Atsuo Kojima

Surgical Treatment of Retroperitoneal Leiomyosarcoma Invading the Inferior Vena Cava: Report of Three Cases

Abstract.Retroperitoneal leiomyosarcoma is a rare neoplasm for which complete surgical removal provides the only effective treatment, as local recurrence adversely affects prognosis. However, invasion of major vessels may occur, making complete resection difficult. This report describes the cases of three patients who required concomitant resection of parts of the inferior vena cava because of direct tumor invasion. The major vessels should be isolated in preference to the tumor capsule during surgery to prevent sudden exsanguination or incomplete tumor resection. Resection of a recurrent sarcoma or a solitary metastasis can be effective in selected patients.

Successful surgical treatment of a patient with multiple visceral artery aneurysms due to fibromuscular dysplasia

Multiple visceral artery aneurysms due to fibromuscular dysplasia are rare. A 43-yr-old man with a pulsatile abdominal mass detected by ultrasonography had multiple visceral artery aneurysms diagnosed by angiography. This included a huge superior mesenteric artery aneurysm. Aneurysm resection and arterial reconstruction was performed successfully. Pathologic examination revealed fibromuscular dysplasia of the medial fibroplasia type.

Is the size of an abdominal aortic aneurysm associated with coagulopathy

Abdominal aortic aneurysm (AAA) volume and intraluminal thrombi were analyzed with respect to the number and function of platelets, blood cells, and coagulation factors. A group of 43 patients who underwent repair of an AAA were enrolled in this study. The maximum diameter and volume of the AAA, and the volume of intraluminal thrombi and lumen were measured by computed tomography with planimetry. The platelet count and platelet function, prothrombin time, activated partial thromboplastin time, fibrinogen, plasminogen, antithrombin 3, fibrin degradation products (FDP), D-dimer, and blood cell counts were measured. Spontaneous platelet aggregation and the FDP, and D-dimer levels were elevated; all other factors remained within the normal range. Intraluminal thrombus volume was strongly correlated with the volume and diameter of the AAA. However, no correlation was observed between the size of the AAA and coagulating factors, including the number and aggregation value of platelets. AAAs are frequently associated with a coagulating disorder. However, its size and thrombus volume are not correlated with coagulation changes. Although an intraluminal thrornbus increases along with fee enlargement of the AAA, the clinical manifestation of bleeding is rarely associated with an AAA. Therefore coagulopathy in patients with an AAA is not fully explained by its morphology.

Inflammatory Solitary Iliac Artery Aneurysms: A Report of two Cases

Inflammatory abdominal aortic aneurysms are associated with atherosclerosis, which are characterized by specific clinical manifestation. We treated two patients with unilateral solitary iliac artery aneurysms with perianeurysmal fibrosis which compressed the ureter resulting in ipsilateral hydronephrosis. After the iliac artery aneurysm was repaired with a prosthetic graft, the hydronephrosis resolved. Microscopically, there was clear evidence of atherosclerosis in one case. There was a characteristic inflammatory reaction around the adventitia in both aneurysms. Localized iliac perianeurysmal fibrosis has not been particularly described. The clinicopathologic similarities between these cases and inflammatory abdominal aortic aneurysms suggest the same pathogenesis.

Thoracic aortic aneurysm associated with pseudocoarctation of the aorta

Pseudocoarctation is a rare anomaly in the descending thoracic aorta. A 44-year-old man experienced sudden onset of back pain for 5 days prior to admission. Computed tomography showed kinking and stenosis in the distal aortic arch with a distal aneurysm. The patient underwent emergency surgery, with a diagnosis of impending rupture. The aneurysm was lobular with a very thin wall. Pseudocoarctation is rare and most often is asymptomatic. However, the aneurysm should be treated surgically, and the area of stenosis resected.

Abdominal Aortic Aneurysm Repair with Arterial Branch Reconstruction: Utility of the Temporary Bypass Technique

Between June 1992 and May 1996, five patients underwent an abdominal aortic aneurysm (AAA) repair with concomitant arterial branch reconstruction. All of the patients were males ranging in age from 55 to 66 years (mean: 61.6 years). The operations were performed for a localized abdominal aortic dissection, a pseudoaneurysm after patch angioplasty of a supraceliac AAA, a pararenal AAA, a total AAA with retrograde descending thoracic aortic dissection, and a supraceliac AAA after an infrarenal AAA repair. All patients underwent bilateral renal artery (RA) reconstruction. Three patients also had a concomitant reconstruction of the superior mesenteric artery ad celiac axis. The renal arteries were preferentially reconstructed. Visceral circulation during aortic cross-clamping was maintained via a temporary bypass circuit. A temporary division of the left renal vein was necessary in two patients. Overall, the mean renal ischemia time was 17.2min (range: 10 to 32 min). There was one perioperative death due to sepsis from a graft infection. Another patient died 6 months postoperatively due to pyothorax. One patient required postoperative hemodialysis for 1 month. Based on the above findings, the temporary bypass technique is thus considered to be useful for maintaining physiologic organ perfusion during aortic clamping without the need to use any complicated devices.

Vascular prosthetic implantation is associated with prolonged inflammation following aortic aneurysm surgery

The purpose of this study was to semiquantify the magnitude of surgical stress in patients undergoing aortic surgery by measuring inflammatory responses perioperatively, focusing on cytokine secretion. Serum concentrations of interleukin (IL) 1Α, IL-6, IL-8, and tumor necrotizing factor (TNF) Α were measured in patients undergoing abdominal or thoracic aortic aneurysmectomy preoperatively and periodically thereafter for 2 weeks. Urinary trypsin inhibitor (UTI/Cr) and C-reactive protein (CRP) concentration and the systemic inflammatory response syndrome (SIRS) score also were determined. Indices of inflammation and cytokine concentrations peaked at 1–3 days after surgery and decreased thereafter; however, IL-8 increased again after day 7. Concentrations of IL-8, UTI/Cr, and CRP and the SIRS score were still higher 14 days after surgery than preoperatively. The maximum concentrations of IL-6 and IL-8 were higher after thoracic than abdominal aortic repair; however, the maximum values of cytokines were not correlated with operative factors in all patients. A patient suffering from graft infection showed an increase in cytokine concentrations on day 7. The inflammatory response does not return to preoperative values within 2 weeks of surgery in patients undergoing thoracic or abdominal aortic aneurysm repair. The prolonged secretion of IL-8 suggests a host reaction to the synthetic prosthesis. A large increase in inflammatory cytokines on day 7 may indicate infection of the vascular graft.

Staged Vascular Reconstruction Along with Repeatedly Performed Angiography to Prevent Ischemic Limb Loss with Buerger's Disease: Report of a Case

Abstract An aggressive approach to vascular reconstruction should be adopted in patients with Buergers disease and peripheral ischemia who are often young and otherwise active. A patient with severe Buergers disease is reported who was treated successfully by complete vascular reconstruction with staged bypass surgery while also performing repeated angiography to preserve the foot function. A 48-year-old man with Buergers disease presented with necrosis of the foot. Angiography showed occlusion of the right distal external iliac artery and no runoff below the knee. Repeated angiography after performing a lumbar sympathectomy demonstrated patency of the distal portion of the deep femoral artery. Angiography was again performed after a reconstruction of the deep femoral artery and patency of the anterior tibial artery was observed. A staged bypass operation on the tibial artery was therefore able to achieve a prompt healing of both the toe ulcers and plantar wound.

Preliminary results of intermittent retrograde cerebral perfusion during proximal aortic arch surgery.

OBJECTIVE Continuous retrograde cerebral perfusion during aortic arch surgery is associated with cerebral edema. In this report, we describe the clinical use of a new type of intermittent retrograde cerebral perfusion. SUBJECTS AND METHODS Fourteen patients with a Stanford type A dissection were included in this study. With the usual method of retrograde cerebral perfusion, about 2,500 mL venous blood is drained from bicaval cannulae into a hard-shell reservoir, and oxygenated blood is perfused through the superior vena caval cannula. The flow rate is 300 mL/min. After about 15 min, retrograde perfusion is discontinued, and drainage from the bicaval cannulae is restarted. When a bloodless field is necessary, perfusion also is discontinued. RESULTS Two to seven cycles of intermittent retrograde cerebral perfusion were administered (average, 3.1+/-0.4, mean+/-SD). The total retrograde perfusion time was 36.0+/-1.9 min which was equivalent to 74.8% of the circulatory arrest time. No patient developed edema of the upper body. The time to wake-up was 3 to 14 h (average, 6.5+/-1.0 h). No patient suffered any neurologic complications even though the time of circulatory arrest was greater than 60 min in four cases. Head magnetic resonance imaging or computed tomography was performed in 12 cases, and no evidence of hypoxic brain injury was detected. CONCLUSIONS Our clinical experience using a moderate amount of intermittent retrograde cerebral perfusion is superior to continuous retrograde cerebral perfusion for protecting the brain during aortic arch surgery.

Peroneal artery reconstruction via medial approach using tourniquet occlusion.

As peroneal artery bypass surgery is technically demanding, a simplified medial approach was used in 23 peroneal artery reconstructions in 21 patients between January 1993 and December 2001. The outcomes were reviewed retrospectively. Peroneal artery reconstruction was undertaken through a medial skin incision using tourniquet occlusion and saphenous vein grafts. Graft patency was confirmed by angiography or duplex color imaging. Peroneal bypass was possible through the medial approach in 20 cases; in 1 limb, the target was occluded. During a mean follow-up of 43.9 months, there were 4 graft occlusions. None of the failures was due to a technical error related to the procedure. All of the other patients had relief of their symptoms, including those who presented with disabling claudication. Technical improvements have made peroneal bypass a reasonable choice in below-knee arterial reconstruction. This technique should not be restricted to limb salvage.