Correlation of hemostatic molecular markers and morphology of the residual false lumen in chronic aortic dissection.

We evaluated our hypothesis that morphological change of the aortic dissection can be predicted by serial measurements of hemostatic molecular markers. Between February 1999 and February 2003, 50 patients with chronic aortic dissection of the descending thoracic aorta were studied at random intervals of 1 to 59 months (mean, 15.4+/-14.3) after onset. Morphologies of the false lumen of the aortic dissection determined by computed tomographic (CT) images were divided into four groups. Twenty-two images had aortic dissection associated with intramural hematoma or a completely thrombosed false lumen without ulcer-like projections (group 1), 14 had a thrombosed false lumen with ulcer-like projections (group 2), 18 had patent, but a partially thrombosed false lumen (group 3), and 15 had a completely patent false lumen (group 4). Blood samples for detection of hemostatic molecular markers were collected on the same day or within 1 month of the CT scan being performed. Thrombin-antithrombin complex (TAT) and D-dimer proved to be significantly higher in group 3 than in group 1. There was no significant correlation between the external diameter and hemostatic molecular markers except for prothrombin fragments 1+2 (PTF1+2). Simultaneous determinations of these hemostatic markers and multiple CT scans were performed more than twice in 19 of the patients. These cases were divided into three groups according to the morphological changes of the false lumen in the interval; morphologically progressive, regressive and no change cases. Five cases showed reduction or disappearance of the false lumen (the regressive cases). Only one case showed that the false lumen progressively enlarged and was partially patent thereafter (the progressive case). Mean plasma levels of TAT and D-dimer were changed correlated with the morphological progressive or regressive changes. The morphology of aortic dissection was correlated with hemostatic molecular markers such as TAT or D-dimer. We concluded that the serial measurement of D-dimer and TAT is useful for predicting morphological changes in chronic aortic dissection, and it can be an alternative way to follow up for patients of aortic dissection.

Pre- and post-operative serum carcinoembryonic antigen in primary lung adenocarcinoma.

The clinical value of pre- and post-operative serum carcinoembryonic antigen (CEA) concentration (mean +/- SEM, ng/ml) in surgically treated primary lung cancer patients with adenocarcinoma (n=97) was studied. Preoperative CEA in pT2 patients (18.3+/-8.0) was higher than in pT1 (10.5+/-6.4, p<0.05) but was not different from pT3 patients (19.7+/-6.7). Preoperative CEA in pN1 patients (5.9+/-1.6) was lower than in pN2 (28.2+/-13.2, p<0.05) but not different from pN0 patients (8.8+/-3.8); p-stage II patients (8.2+/-4.7) had lower values than p-stage III patients (26.7+/-10.5, p<0.05), but not p-stage I patients (7.9+/-3.9). The CEA was not different between p-stages IA and IIA (3.5+/-0.6, 6.1+/-3.2) and IB and IIB (17.0+/-11.8, 11.7+/-7.8), but was different between IA and IB (p<0.05) and IIA and IIB (p<0.05). Preoperative CEA did not differ between patients who received complete (12.7+/-4.7) versus incomplete (9.5+/-6.0) resections, nor between patients who developed recurrence after surgery (21.9+/-10.4) versus those who were disease-free (30.9+/-21.7). CEA obtained 2 months after surgery in patients who recurred or metastasized after surgery (63.1+/-47.0) was higher than in disease-free patients (4.8+/-1.6, p<0.05). The post-/pre-operative CEA ratio in patients who recurred or metastasized after surgery (146.6+/-53.3%) was also higher than in disease-free patients (91.0+/-10.9%, p=0.05). In conclusion, CEA reflected tumor size but not the tumor invasion nor hilar lymph node disease; patients with mediastinal lymph node involvement had higher CEA values. Preoperative CEA did not reflect the likelihood of complete resection nor postoperative metastasis, but postoperative CEA obtained 2 months after surgery did reflect postoperative metastasis.

Surgical treatment of atherosclerotic and dysplastic aneurysms of the extracranial internal carotid artery.

Atherosclerotic and dysplastic aneurysms of the extracranial internal carotid artery are rare in Japan. We have experienced only four cases since 1982. The patients were two men and two women with a mean age of 67 years (range 51 to 82 years). All four patients had a saccular type aneurysm; sizes ranged from 30 to 75 mm. Aneurysmectomy and end-to-end anastomosis of the internal carotid artery could be performed in two patients. One patient underwent aneurysmorrhaphy followed by primary closure of the internal carotid artery, and the remaining patient underwent aneurysmectomy followed by a prosthetic graft replacement (6 mm-PTFE graft). During aneurysm repair, simple arterial cross-clamping (time 18 to 57 min; mean +/- SD: 31.3 +/- 18.0 min) was used in all patients. During arterial clamping of the carotid artery in two patients, somatosensory evoked potentials and regional cerebral oxygen saturation detected by near-infrared spectroscopy remained within normal ranges. All patients survived without neurologic deficits. These findings indicate that intraluminal shunting may be unnecessary during aneurysm repair if the patient does not have obstructive disease in the contralateral carotid artery and if no somatosensory evoked potentials or regional cerebral oxygen saturation abnormalities occur during proximal arterial clamping. After aneurysmectomy, end-to-end anastomosis of the internal carotid artery is the preferred method of repair if the length of the distal internal carotid artery permits.

Resection of thymic carcinoma in a patient with thoracic aortic aneurysm.

A 72-year-old man with a history of brain infarction presented with left sided anterior chest pain secondary to a thymic carcinoma. He received induction radiotherapy, 45 Gy. Preoperative computed tomography showed the tumor was adherent to a thoracic aortic aneurysm (TAA) which had extensive mural thrombus and calcification. To obtain adequate exposure without exerting tension on the fragile aneurysmal wall, ribs were resected to allow us to separate the tumor from the TAA, after which median sternotomy was performed uneventfully, creating generous exposure. The tumor had invaded the sternum, ribs, innominate vein, phrenic and recurrent laryngeal nerves, and lung. The tumor was removed en bloc, and the chest wall was reconstructed. Intra- and post-operative brain infarction and rupture of the TAA were avoided. The patient is alive and well without recurrence 10 months after surgery.

Anticoagulant therapy after prosthetic valve replacement -optimal PT-INR in Japanese patients-.

Values of the international normalized ratio of prothrombin time (PT-INR) were analyzed at the time when anticoagulant-related complications developed in patients undergoing prosthetic valve replacement so as to evaluate the optimal therapeutic range in PT-INR value in Japanese patients. A total of 102 patients with a prosthetic heart valve who have been followed up at our department during the past 25 years were enrolled in this study. PT-INRs were determined regularly in these patients for the period between October 1996 and March 1999. Although no thromboembolic complications occurred during the period of this study, hemorrhagic complications developed in 26 (25.5%) patients. Three (2.9%) patients suffered from life threatening bleeding, such as cerebral bleeding and gastrointestinal bleeding and were defined as the major hemorrhagic group. Another 23 (22.5%) patients had minor bleeding complications such as nasal, gingival or subcutaneous bleeding and were defined as the minor hemorrhagic group. Mean PT-INR values were 3.8 2.0 and 3.2 1.0 at the onset of the complications in major and minor hemorrhagic groups, respectively, and there was no significant difference between the two groups. However, mean PT-INR values in the minor bleeding group differed significantly from that in a patient group with no hemorrhagic complications (N=76). Among the cases with bleeding complications, only 19% of the patients belonged to the range below 2.5 of PT-INR value and 54% of the patients were included in the range from 2.5 to 3.5 (p<0.05). In conclusion, the optimal therapeutic range between 2.5 and 3.5 in PT-INR recommended by the American Heart Association for patients with a prosthetic heart value in Western countries may be too high in Japanese patients. PT-INR below 2.5 is considered to be safe to prevent hemorrhagic complications.

[Traumatic rupture of the thoracic aorta].

Nowadays, trauma victims are quickly transported from the scene to the therapeutic facility, therefore, even patients with traumatic aortic rupture (TAR) who were considered to be unlikely to survive several hours in the past are able to have more chance to undergo surgical treatment. In such patients who need emergency surgical repair of TAR regardless of the presence of multiple other organ injuries, massive contrast dye extravasation into the mediastinum is usually demonstrated on the contrast-enhanced computed tomography (CT) images. But, in most of the cases showing a pseudoaneurysm or dissection, delayed aortic repair is preferable when other organ injuries have therapeutic priority. The use of active adjunct means for distal support is definitely advantageous to prevent paraplegia. Heparin-bonded bypass by the use of low dose of heparin or intravenous argatroban is safe and avoids the risk of bleeding of other injured organs.

Stent graft treatment for thoracic and thoracoabdominal aortic disease using a unibody Z-stent that adapts to flexure.

Positioning a stent graft (SG) that adapts to the anatomical shape of the aorta is important to prevent complications after SG procedures to treat aortic disease. The Gianturco Z-stent has several benefits, but its rigid structure prevents adaptation to flexure. We improved this stent and studied its ability to adapt in the clinical environment. We positioned SGs and inspected their adaptability to flexure in an aortic arch model. We examined several gap lengths and strut directions, and determined the distance generated between the stent and the aortic wall. We found that adaptation was quite satisfactory with a gap of more than 10 mm or when the struts faced the major flexure or the side of the model aorta. Based on these findings and to facilitate placement, we manufactured the unibody Z-stent with 10-mm gaps. The unibody Z-stent was applied to treat thoracic and thoracoabdominal aortic disease in seven patients. The SG was positioned from the femoral or iliac artery in five patients and from an anastomosed graft to the ascending aorta after median sternotomy and bypass of the arch branches in two patients. A minor endoleak developed in one patient. None of the other six patients developed complications or died during the procedure, although one patient died in the hospital due to cerebral infarction. The unibody Z-stent was applied as a SG that adapts to flexure of the aorta and was easy to apply. The frequency of complications was apparently decreased after clinical application of the unibody Z-stent in SG treatment for thoracic and thoracoabdominal aortic disease.

Congenital anomaly of the external iliac artery: a case report.

A 51-year-old man was admitted with acute ischemic pain in the left leg. An angiogram demonstrated a well-developed left internal iliac artery that appeared to be continuous with the left common femoral artery, but no left external iliac artery. The left superficial and proximal deep femoral arteries were obstructed with thrombi. At surgery it was revealed that the distal end of the left common iliac artery was continuous with the dilated left internal iliac artery, forming the continuation with the left common femoral artery in the pelvic cavity. The left external iliac artery was absent between the common iliac and femoral arteries.

Simultaneous monitoring of somatosensory evoked potentials and regional cerebral oxygen saturation combined with serial measurement of plasma levels of cerebral specific proteins for the early diagnosis of postoperative brain damage in cardiovascular surgery.

Combined somatosensory evoked potential (SEP) and regional brain oxygen saturation (rSO(2)) monitoring and simultaneous measurement of plasma levels of S100Beta and creatine kinase-isozyme BB (CK-BB) were performed to evaluate how reliable these diagnostic modality complexes are in the early prediction of neurological complications after surgery. Between 1999 and 2002, intraoperative SEP and rSO(2) monitoring combined with measurements of S100Beta and CK-BB levels in blood were performed in 82 consecutive patients undergoing cardiovascular operations with cardiopulmonary bypass (CPB). Twelve (14.6%) of these patients were diagnosed as having neurological complications after surgery; seven with transient neurological dysfunction (8.5%), and five with permanent stroke (6.1%). Twenty one of 82 patients in whom rSO(2) was recorded were judged abnormal; however, only nine of the 21 (42.9%) were diagnosed as having brain damage - diagnostic sensitivity and specificity being 75.0% and 82.9%, respectively. All six patients who showed abnormal SEP during surgery had neurological complications, but normal SEP was recorded in six other patients with apparent evidence of neurological complications - diagnostic sensitivity and specificity being 50% and 100%, respectively. There were no significant differences in S100Beta levels between patients with and without brain complications at 1 h and 24 h after CPB, but significant differences were detected in CK-BB levels at 24 h after CPB. In conclusion, simultaneous abnormalities detected in SEP and rSO(2) are highly predictive of cerebral neurocirculatory disturbances, but they are not so sensitive in diagnosing restricted focal cerebral lesions. Additional determinations of blood CK-BB levels might be valuable only to confirm the newly established brain complications.