Akihiro Yamaoka

Clinical Experience with Temporary Vena Cava Filters

An experience with temporary filter placement, which seems to be safe and effective for temporarily preventing pulmonary embolism, is reported. Since October 1997, six patients had temporary filters. There were two men and four women, with a mean age of 37 years. Three filters were placed at the infrarenal inferior vena cava, two at the suprarenal inferior vena cava, and one at the superior vena cava. All filters were placed before various surgical interventions. During filter placement, anticoagulation therapy was routinely performed. There were no complications at and during filter placement. No pulmonary emboli occurred during surgical intervention. All filters were successfully removed, two of which were exchanged for permanent filters. All patients are alive and well without recurrent deep vein thrombosis and/or pulmonary emboli during a follow-up period of 11 to 25 months. Although this experience is small, temporary filter placement is safe and effective for short-term prevention of pulmonary emboli even in older patients or those with malignant disease. Veins of the upper part of the body may be more favorable than the femoral vein for insertion of a temporary filter. Temporary filters can be safely placed not only at the infrarenal inferior vena cava, but also at the suprarenal inferior vena cava or superior vena cava.

Organ malperfusion in acute aortic dissection.

OBJECTIVE Organ malperfusion in aortic dissection can precipitate a serious condition. The strategy of treatment for it has been controversial. We have focused on the strategy and outcome of acute aortic dissection with organ malperfusion. SUBJECTS AND METHODS Between January 1995 and December 1998, 134 acute aortic dissection patients were admitted. There were 73 males (65.4 +/- 8.0 years old) and 61 females (66.7 +/- 7.4 years old). There were 83 patients of Stanford type A, and 51 patients of type B. Of them, 24 patients (17.9%) were complicated by organ malperfusion. The brain was affected in 4, the heart in 5, the spinal cord in 2, the liver in 1, the intestine in 1, the kidney in 4, and the lower extremities in 10 patients. Our management strategy for a patient with malperfusion in acute aortic dissection was that the antecedent operation was initially mandatory, and central grafting was secondarily considered. RESULTS Refusal of operation or lethal conditions excluded 8 of the 24 patients from operation. An antecedent operation was mandatory in eight of the remaining 16 patients. The overall mortality was 33.3% (8/24 patients), and operative mortality was 31.3% (5/16 patients) in the patients with malperfusion. The overall mortality was 11.8% (13/110 patients), and the operative mortality was 11.1% (9/81 patients) in the patients without malperfusion. CONCLUSION Organ malperfusion is a major component in the management and treatment of acute aortic dissection. Only an appropriate strategy and therapy could result in a satisfactory outcome.

Preoperative autologous donation of blood in cardiac surgery —Age related factors—

We have studied influence of the age related factors on preoperative autologous donation (PAD) of blood in cardic surgery. PAD was undertaken in 246 cases of elective cardiac surgery by means of simple or leap-frog method, starting at approximately 4.5 weeks before operation. It provided 1726 ml of autologous blood storage on the average. Sorting the patients into three groups with age, leading surgical procedures were as follows: closure of the atrial septal defect (ASD) in teen 30s (group L, n = 51), aortic valve replacement (AVR) or mitral valve replacement (MVR) in 40s-50s (group M, n = 83) and 60s and over (group H, n = 112). Coronary artery bypass grafting (CABG) was more common in group H. Percent-freedom from allogeneic blood transfusion was 82.3% in group L, 80.7% in group M and 61.6% in group H, respectively (p < 0.05; L, M vs. H), donated blood volume in group H was significantly less than that of group M (p < 0.05, M: 1987 +/- 63, H: 1610 +/- 60 ml), because blood volume and hemoglobin level before donation tended to be less in group H. Each group did not differ in blood loss during and after operation, which showed a significant positive correlation with operation time and cardiopulmonary bypass (CPB) time. Comparing factors in ASD, CPB time was relatively long, and postoperative blood loss was significantly larger in group H (p < 0.05; L: 432 +/- 71 ml, M: 369 +/- 34 ml, H: 754 +/- 124 ml). This finding suggests that the secondary lesions in age ASD cases adversely affected hemostasis. As to AVR, MVR and CABG, there were no differences in these factors but donated blood volume among three groups. We conclude that elderly patient (60s and over) tends to necessitate allogeneic blood transfusion in cardiac surgery because of the insufficient PAD. Earlier commencement of PAD or concomitant application of erythropoietin will improve this situation.

Portal vein obstruction accompanied by intrahepatic stones

This study was conducted to clarify the pathogenesis of portal vein obstruction (PVO) associated with intrahepatic stones. Five cases with PVO and intrahepatic stones were studied retrospectively. The coincidence rate of PVO in intrahepatic stones was 5.8% (5 of 86 cases), and that of intrahepatic stones in PVO, 45.5% (5 of 11 cases). All cases had one or more symptoms of cholangitis, such as high-grade fever, abdominal pain, and jaundice prior to diagnosis of PVO. The portal vein was occluded at the main trunk in 4 and in the left branch in 1. Intrahepatic stones were found in bilateral hepatic lobes in 3 and in the left lobe in 2. Numerous calcium bilirubinate stones were packed in dilatated intrahepatic bile ducts of an excised specimen of the liver. Microscopically, arterial structures could be seen, but the portal vein ceased to be evident about the involved bile duct. Based on the results of this study, persistent cholangitis and packed gallstones were concluded essential to the development of PVO accompanied by intrahepatic stones.

Malignant Melanoma of the Chest Wall With an Unknown Primary Lesion

We report herein the case of a 66-year-old man who underwent resection and reconstruction of the chest wall due to the presence of a malignant melanoma without a detectable primary lesion. The patient was discharged in good condition after receiving chemotherapy but eventually died of multiple bone metastases 2 years after surgery. Throughout the postoperative course, there were no specific symptoms or findings suggesting the presence of a primary lesion. It was considered likely that the primary tumor was resolved by spontaneous regression after chest wall metastasis had been established.