Kazuto Maruta

Surgical lead-preserving procedures for pacemaker pocket infection

BACKGROUND In the treatment of pacemaker pocket infection, removal of the entire pacing system has been considered necessary to avoid recurrent infection. We report a series of patients treated surgically by our lead-preserving procedures. METHODS Between 1990 and 2001, a total of 18 patients underwent one of two types of lead-preserving procedures. Procedure 1 preserves the full length of the lead, and procedure 2 preserves only the distal part of the lead. Signs of bacteremia, endocarditis, or purulent material within the lead insulation preclude application of these procedures in patients with potential or definite pacemaker pocket infection. RESULTS Seventeen patients who met the indications for our procedures were discharged 7 to 14 days (8.9 +/- 2.4 days, mean +/- SD) postoperatively without signs of infection and were followed up for a total of 987 patient-months until the close of the study or death without recurrent infection. The remaining 1 patient, who did not meet the indications, suffered reinfection soon after the operation. CONCLUSIONS The follow-up data suggest that our lead-preserving procedures should be considered as alternatives to conventional removal of the entire pacing system in cases of pocket infection that meet specific criteria.

Atrophy of the abdominal wall muscles after extraperitoneal approach to the aorta

OBJECTIVE We retrospectively assessed computed tomography (CT) scans to determine degree of anterolateral abdominal muscle atrophy in patients who underwent infrarenal aortic repair with 2 kinds of incisions for the extraperitoneal approach. METHODS CT scans obtained before surgery and final scans obtained 2 to 100 months after surgery were assessed in 12 patients with paramedian incision (PM group) and 27 patients with flank incision (F group) who could be followed up at our hospital. We considered muscle thickness before surgery on the incision side to be 100% thickness (baseline value), and we calculated, by measuring the incision side after surgery, the corrected percent thickness (CPT%), which represents percentage of remaining muscle thickness that has escaped incision-induced atrophy. CT scans obtained at the level of the third (L3) and fifth (L5) lumbar vertebrae and the center of the sacrum (S) were selected for CPT% measurement. RESULTS Duration from surgery to final CT scan was 2 to 65 months (mean +/- SD, 34.33 +/- 21.38 months) in PM group and 3 to 96 months (27.85 +/- 20.74 months) in F group. In PM group, mean CPT% values of the rectus abdominis muscle were 55.83 +/- 21.65% at L3, 35.50 +/- 10.79% at L5, and 31.92 +/- 11.00% at S; these values were statistically much smaller than baseline (P <.01). Mean CPT% values of the lateral abdominal muscles were not statistically different from baseline. In F group, mean CPT% values of the rectus abdominis muscle were 82.19 +/- 23.15% at L5 and 64.41 +/- 31.34% at S; these values were statistically smaller than baseline (P <.01). Mean CPT% values of the lateral abdominal muscles were 87.59 +/- 22.30% at L3 and 84.59 +/- 26.90% at L5; these values were statistically smaller than baseline (P <.05). CONCLUSIONS Paramedian incision induced severe rectus abdominis muscle atrophy. Although flank incision induced various degrees of atrophy in both muscles, some patients had no muscle atrophy. These data indicate that further anatomic investigation into the relation between flank incision and abdominal wall innervation may contribute to prevention of muscle atrophy after flank incision.

Thoracic Endovascular Repair for Aorto-Esophageal Fistula in Patients With Esophageal Carcinoma Report of 3 Cases

Aorto-esophageal fistula (AEF) is a rare complication of esophageal carcinoma. Left untreated, it may be lethal due to massive upper gastrointestinal bleeding, while open thoracic surgery is associated with high operative mortality and morbidity. In contrast, thoracic endovascular aortic repair (TEVAR) for AEF is less invasive than open thoracic surgery. Here, we report 3 successful cases of AEF with esophageal carcinoma treated using TEVAR under local anesthesia in the emergent or urgent phase. General condition of all the patients was dramatically improved, but 1 patient with exsanguinations developed infection of the implanted stent-graft and died due to sepsis. The other 2 patients were treated before esophageal bleeding and remained alive for 1 year without infection. The TEVAR should be considered as early as possible in patients with advanced esophageal carcinoma receiving radiation or chemotherapy who develop early signs of AEF such as symptoms of chest discomfort or descending aortic irregularity on computed tomography scan.

Surgical Outcome in Hemodialysis Patients with Active-Phase Infective Endocarditis

PURPOSE The aim of this study was to elucidate the characteristics of chronic hemodialysis (HD) patients requiring surgery during the active phase of infective endocarditis (IE). METHODS From December 2004 to July 2015, 58 patients underwent surgery in our institute for active IE. Seven patients had been on HD for 1-15 years. Their preoperative profiles and surgical outcomes were compared to those of the other 51 patients (non-HD group). RESULTS The predominant causative microorganisms in the HD group were Staphylococcus spp, particularly methicillin-resistant Staphylococcus aureus (MRSA), whereas Streptococcus spp were predominant in the non-HD group. Prosthetic dysfunction (stuck valve after mechanical and structural valve dysfunction following bioprosthetic valve replacement), complete atrioventricular (AV) block, and annular abscess formation were more frequent in the HD group. In-hospital mortality was higher in the HD group (29% vs. 6%, p = 0.044). Actuarial survival in the HD and non-HD groups was 43% vs. 87% at 5 years and 43% vs. 76% at 10 years (p = 0.007). CONCLUSIONS Early and long term outcomes in patients with chronic HD were poor. Compared to other patients, chronic HD patients undergoing valve surgery during active IE had higher incidences of MRSA infection, annular abscess formation, postoperative valve dysfunction, and postoperative complete AV block.

Antero-lateral partial sternotomy for extensive thoracic aortic aneurysm

OBJECTIVES Surgical strategies for patients with aortic arch aneurysm extending to the descending aorta remain controversial. The antero-lateral partial sternotomy (ALPS) approach has been developed as a less invasive alternative single-stage strategy for extensive thoracic arch aneurysm (ETAA). METHODS From September 2007 to April 2011, 18 patients underwent elective total arch replacement for ETAA by the ALPS approach (ALPS group). In this approach, a skin incision was made from the bottom of the xiphoid to the anterior axillary line at the third intercostal space with a convex curved line. The thorax was entered through the third intercostal space and a partial lower sternotomy was done. Surgical outcomes were compared with those of 22 patients with ETAA who underwent elective total arch replacement by median sternotomy alone (MS) with regard to the level of distal anastomosis, postoperative complications and mortality. RESULTS In the ALPS group, no hospital mortality occurred and one patient experienced pneumonia. No significant difference between the ALPS and MS groups was seen in operative time (384.1 ± 41.6 min vs 402.3 ± 85.3 min P = 0.423) and cardiopulmonary bypass time (220.8 ± 47.1 min vs 236.9 ± 45.4 min P = 0.286). In contrast, distal anastomosis was at a significantly lower vertebral level in the ALPS than in the MS group (5.5 ± 0.4 vs 4.3 ± 0.9, respectively: P < 0.0001). CONCLUSIONS The ALPS approach provides good surgical exposure for distal aortic arch aneurysms extending to the descending aorta and ensures the accurate reconstruction of the distal anastomosis without major complications.

Surgical treatment for right aortic arch with Kommerell’s diverticulum

Kommerell’s diverticulum causes compression of the esophagus between the aberrant origin of the left subclavian artery and ascending aorta, leading to dysphagia or dyspnea. We describe 3 cases of successful surgical treatment of right aortic arch with Kommerell’s diverticulum and aberrant origin of the left subclavian artery, using a right anterolateral partial sternotomy. This allows both resection of the Kommerell’s diverticulum as well as reconstruction of the aberrant origin of the left subclavian artery anatomically.

Evaluation and Coil Embolization of the Aortic Side Branches for Prevention of Type II Endoleak after Endovascular Repair of Abdominal Aortic Aneurysm

Objectives: Aneurysm shrinkage after EVAR is the strong factor of favorable outcomes after endovascular abdominal aortic aneurysm repair (EVAR), and type II endoleaks is the risk factor of no aneurysm shrinkage or aneurysm enlargement in the long term. In this study, we evaluate the aortic side branches relate to early postoperative type II endoleak, and performed coil embolization for those vessels for prevention of type II endoleak. Methods: Patency and diameter of aortic side branches including inferior mesenteric artery (IMA) and lumbar artery (LA) were evaluated in 56 consecutive patients with abdominal aortic aneurysm who were scheduled for EVAR. Coil embolization with Interlock was performed in 24 patients during EVAR for all patent IMA and LA with maximal diameter more than 2.0 mm. Computed tomography was performed one week after EVAR for evaluation of endoleak. Results: In patients with IMA more than 2.5 mm in diameter, the frequency of type II endoleak was approximately 90% regardless of the number of patent LA. In case with patent IMA less than 2.5 mm or with 2 or more patent LA larger than 2.0 mm, the frequency of type II endoleak was 46 to 67%. Coil embolization for IMA was successfully performed in 15/16 patients (94%). Coil embolization of LA was performed for patent LA larger than 2.0 mm and 29 out of 45 LA (64%) were successfully occluded. There was no perioperative complication associated with coil embolization. The frequency of type II endoleak was significantly lower in patients with coil embolization than those without coil embolization (4.2% vs 58.9%, p<0.0001). Conclusion: Patent IMA and LA in diameter larger than 2.0 mm were associated with type II endoleak one week after EVAR, and coil embolization with Interlock during EVAR is safe and effective procedure to prevent type II endoleak. (This is a translation of Jpn J Vasc Surg 2016; 25: 321–328.)

Coarctation of the Abdominal Aorta Associated with Aneurysm of the Descending Thoracic Aorta Probably due to Aortitis Syndrome.

大動脈炎症候群が疑われた腹部大動脈縮窄症に胸部下行大動脈瘤を合併した症例に対し下行大動脈置換と下行-腹部大動脈バイパス術を行い良好な結果を得たので報告する.症例は67歳,女性.左側胸部痛精査のCT,DSAで最大径60mmの下行大動脈瘤と腎動脈分岐後の腹部大動脈縮窄を認めた.さらに上腸間膜動脈から下腸間膜動脈に著しく拡張したmeandering mesenteric arteryを介した側副血行路がみられた.血液検査上炎症所見はなかったが形態学的に大動脈炎症候群が疑われた.手術は左第4肋間開胸と左腹部斜切開でF-Fバイパス下に下行大動脈瘤切除,人工血管置換を行い,下行置換のグラフトに作製した分枝と大動脈分岐上の腹部大動脈との間に後腹膜経路でバイパス術を行った.術後経過は良好で術後42日で軽快退院した.大動脈炎症候群では術後の炎症再燃,吻合部動脈瘤の発生が危惧されるが,術後約1年の経過観察中合併症なく社会復帰している.