Kinichi Furukawa

The surgical treatment of aortic dissection in a patient with Turner's syndrome: Report of a case

We report herein the successful surgical management of a 42-year-old patient with Turners syndrome (TS) complicated by Stanford type B aortic dissection. The patient had a single entry in the proximal descending aorta with dissection extending from the entry point to the abdominal aorto-left iliac bifurcation. A patch plasty using felt reinforcement was performed through a left 4th intercostal space thoracotomy. Her postoperative course was uneventful and she has been well during the 3 years since her operation. There have been only nine reports of patients with TS complicated by aortic dissection for whom operations were performed; however, the details of surgical treatment have not been well documented. This paper reports the course of aortic dissection and the surgical methods employed in the treatment of our patient.

Six year experience with wrinkled ePTFE vascular prostheses for arteriosclerosis obliterans

From November 1986 to January 1993, 97 wrinkled ePTFE prosthetic vascular grafts were implanted in 90 peripheral arterial reconstructions for 87 patients with arteriosclerosis obliterans (ASO) (79 men and 8 women). Grafts used in this series were 54 Vitagraft and 33 Technograft. Initial results for a period of as long as 6 years are summarized here. Forty-four (45.3%) grafts were implanted anatomically, and the remaining were extra-anatomically routed. The mean age of patients in the anatomic bypass group was 64.7 years, and that of patients in the other group was 71.4 years. Twenty-three (43.3%) grafts in the extra-anatomic group were anastomosed sequentially. Mean follow-up periods for each group were 32.4 months and 30.9 months, respectively. None of nine late deaths during the follow-up period was graft related. There was one primary obstruction in the anatomic group; in the extra-anatomic groups, primary graft occlusion occurred in four grafts. In addition, one perigraft seroma and one pseudoaneurysm requiring surgical repair were seen. Cumulative event free ratio for this group was 80.8% at 72 months. These results reveal that the wrinkled ePTFE graft is clinically applicable to arterial reconstruction for ASO with satisfactory long-term patency, even in extra anatomic sequential bypasses.

A Study of Oral Anticoagulant Therapy at an Early Stage after Cardiac Operation to Determine the Starting Dose of Warfarin Therapy.

心臓手術後早期に0.1mg/kgのワーファリン単回投与を行い, 投与24時間のワーファリンおよびビタミンKの血中濃度の変化, 凝固系因子の変化について検討し, 術後早期における投与開始方法および投与量について検討を行った. 対象は心臓手術症例30例, 健常人20例を対照とした. 心臓手術後症例のプロトロンビン時間は, ワーファリン投与24時間後には中等度治療域に近い抗凝血効果が得られた. 一方, ビタミンK血中濃度はビタミンK1, ビタミンK2ともに心臓手術後群は対照群と比較して低値を示した. 両群間の抗凝血能の差は肝細胞におけるビタミンK供給量の差異が大きな要因と考えられた. したがって心臓手術後のワーファリン開始量によっては, ビタミンKの欠乏状態に応じ, 急激に凝血能の低下する危険性が示唆される. 心臓手術後早期のワーファリン開始量は0.1mg/kg程度より開始するのが安全かつ有効な方法であると考えられる.

Internal Felt-reinforced Patch-plasty for Dissecting Aortic Aneurysm.

解離性大動脈瘤11例 (I型4例, II型1例, III型5例および弓部限局解離1例) に対して entry 閉鎖を目的としたフェルト内挿補強パッチ形成術を試案した. 血流遮断時間は平均84±19分で, 解離腔内にもフェルトを挿入した初期の1例を除き entry 部の完全閉鎖が得られた. III型の1例を遠心ポンプ離脱直後の不整脈にて失ったが, 術式に起因した死亡はみられなかった. 術後1か月以上の経過において, 解離腔はI型およびII型で上行部に, III部では下行部に血栓閉鎖が得られ, 弓部解離例は完全閉鎖した. 術後平均16か月の経過で全例良好な社会生活を送っている. 本法は, 解離性大動脈瘤における entry 閉鎖を目的とした簡便かつ確実な術式であり, 症例により試みるべきものと考える.

Evaluation of intra-Aortic-aneurysmal thrombotic-activity by 111In-labeled-platelet scintigraphy.

大動脈瘤内に形成される血栓は,ときに血栓塞栓症や消費性凝固障害などの原因となり,その器質化は患者の予防を左右する重要な因子であることが知られている.したがって,瘤内血栓の動態を知ることは,手術適応や手術術式の検討,さらに術後経過観察にあたって有力な臨床情報となる.そこで真性大動脈瘤13例,解離性大動脈瘤14例,解離性大動脈瘤術後解離腔遺残13例に対し,in vivoにおける血栓活性の指標として,111In標識血小板による血栓シンチグラフィー(以下血小板シンチと略)を施行し,同時に施行した造影CTとの所見の相違から瘤内血栓の活性の評価を試みた.血小板シンチのRI集積は,真性大動脈瘤では腹部が胸部に比して強い傾向を示した.また,解離性大動脈瘤では病期の進行に伴いRI集積は減弱していく傾向を示し,解離腔の血栓性閉塞の完成をみた症例が存在した.術後解離腔遺残で抗凝固療法施行中の症例ではRI集積は認めなかったが,末梢側に血栓塞栓症を併発した症例では遺残解離腔に強いRI集積を認めた.これらのことから血小板シンチ像は臨床で予測される血栓活性と一致するものであった.血小板シンチはin vivoにおける血栓活性の指標として大動脈瘤の予後や合併症の予測,手術適応や手術術式の検討,さらに,術後経過観察にあたって有力な臨床情報となる.

A case of pulmonary embolism treated with tissue plasminogen activator

A 47-year-old female manifesting deep vein thrombosis of the left leg had severe pulmonary embolism after thrombolytic therapy with t-PA for 5 days. Dyspnea was improved and PaO2 was restored from 39mmHg to 64mmHg soon after additional dosages of t-PA. Right ventricular pressure decreased from 71mmHg to 34mmHg after 1 month. Although t-PA level and D-dimer increased after giving 120.000u of t-PA, there were no obvious changes in fibrinogen, plasminogen, FDP nor α2-PI levels. Efficacy of thrombolytic therapy wtih t-PA was demonstrated by digital subtraction pulmonary angiograms taken before and after treatment.

Investigations on the anticoagulation therapy after cardiac valve replacement surgery

Features of blood coagulation system and postoperative anticoagulation therapy with Warfarin on 22 patients in which cardiac valve replacement was performed, were investigated by compared to 18 patients from peripheral vascular disease.Coagulation factor VIII was increased in both group of valvular disease and vascular disease before operation. There was no tendency of increase in F. VIII during Warfarin therapy continued for 36 months after operation. Prothrombin time was not correlated well with Thrombotest nor Hepaplastintest during Warfarin therapy. Thrombotest was affected by protein induced by vitamin K abscence (PIVKA) increased above 6-8μg/ml. It was noteworthy that % F. VIII (AHF/RAG) was reduced after valve replacement surgery, as compared with vascular disease in which reconstructive surgery was performed. These results suggest that postoperative anticoagulation therapy with Warfarin should be controlled by combination of thrombotest and Hepaplastintest. Decrease in % F. VIII (AHF/RAG) might indicate the hypercoagulability induced by mechanical valve prosthesis implantation.