[Initial Clinical Experience of the Herbal Medicine Inchinkoto for Refractory Hyperbilirubinemia Following Open-heart Surgery].

We retrospectively assessed our initial clinical experience of the herbal medicine Inchinkoto for refractory hyperbilirubinemia following open-heart surgery. Six patients developed hyperbilirubinemia in an acute phase after surgery and their maximum total bilirubin levels were 6.4~26.4 mg/dl( mean:13.1± 8.2 mg/dl). They were initially treated with ursodeoxycholic acid and/or Stronger Neo-Minophagen C containing monoammonium glycyrrhizinate, glycine, aminoacetic acid, and L-cysteine hydrochloride hydrate. These treatments, however, were ineffective, and Inchinkoto was introduced at 5~34 day (mean:13.3±11.3 days) after surgery. Hyperbilirubinemia improved in all patients after the introduction of Inchinkoto:1 day after in 1 case, 2 days after in 2 cases, 3 days after in 2 cases, and 4 days after in 1 case. These results indicate the potential of Inchinkoto to attenuate refractory hyperbilirubinemia following cardiac surgery with cardiopulmonary bypass.

A case of vascular graft infection caused by Staphylococcus lugdunensis after femoropopliteal bypass operation.

A 79-year-old man who had undergone a right femoropopliteal (FP) bypass operation 6 weeks previously was diagnosed with vascular graft infection caused by Staphylococcus lugdunensis. Another FP bypass operation was performed, with long-term administration of antibiotics, and the patient eventually recovered well without any recurrences for over 2 years. Although S. lugdunens is classified as coagulase-negative Staphylococcus, its pathogenicity has been reported to be equal to that of S. aureus. Based on the literature review, the organism characteristically colonizes the inguinal area of human skin;thus, operations such as FP bypass grafting may place patients at a relatively high risk for infection by S. lugdunensis, a potentially high-pathogenicity organism.

Hypogastric and lumbar artery bypasses to restore gluteal perfusion after open aortoiliac aneurysm repair.

Gluteal ischemia is a rare but often fatal complication after open abdominal aortic aneurysm repair. A 67-year-old man with an aortoiliac aneurysm presented with a patent right internal iliac artery (IIA) and an occluded left IIA. A bifurcated graft replacement was performed with both limbs of the graft anastomosed to the external iliac arteries. The right IIA was ligated and the inferior mesenteric artery was reimplanted. Postoperatively, the patient developed right gluteal ischemia. Hypogastric and lumbar artery bypasses were immediately performed and the patient recovered without gait disturbance. This treatment prevented potentially fatal necrosis of the buttock.

[Surgical treatment of traumatic aortic rupture].

This report focuses on 3 cases of traumatic aortic dissection or rupture at the isthmus. We selected 3 different methods of treatment. In the 1st case, we performed an emergency operation with graft replacement of the proximal descending aorta. In the 2nd case, we performed elective graft replacement 5 months after the rupture under careful blood pressure control. Thirdly, we performed emergency stent grafting at the isthmus, the rupture site. All cases were successfully treated, but it remains difficult to select the method of treatment for multisystem disorder. Our current strategy for traumatic rupture at the isthmus is immediate stent grafting. It will also be a very useful procedure for multisystem trauma.

[Aortic valve-sparing operation for chronic dissecting aneurysm of the sinus of valsalva associated with redissection in a young woman who experienced out-of-hospital cardiac arrest].

A 38-year-old woman was admitted to our hospital because she experienced cardiopulmonary arrest at her wedding;her cardiac beats were resumed 20 min after cardiopulmonary resuscitation performed by her relatives and hotel staffs. Enhanced computed tomography revealed acute aortic redissection in chronic dissecting aneurysm in the right sinus of Valsalva, which was believed to have occurred in the 4th month of pregnancy 2 years before. Echocardiography showed moderate aortic regurgitation. We performed aortic valve-sparing operation and ascending aortic replacement with partial remodeling of the right sinus of Valsalva. She returned to work 2 months later without high-order dysfunction.

Intraoperative collection of autologous platelet-rich plasma from the cardiopulmonary bypass circuit upon initiation of extracorporeal circulation.

OBJECTIVES: The aim of this study is to evaluate the possibility of the autologous platelet-rich plasma (PRP) collection from the cardiopulmonary bypass (CPB) circuit and to evaluate its effect on the aggregative function. METHODS: For seventy-two patients undergoing cardiac surgery with CPB, an autologous PRP was prepared using the Haemonetics Component Collection System® by drawing blood from the CPB circuit immediately after CPB was established. The blood samples were taken at three points for examination, A: beginning of surgery, B: immediately after heparin reversal with protamine following discontinuation of CPB, C: after the collected autologous PRP was returned to the patient. Platelet count and platelet aggregation ability were analyzed. RESULTS: The mean platelet count in autologous PRP was 5.5 (range: 3-14) units. Platelet count decreased by 115.0 (±27.3) × 1000/µl from A to B and increased by 27.3 ± 17.2 (× 1000/µl) from B to C. When platelet aggregation was measured by Adenosine Diphosphate (ADP) 3.0 µM, it decreased by 42.6% ± 12.1% from A to B and increased by 8.7% ± 7.4% from B to C. CONCLUSIONS: Autologous PRP can be safely collected by drawing blood from the CPB circuit, platelet count and aggregation ability significantly decreased after CPB including autologous PRP collection. Some improvement was detected in the number of the platelets count and platelet aggregation ability by administrating an autologous PRP even if autologous PRP is collected from CPB circuit. TRIAL REGISTRATION: UMI-CTR, UMIN000023776 . Registered 1 October 2016.

Treatment of ventricular septal perforation caused by blunt trauma using the right ventricle approach: A case report.

Traumatic ventricular septal perforation (VSP) is a rare condition that can occur following chest trauma and can lead to heart failure. Herein, a case of VSP caused by blunt chest trauma successfully closed using the double-patch technique via the right ventricle after medial sternotomy is presented. This case report highlights the necessity of emergency surgery in the acute phase of traumatic VSP if heart failure is difficult to control. This technique was useful for acute surgery. .

Surgical management of large undifferentiated cardiac sarcoma involving the right ventricle to pulmonary trunk.

A large intra-cardiac tumor from the right ventricle to pulmonary trunk was detected by contrast-enhanced computed tomography and transthoracic echocardiography in a 59-year-old woman with progressive dyspnea on effort and acute congestive right-sided heart failure. Emergent surgical management was performed with cardiopulmonary bypass under cardiac arrest, however, tumor resection was incomplete, because it originated from the interventricular septum. Concomitant tricuspid valve replacement using a bioprosthesis was required due to the involvement of the septal leaflet of the tricuspid valve. Although large pulmonary thromboembolism was initially suspected, a pathological examination confirmed undifferentiated cardiac sarcoma. The patient did not consent to additional neoadjuvant chemotherapy or radiation therapy. After palliative surgical management, she was discharged. Recurrence rapidly progressed and the patient died approximately 2 months after surgery. We herein present a successful palliative surgical case of large cardiac undifferentiated sarcoma originating from the intraventricular septum and involving the right ventricle to pulmonary trunk.

A surgical case of triple valve replacement for triple valve endocarditis with multiple vegetations.

A 68-year-old man with cerebral infarction and right hemiplegia was diagnosed with active infective endocarditis, and multiple large vegetations and more than moderate valve regurgitation by three different valves were detected using transthoracic echocardiography. An urgent surgical intervention was selected, and aortic and mitral valve replacements using bioprostheses were initially performed due to large vegetation on both these valves with valve cusp destruction. Residual severe regurgitation persisted despite tricuspid valve plasty; therefore, tricuspid valve replacement using a tissue valve was performed, and triple valve replacement was eventually accomplished without any serious hemodynamic compromise. The postoperative clinical course was fair and the patient was discharged after 3 months of inpatient strict management and cardiac rehabilitation. However, he died approximately 9 months after the initial surgery due to multiple organ failure. We herein presented a rare surgical case of triple valve replacement for triple valve endocarditis with multiple large vegetations.

Local administration of the powder minocycline during surgical intervention for active infective endocarditis.

OBJECTIVES: We retrospectively assessed the initial clinical impact of the locally administered bacteriostatic antibiotic, powder minocycline, during surgery for active infective endocarditis (AIE). METHODS: Among 38 surgical AIE patients, 36 patients who underwent surgical intervention for AIE using local administration of powder minocycline between January 2008 and August 2017 in our institute were enrolled. During surgery, the local administration and dispersion of powder minocycline at not only the valvular annulus and perivalvular cavity, but also the prosthetic cuff and ring were performed following the complete resection and aggressive debridement of infectious tissues. Early clinical outcomes, including survival, postoperative co-morbidities, and freedom from re-intervention or significant paravalvular leakage (PVL), were assessed. RESULTS: Early mortality within 30 days was 5.6% and hospital death was 13.9%. There was no reoperation within 30 days and only one patient (3.8%) developed recurrent infection, which improved with additional antibiotic treatments. More than moderate PVL within 30 days was detected in one patient only (3.8%). Over a median follow-up period of 38.3 ± 35.5 months, a Kaplan-Meier analysis revealed that 1- and 5-year survival rates were 75.7 and 66.8%, respectively, and freedom from reoperation was 100% at 5 years. Freedom from significant PVL at 5 years was 91.0%. CONCLUSIONS: The local administration of powder minocycline may be a simple and effective manipulation during surgical intervention for AIE without extensive reconstruction; however, the surgical management of AIE remains challenging.

Angiographic appearance of patent saphenous vein grafts more than 25 years after coronary artery bypass grafting.

Nine patients with ten angiographical patent saphenous vein grafts (SVG) more than 25 years after coronary artery bypass grafting (CABG) at Kawasaki Medical School Hospital between 1976 and 1992 were reviewed. Patent SVG disease was assessed using the FitzGibbon classification, and clinical characteristics which might affect the longevity of SVG were retrospectively evaluated. The mean duration between surgery and current coronary angiography was approximately 30 years (25-35 years). There were two perfectly patent SVGs (FitzGibbon AI, 35 and 32 years after surgery), both of which were bypass grafts to the left anterior descending arteries (LAD). The other eight grafts exhibited some vein graft disease (BII:3, BIII:5). The sequential anastomosis was performed for 5 SVGs. The SVGs bypassed to the good run-off LAD, sequential bypass, strict medical management including cessation of smoking and body weight control may contribute to the slow progression of vein graft disease after CABG.

Treatment of Acute Type A Aortic Dissection Involving Upper Extremity Reperfusion Injury.

A 70-year-old man underwent emergent primary central repair for acute type A aortic dissection (AAAD) with right upper extremity ischemia. Ascending aorta and hemi-arch replacement concomitant with additional right upper peripheral bypass was performed for persistent right upper arm ischemia. The early reperfusion injury (RI) of the right upper extremity was defined the next day, and managed by continuous hemodialysis (CHD) and infusion therapy, resulting in the arm being salvaged. This is an extremely rare adverse phenomenon, and we herein described its successful treatment with perioperative intensive management following central repair of AAAD.

Initial clinical evaluation of preoperative frailty in surgical patients with Stanford type A acute aortic dissection.

BACKGROUND: We retrospectively assessed the initial clinical role of preoperative frailty in surgical patients with Stanford type A acute aortic dissection (AAAD). METHODS: One hundred and fourteen consecutive patients who underwent emergent or urgent surgical interventions for AAAD in our institute between April 2000 and March 2016 participated in this retrospective study. Patients with more than three of the following six modalities were defined as being frail: age older than 75 years, preoperative requirement of assistance in daily living, body mass index less than 18.5 kg/m2, female, history of major stroke, and chronic kidney disease greater than class 3b. Twenty-three patients (20.2%) were diagnosed with frailty (group F), while 91 patients (79.8%) were not (group N). Early clinical outcomes, major postoperative complications, postoperative recovery of activity, and early or mid-term survival were evaluated. RESULTS: Although early clinical outcomes and the prevalence of major postoperative complications were similar in both groups, postoperative activity of daily living (ADL), such as the rate of being ambulatory on discharge (p < 0.05) and home discharge (p < 0.01), was significantly lower in group F than in group N. A Kaplan-Meier analysis revealed that 1- and 5-year survival rates were similar in groups F (85.9 and 76.4%, respectively) and N (86.0 and 76.9%, respectively). CONCLUSIONS: Preoperative frailty in AAAD surgical patients has potential as a prognostic factor that affects delays in ADL recovery, but does not influence the early or mid-term clinical outcomes of prompt surgical strategies for life rescue in AAAD patients with frailty.

Surgical management of extensive dissecting thoracic aortic aneurysm via the semi-clamshell approach.

BACKGROUND: We retrospectively evaluated the initial clinical experience of the surgical management of extensive dissecting thoracic aortic aneurysm (TAA) via the semi-clamshell approach. METHODS: Thirteen patients (3 women and 10 men, mean age 67 ± 15 years) who underwent elective surgical intervention for extensive dissecting TAA via semi-clamshell approach in our institute between May 2007 and April 2017 participated in this study. Regarding surgical techniques, left thoracotomy with transverse sternotomy was initially performed via the third or fourth intercostal space following an incision from the right sternal borderline to the anterior axillary line on the left sternal borderline. Cardiopulmonary bypass was then established and extensive graft replacement was conducted with hypothermia. RESULTS: Extensive total arch replacement (TAR) was performed on 4 patients, TAR with descending thoracic aortic replacement (DTAR) on 4, distal hemiarch replacement with DTAR on 3, and extensive graft replacement from the ascending to descending thoracic aorta on 2. There was one (7.7%) case of surgical and hospital mortality due to low-output syndrome. None of our patients developed respiratory failure requiring secondary tracheotomy; however, new-onset cerebrovascular infarction was noted in 2 (15.4%). No mediastinitis or serious infectious complications were observed after surgery. With a mean follow-up period of 45.1 ± 44.1 months, a Kaplan-Meier analysis revealed that 1- and 5-year survival rates were both 92.3%, respectively. CONCLUSIONS: The surgical management of extensive dissecting TAA by semi-clamshell approach may contribute to acceptable early clinical outcomes in high-risk patients, and represents an alternative surgical option in the current endovascular era.

Long-Term Results of Obturator Bypass.

OBJECTIVE: We evaluated the long-term outcomes of obturator bypass. MATERIAL AND METHODS: A total of 16 patients (13 males and 3 females; 17 limbs) who underwent obturator bypass surgery at our department between April 1995 and March 2008 were included. RESULTS: Their ages ranged from 50 to 90 with a mean of 74 years. Inguinal infections observed in the 16 patients consisted of vascular graft infections in 13 patients, hemostatic device infections following endovascular therapy in two patients, and femoral artery infections following coronary angiography in one patient. The cumulative patency rate was 69% for 3 years and 43% for 5 years. The cumulative survival rate was 64% for 3 years and 55% for 5 years. CONCLUSION: Obturator bypass surgery was successfully performed with favorable results for arterial infections and vascular graft infections in the inguinal region.

Positioning for Endovenous Laser Ablation: Comparative Study with Thigh Stripping.

We performed a comparative study of surgical outcomes and venous functions between endovenous laser ablation with a 980-nm diode laser (EV group) and thigh stripping (ST group). There were no severe complications and initial success rates were 100% in both groups. In the EV group, preoperative symptoms improved in 94.3% of cases, the venous occlusion rate was 98%, and endovenous heat induced thrombosis had occurred in 11.9% (Class 3: 0.7%) at 12 months after the operation. Although comparative study of postoperative venous function by air plethysmography showed significant improvement in both groups, there was less recovery of postoperative venous function in the EV than in the ST group. (This article is a translation of J Jpn Coll Angiol 2015; 55: 13-20.).

Bypass vs. Endovascular Therapy of Infrapopliteal Lesions for Critical Limb Ischemia.

OBJECTIVE: This study was conducted to determine whether to perform endovascular intervention or bypass surgery as a treatment option for critical limb ischemia (CLI) with lesions in the popliteal artery or below. SUBJECTS AND METHODS: A total of 150 patients (164 limbs) with CLI underwent endovascular intervention or bypass surgery for lesions in the popliteal artery or below at our department between May 1995 and June 2011. Therapeutic outcomes were examined by surgical technique. An indication for endovascular intervention was established with the combination of (1) poor general condition, and (2) a stenotic or occlusive lesion ≤5 cm. RESULTS: The bypass group (group B) comprised 119 patients (99 males, 20 females) with 131 affected limbs at 46 to 89 years of age (mean: 70 years). The endovascular intervention group (group E) comprised 31 patients (25 males, 6 females) with 33 affected limbs at 47 to 89 years of age (mean: 72 years). There was no significant difference in patient demography between the two groups. Regarding preoperative complications, hypertension was observed in 54% and 61% of the subjects in groups B and E, respectively, diabetes in 36% and 55%, renal dysfunction in 29% and 58%, ischemic heart disease in 27% and 32%, and cerebrovascular disorder in 18% and 23%; renal dysfunction accounted for a significantly higher percentage in group E. As for early postoperative complications, subjects in group B experienced wound infections (6 patients), hemorrhage (2), thrombosis (2), pneumonia (1), and another complication (1), and those in group E experienced wound infections (1) and another complication (1). The hospital mortality rate was 0.8% (1 patient) for group B and 0% for group E. The 3-year cumulative primary patency rate was 72% for group B and 54% for group E; the rate was significantly higher for group B. The 3-year secondary patency rate was 82% for group B and 60% for group E. The 3-year limb salvage rate was 86% for group B and 82% for group E; there was no significant difference between the two groups. The 5-year survival rate was 57% for group B and 42% for group E; the survival rate was significantly lower for group E. CONCLUSION: For the study population of CLI patients with lesions in the popliteal artery or below, the patency rate was higher for the bypass group than for the endovascular intervention group, whereas there was no difference in the limb salvage rate. Based on the findings in prognosis for survival, the indication for endovascular intervention at our department is believed to be appropriate. (English translation of Jpn J Vasc Surg 2013; 22: 715-718).

Assessment of the characteristics and detectability of skin perfusion pressure measured using a thermostatic heating probe.

OBJECTIVES: To assess the characteristics of skin perfusion pressure (SPP) measured using a thermostatic heating probe and whether a thermostatic heating probe improves SPP detection. METHODS: We studied 8 feet of healthy young subjects and 31 feet of elderly patients suspected to have severe limb ischemia. We measured SPP at the dorsum and plantar aspects of each foot using a plain laser Doppler probe and a thermostatic heating probe heated at 44°C. Results were expressed as median. Comparisons were analyzed using a non-parametric test. RESULTS: In the healthy subjects, the SPP values at both the dorsum and the plantar aspect were not significantly different after heating. The thermostatic heating probe did not improve the SPP detection rates. In the patients with ischemic limb, the SPP values at both the dorsum and the plantar aspect significantly increased after heating (p <0.001 for both). The SPP detection rate at the dorsum remained at 96.8%; however, it was improved from 87.1% to 100% at the plantar aspect after heating. CONCLUSION: The thermostatic heating probe was shown to be useful for improving the detectability of SPP in the ischemic limbs. An SPP increase after heating may be considered as a parameter of limb ischemia.