Kenichi Okamura

Conservative Therapy as a Primary Treatment for Spontaneous Isolated Dissection of the Superior Mesenteric Artery

BACKGROUND Spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) is a rare and potentially fatal disease. Several therapeutic options are available, including conservative therapy, endovascular repair, and open surgery. Herein, we report our experiences in the treatment of SIDSMA. METHODS Between February 2009 and June 2013, 17 patients were diagnosed as having SIDSMA. We retrospectively reviewed and analyzed their clinical characteristics, medical history, risk factors, symptoms, diagnostic imaging modality, treatment, and outcome. The lesions were categorized according to the modified Sakamotos classification. If no evidence of bowel necrosis or arterial rupture was present in the patients with symptomatic SIDSMA, we first performed conservative therapy, even if the patients had abdominal pain. RESULTS The subjects included 15 men and 2 women, with a median age of 62.8 years. Eight patients were symptomatic and 9 were asymptomatic. Conservative therapy included the use of antithrombotic agents in 3 patients but not in 5 patients. During the follow-up period (mean, 21.1 months), all the patients were discharged without any significant complications, and none of the patients showed the progression of the dissection on follow-up computed tomography angiography examinations. CONCLUSIONS Conservative therapy without antithrombotic agents should be the primary treatment for SIDSMA. Endovascular repair for SIDSMA is associated with several risks, thus the procedure might occasionally be useful and necessary.

A rare case of axillobifemoral bypass graft infection caused by Helicobacter cinaedi.

Helicobacter cinaedi infection is rarely encountered in nonimmunocompromised patients. We report the case of an 85-year-old man who presented with axillobifemoral bypass graft infection caused by Helicobacter cinaedi. The patient was not immunocompromised. We successfully treated him by iliac stenting of the native iliac artery, with near-total removal of the infected graft. At present, 48 months later, the patient is doing well at home, with no evidence of infection. To the best of our knowledge, this is the first report of infection of a prosthetic graft caused by Helicobacter cinaedi.

Coronary artery aneurysm occurring very late after drug-eluting stent implantation

An 82-year old woman presented with chest pain and was diagnosed as having acute myocardial infarction. Coronary angiography (CAG) showed 90% stenosis in the proximal left anterior descending artery (LAD). The patient underwent percutaneous coronary intervention using a sirolimus-eluting stent (SES). A repeat CAG performed 6 months after SES implantation revealed no problems. Eight years later, the patient presented with recurrent angina. CAG showed severe stenosis of the SES with a large aneurysm. We performed off-pump coronary artery bypass grafting without ligation or plication of the LAD, but with the application of fibrin glue to the coronary artery aneurysm. The postoperative course was uneventful. The mechanism responsible for the occurrence of coronary artery aneurysms occurring late after drug-eluting stent implantation remains unclear, and the treatment strategy remains controversial. Herein, we discuss a surgical treatment for this rare entity.

Hybrid stenting therapy for dysphagia aortica with Rokitansky's diverticulum concomitant with thoracic aortic aneurysm

An 87-year old man with a past medical history of a descending aortic aneurysm for 20 years presented with progressive dysphagia and aspiration pneumonia. Computed tomography angiography demonstrated the impending rupture of the thoracic aortic aneurysm (TAA) and endoscopic examinations revealed the extrinsic compression of the middle oesophagus with Rokitanskys diverticulum proximal to the compression area. He underwent urgent thoracic endovascular aortic aneurysm repair, followed by oesophageal stenting. The patients symptoms immediately improved, and the postoperative period was uneventful. This report is the first to describe a hybrid stenting therapy for dysphagia aortica with Rokitanskys diverticulum concomitant with a TAA.

Stanford type A aortic dissection after urgent prosthetic valve replacement: case reports

Occurrence of acute aortic dissection after aortic valve replacement is rare, however, it is associated with high mortality and morbidity rates. We report two Asian cases in which acute aortic dissection occurred after urgent aortic valve replacement for infective endocarditis. Successful graft replacement was carried out with preservation of the prosthetic valves in both cases. Our experience with these cases suggests that, even in urgent or emergent situations, surgical intervention for associated aortic dilatation should be considered when aortic valve replacement is performed.