[Idiopathic pulmonary trunk aneurysm].

Pulmonary trunk aneurysm is generally associated with congenital cardiac defects, pulmonary hypertension, or infection. Idiopathic pulmonary trunk aneurysm without any associated diseases is a rare lesion and has seldom been reported. Here, we report a case of a 68-year-old woman with idiopathic pulmonary trunk aneurysm. The maximum diameter of the aneurysm was 53 mm while she was 142 cm in height. We successfully performed aneurysmorrhaphy and her postoperative course was uneventful. Aneurysmorrhaphy was an effective technique for idiopathic pulmonary trunk aneurysm without pulmonary hypertention.

Fenestrated stent-graft facilitates emergency endovascular therapy for blunt aortic injury.

BACKGROUND: Endovascular stent-grafting with intentional coverage of the left subclavian artery may be used to treat aortic isthmus injury, but this procedure may have serious neurologic sequelae and may not provide an adequate proximal landing zone. In 2005, in an effort to mitigate these problems, we began to use fenestrated stent-grafts for emergency repair of blunt aortic injury (BAI). METHODS: Between 2005 and 2007, all patients in our practice with a BAI with mediastinal hematoma (except young patients without an associated critical injury) were treated with immediate endovascular stent-grafting, if anatomically possible. A fenestrated stent-graft was placed from the aortic arch, if the BAI was less than 20-mm distal of the left subclavian artery. The records of the 13 patients in the series were reviewed retrospectively. RESULTS: The BAI treatment was successful in all 13 patients. Eight patients (61.5%) were given a fenestrated stent-graft, placed distal to either the ascending aorta (n = 2), brachio-cephalic artery (n = 4), or left common carotid artery (n = 2), without concomitant bypass grafting or transposition of the head vessels. Two patients died of an associated critical brain injury (hospital mortality rate, 15.4%). There were no perioperative complications related to stent-graft usage and no unintentional occlusions of the head vessels by a fenestrated device. One patient underwent open repair of a newly developed type Ia endoleak 7 months after placement of a nonfenestrated stent-graft. CONCLUSION: Fenestrated stent-grafts can be used to treat BAI, without any concomitant procedures to provide an adequate proximal landing zone.

Is video-assisted thoracoscopic surgery a feasible approach for clinical N0 and postoperatively pathological N2 non-small cell lung cancer?

OBJECTIVE: It remains controversial whether video-assisted thoracoscopic surgery (VATS) major pulmonary resection (VMPR) with systematic node dissection (SND) is a feasible approach for clinical N0 and pathological N2 non-small cell lung cancer (cN0-pN2 NSCLC). We compared the clinical outcome of patients who underwent VMPR with SND for cN0-pN2 NSCLC with the outcome of patients who underwent MPR with SND by thoracotomy. We conducted this study to determine the feasibility of VMPR for cN0 and pN2 NSCLC patients and intraoperative node staging by node sampling. METHODS: Between 1997 and 2006, 770 patients underwent MPR with SND for NSCLC, wherein 450 patients had VMPR and 320 were subjected to open thoracotomy. There were 673 clinical N0 patients. Among them, we retrospectively reviewed 69 patients (10.3%) with cN0-pN2 NSCLC of which the greatest tumor dimension ranged from 20 to 50mm. These patients were divided into two groups: 37 patients under group V, who underwent VMPR, and 32 patients under group T, who underwent MPR by thoracotomy, for cN0-pN2 NSCLC. The majority of the patients underwent postoperative chemotherapy. RESULTS: There were no differences between the two groups regarding preoperative data or the number of nodes dissected. The rate of nodal metastasis (number of metastatic nodes/number of dissected nodes) was similar between the two groups (group V vs group T, 0.24 vs 0.24 in total nodes dissected, 0.24 vs 0.23 in mediastinal nodes dissected). The 3-year and 5-year recurrence-free survivals were similar (60.9% vs 49.6% and 60.9% vs 49.6%), as well. Most of the pattern of recurrence was due to remote metastasis. In like manner, the 3-year and 5-year survivals were similar (67.6% vs 57.7% and 45.4% vs 41.1%). CONCLUSIONS: This study demonstrates that VMPR with SND is a feasible surgical therapy for cN0-pN2 NSCLC without loss of curability. It is unnecessary to convert the VATS approach to thoracotomy in order to do SND even if pN2 disease is revealed during VMPR.

Minimally ischemic off-pump coronary artery bypass grafting: active perfusion-assist with nitroglycerin-supplemented blood.

During off-pump coronary artery bypass surgery, concern remains about possible myocardial injury associated with the transient occlusion and stabilization of the target vessels. To try to minimize myocardial ischemia and achieve hemodynamic stability, we used a coronary perfusion catheter combined with the perfusion-assisted direct coronary artery bypass system, which enables active and modified coronary perfusion of the target vessel throughout the duration of multiple grafting.

Feasibility of video-assisted thoracoscopic surgery segmentectomy for selected peripheral lung carcinomas.

OBJECTIVE: Segmentectomy for non-small cell lung cancer (NSCLC) is believed to increase the rates of recurrence and postoperative air leak. We sought to present our clinical data and outcome of VATS (video-assisted thoracoscopic surgery) segmentectomies with systematic node dissection for selected NSCLC patients. METHODS: Inclusion criteria were clinical T1N0M0 peripheral NSCLC measuring 7 days), which required no surgical intervention, occurred in two patients. The chest tube drainage duration was 3 days. There were no in-hospital deaths. The numbers of resected subsegments and reserved subsegments in comparison with lobectomy were 5 (2-13) and 5 (3-13), respectively. The FEV1.0 after VS was higher than the predictive FEV1.0 after lobectomy, if the latter was performed as standard procedure. We experienced four cases of distant metastasis after segmentectomy, but there was no case of local recurrence. The 5-year survival and recurrence-free survival rates in pathological stage IA NSCLC were 89.9% and 93.3%, respectively. CONCLUSIONS: VATS segmentectomy with systematic node dissection is a reasonable treatment option for selected peripheral NSCLC.

Less-invasive management of left subclavian artery in stent-grafting for distal aortic arch disease.

Simple coverage of the left subclavian artery (LSA) in thoracic endovascular aortic repair (TEVAR) is still a controversial procedure. We present our modified strategy dealing with LSA in TEVAR. Hand-made stent grafts were placed more proximal beyond the LSA for 104 patients. In elective 76, preoperative LSA occlusion test was performed on 31 patients, and preoperative computed tomographic angiography (CTA) of the vertebro-basilar artery was performed on the remaining 45. Head vessels were planned to be kept patent using fenestrated stent grafts, if possible. Stent grafts were placed from zone 0 in 23, zone 1 in 39, and zone 2 in 42. The LSA occlusion tests revealed harmful effects, such as loss of consciousness and vertigo in two out of 31 patients (6.5%). Vertebro-basilar arterial CTA revealed possible risks, if LSA covered, in three out of 45 patients (6.7%). Fenestrated stent grafts could successfully preserve 131 head vessels, except for one unintentional occlusion of the left carotid artery (0.75%). There was no LSA-related complication in any of the cases. A combination of preoperative vertebro-basilar arterial CTA and fenestrated stent grafts is useful to avoid possible LSA-related complications in TEVAR.

Is lung cancer resection indicated in patients with idiopathic pulmonary fibrosis?

OBJECTIVE: The purpose of this study was to determine the implication of idiopathic pulmonary fibrosis on the surgical treatment for primary lung cancer. METHODS: Between January 1994 and June 2006, 870 patients with primary lung cancer were surgically treated. Fifty-six (6.4%) of 870 patients had complications with idiopathic pulmonary fibrosis, and their data were retrospectively reviewed. There were 50 men and 6 women with an average age of 68 years. The incidence of squamous cell carcinoma was 28 (50.0%). Surgical procedures consisted of 7 wedge resections of the lung, 5 segmentectomies, 43 lobectomies, and 1 bilobectomy. RESULTS: Surgery-related hospital mortality was higher in patients with idiopathic pulmonary fibrosis than in patients without (7.1% vs 1.9%; P = .030). Four (7.1%) of these 56 patients had acute postoperative exacerbation of pulmonary fibrosis and died because of this complication. No factors such as pulmonary function, serologic data, operative data, and histopathologic data were considered predictive risk factors for the acute exacerbation. The postoperative 5-year survival for pathologic stage I lung cancer was 61.6% for patients with idiopathic pulmonary fibrosis and 83.0% for patients without (P = .019). The causes of late death were the recurrence of cancer or respiratory failure owing to idiopathic pulmonary fibrosis. CONCLUSIONS: Although idiopathic pulmonary fibrosis causes high mortality after pulmonary resection for lung cancer and poor long-term survival, long-term survival is possible in patients with these two fatal diseases. Therefore, in selected patients, idiopathic pulmonary fibrosis may not be a contraindication to pulmonary resection for stage I lung cancer.