[Rupture of Artificial Blood Vessel by a Sternal Wire:Report of a Case].

Formation of a pseudoaneurysm due to blood leakage from the anastomotic site of the vascular graft in large-diameter vessels is often seen, but formation of a pseudoaneurysm from the non-anastomotic site is extremely rare. A 68-year-old woman presented with a history of double valve replacement for combined valvular disease at 37 years old and hemiarch replacement for thoracic aortic dilatation at 65 years old. She visited the emergency room with a 2-week history of chest pain. Contrast-enhanced computed tomography (CT) revealed a 5-cm-diameter pseudoaneurysm and extravasation from the ascending aorta, so emergency surgery was performed. Around the ascending aorta area, we confirmed bleeding from a 5-mm dehiscence in the non-anastomotic part of the graft prosthesis, so hemostasis was performed with a cross-stitch mattress suture over a felt strip. Initially, the cause of the pseudoaneurysm was unknown, but re-examination of CT images from after the previous hemiarch replacement confirmed contact between the sternal wire and graft prosthesis. The wire was thus considered to have caused damage and bleeding. The patient was discharged from the hospital with a good postoperative course and is being followed-up in the outpatient department.

[Pulmonary Artery Transection in Surgery for Coronary Artery Fistula].

Coronary artery fistula is a rare abnormality in the communication between a coronary artery and any of the cardiac chambers or major vessels. At present, there is no standard surgical treatment and the most appropriate method is selected on a case-by-case basis. We report one case of coronary artery fistulae in which pulmonary artery transection was required around the left main trunk (LMT). A 62-year-old man who had coronary artery fistulae with an aneurysm which increased from 12 mm to 16 mm in a two-year span. The fistula was located adjacent to the LMT. A complete aneurysm excision under cardiopulmonary bypass was performed, which required pulmonary artery transection. No postoperative complications occurred. Postoperative coronary computed tomography scan showed intact coronary arteries and complete aneurysm removal.

Simultaneous upper and lower body perfusion using hypothermia during thoracoabdominal aortic surgery.

BACKGROUND: In open thoracoabdominal aortic aneurysm (TAAA) repair, we have been performing vascular reconstruction under moderate to deep hypothermia and assisted circulation using simultaneous upper and lower body perfusion. This method is effective for protecting the spinal cord and the brain, heart, and abdominal organs and for avoiding lung damage. METHODS: TAAA repair was performed under hypothermia at 20-28 °C in 18 cases (Crawford type I in 0 cases, type II in 5, type III in 3, type IV in 4, and Safi V in 6) between October 2014 and January 2023. Cardiopulmonary bypass was conducted by combined upper and lower body perfusion, with perfusion both via the femoral artery and either transapically or via the descending aorta or the left brachial artery. RESULTS: The ischemic time for the artery of Adamkiewicz and the main segmental arteries was 40-124 min (75 ± 33 min). No spinal cord ischemic injury or brain or heart complications occurred. One patient with postoperative right renal artery occlusion and one with an infected aneurysm required tracheostomy, but the intubation time for the other 16 was 32 ± 33 h. The duration of postoperative intensive care unit stay was 6.5 ± 6.2 days, the length of hospital stay was 29 ± 15 days, and no in-hospital deaths occurred. CONCLUSIONS: Simultaneous upper and lower body perfusion under moderate to deep hypothermia during thoracoabdominal aortic surgery may avoid not only spinal cord injury, but also cardiac and brain complications.

Mechanism of Increased Spinal Cord Blood Flow due to Noradrenaline Administration Using Vascular Resistance: An Experimental Study Using a Canine Model.

Background: During thoracoabdominal aortic surgery, the spinal cord is placed under ischemic conditions. Elevation of systemic blood pressure is thus recommended as a method of increasing the blood supply from collateral networks. This study examined the mechanisms by which noradrenaline administration increases spinal cord blood flow (SCBF) by elevating systemic blood pressure. Methods: In beagles (n = 7), the thoracoabdominal aorta and L2-L7 spinal cord segmental arteries (SAs) were exposed and a distal perfusion bypass was created to simulate clinical practice. SCBF was measured by laser flowmetry at the L5 dura mater and spinal cord perfusion pressure (SCPP) was measured inside the clamped aorta. The six pairs of SAs from L2 to L7 were clamped, and mean systemic blood pressure (mSBP), SCBF, and SCPP were measured before and after clamping and after starting continuous infusion of noradrenaline at 0.5 µg/kg/min. Rates of change in systemic vascular resistance (SVR) and spinal cord vascular resistance (SCVR) were calculated from the measured values. Results: With no SA clamping (control), the rate of increase in SCVR was 0.74 times the rate of increase in SVR (y = 0.2 + 0.74x, r = 0.889, r2 = 0.789; P < 0.01). When all six pairs of SAs were clamped, a weak correlation was evident between rate of change in SCVR and rate of change in SVR, and the rate of increase in SCVR was lower than the rate of increase in SVR (y = 0.39 + 0.07x, r = 0.209, r2 = 0.039; P < 0.01). When all six pairs of SAs were clamped in the absence of distal perfusion, a weak correlation was also evident between rate of change in SCVR and rate of change in SVR, and the rate of increase in SCVR was lower than the rate of increase in SVR (y = 0.19 + 0.08x, r = 0.379, r2 = 0.144; P < 0.01). Conclusions: The rate of increase in SCVR induced by noradrenaline administration was lower than the rate of increase in SVR in the control group with no spinal cord SA clamping and in both experimental groups with clamped SAs (with and without distal perfusion), creating an environment conducive to spinal cord flow distribution.

Three Arterial Ruptures in a Patient with Neurofibromatosis Type 1.

Neurofibromatosis type 1 (NF-1) is a rare disease known to cause vascular fragility. A case of a 59-year-old man with NF who had ruptures in three different arteries within a month is presented. The first rupture occurred in the right renal artery and was treated using a stent graft and embolization coils. The second and third ruptures occurred in an artery that had been compressed by a hematoma formed during the first bleed; both were embolized. In patients with NF-1, blood vessel fragility must be considered in treatment selection, especially when performing surgery or other invasive procedures near the great vessels.

Open Repair for Patent Ductus Arteriosus Aneurysm in an Adult.

Ductus arteriosus aneurysm (DAA) is rarely encountered in adults. There have been several hypotheses regarding its origin and potential indications for intervention in asymptomatic cases. If left untreated, rupture, compression of surrounding organs, and serious complications due to thromboembolism may occur, and aggressive surgical intervention appears desirable for patients who can tolerate surgery. We report a case involving a 30-mm, saccular, patent DAA that was incidentally discovered in a 49-year-old man on computed tomography. Open repair was performed by femorofemoral bypass assistance, which allowed decompression of the aorta and aneurysm and successful closure of the aortic and pulmonary artery ends.

Long-term results of microscopic lymphatic vessel-isolated vein anastomosis for secondary lymphedema of the lower extremities.

PURPOSE: To evaluate the effectiveness of microscopic lymphatic vessel-isolated vein anastomosis in patients with secondary obstructive lymphedema of a lower extremity, refractory to nonoperative management. METHODS: Nine women suffered from nonpitting edema of one or both legs (11 limbs) after radical hysterectomy with postoperative irradiation for uterine cancer. The indications for this operation were repeated cellulitis and severe nonpitting edema impairing limb function. Under microscopy of 3.2 on average, the identified lymphatic vessels were anastomosed to an isolated saphenous vein using the pull-through technique with modifications. RESULTS: The follow-up period ranged from 21 to 87 months and the operation achieved excellent reduction, of more than 5 cm, in six limbs; good reduction, of 2-5 cm, in two limbs; and poor reduction, of less than 2 cm, in three limbs. The frequency of cellulitis decreased from 2.4 infections per patient per year to 0.2 infections per patient per year. CONCLUSION: These results show that microscopic lymphatic vessel-isolated vein anastomosis is a minimally invasive operation, with good long-term effects, making it the treatment of choice for intractable secondary lymphedema of the lower extremities refractory to physiotherapy.

Autologous peripheral blood mononuclear cell implantation for patients with peripheral arterial disease improves limb ischemia.

BACKGROUND: Implantation of bone marrow mononuclear cells, including endothelial progenitor cells, into ischemic limbs has been shown to improve collateral vessel formation. In the present study the safety and feasibility of autologous peripheral blood mononuclear cells (PBMNCs) implantation after granulocyte-colony stimulating factor (G-CSF)-induced mobilization was investigated in patients with severe peripheral arterial disease. METHODS AND RESULTS: Six cases were enrolled: 5 of thromboangitis obliterans and 1 of arteriosclerosis obliterans. Following administration of G-CSF (10 microg . kg(-1) . day(-1)), PBMNCs were harvested and injected intramuscularly (5 legs and 1 arm) for 2 days for the patients with ischemia of the legs. No serious adverse events related to G-CSF administration, harvest or implantation were observed during this study period. Improvement in the ankle - brachial pressure index (ABI: >0.1) was seen in 4 patients at 4 weeks and ischemic ulcers improved in 3 of 3 patients. The mean maximum walking distance significantly increased from 203 m to 559 m (p=0.031) at 4 weeks and was sustained for 24 weeks. Significant improvement was seen in physiological functioning subscale of Short Form-36. CONCLUSION: Implantation of PBMNCs collected after G-CSF administration could be an alternative to therapeutic angioplasty in patients with severe peripheral arterial disease.

Air plethysmographic assessment of external valvuloplasty in patients with valvular incompetence of the saphenous and deep veins.

PURPOSE: The indications for deep venous valvuloplasty remain controversial in patients with incompetent deep vein valves associated with primary varicose veins. The purpose of this study was to evaluate the usefulness of external femoral valvuloplasty performed simultaneously with varicose vein surgery from the standpoint of venous function determined with air plethysmography. PATIENTS AND METHODS: Thirty-one limbs of 25 patients (12 men, 13 women; mean age, 56.3 years; range, 33 to 80 years) with chronic venous insufficiency caused by valvular incompetence of both deep veins and saphenous veins were studied in a prospective, nonrandomized fashion. Descending phlebography showed moderate to severe reflux of grade 3 or 4 with Herman and Kistner classifications. Clinical severity of disease was CEAP classification 2S (in six limbs), classification 3 (in three limbs), classification 4 (in 16 limbs), classification 5 (in two limbs), and classification 6 (in four limbs). We performed superficial venous surgery alone in 14 limbs (control group), which consisted of stripping or ligation of incompetent saphenous veins and ligation of all incompetent perforators. In the remaining 17 limbs (study group), we performed superficial venous surgery simultaneously with external valvuloplasty of the femoral vein with intraoperative endoscopic observation. Venous reflux of the limbs was evaluated with air plethysmographic examination before surgery and at 1, 6, 12, and 24 months after surgery in both groups. RESULTS: Preoperative venous filling index (mean +/- standard deviation) in the control and study groups was 9.4 +/- 3.8 mL/min and 8.8 +/- 3.5 mL/min, respectively (not significant), and it decreased to 7.0 +/- 3.6 mL/min (P <.01) and 2.8 +/- 1.0 mL/min (P <.01), respectively, 1 month after surgery. Postoperative index values in the study group were significantly lower than values in the control group (P <.01), and this difference continued for more than 2 years after surgery (P <.05). After a follow-up period of 12 to 37 months (average, 25 months), the venous clinical severity score was higher in the control group (3.4 +/- 1.7) than in the study group (2.1 +/- 0.3; P <.05), and the venous disability score was higher in the control group (1.4 +/- 0.6) than in the study group (0.8 +/- 0.8; P <.05). CONCLUSION: Although further follow-up study is necessary, these results point to the functional and clinical usefulness of femoral valvuloplasty performed simultaneously with varicose vein surgery in patients with moderate to severe deep venous reflux. The venous filling index obtained with air plethysmography is an excellent predictor of the clinical severity of the disease and of postoperative clinical results.