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.

Aorto-Left Atrial Fistula after Aortic Valve Replacement : a Rare Complication / 日本心臓血管外科学会雑誌

A 60-year-old man underwent aortic valve replacement for aortic valve regurgitation, tricuspid valve annuloplasty, and coronary artery bypass grafting. Postoperative echocardiography revealed shunted flow from the noncoronary sinus of Valsalva into the left atrium. The pathogenesis of this complication is considered to be uncertain ; however, it might be due to some kind of intraoperative injury. Three weeks after the initial surgery, we reoperated to repair the aorto-left atrial fistula. According to the intraoperative findings, small slits were found on the left atrial surface close to the posteromedial side of the mitral valve and the noncoronary sinus of Valsalva. The fistula was closed with transmural mattress sutures. Post-operative echocardiography showed no shunt flow. Although an aorto-left atrial fistula is a rare complication after aortic valve replacement, reoperation might be mandatory if the shunt flow is considerable. Surgeons should keep in mind the possibility of intraoperative injury to surrounding structures when performing aortic valve replacement.

A Case of Ruptured Abdominal Aortic Aneurysm Induced by a Hard Blow to the Abdomen / 日本心臓血管外科学会雑誌

A 77-year-old man was transferred to our hospital with a complaint of a sudden abdominal pain after receiving a hard blow to the abdomen. Contrast-enhanced CT revealed rupture of the abdominal aortic aneurysm with a massive retroperitoneal hematoma. Because of severe hemorrhagic shock, he underwent graft replacement with a woven bifurcated graft through a median laparotomy on an emergent basis. His postoperative course was uneventful and now he is doing well 3 years after surgery. Most blunt abdominal aortic injuries are caused by high-energy trauma, such as motor vehicle collisions and fall injuries. Although body blow is considered as a low-energy trauma, abdominal aortic injury could be caused in patients with an abdominal aortic aneurysm.

Successful Surgical Treatment of Tracheo-Innominate Artery Fistula Complicated with Tracheostomy / 日本心臓血管外科学会雑誌

Tracheo-innominate artery fistula is a rare complication after tracheostomy, but sometimes presents with fatal bleeding. A 10-year-old girl presented with massive bleeding from a tracheostomy that she underwent for prolonged respiratory failure caused by sequelae of mumps encephalitis. Tracheo-innominate artery fistula, complicated by tracheostomy was diagnosed, and she was transferred to our institution. Under general anesthesia, she underwent transection of the innominate artery to exclude the tracheo-innominate artery fistula via median sternotomy. Her postoperative course was uneventful without recurrent bleeding or infection. Considering the risk of tracheo-innominate artery fistula, careful observation is necessary to prevent catastrophic bleeding in patients with mechanical respiratory support via tracheostomy.

Surgical Experience of Radiation-Induced Coronary Artery Ostial Stenosis / 日本心臓血管外科学会雑誌

Radiation-induced heart disease includes various types of cardiac disorders that occur after thoracic irradiation therapy. The coronary artery has been known to be affected in this kind of pathological condition. A 37-year-old man diagnosed with acute coronary syndrome was referred to our institution. He had received irradiation therapy for mediastinal malignant lymphoma at the age of 10 and 11 years. An extended thymectomy for a thymoma via median sternotomy was performed at 18 years old. He also underwent thoracoscopic pericardial fenestration for a pericardial effusion at 26 years old. Coronary angiography revealed severe stenosis of the left and right coronary ostia. Considering the patient's characteristics, including a history of thoracic irradiation therapy, radiation induced heart disease was suspected as a pathogenesis for severe ostial stenosis of the coronary arteries. He underwent conventional on-pump beating coronary artery bypass grafting (CABG) on an urgent basis. Neither internal thoracic artery was suitable for bypass conduit because of dense adhesion. Therefore, the radial artery and great saphenous vein were used as free grafts for coronary revascularization. Furthermore, partial clamping of the ascending aorta seemed to be difficult and inappropriate owing to severe adhesion, so proximal anastomosis devices were used without a side biting clamp. The postoperative course was uneventful and both bypass grafts were patent. Now, he is doing well 10 years after the CABG without any other cardiac event.

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.

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.

Popliteal Artery Pseudoaneurysm Associated with Osteochondroma / 日本心臓血管外科学会雑誌

Osteochondromas, or exostoses, are the most frequent benign bone tumors. Although many osteochondromas are asymptomatic, they are sometimes responsible for vascular complications, most often associated with the popliteal artery. Here, we present a rare case of pseudo-aneurysm of the popliteal artery secondary to an osteochondroma of the femur in a 48-year-old woman. During surgery, a pseudo-aneurysm developed from a 1-mm hole in the anterior aspect of the popliteal artery, which was closely related to the protrusion of the femoral osteochondroma. The surface of the osteochondroma was quite sharp, rigid and firm. It was removed completely through the lumen of the aneurysm. A short segment of the popliteal artery, including the hole, was resected with an end-to-end anastomosis. The postoperative course was uneventful, and the patient recovered completely. The precise pathogenesis of pseudo-aneurysmal formation is still unknown. We speculate that local compression of the popliteal artery by a spiky osteochondroma can stretch the vessel and lead to rupture of the artery by continuous friction. Considering the potential risk of this vascular complication, shonld be closely monitered patients with osteochondroma of the femur.

A Strategy of Cardiopulmonary Bypass for a Pseudoaneurysm of Ascending Aorta after Aortic Valve Replacement / 日本心臓血管外科学会雑誌

A 29-year-old man with high fever and chest pain was admitted to our hospital. He had undergone aortic valve replacement 1 month before admission to our hospital. Since computed tomography revealed a pseudoaneurysm in the ascending aorta, he underwent an emergency operation. An occlusion catheter was inserted into the ascending aorta via the left femoral artery, in preparation for pseudoaneurysm rupture. Cardiopulmonary bypass was established with inflow via the right femoral artery and the right axillary artery, and with vacuum-assisted venous drainage via the right femoral vein. After core cooling, we performed resternotomy. The pseudoaneurysm ruptured while we were exfoliating the adhesion around the aorta. We inflated the occlusion catheter in the ascending aorta and controlled the bleeding. We continued core cooling and ventricular fibrillation occurred at 30°C. Subsequently, we induced circulatory arrest, and selective cerebral perfusion was initiated. We inflated the occlusion catheter in the descending aorta and initiated systemic circulation with inflow via the right femoral artery. The origin of the pseudoaneurysm was the region of cannulation in the previous operation. Therefore, we replaced the ascending aorta and performed omentopexy. In this case we reported the use of a strategy involving cardiopulmonary bypass for a pseudoaneurysm in the ascending aorta.

Stanford Type A Acute Aortic Dissection with Left Extra-pleural Hematoma and Lung Hemorrhage / 日本心臓血管外科学会雑誌

A 68-year-old woman with a sudden onset of back pain was brought to our hospital by ambulance. Computed tomography (CT) showed Stanford type A (DeBakey type II) acute aortic dissection, left hemothorax, and hematoma extending along the pulmonary artery ; therefore, the patient underwent emergency operation. We performed a median sternotomy. Pericardial effusion was not observed ; however, a hematoma was found around the ascending aorta. Preoperative CT showed left hemothorax, but pleural effusion was not observed in the left pleural cavity. The left hemothorax, which was detected on preoperative CT, was diagnosed as an extrapleural hematoma. The dissection entry site was located at the proximal aortic arch ; therefore, ascending aorta-hemiarch replacement was performed. After weaning from cardiopulmonary bypass, the patient experienced sudden airway bleeding. The bleeding was attributed to the hematoma extending along the pulmonary artery. Here, we have reported a rare case of Stanford type A acute aortic dissection with the left extrapleural hematoma and lung hemorrhage.

Emergency Redo Aortic Root Replacement for Composite Graft Dehiscence due to Aortitis Syndrome in a Child / 日本心臓血管外科学会雑誌

We report a case of 10-year-old woman with aortitis syndrome who had a graft dehiscence at the site of proximal anastomosis 8 months after aortic root replacement. Because she suffered severe chest compression and ST depression was demonstrated on 12 lead ECG, she was admitted on a suspicion of vasospasmic angina. However, transesophageal echocardiogram and CT showed an echo-free space around the previous operated aortic composite graft, so we concluded that a proximal graft dehiscence and bleeding around it was the cause of her severely deteriorated circulatory condition, and emergency redo aortic replacement was planned. After deep hypothermic circulatory arrest was accomplished, selective cerebral perfusion was performed following re-sternotomy. Previous composite graft was detached at the site of proximal anastomosis, and the aortic annulus was friable and edematous. Redo aortic replacement successful. Laboratory findings revealed uncontrollable aortitis syndrome as the etiologic factor of graft dehiscence. Postoperatively, she was complicated with cerebral infarction due to a stuck valve. She was discharged at 56 postoperative day.

Adrenal myelolipoma associated with gastric cancer, Report of a Case / 日本農村医学会雑誌

A 56- year-old woman visited our hospital complaining of right hypochondralgia. X-ray and endoscopic examinations revealed Borrmann 2 type gastric cancer in the anterior wall of an upper part of the stomach. Ultrasonography showed an echogenic mass in the suprarenal area. The mass which had septal formation within it, was about the same in density as fat on computerized tomography, and was hypovascular fed by the right inferior adrenal artery on angiography. These findings suggested that the mass might be adrenal myelolipoma. After total gastrectomy and right adrenectomy were done, histopathological study confirmed that the case is adrenal myelolipoma associated with Borrmann 2 type gastric cancer. In Japanese literature, only 54 cases of surgically resected adrenal myelolipoma have been reported, and this is the second case of adrenal myelolipoma associated with gastric cancer.

A case of multiple splenic abscess / 日本農村医学会雑誌

The patient, a 71-year-old man, was admitted to our department with fever from unknown causes. Ultrasonic examination of the abdominal regions revealed abnormal multiple low-density echo legions (that could be) associated with splenomegaly. For diagnostic purposes, splenic puncture was performed with the aid of an ultra-sound imaging device. Pale yellow-green pus was obtained from the lesions. Based on this finding, we made a diagnosis on the case as multiple abscess of the splean. The patient underwent intensive chemotherapy. However, he dontinued to have a high fever. On the ninth day from hospitalization, splenectomy was performed. Since then, his fever has subsided. Abscess of the spleen is a rare disease. It is generally classified into two types: one is a multiple type, and the other, a solitary type. Multiple splenic abscess mostly occurs as one of the abnormal conditions during the course of a primary disease, which is often severe. Our case, however, did not exhibit any sign of a primary disease.