Hideki Kazui

Treatment for Aortic Graft Infection

Abstract Nine patients with an aortic graft infection presented after undergoing aortic grafting. Seven of 9 patients underwent an initial aortic reconstruction in our hospital. The incidence of aortic graft infection was 1.5% (7/456). There were 6 cases of paraprosthetic infection and 3 cases of aortointestinal fistulas. The treatments consisted of a complete graft excision and an axillofemoral bypass in 6 patients, a complete graft excision alone, a partial graft excision and a femorofemoral bypass, and the preservation of the graft with omental wrapping and irrigation in 1 each. Broad-spectrum antibiotics were intravenously administered to all patients and were then replaced by selective antibiotics for the responsible organisms. All surviving patients received antibiotics orally for 3–6 months. The early postoperative mortality rate was 11.1%. Aortoduodenal fistula occurred in 1 patient with graft excision alone. Graft thrombosis occurred in 2 patients with an axillofemoral bypass. No late graft infection or stump blowout occurred in any patient. We believe that a complete excision of the infected graft as well as the maintenance of distal tissue perfusion is necessary. However, based on the condition of the patient, the appearance of the operating field, and the difficulty of a repeat operation, we would like to stress the importance of selecting the best and safest treatment plan for each case.

LIMB SALVAGE AND SURVIVAL RATES AMONG ELDERLY PATIENTS WITH ADVANCED LIMB ISCHEMIA

The purpose of this study was to clarify the incidence of limb salvage and patient survival rates among elderly patients with advanced leg ischemia. We reviewed the records of 159 patients treated for advanced ischemia over a 15-year period at Aichi Medical University, 74 of whom were aged over 75 years and 85, between 65 and 74 years. There was a collective total of 186 limbs; 82 in the older group and 104 in the younger group. The older group had a greater proportion of women, and a higher incidence of coronary heart disease, pulmonary dysfunction, and acute onset of advanced ischemia than the younger group. Limb salvage was achieved in 73% of the affected limbs in the older group and in 92% of the limbs in the younger group. The poor limb salvage rate in the older group was mainly related to the high initial amputation rate. Early recognition of the sentinel ischemic signs before the ischemia is essential, especially in the elderly. Timely revascularization should be attempted whenever possible, and it should not be abandoned simply because the patient is deemed too old. The 1-, 3-, and 5-year survival rates in the older group were 59%, 28%, and 23%, respectively, which were markedly poorer than the expected survival rates of the age- and sex-matched Japanese population at 1, 3, and 5 years, which were 93%, 79%, and 65%, respectively. Thus, advanced limb ischemia carries a poor prognosis to the point of being life-threatening, and further continuous systemic management with the collaboration of physicians and surgeons must be provided even after the patient has left the hospital.

Case report of abdominal aortic aneurysm associated with left-sided inferior vena cava

Report on a 63-year-old man with an abdominal aortic aneurysm (AAA) complicated with a left-sided inferior vena cava (It-IVC). A computerized tomographic scan showed that the It-IVC crossed anteriorly over the AAA body from the left to the right side. A superimposed digital subtraction angiogram of the AAA and the It-IVC disclosed a topographic relationship between the two, and also provided useful preoperative imaging data. By dissecting the It-IVC through a transection of several lumbar veins and cranial traction of a transverse portion of the It-IVC, safe proximal aortic control was achieved. The aneurysm was successfully replaced with a bifurcated woven Dacron graft. The development of the It-IVC anomaly and methods for exposing the neck of the AAA when this anomaly is present are also discussed.

Disruption of externally supported knitted Dacron graft three years after implantation—A case report*

A knitted Dacron velour externally supported prosthesis was broken in two pieces at the supported portion 3 years after femoroposterior tibial bypass grafting. This type of graft problem has never been reported. Details of the clinical course, angiogram, CT scan, and scanning electron micrograph of a portion of the graft are shown. The externally supported Dacron prosthesis broke into two pieces along the broken coil of the middle portion. A possible cause of this failure may have been due to damage of the Dacron fibers in the process of heat fusing the coil. This presentation emphasizes the possibility of this rare externally supported graft complication, and the necessity for careful follow-up not only of the graft patency but also for the mechanical defects of the implanted externally supported Dacron graft itself.

Benefits of arterial reconstruction in claudication

We conducted a midterm follow-up of 150 claudicants who underwent surgical reconstruction by assessing cumulative patency, survival, and palliation (graft patency in live patients) rates. Eighty-nine claudicants (group I) underwent direct (in situ) proximal revascularization, 33 (group II) had indirect (ex situ) proximal revascularization, while 28 (group III) had distal revascularization. The secondary patency rates at 3 years were 97.5% in group I, 97.0% in group II, and 75.0% in group III, respectively. Only one patient with limb graft thrombosis required below-knee amputation. There were 3 perioperative deaths (2 in group I and 1 in group II). The survival rates at 3 years were 86.0% in group I, 69.5% in group II, and 95.8% in group III, respectively. The palliation rates at 3 years were 84.8% in group I, 70.0% in group II, and 77.9% in group III, respectively. These findings indicate the midterm benefits of supra- and infrainguinal arterial reconstructions, and also suggest that the preoperative assessment of risks in individual patients, the selection of the appropriate operative procedure and graft material, and intensive postoperative follow-up and management of any associated disease are all important aspects in the treatment of claudicants.

Operative Mortality and Long-Term Relative Survival Rate Following Surgery for Abdominal Aortic Aneurysms.

腹部大動脈瘤 (AAA) 240例を破裂群 (31例) と非破裂群 (209例) に分け, 非破裂群をASO合併群 (48例) とASO非合併群 (161例) に分けて検討した. 追跡期間は最長15年10か月, 平均4年2か月, 遠隔期追跡率は97%であった. 手術死亡率は破裂群41.9%, 非破裂群2.9%, ASO合併群6.3%, ASO非合併群1.9%であった. 遠隔期死亡原因は心疾患32%, 悪性腫瘍22%, 脳血管障害10%, 腎疾患10%などであったが, 手術時リスクファクターと関連したのは腎不全のみであった. 術後相対生存率は破裂群5年79%, 10年0%, 非破裂群5年90%, 10年70%で, 同年代一般人より低く, ASO非合併群は5年95%, 10年78%, ASO合併群は5年74%, 10年52%であり, ASO合併群ではさらに低値であった. ASO合併群は手術時, 虚血性心疾患, 糖尿病の合併が多く, 全体の遠隔期死亡原因は心疾患, 腎不全が多かった. これらを念頭においた遠隔期フォローアップが重要である.

New Leg Position for Venous Photoplethysmography

A new position for photoplethysmographic (PPG) assessment of lower leg venous function is described and tested. The aim of this study is the selection of patients for more limited stripping operation [1,2].

A case ofVibrio vulnificus infection

Vibrio vulnificus, a recently described strain of the halophilicVibrio species, was isolated from the blood of a 73-year-old man, who developed rapidly progressive wound infection and fatal septicemia. Twenty-one patients withVibrio vulnificus infection have been reported in the Japanese literature.Vibrio vulnificus most frequently causes primary septicemia and necrotising cellulitis after the eating of raw fish or shellfish or after exposure to seawater. The infection is characterized by its occurring during the warm months of the year, in patients with underlying diseases, especially liver diseases, and the mortality rate is surprisingly high. Clinicians should therefore consider the possibility ofVibrio vulnificus infection in the differential diagnosis of severe wound infections. Early surgical intervention and intensive antibiotic therapy are recommended for preventing the progress of the septicemia.