ABSTRACT
The purpose of this study was to clarify the effects of bicycle ergometer training and prostaglandin E<sub>1</sub> (PGE<sub>1</sub>) for patients with intermittent claudication. Subjects were divided into four groups : the medication group (M), the PGE<sub>1</sub> group (P), the exercise group (E) and the PGE<sub>1</sub> and exercise group (PE). The P group was injected with 10<i>μ</i>g of PGE<sub>1</sub>, the E group performed bicycle ergometer exercise 3 times a week for 6 weeks, and the PE group was injected with PGE<sub>1</sub> and performed exercises. The maximal walking distance (MWD) was evaluated by a treadmill test. Muscle oxygenation level was measured by near-infrared spectroscopy and recovery half time (T<sub>1/2</sub>) was calculated. MWD was significantly improved for P (142%), E (216%) and PE (240%) groups. T<sub>1/2</sub> was significantly improved in the E and PE groups. This study indicates that improvement of MWD was a result of development of muscle perfusion in lower limbs and PGE<sub>1</sub> injection may support exercise therapy.
ABSTRACT
Infra-renal abdominal aortic aneurysms were electively treated by bifurcated endovascular stent grafts (Power Web<sup>TM</sup> system, Endologix Co., USA) at 5 Japanese centers. The stent grafting (SG) was applied for candidates nominated by the selection committee after informed consent was obtained according to the IRB in each center. The delivery success rate of 60 patients (53 males) was 96.7%. There were 2 patients with type I endoleaks, resulting in a technical success rate of 93.3%. The operation time of 193±55min and blood loss of 440±240g were significantly shorter and less, respectively in the SG group when compared with 303±88min and 1, 496±2, 025g in 97 patients (83 males) treated by conventional open surgery. Endoleaks were detected in 4 patients (type I: 3, type II: 1) by CT scan taken at the time of discharge or 1 month after SG procedure. Type I endoleak was observed in patients with short and severely angulated SG landing zones. Renal artery obstruction, and temporary buttock pain caused by internal iliac artery occlusion occurred, but there was no hospital death. In 56 patients excluding an SG-unrelated death and a dropout from surveillance, there was no secondary endoleak or marked adverse events at all except 1 SG limb occlusion during a 6-month follow up period. The aneurysm size shrank in 26 patients and remained unchanged in 30 patients. No aneurysm enlargement was observed. The Power Web<sup>TM</sup> system is appropriate for minimally invasive surgery for abdominal aortic aneurysms. Long-term follow-up studies will follow.
ABSTRACT
Patients with mechanical valve prosthesis must receive long-term oral anticoagulant therapy, thus it is important to set the optimal international normalized ratio of prothrombin time (PT-INR) that effectively prevented thromboembolic complications without excessive bleeding. In this study, anticoagulant therapy was evaluated in terms of the activity of coagulation and fibrinolysis in 137 patients after isolated mechanical valve replacement. With a lower target range of 1.5-2.0 for the PT-INR, thrombin antithrombin III complex (TAT) increased to more than 3.0ng/ml in 30 cases, and the activity of coagulation appeared to increase due to insufficient anticoagulant therapy. After the target range was raised to 2.0-2.5 in all cases, the PT-INR increased significantly from 1.63 to 2.25 (<i>p</i><0.01) and TAT decreased significantly from 7.58 to 2.81ng/ml (<i>p</i><0.01). This showed that activity of coagulation and fibrinolysis was suppressed by high intensity anticoagulation. It is necessary to review the individual activity of coagulation and fibrinolysis to determine the intensity of anticoagulation. We recommend 2.0-2.5 as the target range for the PT-INR.
ABSTRACT
Postoperative quantitative evaluation of left internal thoracic artery (LITA) grafts is usually performed by angiography, scintigraphy and Doppler flowire. However it is difficult to observe the characteristics of the intima of the LITA graft. The purpose of this study was to evaluate the characteristics and quantity of plaque of intima of LITA grafts in 6 cases after coronary artery bypass surgery using an intra-vascular ultrasound device (IVUS). There was no stenosis or calcification of LITA grafts on angiography. However we found atherosclerotic plaque in all LITA grafts by IVUS. Characteristics of plaque were eccentric in all cases, and soft, hard and mixed plaque were found. The average minimal lumen diameter of LITA grafts was 2.6±0.2mm. The average lumen area of LITA grafts was 5.4±0.7mm<sup>2</sup>. The rate of plaque area was 37.1±5.9%. The eccentric arteriosclerotic plaques were seen in all cases, contradicting the established theory that LITA do not form arteriosclerosis easily. We suggest that IVUS is an effective follow-up device for evaluating the morphological findings and quantitative evaluation of LITA graft in a timely manner.
ABSTRACT
A 59-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) had been treated by β-blocker for 15 years. Since June 2001 the patient has had symptoms of heart failure on sudden onset. Transesophageal echocardiography showed ruptured mitral chordae tendineae. After medical treatment to improve heart failure, open heart surgery was performed and anterior and posterior ruptured mitral chordae tendineae were recognized. Prosthetic valve replacement was performed. Histopathologic diagnosis of the chordae tendineae was myxoid degeneration. The postoperative course was excellent. Echocardiogram demonstrated that the preoperative left ventricular pressure gradient of 55mmHg reduced to 0mmHg postoperatively, which indicated that the left ventricular outlet stenosis had disappeared. In patients with HOCM accompanied by ruptured mitral chordae tendineae, early diagnosis by transesophageal echocardiography and timely surgical treatment are essential for successful outcome.
ABSTRACT
A 31-year-old man underwent mitral valve replacement because of mitral regurgitation due to continued active infective endocarditis despite antibiotic therapy. Because cerebral mycotic aneurysm was suggested by preoperative IVDSA (Intravenous Digital Subtraction Angiography), cerebral angiography was performed on the first postoperative day. Cerebral mycotic aneurysm was detected in the middle cerebral artery and emergency aneurysm trapping was successfully performed. Although the patient had no neurologic deficit and postoperative cardiac function was stable, impending rupture of the mycotic aneurysm of the superior mesenteric artery occurred suddenly on the twelfth postoperative day. Endovascular treatment using the coil-embolization technique was immediately performed, and the postoperative course was uneventful.
ABSTRACT
During a 9-year period from January 1991 through December 2000, 30 patients underwent surgical interventions for peripheral vascular injuries associated with catheterizations. Pseudoaneurysm, the most frequent complication, was seen in 19 patients (63.3%). This was followed by arteriovenous fistula in 6 patients (20%), uncontrolled hemorrhage in three (10%), arterial thrombosis in one (3.3%), and pseudoaneurysm complicated with arteriovenous fistula in one patient (3.3%). We performed repair of the puncture site in 26 patients (86.6%), followed by arterial ligation in two (6.6%), thrombectomy combined with percutaneous transluminal angioplasty and aneurysmectomy in one patient (3.3%) respectively. There was a tendency for patients to have diabetes mellitus or hypertension. Though secondary suture had to be performed in two patients with wound infection postoperatively, there was no other complication. In pseudoaneurysmal patients proximal arterial control followed by direct incision into the aneurysm cavity and tangential finger pressure over the hole in the artery was a safe method to control bleeding. In arteriovenous fistula patients aggressive repair resulted in good outcome. In uncontrolled hemorrhage and arterial thrombosis patients prompt intervention is essential. By using accurate techniques in arterial puncture and adequate arterial compression following removal of the catheter, the incidence of vascular injuries can be reduced.
ABSTRACT
We studied the appearance of pleural effusion and inflammatory reactions after endovascular grafting in cases of aortic dissection. From December 1995 to January 2000, 16 patients with chronic double-barrel type aortic dissection (DeBakey type III b) were treated by endovascular grafting. In all cases, enhanced computed tomography (CT) of the chest was examined before operation and at about the 7th postoperative day (POD). Patients were divided into 3 groups. Group P: patients who had pleural effusion before the operation. Group E: patients who had new pleural effusion after the operation. Group N: patients who did not have any pleural effusion. In each group, onset of dissection, patient's age, maximum diameter of dissecting aorta, period of postoperative fever (above 37.0°C), and WBC counts and CRP value at POD 1, 3, 7 and 14 were compared. Four patients were in group P, 4 patients were in group F, and 8 patients were in group N. Period between onset and operation was 41.6±34.6 months in group P, 18.2±27.3 months in group E and 7.3±11.6 months in group N. There was no relation between the effusion and the period after onset. Postoperative fever continued for 5.0±2.0 days in group P, 13.5±2.6 days in group E and 2.5±0.3 days in group N. The period of fever of group E was significantly longer than in group N and P (p<0.01). WBC showed a peak on the first POD in each group. CRP showed a peak value on POD 3 in group P and N. There was no significance among the 3 groups about WBC and CRP, but group E showed slightly high CRP values on POD 7 and 14. No patient had complications regarding respiratory function. After endovascular grafting for aortic dissection, postoperative pleural effusion appeared in 25% of patients. They had prolonged postoperative fever, but there was no respiratory function complication. Endovascular grafting is a minimally invasive procedure with regard to respiratory function.
ABSTRACT
We tried to identify the risk factors affecting the high mortality rates associated with ruptured abdominal aortic aneurysm (AAA). The subjects consisted of 18 patients, operated on for ruptured AAA, who were admitted to our hospital between 1992 and 1999. The preoperative factors, which were hemoglobin levels less than 9.0g/dl, creatinine levels higher than 2.1mg/dl, type 4 on the Fitzgerald classification, shock state lasting longer than 6h and a shock time index (the time from shock state onset to the beginning of operation divided by the time from complaint of abdominal pain to the beginning of operation) higher than 0.3, were associated with increased intraoperative and overall mortality rates. The postoperative factors, which were bleeding and blood transfusion more than 6, 000ml and an operating time of more than 400min, were associated with increased intraoperative and overall mortality rates. It is concluded that these risk factors were predictors of mortality and it is necessary to operate early because of the risk factors.
ABSTRACT
A 40-year-old man was admitted because of prolonged fever after extraction of teeth. Infective endocarditis, congestive heart failure and hepatorenal failure were diagnosed in a series of examinations. Electrocardiograms showed complete atrio-ventricular block and QT prolongation. After continuous hemodiafiltration (CHDF) and high doses of antimicrobials promptly initiated for the treatment of multiple organ failure, the aortic valve with regurgitation and vegetation was replaced with an artificial valve. Serious arrhythmias occurred after the operation, which disappeared by the administration of antiarrhythmic agents. In cases of infective endocarditis with multiple organ failure, preoperative intensive treatment such as CHDF in combination with high doses of antimicrobials and surgical intervention represent a good strategy for successful outcome.
ABSTRACT
A 32-year-old man was admitted with dyspnea on exertion and a prolonged common cold. Swelling of mediastinal lymph nodes, pericardial thickening and pleural effusion were detected by chest CT. Mycobacterial culture of sputa and pleural effusion were negative. Serum adenosine deaminase (ADA) activity was normal. A tuberculin test showed a positive reaction (20×15mm). Viral antibody titers (Coxsackie A9, echo 3, influenza B) were negative. Ten days after admission, the patient had pyrexia and low cardiac output symptoms. Right ventricular pressure curve cardiac catherterization showed a“dip and plateau”pattern which indicated constrictive pericarditis. We performed subtotal pericardiectomy (from the right phrenic nerve to the left phrenic nerve). Pathological examination of pericardium showed Langerhans' giant cell infiltration and caseous necrosis which could be diagnosed as tuberculosis. Although the patient had transient pleural effusion, symptoms disappeared postoperatively. At present there are no signs of recurrent infection.
ABSTRACT
A 71-year-old woman was admitted with sudden onset of abdominal pain. CT scan image and symptoms showed an impending ruptured suprarenal abdominal aortic aneurysm therefore we performed an emergency operation. The abdominal aorta was replaced with a trunk prosthetic graft with four branches for visceral and lumbar arteries. The post-operative course was uneventful. Pathological examination showed that the aorta had severe atherosclerotic changes. The fibrous tissues increased in the aneurysmal wall which was not consistent with the normal aorta. Intima and media of the aorta everted into the aneurysm. These findings suggested that aneurysm was caused by a penetrating atherosclerotic ulcer.
ABSTRACT
Coronary artery disease is common in patients with abdominal aortic aneurysm and arteriosclerosis obliterans, and one-stage or two-stage coronary artery bypass grafting have been performed. However, few operative cases of concomitant heart valve disease and arteriosclerotic disease have been reported. This case presented with severe aortic valve regurgitation (LVEF 24.3%) and arteriosclerosis obliterans (ASO) of both iliac arteries. To maintain the IABP catheter route and to prevent lower limb ischemia, aortic valve replacement with a bileaflet mechanical valve and abdominal aortic replacement with a bifurcated graft were carried out simultaneously. In spite of the high degree of operative invasiveness with median sternotomy and abdominal incision, the postoperative course was uneventful due to the shortened operation time and maintenance of good peripheral circulation.
ABSTRACT
A high-risk abdominal aortic aneurysm patient with multiple complications was treated by a transluminally placed endovascular stent-graft. A tapered stent-graft composed of 3 units of self-expandable Z stents covered with ultra-thin woven Dacron was inserted through an 18 Fr sheath via the femoral artery. The stent-graft was deployed successfully, and endovascular exclusion of the abdominal aortic aneurysm was achieved. The endoluminal stent-graft treatment is an option for minimally invasive operation in comparison with conventional open surgery, and appears to be effective for aortic aneurysms in certain selected cases.
ABSTRACT
A 60-year-old woman with acute Stanford type A dissecting aneurysm underwent Dacron graft replacement of the total aortic arch combined with the modified elephant trunk technique. Follow-up CT and angiogram demonstrated blood flow into the false lumen from the distal anastomosis. In order to interrupt the blood flow, endovascular stent grafting was undertaken. She recovered uneventfully, and was discharged on the 14th postoperative day. Follow-up CT taken in the third postoperative month demonstrated exclusion of the blood flow into the false lumen of descending thoracic aorta. Aortic arch replacement followed by endovascular stent grafting of the descending thoracic component is a potential therapeutic option in patients with dissecting aneurysm.
ABSTRACT
Ten cases of pseudoaneurysms that developed after thoracic aortic surgery were treated with an endovascular technique using stent grafts for redo operations. All patients were treated under general anesthesia and the stent grafts were implanted through 18 Fr or 20 Fr sheath introducers via femoral arteries under fluoroscopic guidance. The stent graft was composed of several units of self-expanding stainless-steel Z stents covered with an ultra-thin polyester fabric. Stent graft deployment was technically successful in all patients and in 7 of 10 cases exclusion of the aneurysms with no endoleak was achieved within two weeks after the operation (initial success rate: 70%). Minor endoleak was found in 3 patients and one of those finally underwent conventional surgery because of stent graft migration 6 months after the stent graft repair. Two of ten patients died, 10 days and 18 weeks after the operation, due to hemoptysis, which had already been observed before the operation. Endovascular stent graft repair of pseudoaneurysms after thoracic aortic surgery is a minimally invasive operation in comparison with conventional redo surgery with extracorporeal circulation. These results and experiences suggest that stent graft repair can be a safe and useful redo treatment for pseudoaneurysms. However, careful long-term investigations are necessary to prove the value and effect of this endovascular treatment and a new strategy for cases with hemoptysis is required.
ABSTRACT
The stump pressure of the inferior mesenteric artery (IMA) was measured before and after aortic cross clamping during infra-renal abdominal aortic aneurysmal surgery in 50 cases. We analyzed the hemodynamics in IMA-supplied areas, and established an appropriate index to indicate intestinal ischemia. The IMA stump pressure after aortic cross clamping decreased significantly (<i>p</i><0.0001), by 11% on an average. This means that the collateral blood supply from the internal iliac artery (IIA) is 11% of the total pressure and the collateral blood supply from the superior mesenteric artery (SMA) is 89%, therefore the SMA supply dominates that of the IMA. Intestinal ileus due to ischemia occurred in one patient who had the highest rate of pressure decrease after aortic cross clamping. The cause of ileus might be poor collateral blood supply from SMA and insufficient IIA blood flow preservation. The IMA stump pressure might be an index to predict intestinal ischemia. We analyzed the IMA stump pressure in 38 cases without IMA reconstruction who had no ischemia. The ratio of 0.6 in IMA stump pressure versus systemic pressure could be a safe index suggesting sufficient blood flow in IMA-supplied areas. IMA reconstruction and IIA preservation should be performed to maintain an IMA stump pressure ratio of 0.6.
ABSTRACT
A 58-year-old diabetic man underwent emergency coronary artery bypass grafting for ischemic heart failure. Although postoperative cardiac function was good but acute renal failure developed. We started continuous hemodiafiltration (CHDF) from 5 hours after the operation and continued it for 7 days without any undue influence on hemodynamics or bleeding side effects. The renal function gradually improved and CHDF was halted. It is reported that CHDF can prevent renal failure caused by inflammatory cytokines produced after cardiac surgery. CHDF appears to be useful for the management of acute renal failure in the early postoperative period after cardiac surgery.
ABSTRACT
This report describes the results of endovascular stent graft repair for abdominal aortic aneurysms in comparison with conventional open surgery. Endovascular repair of abdominal aortic aneurysm was performed in 21 patients (SG group) and 69 patients were treated with conventional open surgery (OS group). The SG group had a higher preoperative risk than the OS group. The complete exclusion of the aneurysm at 2 weeks after the stent graft treatment was obtained in 16 out of 21 SG cases (76%). On the other hand, in the OS group, 68 of 69 cases underwent successful surgery (99%). The average amount of bleeding during the endovascular stent graft repair was 427ml and the average operation time was 242 minutes. Both blood loss and operation time were significantly lower compared to the OS group. The endovascular stent graft repair was less invasive in comparison with conventional open surgery. However, judging from the initial success rate, open surgery is more reliable than the endovascular stent graft repair. Our data suggested that the endovascular stent graft repair should be performed only in selected cases.
ABSTRACT
Prosthetic graft replacement for thoraco-abdominal aneurysm was performed in a 69-year-old man. Fever and CRP elevation developed 8 days after the operation. A subcutaneous abscess was found in the wound. The culture of pus and thoracic discharge revealed methicillin-resistant staphylococcus aureus (MRSA). Infected tissues were debrided and an omentopexy was performed without removing the prosthetic graft to avoid spinal cord ischemia. The thoracic cavity was irrigated continuously with 1% Povidone-iodine for three days. The infection subsided gradually and the patient was discharged. Graft infection due to MRSA has recently increased and we experienced such a case which we treated successfully by complete debridement, omentopexy and continuous irrigation.