Kenji Komoda

Successful utilization of the median sternotomy approach in the management of descending necrotizing mediastinitis: Report of a case

We describe herein the case of a patient in whom a median sternotomy was successfully employed for mediastinal drainage in the treatment of descending necrotizing mediastinitis (DNM). Although most reports describe cervical or thoracotomy approaches, our experience strongly suggests that median sternotomy is a satisfactory alternative approach for treatment of this disease.

Postoperative renal function after an abdominal aortic aneurysm repair requiring a suprarenal aortic cross-clamp.

Abstract: We describe herein the postoperative renal functions of patients who required a suprarenal aortic cross-clamp during abdominal aortic surgery. Seven patients required a unilateral suprarenal aortic cross-clamp (group A) and six patients required a bilateral suprarenal clamp (group B). Eighty-three patients who required an infrarenal aortic clamp were assigned to group C. Renal hypothermia with renal perfusion or topical cooling during suprarenal clamp was not performed. No hospital deaths were encountered. In group B, the postoperative creatinine and blood urea nitrogen (BUN) levels remained statistically significantly higher than that of group C until the seventh postoperative day. The postoperative renal dysfunction (serum creatinine level >2.0 mg/dl) was 28.6% in group A and 50% in group B, while it was only 8.4% in group C, although no patient required either temporary or permanent hemodialysis. The postoperative peak BUN over 30 min suprarenal clamp was significantly higher than that within 30 min. In summary, the postoperative renal function was impaired after an extended bilateral suprarenal clamp. These findings suggest that if prolonged renal ischemia is thus expected, then renal preservation should be considered.

Coagulopathy associated with residual dissection after surgical treatment of type A aortic dissection

PURPOSE This study was performed to evaluate the effects of a residual dissection on coagulation, fibrinolysis, and platelet function after surgical treatment of acute type A aortic dissection. METHODS Between 1987 and 1995, 48 consecutive patients underwent emergency surgery for acute type A aortic dissection. Thirty-five of 41 survivors were followed-up for periods ranging from 6 to 112 months (median, 30.3 months). These survivors were classified into three groups by computed tomographic scanning and angiography. Fifteen patients had no residual dissection (group I). Of the 20 patients who had residual dissection, nine had an enlarged aorta greater than 45 mm in maximal diameter (group II), and 11 had an aorta less than 45 mm in maximal diameter (group III). For all patients, blood samples were collected for coagulation, fibrinolysis, and platelet function studies on the same day that the computed tomographic scanning had been performed. RESULTS beta-thromboglobulin, thrombin-antithrombin III complex, D-dimer, and alpha 2 plasmin inhibitor-plasmin complex concentrations were significantly higher in group II than in the other two groups. Strong correlations between the maximal diameter of the dissected aorta and beta-thromboglobulin, thrombin-antithrombin III complex, D-dimer, and plasmin inhibitor-plasmin complex concentrations were evident. In contrast, correlations between the length of the dissected aorta and coagulation/fibrinolysis measurements were weak. CONCLUSIONS Our findings suggest that the coagulopathy worsened in proportion to the degree of dilatation of the dissected aorta.

A ruptured thymic branch aneurysm mimicking a ruptured aortic aneurysm, with associated bronchial artery aneurysms: Report of a case

A 57-year-old woman who went into shock following an acute left hemothorax was operated on after stabilization under the diagnosis of a ruptured aortic aneurysm. A left fifth intercostal thoracotomy was done which revealed approximately 500 ml of bloody effusion in the extrapleural space and 2,000 g of clotted blood in the pleural cavity. While the aneurysm was initially thought to have originated in the isthmic or descending aorta, intraoperative findings revealed a swollen hematomatous thymus adherent to the aorta. A ruptured thymic branch aneurysm, 3 cm in diameter, was subsequently found in the resected hematomatous thymus. Histological examination also revealed several small aneurysms in the tortured bronchial arteries. Postoperative angiography showed a saccular aneurysm, 1.5 cm in diameter, and several smaller aneurysms in the bronchial artery of the left lung. The aneurysm was successfully treated by a transcatheter arterial embolization, and the patient has had no further symptoms since then. To our knowledge, there has been no other case of a ruptured thymic artery aneurysm reported in the literature, and only a few cases of bronchial artery aneurysms have been documented.

COMBINED TOTAL REPLACEMENT OF THE SUPRARENAL INFERIOR VENA CAVA WITH A POLYTETRAFLUOROETHYLENE TUBE GRAFT AND HEPATIC VEIN RECONSTRUCTION FOR RENAL CELL CARCINOMA

Although aggressive surgical treatment for renal cell carcinoma remains controversial, the intraluminal inferior vena caval extension should be managed with aggressive surgical extirpation in the absence of distant metastases and advanced regional lymph node involvement. 1 We report on a patient with renal cell carcinoma with tumor thrombus that extended to the right atrium. The suprarenal inferior vena cava was replaced up to the antrum with a tube graft of expanded polytetrafluoroethylene, where the hepatic veins were reconstructed. In our case prosthetic reconstruction of the total suprarenal inferior vena cava was successful. CASE REPORT

Subclavian artery aneurysm associated with absence of the ipsilateral internal carotid artery

A 48-year-old male presented with a rare subclavian artery aneurysm associated with absence of the ipsilateral internal carotid artery. The aneurysm was resected and replaced with a Gore Tex artificial graft. Computed tomography, angiography and cerebral blood flow findings suggest that defect of the right internal carotid artery occurred in the developmental stage. There was no past history of trauma, nor histological evidence of inflammatory or sclerotic changes in the aneurysmal wall. The two vascular lesions may have been influenced by a synchronous causative factor in his developmental stage.

Aortic valve stenosis with left ventricular outflow tract pressure gradient

A 61-year-old man was diagnosed with severe aortic valve stenosis with left ventricular outflow tract pressure gradient due to systolic anterior movement of the mitral valve and a large poststenotic dilation of the ascending aorta. He underwent successful aortic root replacement and concomitant septal myectomy.

Retroaortic Left Renal Vein Associated with Juxtarenal Aortic Abdominal Aneurysm Repair.

症例は53歳の男性. 狭心症の精査のさい juxtarenal type の腹部大動脈瘤を指摘された. 瘤径は7.2cmであったが3枝病変であったため冠動脈バイパス術を優先し, 2期的に腹部大動脈瘤に対しY型人工血管置換術を施行した. 術前のCTにて瘤の後面を走行する大動脈後性左腎静脈を認めたが術中損傷は認めず順調に経過した. 大動脈後性左腎静脈の発生頻度は2%程度であるが, 大動脈後面を腰静脈, 奇静脈または半奇静脈との吻合静脈が複雑に走行し, これらは非常に脆弱であるため腹部大動脈の不用意な剥離により予期せぬ大出血をきたす可能性があり, 死亡例も報告されている. このため的確な術前診断および慎重な術中操作が重要である. さらに本疾患は血尿などを主徴候とする大動脈左腎静脈瘻, 左腎静脈補捉症候群と関連することも念頭におく必要がある.

Impaired Peripheral Vasodilation in Ischemic and Nonischemic Limbs of Patients with Unilateral Arteriosclerosis Obliterans Effect of Revascularization on Leg Hemodynamics

Limb vessel vasodilation plays an important role in the regulation of skeletal muscle blood flow during exercise. However, little documentation is available that describes the vasodilatory response of peripheral vessels in patients with arteriosclerosis obliterans (ASO). This study investigates possible impairment of basal blood flow and response in ischemic and nonischemic legs of patients with ASO, and the effect of revascularization on leg hemodynamics. Basal calf blood flow and reactive hyperemic response to femoral occlusion were measured plethysmographically in 20 patients with unilateral ASO (20 stenotic legs and 20 nonstenotic legs) and eight healthy subjects (eight control legs). Eight stenotic legs underwent percutaneous transluminal angioplasty or surgical revascularization. Basal calf blood flow and peak hyperemic flow was significantly lower in stenotic and nonstenotic legs than in control legs. After revascularization, basal flow was unchanged in stenotic legs but elevated in nonstenotic legs (from 2.5 ±0.3 to 3.4 ±0. 4 mL/min/dL tissue, p<0.01). Peak flow in both legs was significantly elevated (stenotic legs, from 12.8 ± 1.9 to 17.6 ± 1.6 mL/min/dL tissue, p<0.01; nonstenotic legs, from 14.3 ± 1.0 to 20.0 ±1.6 mL/min/dL tissue, p<0.01), although still below control values. Basal blood flow and maximum vasodilatory response of resistance vessels are impaired irrespective of the side of conduit vessel involvement. The vascular response of the nonstenotic side is significantly enhanced after revascularization of the contralateral stenotic lesions. These suggest that neural or circulating vasoacting factor(s) originating from the stenotic limb may contribute to peripheral circulatory disturbance in claudicants.