Junetsu Akasaka

Preoperative MDCT evaluation of the artery of Adamkiewicz and its origin.

Objective: To assess the usefulness of MDCT in the preoperative evaluation of the artery of Adamkiewicz (ARM) and its parent artery. Methods: Ten patients with thoracoabdominal vascular diseases underwent MDCT of the entire aorta and iliac arteries. The visualization of the ARM, and its branching level and site of origin, and the continuity of the intercostal/lumbar arteries with the ARM were investigated. Results: In 9 of the 10 patients, the ARM was clearly visualized. The entire length from the intercostal/lumbar arteries to the ARM could be traced in 8 of the 10 patients. Surgical treatment or stentgraft insertion was based on a consideration of the vascular supply to the ARM. No postoperative ischemic spinal complications occurred. Conclusions: MDCT permits the evaluation of the ARM for its entire length and provides information on the intercostal and lumbar arteries and entire aorta.

Protection from postischemic spinal cord injury by perfusion cooling of the epidural space during most or all of a descending thoracic or thoracoabdominal aneurysm repair

ObjectiveIt is reported that hypothermia has some protective effect against ischemia of the spinal cord during thoracoabdominal aneurysm repair. However, it has not been elucidated clinically whether regional spinal cord hypothermia by epidural perfusion cooling is effective and safe. The purpose of this study was to assess the effect and safety of perfusion cooling of the epidural space during most or all of descending thoracic or thoracoabdominal aneurysm repair.MethodsFrom January 1998 to December 2007, a total of 102 patients with a mean age of 61 years underwent replacement of most or all of the descending thoracic aorta or thoracoabdominal aorta with the aid of mild hypothermia via epidural perfusion cooling and cerebrospinal fluid (CSF) drainage. Risk factors for spinal cord injury and hospital death were analyzed using univariate and multivariate analyses. The actuarial survival rate was calculated by the Kaplan-Meier method.ResultsThe mean lowest CSF temperature was 23.3°C during epidural perfusion cooling. The mean temperature difference between the nasopharynx and CSF was 8.4°C. The incidence of spinal cord injury was 3.9% (4/102), and that of hospital death was 5.9% (6/102). There was no significant risk factor associated with spinal cord injury. Type III aneurysm and postoperative cerebrovascular accident, respiratory failure, liver failure, and infection were predictors of hospital death. The actuarial survival rates at 3 and 5 years were 82.1% and 75.9%, respectively.ConclusionEpidural perfusion cooling is a safe method to employ in clinical situations. Our contemporary management strategies enabled patients to undergo thoracoabdominal aneurysm repair with excellent early and late survival and acceptable morbidity.

Endovascular flexible stent grafting with arch vessel bypass for a case of aortic arch aneurysm

The Matsui-Kitamura (MK) stent graft (Kitagawa, Kanazawa, Japan) is designed to fit the curvy portions of the aorta because first-generation rigid skeleton–type stent grafts potentially cause kinking and endoleak as a result of limited flexibility. The MK stent graft consists of a custom-made, self-expandable spiral mesh of a single nitinol wire and thin-walled polyester fabric. We report the first surgical case of aortic arch aneurysm treated with this flexible and curved stent graft after extra-anatomic bypass of the arch vessels to prepare a landing zone for the stent graft.

Use of cuffed anastomosis in total aortic arch replacement.

The distal aortic anastomosis portion of the total arch surgery remains technically complex especially in cases in which an aortic arch aneurysm extends below level of carina. We present the cuffed anastomosis that overcomes this difficulty. We applied this technique in 49 patients of elective total aortic arch aneurysm repair using selective cerebral perfusion from 1996 to 2001. Hospital mortality was 2%.

Successful Management of Esophagoparaprosthetic Fistula After Aortic Surgery

Aortoesophageal fistula is a relatively rare but highly fatal condition, especially in the case of secondary aortoesophageal fistulas after previous thoracic aortic surgery in which the aortic prosthetic graft itself may be involved in the infection, resulting in an esophagoparaprosthetic fistula. In this report, we describe a complicated case of esophagoparaprosthetic fistula arising after descending thoracic aortic replacement and endovascular pseudoaneurysm repair that was successfully treated by surgical resection and in situ aortic graft replacement using a homograft completely covered with an omental flap, combined with subtotal esophagectomy and staged reconstruction of the alimentary tract. The patient has been doing well for 24 months without signs of recurrent infection.

Vacuum-assisted closure system for the treatment of mediastinitis after total aortic arch replacement

A 77-year-old man developed deep sternal wound infection with Enterobacter cloacae 4 days after total aortic arch replacement for distal aortic arch aneurysm. Reexploration and open drainage of the mediastinum was carried out for 4 days, and the vacuum-assisted closure system was applied and continued for 10 days. During the treatment, granulation formation and neovascularization was apparently enhanced which lead us to perform omental transfer and chest closure on the 18th postoperative day. The patient has been free from recurrent sign of mediastinal infection or graft infection for the 19 months of the follow-up period.

Pulmonary venous obstruction in a patient with Marfan syndrome: Rare presentation of an expanding dissecting descending thoracic aortic aneurysm with annuloaortic ectasia

may have been promoted. In this case, endocarditis was initially suspected because of vegetation-like mobile masses that were found in the aortic valve on the transesophageal echocardiogram, but infection was negative in all other examination findings. We determined before surgery that these masses were most likely cardiac tumors. Mild exertional dyspnea was the only clinical symptom, but it is known that mobile tumors attached to an aortic valve can cause serious complications such as thromboembolism and myocardial ischemia, and we decided that a surgical excision was necessary. QAV with a narrow aortic annulus presenting with the development of multiple CPFs is a rare complication. There have been no similar cases reported in the literature. However, according to the characteristics of each pathologic condition, there is a possibility that CPF may develop with QAV.

Total Aortic Arch Replacement with Open Stent-Grafting of Descending Thoracic Aorta for Chronic Type A Dissecting Aneurysm after Replacement of the Ascending Thoracic Aorta-A Case Report-

症例は74歳,女性.平成11年2月13日に急性A型大動脈解離の診断にて上行大動脈置換術を施行した.平成13年4月遠位弓部大動脈より左総腸骨動脈に及ぶ残存解離と胸部下行大動脈の拡大を指摘され手術適応とされた.手術は開放式ステントグラフティングを併用した弓部大動脈置換術を施行した.術後呼吸障害を合併したが,対麻痺の合併なく軽快退院した.