Katsuya Arakaki

A three-decade experience of radical open endvenectomy with pericardial patch graft for correction of Budd-Chiari syndrome

BACKGROUND We previously reported the value of our operative procedure for Budd-Chiari syndrome (BCS) that comprised reconstruction of the occluded or severely stenosed inferior vena cava (IVC) using an autologous pericardium patch and reopening as many occluded hepatic veins as possible. Here, we present the long-term durability and efficacy of the autologous pericardium patch for reconstruction of the IVC in BCS. METHODS We retrospectively analyzed a series of 53 consecutive patients (mean age, 48.4 +/- 12.8 years; range, 24-76 years; 34 men) who underwent surgical treatment for BCS at our institution from 1979 to 2008. Patency of the IVC and hepatic veins was examined by venography at discharge. Patients attended an outpatient clinic every 1 or 2 months for follow-up. The reconstructed IVC was evaluated by enhanced computed tomography every 1 or 2 years. RESULTS Two in-hospital (operative mortality, 3.7%) and 15 late deaths occurred. During a mean follow-up of 7.6 +/- 6.5 years (range, 0.08-24.1 years), the reconstructed IVC became totally obstructed in three patients, of whom two underwent reoperation, and severely stenosed in two patients, who required percutaneous transvenous balloon venoplasty (PTV). The 5- and 10-year patency rates without reoperation or PTV for the reconstructed IVC were 90.5% and 84.3%, respectively. The cumulative 5- and 10-year survival rates were 89.8% and 70.7%, respectively. CONCLUSION The autologous pericardium patch is effective and durable for reconstructing a diseased IVC in BCS.

Intraoperative retrograde type I aortic dissection in a patient with chronic type IIIb dissecting aneurysm

Iatrogenic acute aortic dissection of the ascending aorta during cardiac surgery is a rare but potentially fatal complication. We describe the emergency repair of iatrogenic acute aortic dissection of the ascending aorta during distal arch replacement in a patient with a chronic type IIIb dissecting aneurysm. We scheduled distal arch and descending aortic aneurysm repair through a left anterolateral thoracotomy with a femoro-femoral bypass. While trimming the proximal suture line, retrograde aortic dissection occurred from the cross-clamped site to the aortic root. Transesophageal echocardiography revealed aortic dissection at the ascending aorta. As soon as the additional median sternotomy was established, the ascending aorta was transected and antegrade selective cerebral perfusion was applied without waiting for further cooling. Total arch replacement with descending aortic and root replacements then proceeded. The patient recovered uneventfully after extensive surgical replacement of the thoracic aorta and remains asymptomatic at two years after the procedure. To prevent possible neurological complications, this patient was managed by selective antegrade cerebral perfusion at 31 degrees C because we could not afford to wait for the induction of deep hypothermia. Successful management of iatrogenic acute aortic dissection depends on immediate recognition and the appropriate choice of surgical repair.

Aortic Replacement via Median Sternotomy with Left Anterolateral Thoracotomy

Prevention of cerebral injury is an important consideration during repair of aortic arch aneurysm, and the major goal of cerebral protection techniques. We describe our surgical strategy for treatment of extended thoracic aortic aneurysms. Between January 2001 and June 2008, 17 men and 6 women, with a mean age of 67.9 ± 8.3 years, underwent total replacement of the arch and descending aorta. Six (26.1%) patients required emergency surgery. A median sternotomy with a left anterolateral thoracotomy provided a good visual field, and bilateral axillary arteries were preferentially used for systemic as well as selective cerebral perfusion. Two (8.7%) patients died in hospital. Prolonged mechanical ventilation was required for 7.3 ± 8.4 days after surgery in 17 patients who all recovered uneventfully. Permanent neurological dysfunction developed in 1 (4.3%) patient who died of sepsis 2 years after the operation. Our results suggest that total arch replacement through a median sternotomy plus a left anterolateral thoracotomy is helpful for extended replacement of the thoracic aorta as well as distal reoperation for dissecting type A aortic aneurysm. Perfusion via bilateral axillary arteries may improve cerebral protection.

Improvement of Liver Function After Surgery for Budd-Chiari Syndrome

PurposeWe evaluated the relationship between liver histology and postoperative improvement of liver function after surgery for Budd-Chiari syndrome (BCS).MethodsOver a period of 23 years, we operated on 46 patients with BCS by reconstructing the occluded inferior vena cava (IVC) and reopening as many occluded hepatic veins as possible. We divided the patients into a liver cirrhosis group (group I, n = 30) and a hepatic fibrosis or liver congestion group (group II, n = 16), and compared the ages, duration of illness, preoperative liver function, changes in liver function, and changes in esophageal varices (EV).ResultsThere were no hospital deaths. In group I the patients were older, and the duration of illness was longer. The group I patients also had a lower thrombotest percentage and a higher serum ammonia. The indocyanine green clearance (ICG) test showed more remarkable improvement in liver function in group II. The rate of disappearance of EV was also higher in group II.ConclusionSurgery during the early stage of BCS is important in improving postoperative liver function.

Delayed response of transcranial myogenic motor-evoked potential monitoring to spinal cord ischemia during repair surgery for descending thoracic aortic aneurysm

The efficacy of transcranial myogenic motor-evoked potential (tc-MEP) monitoring during thoracic aortic surgery has been the subject of some reports, because tc-MEP monitoring can rapidly reflect changes in spinal cord blood flow during thoracic aortic cross-clamping. In this article, we present a case in which delayed loss of tc-MEP signals was observed after cross-clamping of the descending thoracic aorta. We must be aware that tc-MEPs recorded from the lower extremities can fail to provide rapid detection of spinal cord ischemia in the upper thoracic level after cross-clamping of the descending thoracic aorta.

Post-sternotomy hemorrhage due to left internal thoracic artery pseudoaneurysm.

We describe a case of pseudoaneurysm of the internal thoracic artery, which was probably caused by infection. Four weeks after aortic valve replacement and coronary artery bypass surgery, an 84-year-old woman suddenly developed painful sternal instability and hypotension, with active hemorrhage from a left parasternal swelling. Selective arteriography revealed a pseudoaneurysm of the left internal thoracic artery. It was surgically excised, and the patient recovered uneventfully.

Type B Dissection Complicated with Subacute Visceral Ischemia

A 63-year old man presented with back pain and abdominal pain that worsened after eating. Contrast-enhanced computed tomography revealed type B aortic dissection. Arteriography 20 days after dissection revealed celiac trunk stenosis and the superior mesenteric artery did not arise from the true lumen. Saphenous vein bypass grafting from the right common iliac artery to the superior mesenteric and gastroduodenal arteries was performed. The postoperative course was uneventful and the abdominal symptoms completely disappeared.

Repeat Operation for Pseudoaneurysm of Left Ventricular Outflow in a Patient with Concomitant Takayasu's Arteritis and Marfan Syndrome

We describe concomitant Marfan syndrome and Takayasus arteritis complicating a pseudoaneurysm of the left ventricular outflow that developed after aortic root reconstruction. A patient was admitted with a high fever four months after initial root reconstruction that included valve sparing (reimplantation) as well as coronary artery reconstruction using a Carrels button technique. Computed tomography revealed a pseudoaneurysm at the posterior side of the aortic root. We applied a modified Bentall procedure including coronary artery reconstruction using the Piehler technique. Pathological assessment of a specimen of the aorta revealed no central medial necrosis, but significant lymphocytic infiltration and thick fibrous adventitia indicating Takayasus arteritis. This case was unique in terms of having simultaneous Takayasus arteritis and cardiovascular manifestations of Marfan syndrome that were surgically treated.

Coronary Artery Bypass Grafting for Patients in Whom Preoperative Angiography Determined That the In Situ Left Internal Thoracic Artery Could Not Be Used.

1998年1月から2001年8月までに当科で施行したCABG274例中,術前血管造影検査にて左内胸動脈(LITA)使用不能と判断された7例(7/262=2.7%)を対象として検討した.全例男性で,平均年齢は68.6歳,4例が鎖骨下動脈閉塞あるいは狭窄,3例がLITA閉塞あるいは狭窄であった.3例でRITAに橈骨動脈を端側吻合しcomposite Y graftとして使用,ほかの3例で橈骨動脈をsequential graftとして使用し,バイパス枝数は2.7±1.0であった.グラフト開存率は94.7%(18/19)で,1例にPMIを合併したが,対症療法にて軽快しており,ほかの症例に合併症はなく全例軽快退院した.冠動脈疾患を有する患者は高脂血症,末梢血管病変を有することが多く,このような症例においてはLITAの動脈硬化が有意に高率に認められるとの報告も見受けられ,有茎動脈グラフトに対する術前の十分な検討が重要であると考える.

Impact of Segmental Aortic Clamp and Distal Aortic Perfusion on Postoperative Paraplegia During Thoracoabdominal Aortic Graft Replacement

A variety of different measures have been instituted to decrease spinal cord injury during thoracoabdominal aortic aneurym surgery. However, paraplegia is still a most devastating complication. During the past twelve years, 40 consecutive patients were operated on for thoracoabdominal aortic aneurysms at our hospital. The mean age was 56.7 years and the range 22 to 82 years. Eighteen patients had dissecting aneurysms (DeBakey type III in fourteen patients and type I in four patients). Eight patients (20%) had had prior surgical aortic reconstruction. According to Crawford’s classification, 15 patients were type I, 5 were type II, 11 were III and 9 were type IV. A temporary left heart bypass (PA-FV or FA-FV) to maintain an adequate distal organ perfusion pressure and monitor of sensory evoked spinal cord potentials for detection of intraoperative cord injury was used in all patients. The mean number of cross-clamped aortic segments during surgery was 2.5 (range 1 to 5) in the nondissecting group and 3.4 (range 2 to 5) in the dissection group. Reimplantation of intercostal or lumbar arteries was performed in 18 patients (81.8%) in the nondissection group and in 17 patients (94.4%) in the dissection group. During surgery, selective visceral artery perfusion was undergone in 18 patients for organ preservation. The hospital mortality was 10% (4/40), 6.1% for elective cases (2/33) and 28.6% for emergency operations (2/7). Temporary paraparesis occurred in one patient who underwent emergency operation. No neurologic deficit was observed in the remaining patients.