, we found the annulus suture of the TAP just under the NCC-RCC commissure of the aortic valve. We speculated that the suture pulled the aortic valve annulus, resulting in severe aortic regurgitation. We removed the suture and replaced the aortic valve with bioprosthetic artificial valve. Postoperative recovery was uneventful, and she was discharged 22 days after the second surgical procedure.

A Pseudoaneurysm of Abdominal Aorta after Intravesical bacillus Calmette-Guerin Therapy / 日本心臓血管外科学会雑誌

We report a patient who underwent an operation for an infectious abdominal aortic aneurysm 10 months after intravesical bacillus Calmette-Guerin therapy. A 68-year-old man had previous gastrectomy for early gastric cancer and intravesical BCG therapy for early stage urinary bladder cancer. His follow up CT scan revealed an abdominal aorta pseudoaneurysm. We performed aneurysmectomy, omentopexy and bilateral axillo-femoral bypass. The culture of an abscess in the aneurysm identified <i>Mycobacterium bovis</i>. The patients improved clinically with antituberculosis agents after operation. Intravesical bacillus Calmette-Guerin therapy is effective in the treatment of early stage urinary bladder cancer. Although this treatment is generally considered safe, serious complications including vascular complications have been reported.

Anterior Small Thoracotomy Drainage and Intermittent Lavage in 2 Cases of Prosthetic Graft Infection after Arch Replacement Surgery / 日本心臓血管外科学会雑誌

Prosthetic graft infection after arch replacement surgery is a serious complication that is often resistant to antibiotics. However, graft replacement is difficult and is very invasive. We performed anterior small thoracotomy drainage and intermittent lavage in 2 patients. First, the prosthetic graft was approached via a left third intercostal thoracotomy. After the ablation of infected tissues and cleansing with saline, drains were placed both proximally and distally to the vascular graft. An irrigation withdrawal drain was then implanted in the left thoracic cavity. After surgery, diluted povidone iodine solution, pyoktanin solution, and saline were used for pleural lavage. Case 1 : An 82-year-old man underwent arch replacement for a ruptured aortic arch aneurysm in November 2005. He suffered from high-grade fever from March 2008 and was referred to our hospital from another hospital with a diagnosis of vascular graft infection. A small anterior thoracotomy and drainage were performed on April 9. Pleural lavage with povidone iodine solution was performed 9 days after surgery, then was performed with saline from days 10-13 after surgery. The patient was discharged on postoperative day 30. Case 2 : A 58-year-old man complained of high-grade fever from March 16, 2009. He had undergone arch replacement for an aortic arch aneurysm in 1997. He consulted a physician and was referred to our hospital with a diagnosis of vascular graft infection. Methicillin-sensitive <i>Staphylococcus aureus</i> (MSSA) was identified by blood culture. A small anterior thoracotomy and drainage were performed on March 24. Immediately after surgery pleural lavage was performed with pyoktanin blue solution changing to povidone iodine on postoperative day 10. Pleural lavage was continued until day 34, and the patient was discharged on postoperative day 64. In both cases, drainage and pleural lavage with antibiotic solutions improved the patients' general condition. The infections have not recurred since discharge. Small anterior thoracotomy for graft infection after arch replacement, in addition to being minimally invasive, can avoid the need for a second median sternotomy, and can provide an adequate view of the full length of the arch prosthetic graft.