Nationwide study of surgery for primary infected abdominal aortic and common iliac artery aneurysms.

BACKGROUND: Primary infected aneurysms of the abdominal aorta and iliac arteries are potentially life-threatening. However, because of the rarity of the disease, its pathogenesis and optimal treatment strategy remain poorly defined. METHODS: A nationwide retrospective cohort study investigated patients who underwent surgical treatment for a primary infected abdominal aortic and/or common iliac artery (CIA) aneurysm between 2011 and 2017 using a Japanese clinical registry. The study evaluated the relationships between preoperative factors and postoperative outcomes including 90-day and 3-year mortality, and persistent or recurrent aneurysm-related infection. Propensity score matching was used to compare survival between patients who underwent in situ prosthetic grafting and those who had endovascular aneurysm repair (EVAR). RESULTS: Some 862 patients were included in the analysis. Preceding infection was identified in 30.2 per cent of the patients. The median duration of postoperative follow-up was 639 days. Cumulative overall survival rates at 30 days, 90 days, 1 year, 3 years and 5 years were 94.0, 89.7, 82.6, 74.9 and 68.5 per cent respectively. Age, preoperative shock and hypoalbuminaemia were independently associated with short-term and late mortality. Compared with open repair, EVAR was more closely associated with persistent or recurrent aneurysm-related infection (odds ratio 2.76, 95 per cent c.i. 1.67 to 4.58; P < 0.001). Propensity score-matched analyses demonstrated no significant differences between EVAR and in situ graft replacement in terms of 3-year all-cause and aorta-related mortality rates (P = 0.093 and P =0.472 respectively). CONCLUSION: In patients undergoing surgical intervention for primary infected abdominal aortic and CIA aneursyms, postoperative survival rates were encouraging. Eradication of infection following EVAR appeared less likely than with open repair, but survival rates were similar in matched patients between EVAR and in situ graft replacement.

Pharmacokinetic differences between rat tumour and lung tissues following isolated lung perfusion with cisplatin.

Isolated lung perfusion has been performed for the treatment of unresectable lung tumours; however, the pharmacokinetics of this procedure remain unclear. This study was conducted to investigate the changes in antitumour drug concentrations in tumour and lung tissues after isolated lung perfusion, using different perfusion times and perfusate drug concentrations. Isolated left lungs were perfused for 20, 40 or 60 min with 25, 50 or 100 micrograms/ml of cisplatin after solitary lung tumour nodules were established in rats, and the total platinum concentrations in the perfused lung and tumour tissues were determined by flameless atomic absorption spectroscopy. The oedema in the perfused lung tissues was evaluated by histological examination and by the wet to dry weight ratios of the lungs. The total platinum concentration increased significantly with perfusion time and increasing perfusate cisplatin concentrations in the lung tissue, but it did not change in the tumour tissue. The wet to dry weight ratios of the lung tissues did not differ significantly among the perfusion groups. Oedema of the perfused lung tissue did not change significantly with the perfusion time or perfusate cisplatin concentration. The results of this study indicate the possibility that different pharmacokinetics exist between tumour and lung tissues following isolated lung perfusion with cisplatin, which could be used as a clinical guide for the selection of appropriate perfusion times and perfusate drug concentrations.

The influence of tumour resection on angiostatin levels and tumour growth--an experimental study in tumour-bearing mice.

The phenomenon of primary neoplasms inhibiting the growth of their metastatic lesions is thought to be related to endogenous angiogenesis inhibitors. The aim of this experiment was to investigate the influence of tumour resection on angiostatin levels and tumour growth using a tumour-bearing mouse model. A primary Lewis lung cancer tumour model was established in C57BL/6 mice and these mice were divided into two groups 10 days after the tumour cells were inoculated. In the surgical resection group (S group) the tumour was resected, but in the control group (C group) a sham operation was performed. The level of angiostatin in the sera was analysed 5 days after the operation by western blotting. To observe tumour growth, four Lewis lung cancer models were established in these mice from both the S and C groups. An immunohistochemical analysis of the tumour tissues was conducted to estimate the proliferation and apoptotic rates of the tumour cells, as well as the amount of neoangiogenesis in the tumours. Angiostatin was observed in the tumour-bearing mice, but disappeared within 5 days after the tumour had been resected. Increased tumour growth was observed in all of the tumour models in the S group compared with the C group and the differences were significant. A significantly higher intratumour vessel density and proliferation cell index, but a significantly lower apoptotic index were also found in the S group compared with the C group. These findings demonstrated that angiostatin was generated directly from the tumour tissue. Furthermore, tumour resection accelerates the growth of other tumours and this is probably related to multiple factors including increased neoangiogenesis, increased tumour cell proliferation, and decreased apoptosis.

Prolonged survival of xenograft fetal cardiomyocytes by adenovirus-mediated CTLA4-Ig expression.

BACKGROUND: Experimental allografting of fetal cardiomyocytes has been performed successfully. In this study, we attempted to transplant rat fetal cardiomyocytes into the hearts of mice by blocking the CD28/B7 costimulatory pathway via CTLA4-Ig gene transfer. METHODS: Fetal cardiomyocytes derived from Dark Agouti rat were infected with CTLA4-Ig-expressing adenovirus vectors (AdCTLA) and injected directly into the normal myocardium of C3H/He mice (n=15). For control, cells infected with beta-Gal-expressing adenovirus vector (AdRL) and cells without infection were injected into additional mice (n=30). Mice were killed at 2 (n=5), 4 (n=5), and 8 (n=5) weeks after xenotransplantation. Transplanted fetal cardiomyocytes were examined for survival by immunostaining with anti-rat atrial natriuretic peptide and anti-CTLA4-Ig antibodies. RESULTS: Fetal cardiomyocytes were successfully infected by AdCTLA and AdRL. The cardiomyocytes infected with AdCTLA expressed CTLA4-Ig and survived to 8 weeks after xenotransplantation in all of these mice. However, cardiomyocytes infected with AdRL and noninfected cells were not detected even 2 weeks after xenotransplantation. CONCLUSION: Survival of xenografted fetal cardiomyocytes is prolonged by adenovirus-mediated CTLA4-Ig expression.

Right axillary cannulation in the left thoracotomy for thoracic aortic aneurysm.

Perfusion from the femoral artery is commonly used in the open proximal method of performing distal aortic arch aneurysm repair or Stanford type B aortic dissection repair under circulatory arrest through left thoracotomy. However, it is associated with a significant risk of retrograde emboli or malperfusion, and with other problems including a restricted time of circulatory arrest to the brain and difficulties in de-airing from the arch branches and proximal ascending aorta. To overcome these problems, we developed a method of performing right axillary perfusion through left thoracotomy.

Evaluation of brain oxygenation during selective cerebral perfusion by near-infrared spectroscopy.

BACKGROUND: Although selective cerebral perfusion (SCP) has been used for cerebral protection in aortic arch operations, the appropriate perfusion conditions of SCP are unclear. METHODS: We used near-infrared spectroscopy, which evaluates brain ischemia noninvasively and continuously, to determine whether perfusion with SCP (core temperature, 20 degrees C; flow rate, 10 mL.kg-1.min-1) was acceptable in terms of oxyhemoglobin and deoxyhemoglobin in patients having SCP for aortic arch operations (SCP group, n = 6) versus patients having cardiopulmonary bypass (CPB) for coronary artery bypass grafting (CPB group, n = 6). RESULTS: There were no significant differences in age (65 +/- 10 versus 63 +/- 12 years), CPB time (199 +/- 67 versus 199 +/- 52 minutes), changes in hematocrit (-12.9% +/- 3.7% versus -12.5% +/- 6.0%), lowest blood pressure (43 +/- 7 versus 45 +/- 10 mm Hg), or highest central venous pressure (8 +/- 2 versus 9 +/- 4 mm Hg) between the SCP and CPB groups. In the SCP group, the maximum decrease in oxyhemoglobin level and the maximum increase in deoxyhemoglobin level were -5.0 to -11.4 mumol/L and -0.1 to 3.9 mumol/L, respectively; in the CPB group, the respective changes were -3.2 to -14.2 mumol/L and -0.4 to 3.6 mumol/L. Changes of oxyhemoglobin and deoxyhemoglobin levels in the SCP group were almost within the range of those in the CPB group. There were no brain complications in either group. CONCLUSIONS: As described here, SCP is acceptable and safe for brain protection in aortic arch procedures.

Granulocyte elastase release and pulmonary hemodynamics in patients with atrial septal defect.

BACKGROUND: In patients with increased pulmonary artery pressure, the pulmonary vascular endothelium is morphologically and functionally abnormal and may be vulnerable to neutrophil-mediated injury induced by cardiopulmonary bypass (CPB). We investigated the relation between levels of granulocyte elastase (GEL), interleukin-6, or interleukin-8 after CPB and preoperative pulmonary hemodynamics or changes in pulmonary function after the operation. METHODS: We measured plasma levels of GEL, interleukin-6, and interleukin-8 before and after CPB in patients who underwent closure of an atrial septal defect. Preoperative and postoperative respiratory index were evaluated. Preoperative pulmonary hemodynamics were determined within 1 month before the operation. RESULTS: The level of GEL rose significantly after CPB from baseline (164.8 +/- 81.3 versus 819.4 +/- 320.3 microg/L; p < 0.01). Levels of interleukin-6 and interleukin-8 showed no significant changes after CPB. Peak level of GEL was significantly correlated with preoperative systolic pulmonary artery pressure (r = 0.76; p = 0.017), mean pulmonary artery pressure (r = 0.75; p = 0.021) and pulmonary-to-systemic arterial pressure ratio (r = 0.77; p = 0.016), but not with the hemodynamic variables for pulmonary blood flow or pulmonary resistance. Moreover, the value of (postoperative respiratory index - preoperative respiratory index)/preoperative respiratory index was positively correlated with the peak level of GEL (r = 0.72; p = 0.030). CONCLUSIONS: The increase in GEL level after CPB is proportional to the increase in preoperative pulmonary artery pressure, which may cause the accordant pulmonary vascular damage.

Digitonin enhances the antitumor effect of cisplatin during isolated lung perfusion.

BACKGROUND: The antitumor effect of isolated lung perfusion with cisplatin was limited because the intracellular platinum concentration did not increase sufficiently. To solve this problem, digitonin, a detergent, was chosen to increase cell permeability and enhance intracellular uptake and antitumor effect. This study was designed to investigate toxicity, pharmacokinetics, and efficacy of isolated lung perfusion with the combined use of digitonin and cisplatin in Fischer 344 rats. METHODS: Systemic and local toxicities of isolated lung perfusion treatment were evaluated on the basis of body weight change, survival rate, and histologic findings. The maximal tolerated dose of digitonin was determined by assessing survival on day 21 after contralateral pneumonectomy, body weight change, and histologic findings. Pharmacokinetics were observed in a solitary lung tumor nodule model by measuring platinum concentration in tumor and normal lung tissue. The antitumor effect was evaluated by the number of tumor nodules in the left lung 21 days after isolated lung perfusion. Isolated lung perfusion was performed 7 days after 1.0 x 10(6) methylcholanthrene sarcoma cells were injected into the external jugular vein. RESULTS: The maximal tolerated dose of digitonin was 20 micromol/L. Platinum concentration of tumor nodules in the digitonin-cisplatin-treated rats was 20% higher than in the cisplatin-only group (5.48 +/- 0.64 microg/g tissue versus 4.50 +/- 1.09 microg/g tissue; p = 0.067). The number of pulmonary nodules decreased significantly by digitonin use (1.3 +/- 1.5 versus 9.7 +/- 2; p < 0.0001). CONCLUSIONS: Isolated lung perfusion with digitonin and cisplatin in combination was performed safely and enhanced the antitumor effect. These drugs in combination show promise for enhancing the effect of clinical isolated lung perfusion.

Digitonin enhances the anti-tumor effect of cisplatin against methylcholanthrene-induced rat sarcoma cells in vitro.

BACKGROUND: This study was designed to evaluate cellular uptake and cytotoxicity of cisplatin in methylcholanthrene (MCA)-induced rat sarcoma cells when used in combination with a detergent, digitonin. MATERIALS AND METHODS: In the cellular intake study, after MCA sarcoma cells (10(7)) were treated with cisplatin alone (50 micrograms/ml) and with cisplatin (50 micrograms/ml) in combination with digitonin at 20 microM and 50 microM, the cells were washed twice with PBS and the platinum levels were measured by flameless atomic spectrometry. For the anti-tumor effect MCA sarcoma cells (10(3)) were seeded in cell culture dishes and loaded for 10 minutes with PBS, digitonin (5 microM), cisplatin (5 micrograms/ml) or a combination of cisplatin (5 micrograms/ml) and digitonin (5 microM). The cells were then washed and incubated for 72 hours. Bromodeoxyuridine uptake was measured with an ELISA system for determining viable cells counts. RESULTS: Cell platinum levels were significantly elevated in proportion to the increase of digitonin (p < 0.0001). The number of viable cells was significantly decreased with, the combined cisplatin (5 micrograms/ml)--digitonin (5 microM) treatment (p < 0.0001 CONCLUSION: Digitonin enhances the antitumor effect of cisplatin against methylcholanthrene-induced rat sarcoma in vitro.

Increasing drug concentration in a rat lung tumor model by combining isolated lung perfusion with hypertensive chemotherapy.

Isolated left lung perfusion (ILP) with cisplatin was performed in Fisher 344 rats. Before perfusion, bolus injection with endothelin was given via the pulmonary artery. The vasoconstrictive potency was estimated by monitoring the perfusion pressure. The toxicity was estimated by tracking body weight change, survival rate after right pneumonectomy, arterial blood gas analysis and histological findings. To observe the pharmacokinetic changes, a solitary Methylcholanthrene-induced sarcoma model was established in a rat lung and the total platinum concentration in perfused lung and tumor tissues was measured. Perfusion pressure was increased significantly in a dose-dependent manner. Pulmonary toxicity from ILP with cisplatin was limited by the use of endothelin. Significantly higher levels of total platinum were obtained in tumors but not in normal lung tissues by endothelin injection before ILP than by ILP alone. The combination of ILP and hypertensive chemotherapy should be one of the available treatments for unresectable pulmonary carcinoma.

Hearing loss in infants with congenital diaphragmatic hernia treated without extracorporeal membrane oxygenation: report of two cases.

The authors report the cases of 2 infants with congenital diaphragmatic hernia (CDH) treated without extracorporeal membrane oxygenation (ECMO) therapy who were discovered to have hearing loss at 1 year of age. Both boys had been diagnosed as having CDH antenatally and were treated with surgery and high-frequency oscillatory (HFO) therapy. The patterns of hearing loss were consistent with sensorineural deafness and believed to be associated with HFO therapy, prolonged mechanical ventilation, and a high pH.

Congenital cystic adenomatoid malformation of the lung with an esophageal cyst: report of a case.

The authors report the case of a 7-month-old girl found to have both congenital cystic adenomatoid malformation of the lung (CCAM) and esophageal cyst. She suffered repeated episodes of pneumonia and exhibited signs of respiratory distress on admission to our hospital. Chest radiography and magnetic resonance imaging (MRI) showed 2 different kinds of cystic lesions. Resection of the lower lobe of the right lung and excision of the posterior mediastinal cyst were performed. Histologic examination showed Stocker type I CCAM and esophageal cyst. Coexistence of both CCAM and esophageal cyst is extremely rare. The authors speculate that the pathologies of this case originated from a regional disturbance of common embryologic origin during 2 different phases of lung-bud foregut malformations.

99mTc-HSA lymphoscintigraphy and leg edema following arterial reconstruction.

Twelve patients with peripheral arterial occlusive disease were evaluated prospectively in an effort to further investigate the etiology of pedal and lower leg edema that occurs following revascularization (e.g., aorto-iliac or femoropopliteal bypass). Serum total protein, albumin, blood urea nitrogen, and creatinine levels were measured (in addition to peripheral venous pressure), and lymphoscintigraphy of the lower leg was performed. These parameters were assessed just prior to surgery, four weeks postoperatively, and again at follow-up. The serum levels obtained four weeks after surgery and on subsequent follow-ups were significantly higher than the preoperative values. Preoperative peripheral venous pressure was not significantly different from that obtained after surgery. There was no correlation between these pressure measurements and the degree of edema (Grades I to IV correspond to increasing degrees of severity). For both the supine and upright positions, lymphoscintigraphic counts in the inguinal region were significantly higher after surgery. However, the relative increase was dependent upon the severity of edema. The postoperative lymphoscintigraphic count in the upright position was 77 +/- 33 CPS in patients with Grades I and II edema (n = 6) and 20.6 +/- 16.2 CPS in patients with Grades III and IV edema (n = 10) (p less than 0.01). Thus, a lesser degree of postoperative pedal and lower leg edema was associated with higher lymphoscintigraphic counts. We conclude that major contributors to the development of lower extremity edema following arterial reconstruction are failed capillary hydrostatic pressure and interrupted lymphatic drainage.

Toxic shock-like syndrome resembling phlegmasia cerulea dolens.

A case of a 71-year-old Japanese woman with toxic shock-like syndrome is reported. She was admitted to the hospital because of swelling of the right leg. On admission, right lower leg was erythematous and swollen with an erosive lesion. On the second day, she rapidly fell into shock. Phlegmasia cerulea dolens caused by massive iliofemoral venous thrombosis was suspected because she had a history of deep venous thrombosis. But deep venous thrombus was not detected by venography at emergent surgery for thromboembolectomy. She died 38 hours after admission despite maximal supportive therapy. Group A beta-hemolytic streptococci were isolated from blood culture and soft tissue after the patient died.

The effects of new platelet inhibitory drug E-5510 on platelet deposition on aortic bifurcation grafts: assessment by indium-111-oxime labeled platelet imaging.

The effects of a recently synthesized anti-platelet aggregation drug (E-5510) on platelet deposition in a knitted Dacron aortic graft underwent preliminary evaluation by In-111 oxime labeled platelet imaging. Seven patients undergoing aortofemoral bypass using this graft for occlusive disease were randomized into two groups: those receiving E-5510 and those receiving no medication. This agent was administered for 17 days postoperatively, and on the 14th day In-111 platelets were injected and images were acquired at 24, 48, and 72 hours. Platelet deposits in the grafts were assessed by the ratios of graft radioactivity to that of the adjacent native iliac arteries. Platelet deposition at the sites of anastomosis and deposition along the entire graft were normalized by initial deposition at 24 hours, and had significantly decreased at 72 hours in the three treated patients, while the normalized deposition increased progressively over time in the remaining four nonmedicated patients. E-5510 seems to have the potential to inhibit excessive platelet deposition on recently implanted grafts.

Effect of elastase on primary graft patency after femoralpopliteal arterial bypass for arteriosclerosis obliterans: a randomized, controlled study.

METHODS: Studies were carried out on 104 limbs with femoralpopliteal bypasses for arteriosclerosis obliterans (ASO). They were randomized to a group receiving elastase (10800 EL. U. P.O. per day) with an antiplatelet drug (Elastase group, 58 patients) or a group receiving only the antiplatelet drug (Control group, 46 patients). The follow-up period ranged from 24 to 36 months after operation at 22 institutions across Japan. RESULTS: The cumulative graft patency rate was higher in the Elastase group than the Control group, but the difference lacked statistical significance. When autogenous saphenous veins were used, the cumulative graft patency rate was significantly higher in the Elastase group than the Control group. CONCLUSIONS: The present study suggests that elastase is effective in maintaining graft patency in femoralpopliteal arterial bypass when an autogenous saphenous vein is used as a graft.

Is the preferential use of polytetrafluoroethylene grafts for below-knee femoropopliteal bypass justified?

The usefulness of polytetrafluoroethylene graft (PTFE) for primary below-knee femoropopliteal bypass was examined. Forty-five primary femoropopliteal bypasses with PTFE were performed in 35 patients during a 7-year period. Patients were divided into two groups: above-knee (A-K group, n = 20) and below-knee (B-K group, n = 25) bypass. Differences in intergroup patient demographics were not significant. The primary patency rate in the A-K group at 3 and 5 years was 83.6% and 50.2%, respectively, and was 76.2% at both 3 and 5 years in the B-K group. These differences were not significant. Cause of graft failure, 3 grafts in the A-K group and 5 grafts in the B-K group, was kinking or thrombus formation associated with intimal hyperplasia at the distal anastomosis. All grafts in the A-K group with more than 10% stenosis in the early postoperative period had more than 50% stenosis in the late postoperative period. On the other hand, the one graft in the B-K group with 25% stenosis in the early postoperative period had 50% stenosis in the late postoperative period. We concluded that the use of PTFE for primary below-knee femoropopliteal artery is reasonable when atherosclerosis in the proximal popliteal artery is slight. However, close follow-up is necessary to detect and treat graft stenosis early.

Laparoscopic surgery in infants with intra-abdominal cysts: two case reports.

OBJECTIVES: We report two cases of infants found to have congenital omental cystic lesion with torsion and ovarian cyst treated by laparoscopy-assisted surgery (LAS). METHODS: A laparoscope was inserted by an open method. The intra-abdominal pressure was maintained at 8 mm Hg. We diagnosed the cystic lesions with torsion. At aspirator was used to aspirate the cystic content and remove the cyst. RESULTS: No intra- or postoperative complications were encountered. Oral intake was commenced on postoperative day 2 in both patients. The cosmetic results following LAS were excellent. CONCLUSIONS: We conclude that LAS is suitable for the management of omental cystic lesions with torsion and ovarian cyst in nursing infants. An aspirator is useful in preventing spillage of cystic contents in patients with intra-abdominal cystic lesion.

[Experimental study of coronary artery anastomosis using VCS clips].

The experiment was intended to test the feasibility of VCS clips for coronary anastomosis during minimally invasive direct coronary artery bypass grafting (MIDCAB). Six dogs were anesthetized under endotracheal intubation and were placed on right lateral position. Three 10.5-mm ports were placed on the left lateral chest wall (3rd, 5th and 7th intercostal space) and the left internal thoracic artery (LITA) was dissected completely from its root to bifurcation under thoracoscope. Chest was opened through the left 6th intercostal space. The anastomotic site of LAD was dissected and was then occluded temporally for 5 minutes to obtain ischemic preconditioning. The anastomosis was performed by the following procedure; horizontal mattress sutures of 8-0 polypropylene were placed on heel, toe and the center of both lateral sides. Two VCS clips (8 in total), 0.9-mm in size, were applied between every two sutures. After the measurement of graft flow, the pedicle was transected and an angiography was done. Graft flow was 12-17 ml/min (mean 14.7 +/- 2.1 ml/min) and cineangiogram showed good patency of LITA and no anastomotic stenosis. VCS clips were supposed to have a potential for facilitating port access coronary artery bypass grafting.

[Dose the serum brain natriuretic peptide (BNP) level after open heart surgery reflect myocardial protection?].

This clinical study was conducted to determine whether the serum BNP level after open heart surgery reflects myocardial protection. The levels of BNP and CPK-MB were measured before and after 12 hours of cardiopulmonary bypass, then 1, 3, and 6 days after open heart surgery, and the relationship between the maximum levels of BNP and the CPK-MB after open heart surgery was examined. The patients were divided into two groups according to whether or not the maximum CPK MB was more than 100 IU/l after open heart surgery. A significant relationship between the maximum BNP and the maximum CPK-MB after open heart surgery was observed (p = 0.013). Moreover, the BNP was significantly increased in the group of patients with a maximum CPK-MB > or = 100 IU/l, compared to that in those with a maximum CPK-MB < 100 IU/l, 12 hours 1 day, and 6 days after open heart surgery (p < 0.01). These findings indicate that the serum level of BNP after open heart surgery can reflect myocardial protection.