Right Coronary Artery with an Intramural and Interarterial Course as a Unique Cause of Myocardial Ischemia: The Unroofing Method Might Still Be the Best Solution.

A 39-year-old man was admitted because of cardiac arrest. Emergent coronary angiography revealed a preserved coronary blood flow; however, multiple-row detector computed tomography (MDCT) revealed that the proximal right coronary artery (RCA) was running inside the aortic wall, creating proximal stenosis without atherosclerotic changes. Surgical intervention with unroofing was performed; however, postoperative stenosis of the proximal RCA required additional coronary artery bypass grafting (CABG). Intraoperative findings during CABG did not reveal hematoma or coronary dissection. However, MDCT one year after CABG depicted improvement of the RCA and graft stenoses, suggesting that the post-unroof stenosis may have been caused by an inflammatory reaction after surgical intervention.

Neoadjuvant Hyperthermia and Chemoradiotherapy for Borderline Resectable Pancreatic Cancer.

Pancreatic cancer(PC)is associated with poor prognosis and low resectability rates. Currently, only 15-20% of all patients are candidates for upfront surgery at the time of diagnosis, which offers the chance of long-term survival. In recent years, patients with borderline resectable PC(BR-PC)have been treated with surgery following neoadjuvant chemoradiotherapy or intensive multi-agent chemotherapy. In PC, which is therapy resistant due to its hypoxic microenvironment, hyperthermia may enhance the effect of chemo(radio)therapy. An 84-year-old man with fatty stool was diagnosed with pancreatic head cancer according to the result of contrast computed tomography(CT), which showed a 37 mm irregular low-density area at the pancreatic head infiltrating nearly half of the superior mesenteric artery(SMA)plexus. There were no findings of lymph node metastasis or distant metastasis. The pretreatment diagnosis was BR-PC, cT3, N0, M0, cStage Ⅱ A. The patient was treated with hyperthermia plus S-1 and radiotherapy. The size of the tumor had reduced from 37 mm to 15 mm after the neoadjuvant therapy, and the infiltration into the SMA plexus had also reduced. Therefore, the patient underwent subtotal stomach-preserving pancreaticoduodenectomy(SSPPD)concomitant resection of the PV, SMV, SV confluence. The histopathological findings were invasive ductal carcinoma with R0 radical resection. There has been no recurrence 18 months after the surgery. Based on the above-mentioned findings, hyperthermia and chemoradiotherapy can be an effective option of neoadjuvant treatment for BR-PC.

Preoperative computed tomographic diagnosis of an aortocaval fistula associated with aneurysm of the abdominal aorta.

Aortocaval fistula is a rare but life-threatening complication of ruptured abdominal aortic aneurysm. We present a case of an aortocaval fistula with acute right heart failure. The condition was accurately diagnosed before operation by physical examination, echo, and especially by computed tomography (CT), thereby enabling proper planning of the operative strategy. At surgery, not only the infrarenal aorta and common iliac arteries on both sides but the inferior vena cava and iliac veins on both sides were also controlled to avoid massive venous bleeding through the fistula. Aortocaval fistula repair was easy, and conventional bifurcated Dacron graft replacement for abdominal aortic aneurysm was successfully performed. Innovative CT images give us prompt preoperative diagnoses and elaborate surgical strategies.

Preoperative visualization of the artery of Adamkiewicz by dual-phase CT angiography in patients with aortic aneurysm.

To improve our ability to visualize the Adamkiewicz artery (AKA), we developed a modified intravenous CT angiography technique, which we refer to as right atrial CT (RA-CT) angiography. In this study, AKA detection rate and visualization of the arterial continuity from the aorta to the anterior spinal cord artery (ASA) was evaluated using RA-CT angiography.We performed RA-CT angiography in 110 patients with abdominal, thoracic descending, or thoracoabdominal aortic aneurysms. In RA-CT angiography, contrast medium with a high iodine concentration (370 mg/dl) was injected twice into the right atrium at a high injection rate (8.0 ml/sec), and two CT scans, starting at 20 sec after the first injection and at 35 sec after the second injection, respectively, were performed. All CT images were obtained using an 8- or 16-detector CT scanner at a slice thickness of 0.625 mm. The AKA was defined as the largest radiculomedullary artery with a characteristic hairpin turn, and with continuity from the aorta to the ASA.The AKA with hairpin turn was detected in all patients (100%), and continuity from the aorta to the ASA was confirmed in 99 of the 110 patients (90.0%). The AKA arose between Th8 and L1 in 86 of these patients (86.8%), and originated from the left side in 71 patients (71.7%).RA-CT angiography may be useful for visualizing the AKA and the arterial continuity from the aorta to the ASA in patients with aortic aneurysm, although the use of more advanced CT machines will provide safe and easy identification of the AKA and arterial continuity with a small amount of contrast medium and a single scan.

Effects of angiotensin receptor blocker and calcium channel blocker on experimental abdominal aortic aneurysms in a hamster model.

Remodeling in the abdominal aortic wall results in abdominal aortic aneurysm (AAA) formation. Many patients with AAA are prescribed antihypertensive drugs. However, the effects of antihypertensive drugs other than their effects on blood pressure control are rarely reported. In this study, we investigated the effects of these drugs on changes in the levels of matrix metalloproteinases (MMPs) and on AAA formation. Experimental AAAs were created in a hamster model by wrapping the abdominal aorta with elastase gauze. Olmesartan medoxomil (angiotensin II receptor antagonist) or azelnidipine (calcium channel antagonist) was administered to the hamsters and then we evaluated the aortic diameter, performed histological analysis, and analyzed the production of MMP-2 and MMP-9 by gelatin zymography. The expansion rate of the aortic diameter was smaller in both treatment groups than in the control group. Elastica van Gieson (EVG) staining showed structural preservation of elastin lamellae in both treatment groups. The active MMP-9 level decreased in both the olmesartan group and the azelnidipine group. Reducing MMP-9 production is important for suppression of AAA formation. Both olmesartan medoxomil and azelnidipine decreased MMP-9 activity, which suppressed degradation of the MMPs and inhibited AAA formation. There are different cascades that determine the production of MMP-9.

Benefits of a beta-blocker for intractable hemolysis due to paraprosthetic leakage.

We describe a 58-year-old man who was successfully treated with a beta-adrenergic receptor blocking agent for intractable hemolysis due to paraprosthetic leakage. After replacement of a mitral prosthetic valve with another mechanical valve, the patient suffered intractable intravascular hemolysis resulting from recurrent paraprosthetic leakage. With oral administration of a beta-adrenergic receptor blocker, betaxolol hydrochloride, for 3 months, the hemoglobin value increased from 9.7 g x dL(-1) to 12.4 g x dL(-1), although glutamic oxaloacetic transaminase and lactic dehydrogenase values remained elevated.

Spontaneous rupture of the dorsalis pedis artery: report of a case.

A 52-year-old man underwent the repair of a spontaneous rupture of the dorsalis pedis artery. We considered that untreated hypertension was one possible cause of the rupture. This is a rare case of spontaneous rupture in a peripheral artery.

Strategy for isolated iliac artery aneurysms.

We retrospectively reviewed 41 patients with isolated iliac artery aneurysms presenting over a 21-year period. The mean age was 72 years. Mean aneurysmal diameter was 6.0 cm (range, 3.2-13 cm). The aneurysms were located in the common iliac artery in 31 patients, internal iliac artery in 7, and both arteries in 3. Rupture occurred in 20 patients (49%). The frequency of rupture of isolated iliac artery aneurysms was significantly higher than that of abdominal aortic aneurysms (8%) during the same period. The 30-day mortality was 9.8%; death in all 4 patients was due to rupture of the aneurysm. The surgical procedure was aneurysmectomy and replacement with a bifurcated prosthetic graft in 24 patients (59%), closure of the common iliac artery with a femorofemoral crossover in 7, minilaparotomy in 3, thromboexclusion in 6, and endoluminal stent-graft repair in one. In contrast to abdominal aortic aneurysms, isolated iliac artery aneurysms can be treated by various methods other than replacement with a bifurcated prosthetic graft. When selecting a strategy for such aneurysms, it is important to choose an approach appropriate to the location and risk, because of the frequency of rupture.

A shorter skin incision technique for the repair of infrarenal abdominal aortic aneurysms.

PURPOSE: We evaluated the effectiveness of a shorter skin incision technique for the treatment of infrarenal abdominal aortic aneurysms (AAA). The aim of the present study was to evaluate whether or not the difference in the length of the skin incision contributed to an early recovery after the operation. METHODS: Between October 2001 and December 2004, we performed 105 elective repairs for AAA. The patients were divided into three groups according to the length of the skin incision as follows: group A, less than 15 cm, group B, from 15 cm to less than 20 cm, and group C, 20 cm or more. RESULTS: There was no significant difference in the intraoperative course among the three groups. The duration of paralytic ileus was shorter in group A than in group C (2.0 +/- 0.9 days versus 3.2 +/- 2.3 days; P = 0.0428). Although the periods before removal of nasogastric suction and before starting a solid diet were slightly shorter in group A than in groups B and C, there were no statistically significant differences. CONCLUSION: We define minimally invasive vascular surgery as surgery performed with a small abdominal skin incision that does not expose the intestine to air while providing a good operative field that does not place any undue stress on the surgeon.

Coronary artery fistula from the left circumflex to the coronary sinus.

A 27-year-old woman, who had received mitral valve repair for mitral regurgitation resulting from infective endocarditis, was admitted for a close examination of abnormal echocardiographic findings in the left atrium. Transthoracic echocardiography showed trivial mitral regurgitation with normal left ventricular contraction and dilatation of the coronary sinus. Auscultation revealed a grade 2 continuous murmur along the left sternal border. Transesophageal echocardiography demonstrated a marked dilatation of the coronary sinus just behind the posterior wall of the left atrium and turbulent blood flow in the dilated coronary sinus. Cardiac catheterization showed no significant step-up of oxygen saturation in the right heart and normal pulmonary artery pressure. Coronary angiography revealed a markedly dilated and tortuous circumflex coronary artery connected to the coronary sinus through a fistula. A left circumflex artery with a fistulous connection to the coronary sinus is extremely rare.