Localized Aortic Root Dissection with a Superior Mesenteric Artery Aneurysm.

In this study, the case of a 46-year-old female patient with localized aortic root dissection and a superior mesenteric artery (SMA) aneurysm is described. Computed tomographic angiography could not clearly delineate an intimal flap in the aortic root, but it detected SMA aneurysm, which implied the presence of a vulnerability of the aortic wall. Finally, transesophageal echocardiography (TEE) evidently showed the intimal flap localized in the aortic root. The present case suggests that TEE is of paramount importance for detecting localized aortic root dissection. In addition, a coexisting vascular lesion may be a clue to diagnose another vascular lesion.

Mediastinal Abscess Caused by an Expanded Polytetrafluoroethylene Membrane.

A 76-year-old man who had undergone tricuspid annuloplasty 13 years earlier was admitted to our hospital because of a high fever. Although he was treated with antibiotics for pneumonia, a mild fever persisted. Computed tomography and gallium scintigraphy revealed a mediastinal abscess with an expanded polytetrafluoroethylene (ePTFE) membrane. There were no positive cultures or sternal changes indicating poststernotomy mediastinitis. The membrane was removed by a left parasternal approach without resternotomy, and its total removal was essential for the patient's recovery. This is the first reported case of sterile mediastinal abscess caused by an ePTFE membrane after a cardiac operation.

Radiopaque Ruler-Guided Frozen Elephant Trunk Technique.

Frozen elephant trunk (FET) technique combines open surgery and endovascular repair for extensive thoracic aortic aneurysms. When a FET is inserted into the descending thoracic aorta, it is difficult to confirm its proper positioning. Here we report a radiopaque ruler-guided FET technique. On the basis of preoperative computed tomography, we create a roadmap which shows the relationship between the descending thoracic aorta and vertebrae. During surgery, a radiopaque ruler placed beneath the patient's back provides the accurate target position under fluoroscopy. Our technique is effective to prevent spinal cord injury because it avoids an overly deep implantation of a FET.

Intravenous Lobular Capillary Hemangioma in the Subclavian Vein.

We report the case of a 73-year-old man with severe edema of the right upper extremity. Computed tomography, magnetic resonance imaging, and venography revealed an intravenous tumor in the middle portion of the right subclavian vein. The tumor was completely resected, and an accompanying thrombus was also removed using the transmanubrial osteomuscular sparing approach. The patient recovered well without any complications or recurrence. The histopathologic diagnosis was intravenous lobular capillary hemangioma, which is also called pyogenic granuloma. To our knowledge, this is the first reported surgical case involving this type of benign tumor originating in a thoracic vein.

Infective endocarditis of an aorto-right atrial fistula caused by asymptomatic rupture of a sinus of Valsalva aneurysm: a case report.

Asymptomatic rupture of a sinus of Valsalva aneurysm is rare. A fistula following rupture of a sinus of Valsalva aneurysm may cause infective endocarditis. Here, we report a case of infective endocarditis of an aorto-right atrial fistula caused by asymptomatic rupture of a sinus of Valsalva aneurysm. A 45-year-old male, who was first diagnosed with a heart murmur at the age of 37 years, presented with fever. Blood culture was positive for Streptococcus gordonii. Ultrasound echocardiography revealed an aorto-right atrial fistula caused by rupture of a sinus of Valsalva aneurysm. After the infective endocarditis was healed by antibiotics, we successfully performed surgical repair of the aorto-right atrial fistula. Although asymptomatic rupture of a sinus of Valsalva aneurysm is uncommon, it should be recognized as a possible cause of infective endocarditis.

Anterior longitudinal aortotomy in aortic valve replacement.

OBJECTIVES: We adopted an anterior longitudinal aortotomy in some cases of aortic valve replacement (AVR), and report them here. The potential of this method is also discussed. METHODS: We analyzed the data on 24 patients (75.5 ± 7.8 years of age) who had undergone AVR through anterior longitudinal aortotomy. The indications for surgery were prosthetic valve complication in 5 patients, aortic stenosis (AS) with left ventricular outflow tract stenosis (LVOTS) in 16 patients, and aortic regurgitation with moderately dilated ascending aorta in 3 patients. The Konno procedure was performed in 6 cases with small aortic annuli. A longitudinal aortotomy was made at the aortic root along the left side of the right coronary ostium, and extended beyond the right coronary annulus to the interventricular septum as needed. RESULTS: Bioprostheses (21.1 ± 1.7 mm) were used in 23 patients and a 21-mm mechanical valve for one (a 59-year-old man). One high-risk patient died of low output syndrome, leading to a mortality rate of 4.2 %. All other patients recovered well, though atrioventricular block occurred in 2 cases. CONCLUSIONS: Anterior longitudinal aortotomy provides a good field of vision at the aortic annulus and the flexibility to develop into anterior annular enlargement. Major indications for this approach are small sino-tubular junction and very small aortic annulus. This approach could be an attractive option in AVR for cases of AS with small aortic annuli and LVOTS. It could also be useful for AVR cases with moderately dilated ascending aorta requiring aortoplasty.

Surgical Fenestration for Lower Limb Ischemia Developing from Chronic Type B Aortic Dissection: A Report of 2 Cases.

Lower limb ischemia caused by type B aortic dissection typically presents with a leg-threatening condition in the acute phase. However, in some cases, lower limb ischemia symptom develops as intermittent claudication in the chronic phase. Although surgical fenestration has been used for treating ischemic complications of aortic dissection, it has recently become an alternative option for such cases because of the significant advance of endovascular treatments. We report 2 cases of chronic type B aortic dissection complicated by lower limb ischemia. Two male patients aged 57 and 43 years presented with intermittent claudication more than 2 weeks after the onset of the disease. On the basis of anatomic condition of the dissected aorta, we successfully performed surgical fenestration through a median laparotomy. In the current endovascular era, surgical fenestration remains an effective and durable option for treating lower limb ischemia caused by chronic type B aortic dissection.

Open Surgical Bypass for Superficial Femoral Artery Occlusion Caused by Blunt Trauma.

Blunt vascular trauma of the lower extremities brings about a high amputation rate, because other organ injuries disturb revascularization. We experienced a case of a superficial femoral artery occlusion caused by blunt trauma. The patient also had a femoral bone fracture and a large skin defect with deep muscular injuries of the thigh. We performed a femoropopliteal (FP) bypass using a saphenous vein which was routed through the contaminated wound. Postoperative vacuum-assisted closure therapy was used to prevent graft infection. Surgical bypasses using saphenous veins are approved treatments for arterial occlusions from blunt trauma if the grafts go through contaminated wounds.

Endovascular Repair of a False Aneurysm Developing from IgG4-Related Periaortitis during Corticosteroid Therapy.

Immunoglobulin G4 (IgG4)-related disease is a systemic autoimmune disease that can affect various organs. Corticosteroid therapy is generally an effective treatment; however, IgG4-related aortic lesions pose a risk of aortic rupture related to corticosteroid use. Here, we report a case of IgG4-related periaortitis complicated with a false aneurysm during corticosteroid therapy. Although endovascular repair was successfully performed, autoimmune pancreatitis and sclerosing cholangitis emerged after surgery. The multiple lesions associated with IgG4-related disease were resolved through continuous corticosteroid therapy. Our case suggests that both appropriate surgical intervention and continuous corticosteroid therapy are essential for the treatment of IgG4-related periaortitis.

Open surgical repair for a ruptured abdominal aortic aneurysm with a horseshoe kidney.

Horseshoe kidney is a congenital anomaly characterized by medial fusion of the bilateral kidneys. Treatment for an abdominal aortic aneurysm (AAA) with a horseshoe kidney is a technical challenge because of the complex anatomy. We report a successful open surgical repair for a ruptured AAA with a horseshoe kidney. An aortic grafting was performed with division of the renal isthmus through a transperitoneal approach. In the case of a ruptured AAA, quick open surgery is the most reliable treatment. If a horseshoe kidney coexists, transperitoneal approach with division of the renal isthmus provides good surgical field for an aortic grafting.

Right atrial myxoma with a large tumor embolus in the left pulmonary artery.

Cardiac myxoma, the most common primary cardiac tumor, usually develops in the left atrium. Right atrial myxomas are rare, especially those accompanied by pulmonary tumor embolism. We describe a case of a right atrial myxoma with a large tumor embolus in the left pulmonary artery. A 74-year-old man was referred to our hospital for the treatment of a right atrial tumor. Upon echocardiography, the right atrial tumor was revealed to have a mobile and tail-like surface projection. In addition, computed tomography showed that an embolus was wedged into the left pulmonary artery. We performed an emergency surgery to remove both the right atrial tumor and the pulmonary embolus. Histopathological examination revealed them both to be myxoma. Right atrial myxoma with a large pulmonary tumor embolus is a serious condition and emergency surgery to remove both cardiac tumors and pulmonary emboli should be performed to avoid the risk of sudden death.

Popliteal venous aneurysm with deep venous thrombosis in the contralateral calf: report of a case.

Although a popliteal venous aneurysm is a rare entity, it is an important cause of pulmonary embolism (PE), which is occasionally life-threatening. We herein report a case of a popliteal venous aneurysm with deep venous thrombosis (DVT) in the contralateral calf. A 65-year-old male, who presented with sudden onset palpitation and dyspnea, was transferred to our hospital. Enhanced computed tomography revealed PE and a venous aneurysm of the left popliteal vein. The popliteal venous aneurysm was saccular and had an intramural thrombus. Furthermore, duplex scanning detected DVT in the contralateral calf. The patient underwent a tangential aneurysmectomy with lateral venorraphy. The surgery and postoperative course were uneventful. The PE and calf DVT disappeared with perioperative anticoagulant therapy. It is recommended that, in the treatment of popliteal venous aneurysms, special attention should be given to the condition of the venous vessels of the contralateral leg, because this can influence the therapeutic strategy.

[Investigation of rescued cases with cardiac rupture caused by blunt trauma].

The mortality of cardiac rupture by blunt trauma is so high that quick diagnosis and appropriate treatment are essential for saving patients. Based on 8 such cases rescued in our hospital and on 70 other rescued cases reported in Japan, we review its treatment strategy. Ultrasound examination, particularly focused assessment with sonography for trauma (FAST), was useful for diagnosing traumatic cardiac rupture. It was, however, impossible to detect the exact site of rupture before surgery. Three quarters of the rescued cases suffered from right cardiac rupture and more than 95% of those were treated successfully without extracorporeal circulation. All the cases with multiple cardiac rupture needed cardiopulmonary bypass or percutaneous cardiopulmonary support (PCPS) for their surgeries. And so did a quarter of the cases with left cardiac rupture. The standard treatment strategy seems to be as follows:to release cardiac tamponade as slowly as possible, to set up an extracorporeal circulation for surgery, and to repair the ruptured heart via median sternotomy.

Abdominal aortic disease caused by penetrating atherosclerotic ulcers.

OBJECTIVE: Penetrating atherosclerotic ulcer (PAU) of the aorta is defined as an atherosclerotic lesion with ulceration of the aortic intima and media and rupture of the internal elastic lamina. PAU induced aortic dissection, aortic rupture, and secular aortic aneurysm and typically occurs in elderly hypertensive patients with severe atherosclerosis. Although it has been reported that atherosclerosis similarly occurs in the abdominal aorta, its natural history and treatment are still unclear. This study investigated the clinical features, natural history, and treatment of PAU of the abdominal aorta. METHOD: Between April 2006 and March 2009, 4 diagnoses of PAU in the abdominal aorta were made by computed tomography (CT) and magnetic resonance imaging (MRI). These 4 cases were analyzed along with 61 previously reported cases from the literature with diagnoses of PAU in the abdominal aorta, aortic rupture, and isolated abdominal aortic dissection over the past 15 years, giving a total of 65 cases. RESULTS: The patients were men with an average age of 63.5 years. All 4 had hypertension, and 2 had concomitant coronary artery disease. Two patients were asymptomatic, and the other 2 were symptomatic and transmural rupture had occurred. All diagnoses were made by CT and MRI. All 4 patients underwent open surgery with a knitted Dacron graft, with no postoperative deaths. In the literature, 53% of cases were symptomatic, including pain (40%, n = 26), shock (4.6%, n = 3), and lower limb embolism (9.2%, n = 6). The remaining 40% of cases were asymptomatic (n = 26). Six patients were treated medically, while 58 patients underwent surgery, with 2 postoperative deaths. CONCLUSION: We suggest that surgical treatment (open surgery or endovascular stent grafting) should be performed to prevent an aortic catastrophe such as intramural hematoma, dissection, or rupture. (English translation of Jpn J Vasc Surg 2010; 19: 723-730.).

[Comparative study between landiolol and amiodarone for therapeutic efficacy after open heart surgery].

Tachyarrhythmia, especially atrial fibrillation, remains as a common complication after open heart surgery and sometimes leads to fatal condition. Many reports showed that landiolol (ultra short-acting beta one blocker) and amiodarone were effective against postoperative atrial fibrillation (POAF). However, there were few comparative studies between these 2 drugs as prophylactic agents, and no report mentioned the therapeutic efficacy. Our study suggests that landiolol be the 1st choice for rate control of tachyarrhythmia because of easy dose adjustment and mild side effects. Amiodarone may be useful for the patients whose left ventricular function is poor.

Surgical treatment for papillary fibroelastoma of the aortic valve.

Although cardiac papillary fibroelastomas are benign tumors, they have the potential to cause life-threatening complications such as stroke and myocardial infarction and may even lead to sudden cardiac death. We report a case of surgical treatment for a papillary fibroelastoma of the aortic valve. The patient was a 62-year-old woman who was asymptomatic for cardiac papillary fibroelastoma. Echocardiography demonstrated a mobile, rounded mass on the left coronary cusp of the aortic valve. The patient underwent surgical excision, had an uneventful recovery, and was discharged 10 days after the operation. Pathology examination confirmed papillary fibroelastoma. Surgical excision of the tumor is recommended for patients with symptoms, but the treatment of asymptomatic patients is controversial. We believe that surgical treatment should be performed if the tumor is mobile.

Hemolytic evaluation using polyurethane microcapsule suspensions in circulatory support devices: normalized index of hemolysis comparisons of commercial centrifugal blood pumps.

We have been developing some types of microcapsule suspensions with polyurethane membranes to evaluate the absolute hemolytic characteristics of the centrifugal blood pumps used in circulatory support devices such as artificial hearts. In order to facilitate/realize hemolysis testing on centrifugal blood pumps that have hemolysis levels as low as those of commercial centrifugal blood pumps, we eliminated capsules with diameters less than 72.2 microm, amounting to 15.4% of all capsules in the conventional suspension (crude suspension [CS]), and adjusted the capsule volume ratio to correspond to a hematocrit of 40%. In this way we succeeded in enhancing the sensitivity of the suspension to microcapsule destruction 61 fold. We used this new suspension (fine suspension [FS]) to perform hemolysis tests on four types of commercial pump with mock circulation systems. Under conditions of 500 mm Hg and 11.2 L/min, we successfully determined the hemolytic characteristics (normalized index of hemolysis [NIH]) of some of the centrifugal blood pumps; the results showed some correlation with those of hemolysis tests on bovine blood and suggest that microcapsule suspensions with polyurethane membranes are useful as standard test solutions for the absolute evaluation of centrifugal blood pumps.

Excision after chemoradiotherapy of invasive thymoma extending into the right atrium: report of a case.

We report a case of invasive thymoma with intracardiac extension, resulting from the progression of intracaval growth, in a 56-year-old woman. Initially, the patient received two courses of chemotherapy, but the tumor showed only a modest response; however, subsequent radiotherapy reduced the tumor size further and the intracardiac lesion disappeared, making it possible to excise the tumor without cardiopulmonary bypass. Thus, when a thymoma does not respond well, we recommend radiotherapy as another treatment option, because its effects may allow for less invasive and more complete tumor excision.

Comparison of hydroxyl radical generation in patients undergoing coronary artery bypass grafting with and without cardiopulmonary bypass.

We measured the hydroxyl radical (.OH) generation in fourteen patients undergoing coronary artery bypass grafting (CABG), of whom seven patients underwent on-pump CABG with cardiopulmonary bypass (CPB) and seven patients underwent off-pump CABG without CPB. To detect .OH generation, we measured the urinary excretion of .OH products of creatinine (Cr), creatol (CTL; 5-hydroxycreatinine) and methylguanidine (MG) with HPLC using the one point sampling and collected urine during and after the operation. The urinary CTL value corrected urinary Cr value of on-pump CABG significantly increased about 3-5 times from the beginning of CPB to 4 h after operation compared to the baseline value before CPB in both the collected urine and the one point sampling urine. The urinary MG/Cr value in both groups did not change significantly. Significantly increased .OH generation was found during and soon after on-pump CABG.

The hemolytic characteristics of monopivot magnetic suspension blood pumps with washout holes.

The hemolytic characteristics of monopivot magnetic suspension blood pumps as a function of impeller washout hole configuration and female pivot shape are observed. The pump impellers are designed with three washout hole configurations for blood circulation, and four female pivot shapes to reduce blood stagnation and to enhance antithrombogenicity. The hemolytic characteristics of the monopivot pumps were observed to be better than those of a currently available commercial centrifugal blood pump, BP-80, and changed to be nearly equal when the female pivot shape was changed. This indicates that hemolysis in monopivot pumps is mainly caused by shear stress between the male and female pivots.