A Case of Anastomotic Pseudoaneurysm due to Late Dysruption of Knitted Dacron Graft Treated by Hybrid Operation / 日本心臓血管外科学会雑誌

Knitted Polyester prosthetic grafts can cause long-term dilatations and formation of anastomotic or non-anastomotic aneurysms, and rupture in result. We experienced a case of anastomotic pseudoaneurysm and recurrent non-anastomotic dilatation of the ascending aorta-abdominal aorta bypass by Cooley Double Velour Knitted Dacron (CDVKD) graft for a patient with atypical coarctation of the aorta (Takayasu Aortitis, type III), which case needed treatment two times over 30 years after the initial operation. The first additional treatment was Thoracic Endovascular Aortic Repair (TEVAR) for non-anastomotic aneurysm was done as 1st operation. Thirty-two years after the initial operation, the second treatment was a hybrid operation consisting of 4 procedures: bilateral axillo-external iliac bypass, taking down of the CDVKD graft at the proximal anastomotic site, endovascular repair (EVAR) with modified Double D Technique, and coil packing at the distal anastomotic site of the CDVKD graft. The patient was discharged at 37-POD. No complication and no endoleak has occurred in the 2.5 years since the operation.

Surgical Closure of an Atrial Septal Defect Attenuated Migraine / 日本心臓血管外科学会雑誌

The prevalence of migraine is higher in patients with atrial septal defect (ASD) (24.2%) than in the general Japanese population (9.4%). A few studies have reported that transcatheter closure of an interatrial shunt is known to attenuate migraine. We experienced hat surgical closure of the ASD improved migraine that was refractory to medication therapy. A 46-year-old man presented to a neurologist for evaluation of severe headache and was diagnosed with migraine. Brain magnetic resonance imaging (MRI) revealed evidence of previous multiple cerebral infarctions. Transesophageal echocardiography detected inferior sinus venosus-type ASD, and a bubble study showed the presence of a right-to-left shunt. Owing to the high index of clinical suspicion for paradoxical embolism via the ASD and the fact that percutaneous catheter closure was contraindicated for inferior sinus venosus-type ASD, we performed surgical closure of the ASD in this patient. The patient's migraine symptoms disappeared immediately after surgery, and no recurrence has been observed eight months after surgery. This is the first case report that surgical closure of ASD led to attenuate migraine. Our study highlights the association between right-to-left shunts and migraine, as well as the usefulness of the surgical closure of ASD as a therapeutic strategy for patients with migraine.

Coronary Artery Bypass Grafting Combined with Total Arch Replacement for Severe Coronary Disease Complicated with Multiple Arch Vessel Stenosis / 日本心臓血管外科学会雑誌

A 72-year-old man was referred to our hospital for coronary artery bypass grafting (CABG) due to asymptomatic severe coronary artery disease. A preoperative CT revealed 99% stenosis of the aberrant right subclavian artery, 90% stenosis at the origin of right common carotid artery, and 75% stenosis at the origin of the left subclavian artery. As he had high risk of a perioperative cerebral ischemic event for CABG, it was difficult to perform a carotid artery stent. We performed a total aortic arch replacement combined with CABG. The postoperative course was uneventful, and he was discharged on the 12th postoperative day.

Surgical Treatment of Renal Artery Aneurysm / 日本心臓血管外科学会雑誌

Most renal artery aneurysms are asymptomatic and the indication of surgery for renal artery aneurysm is controversial. We encountered 3 cases of renal artery aneurysms that were found incidentally during imaging studies. We used urological approach to undergo renal or adrenal surgery and we injected renal protection solution into the kidney after clamping the renal artery, later we underwent renal artery aneurysmectomy. In all cases, we got good operative field, and they went an uneventful postoperative course without deterioration of renal function. In surgical treatment of renal artery aneurysm, this approach method, reconstructive procedure, and renal protection are satisfied enough.

Ascending-to-Descending Aortic Bypass through a Median Sternotomy for Residual Coarctation of the Aorta / 日本心臓血管外科学会雑誌

A 11-year-old boy was admitted to our hospital with a diagnosis of the progressive residual coarctation of the aorta, severe left ventricular hypertrophy and dilatation of the ascending aorta. He had previously undergone 3 operations for coarctation of the aorta. We performed ascending-to-descending aortic bypass through a median sternotomy for residual coarctation of the aorta. Partial cardiopulmonary bypass (CPB) was established via the right femoral artery and right atrium. A cephalad retraction of the heart with a heart positioner and a longitudinal pericardial incision over the descending aorta allowed excellent exposure of the aorta through the posterior pericardium. The graft was anastomosed to the ascending aorta and descending aorta. The graft was brought around the right lateral aspect of the right atrium and through to the anterior aspect of right pulmonary veins and inferior vena cava. The bypass graft size was 14 mm in diameter. The CPB time was 134 min, and operation time was 232 min. The postoperative course was uneventful, and he did not suffer from paraplegia. His blood pressure postoperatively normalized without medication. He was discharged 20 days after surgery. The ascending-descending aortic bypass through a posterior pericardium approach is a safe and effective option for relieving residual coarctation and improving hypertension, for patients who have complex coarctation requiring surgical correction. However, because of his young age (II) it is necessary to follow him up carefully.

Surgical Treatment for Congenital Venous Malformations in the Lower Limb / 日本心臓血管外科学会雑誌

Four patients, 13 to 53 years old, with congenital venous malformation including Klippel-Trenaunay syndrome underwent surgical treatment followed by sclerotherapy. They developed marked dilatation of varicose veins with spots, and complained of pain, dullness, and bleeding. Two patients also had hypertrophy of the diseased leg. Phlebography and color Doppler ultrasonography were performed in all patients to precisely determine the abnormal vein and incompetent communicating veins which were then resected and/or ligated with minimal skin incision. In two patients, additional ligation of incompetent communicating veins was necessary. One to two weeks after surgical therapy, sclerotherapy was performed with 1-2% polidocanol. Symptoms improved after treatment, even in a patient with claudication before operation. Surgical therapy for congenital venous malformation was feasible and satisfactory, with the aid of meticulous identification of abnormal veins and communicating veins by not only phlebography but color Doppler ultrasonography.