Acute occlusion of an abdominal aortic aneurysm--case report and review of the literature.

Acute thrombosis of an abdominal aortic aneurysm (AAA) is a surgical emergency. Only 44 cases have been reported in the literature. The mechanism of the thrombosis has not been delineated. The proposed etiologies include propagation of thrombus from distal artery occlusion, cardiac thromboembolism, and dislodgment of a mural thrombus. Patients often present bilateral lower extremity ischemia, mimicking a saddle embolism. Systemic heparinization immediately after diagnosis and prompt surgical revascularization can reduce the mortality rate. The authors present a patient with sudden thrombosis of an AAA who was successfully treated with an axillobifemoral bypass graft. All published cases of thrombosed AAAs are analyzed.

An aberrant left subclavian artery aneurysm with right aortic arch: report of a case.

The case of a 41-year-old man who developed an aneurysm in his aberrant left subclavian artery is described. The patient had a right aortic arch. After a successful aortosubclavian artery bypass, symptoms due to brain ischemia disappeared. This is a very rare disease that is sometimes associated with an aortic anomaly, therefore the optimal therapeutic procedure need to be carefully selected, including the operative indications and approach.

Spontaneously developed aneurysm of the ductus arteriosus in an adult.

We report an unusual adult case of aneurysm associated with the ductus arteriosus. A 67-year-old female, who suffered recurrent nerve palsy, was diagnosed as having an aneurysm of the ductus arteriosus. The aneurysm, located in the medial aspect of the aortic ischimus and projected toward the pulmonary artery, was successfully repaired using a Dacron patch. A pathologic review of the aneurysm revealed the degeneration of the aortic media.

Coronary atherosclerosis with dual coronary artery fistulas.

Coronary artery fistula (CAF) is an uncommon congenital anomaly. Bilateral CAFs, arising from both right and left coronary arteries are rare. Myocardial infarction is by far a less frequent complication of CAF than angina pectoris. Ligation of CAF and coronary artery bypass graft were performed in the treatment of coronary artery stenosis with CAF.

Genetic risk factor for abdominal aortic aneurysm: HLA-DR2(15), a Japanese study.

PURPOSE: Autoimmunity has been proposed to play a role in the pathogenesis of the abdominal aortic aneurysm (AAA). Several autoimmune diseases are associated with specific HLA DR alleles. These experiments were carried out to determine whether the same HLA DR types that have been reported to be associated with AAA in a mixed North American population are similarly associated with AAA in a more homogeneous group of patients in Japan. METHOD: HLA DR typing was performed by a serologic method on samples of peripheral blood of patients with nonspecific infrarenal AAA in Nagasaki University Hospital in Japan. The frequencies of HLA DR antigens were compared with those of volunteers approximately matched for age and sex from the same referral area. RESULTS: HLA DR haplotypes were determined in 46 Japanese patients with AAA and in 50 patients in a control group. The HLA-DR2(15) antigen was observed in 27 (58.7%) patients (29 alleles 31.5%) with AAA and in 14 (28%) subjects (16 alleles 26.0%) in the control group (p < 0.005). CONCLUSIONS: The data suggest that HLA-DR2(15) has an important role as a genetic risk factor for AAA in Japanese patients, as previously reported in a mixed North American population.

Coronary revascularization and abdominal aortic aneurysm repair in a patient with Behçet's diseases.

Behçet's disease is a systemic disease characterized by oral aphta, genital ulcer, and ocular lesion. Arterial involvement is an uncommon complication of Behçet's disease, and it most frequently affects the abdominal aorta followed by the femoral artery and the pulmonary artery. Coronary lesions in Behçet's disease have been little reported in the literature. In this communication, we present a case with coronary artery stenosis and with subsequently developed supra-renal abdominal aortic aneurysm. The coronary lesions were revasculized with gastroepiploic artery, right internal mammary artery, and saphenous vein graft. Abdominal aortic repair was performed with partial cardiopulmonary stand by, because of the risk of coronary ischemia during the cross clamp including the celiac artery. To our knowledge, this is the first report of successful repair of combined lesions of the coronary and the abdominal aorta in a patient with Behçet's disease.

Hemodynamic effects of nicardipine and phentolamine in combination with norepinephrine in a canine low-output-state model.

Norepinephrine (NE) is one of the most potent positive inotropic drugs available for the treatment of low-output state following open-heart surgery. However, its inotropic effect is often masked by a significant increase of peripheral vascular resistance due to marked vasoconstriction. The purpose of the present study was to investigate whether the use of nicardipine (Nc) and phentolamine (Ph) in combination with NE could ameliorate the adverse vasoconstrictive action of NE. A low-output-state (LOS) model was produced by global myocardial ischemia due to electrically induced intermittent ventricular fibrillations in open-chest dogs. Twenty-eight dogs were divided into 6 groups according to the drugs infused after producing LOS. In the control group, hemodynamic changes similar to the clinical low-output state were observed, e.g., a decrease in cardiac output (CO) and left ventricular dp/dt, and an increase in the systemic vascular resistance (SVR). The use of NE alone produced marked increases in the systemic arterial pressure (SAP), heart rate, and SVR, with a slight increase in CO. The infusion of Nc alone produced decreases in SVR and SAP with a slight increase in CO. The concomitant infusion of NE and Nc produced increases in SV and CO, and decreases in SAP and SVR. The infusion of Ph alone produced no significant hemodynamic changes. The combined use of NE and Ph produced increases in CO, SAP and heart rate, but not to a significant extent. These results suggest that there are major advantages in the concomitant use of NE and Nc for the control of LOS.

[Simultaneous mitral valve replacement and splenectomy in a patient with chronic idiopathic thrombocytopenic purpura].

A 57-year-old female with valvular heart disease and chronic idiopathic thrombocytopenic purpura (ITP) underwent successful open-heart surgery. Preoperative administration of steroids and high-dose gamma-globulin increased the platelet count from 3 x 10(4)/microgram at admission to 10 x 10(4)/microgram before the operation. Splenectomy followed by mitral valve replacement (SJM 27M) were performed simultaneously. No platelet transfusion needed during and after the operation owing to rapid increase in platelets that would occur following splenectomy. The postoperative course was uneventful. The present simultaneous splenectomy and open-heart operation appears to be a safe and effective procedure for minimizing perioperative blood loss in patients with ITP and heart disease.

The role of low-density lipoprotein apheresis as postoperative care of bypass grafting for chronic arterial occlusion.

Since November 1989, low-density lipoprotein apheresis has been applied to patients with intractable hyperlipidaemia following bypass grafting for chronic arterial occlusion of the lower extremities. The treatment group comprised six patients (four men, two women) with arteriosclerosis obliterans. In five patients, the ankle pressure index deteriorated and intermittent claudication recurred due to atherosclerotic progression. Results of low-density lipoprotein apheresis were dramatic; the deteriorated ankle pressure index and intermittent claudication improved significantly after several applications of low-density lipoprotein apheresis. Significant angiographic improvement was obtained in two patients. It is concluded that low-density lipoprotein apheresis appears to be an efficient method to preserve graft patency and treat postoperative patients with deteriorated ankle pressure index.

[Reoperation for lung cancer: indications and operation methods in cardiopulmonary function].

A second pulmonary resection after initial operation for lung cancer was performed 20 patients (10 with a second primary lung cancer, 8 with a metastatic lung cancer, 2 with lung abscess in pulmonary aspergillosis). All patients had radical lobectomy in first operation. Eight patients underwent completion pneumonectomy, one patient had another lobectomy, two patients underwent wedge resection after initial ipsilateral lobectomy. One patient underwent contralateral lobectomy seven patients had contralateral wedge resection after initial lobectomy. Any patient did not dead within 30 days after the reoperation, not hospital death and major complications. When a second pulmonary resection (especially, completion pneumonectomy) is required, its radicality and the need to preserve residual respiratory function and cardiac function (FEV1.0 more than 800 ml/body and %FVC more than 35%, total pulmonary vascular resistance at the unilateral pulmonary artery artery occlusion test less than 700 dyne.sec.cm-5/m2) must be considered in making the decision to operation. The five-year survival rate after reoperation for patients with lung cancer was 41.0% according to the Kaplan-Meier methods. Patients with a second primary lung cancer (the three-year survival rate, 83.5%) have appeared to do better than those with pulmonary metastasis from lung cancer (the five-year survival rate, 25.6%) These results suggest that reoperation for lung cancer can be done safety, patients undergoing reoperation have a reasonable prospect for long-term survival.

Myocardial recovery during post-ischemic reperfusion: optimal concentrations of Na+ and Ca2+ in the reperfusate and protective effects of amiloride added to cardioplegic solution.

The effects of Na+ and Ca2+ concentrations in the reperfusate on post-ischemic myocardial recovery were examined. Also, the myocardial protective effects of amiloride, an inhibitor of the Na+/Ca2+ and Na+/H+ exchange systems, added to cardioplegic solutions were assessed, using an isolated working rat heart perfusion system. Global myocardial ischemia was induced by 30-min normothermic cardioplegic arrest, using St. Thomas' solution. The concentration of Na+ in the reperfusate varied, stepwise, from 75 to 145 mM/l, and that of Ca2+, from 0.1 to 2.5 mM/l. In this study post-ischemic functional recovery was best at 110mM/l Na+ and 1.2-1.8 mM/l Ca2+ in the reperfusate. A significantly greater post-ischemic functional recovery and a lower creatine kinase release were observed when amiloride was added to the cardioplegic solution. Ca2+ overload via Na+/Ca2+ and Na+/H+ exchange systems would, thus, appear to be due, at least in part, to post-ischemic reperfusion injury.

[Axillo-femoral bypass for adult form of extreme coarctation of the aorta--the long term prognosis].

A 33-year-old female with adult form of extreme coarctation underwent axillo-femoral bypass grafting. The postoperative hemodynamic improvement was remarkable. The patient spent excellent quality of life without any hypotensive drug or anticoagulant agent for 14 years until pseudoaneurysms of the bypass graft ruptured. The patient was saved by an emergency operation with 2 steps of surgical procedures. The first step was making the new axillo-femoral bypass at the contralateral side, then the diseased graft was replaced by a new graft as the second step. The postoperative catheterization revealed no pressure gradient between the upper and lower extremities, and the bilateral API's were over 100%. The pseudoaneurysm of the graft seemed to be caused by the stabbed needle holes for the dearing of the graft and the instrument for the partial occlusion of the graft. We learned from this experience that the needle holes of the graft should be repaired by plegeted sutures, and Fogarty clamp or the clamp with rubber sheath should be used for clamping graft. The axillo-femoral bypass is, of course, not a first choice procedure for extreme coarctation, but the hemodynamic improvement was achieved in our case. Therefore, it may be still useful for the compromised host as an alternative procedure to the radical correction.