Mamika Motokawa

In situ replacement with equine pericardial roll grafts for ruptured infected aneurysms of the abdominal aorta

We describe surgical in situ replacement using an equine pericardial roll to treat ruptured infected abdominal aortic aneurysms (AAA) in two patients. A 78-year-old man diagnosed with ruptured infected (Bacteroides fragilis) AAA underwent in situ replacement of the abdominal aorta using a bifurcated equine pericardial roll graft with concomitant omentum flap wrapping. A 50-year-old man diagnosed with ruptured infected (Streptococcus agalactiae) AAA underwent the same procedure, except the graft was straight. Computed tomography of this patient revealed no graft dilation or surrounding fluid accumulation at 48 months after surgery. We therefore suggest that in situ replacement of the abdominal aorta using equine pericardium with concomitant omental flap wrapping may be an option of treating ruptured infected AAAs.

Intermediate and Long-Term Outcomes After Treating Symptomatic Persistent Sciatic Artery Using Different Techniques

Persistent sciatic artery (PSA) is a rare congenital vascular malformation. In this article, we have described the case of a 66-year-old woman presenting with a pulsatile mass in the left buttock and bilateral lower limb ischemia, who underwent surgical therapy. Preoperative computed tomography scanning showed a left thrombosed PSA aneurysm (PSAA) with concomitant occlusion of bilateral iliac, bilateral common femoral, and left popliteal arteries. After recanalization of the left common femoral artery occlusion with a systemic heparin treatment, the patient underwent bypass surgery (left femoropopliteal bypass, right iliofemoral bypass) and PSAA exclusion. Postoperative computed tomography scanning 20 months after surgery revealed that the excluded PSAA was thrombosed with no refilling collateral flow, and that the bypass grafts were patent in both legs. In addition to this case report, a literature review of PubMed articles published between 1965 and 2009 that included the treatment and intermediate/long-term management of symptomatic PSAs was conducted. We found 45 articles (67 limbs), of which 24 (29 limbs) described the intermediate/long-term outcomes in patients treated for symptomatic PSA. Regardless of the method of arterial reconstruction or PSAA repair, intermediate/long-term outcomes of different treatments for lower limb ischemia and PSAAs were satisfactory, and the patients were asymptomatic during the follow-up period which ranged from 2 months to 10 years.

Long-Term Outcomes of Open Surgical Repair for Ruptured Iliac Artery Aneurysms

BACKGROUND Rupture of an iliac artery aneurysm is rare but could be catastrophic unless it is treated with an appropriate strategy. We reviewed our 10-year institutional experience in treating iliac artery aneurysms to elucidate the effectiveness of open surgical repair strategies for ruptured iliac artery aneurysms in terms of short- and long-term postoperative results. METHODS A total of 26 patients (men/women = 22/4), with a mean age of 72 years, underwent open repair of iliac artery aneurysm with or without rupture (unruptured/ruptured = 15/11) between January 2001 and April 2010. There was no difference in the distribution of aneurysm morphology between the unruptured and ruptured groups, and 20 (76.9%) of the 26 patients had aneurysms involving unilateral or bilateral internal iliac arteries. Long-term event-free survival rates and freedom from secondary intervention were analyzed using the Kaplan-Meier method (follow-up: 55 ± 39 and 40 ± 25 months in the unruptured and ruptured groups, respectively). RESULTS There was no difference in the time of surgery between the two groups (351 ± 118 and 348 ± 152 minutes in the unruptured and ruptured groups, respectively), but the ruptured group showed greater blood loss/min (time of surgery) and transfusion volume than the unruptured group. The early postoperative mortality was 6.7% in the unruptured group and 0% in the ruptured group (p = 0.557). There was no difference in the number of postoperative morbidities between the two groups, but the ruptured group showed significantly greater C-reactive protein, lactate dehydrogenase, and total bilirubin levels than the unruptured group. The cardiovascular event-free survival rate at 5 years was 93.3% and 100.0% in the unruptured and ruptured groups, respectively. The secondary intervention-free rate at 5 years was 100.0% and 90.0% in the unruptured and ruptured groups, respectively. CONCLUSIONS The short- and long-term postoperative mortality rates after open repair for iliac artery aneurysms were satisfactorily low and similar in unruptured and ruptured groups. This suggests that open repair strategies remain as a reliable treatment option to obtain successful postoperative results in patients with rupture of an iliac artery aneurysm.

Acute aortic occlusion due to false-lumen expansion after repair of abdominal aortic rupture in type B acute aortic dissection.

We describe a patient with aortic occlusion due to false-lumen expansion after repair of abdominal aortic rupture in acute type B aortic dissection. A 70-year-old man presented to a nearby hospital with severe lower back pain, and was subsequently referred to our hospital with a diagnosis of abdominal aortic rupture. Computed tomography scanning on admission revealed type B aortic dissection with concomitant false-lumen rupture at the level of pre-existing infrarenal abdominal aortic aneurysm. The patient underwent abdominal aortic replacement with the true lumen reconstructed using a bifurcated knitted Dacron graft. On postoperative day 2, the patient developed severe lower body ischemia. Computed tomography scanning revealed complete true-lumen occlusion at the renal artery level because of false-lumen expansion. The patient underwent open fenestration by opening the bulging flap with a transverse graftotomy distal to the proximal graft anastomosis. After fenestration, the patient developed severe metabolic complications (i.e., myonephropathic-metabolic syndrome) and died a day later of cardiac arrest resulting from hyperkalemia. Abdominal aortic replacement with true-lumen reconstruction in patients with abdominal aortic rupture in type B acute aortic dissection could also lead to acute aortic occlusion due to re-dissection or true-lumen compromise accompanying retrograde propagation of false-lumen thrombosis. This lethal sequela after true-lumen reconstruction might be prevented by an adjuvant procedure such as concomitant fenestration.

Aneurysm of a Right-Sided Descending Thoracic Aorta With a Left-Sided Aortic Arch and Aberrant Right Subclavian Artery

We describe a rare case of an arteriosclerotic aneurysm in the right-sided descending thoracic aorta with a left-sided aortic arch and concomitant aberrant right subclavian artery. A 76-year-old woman, who was found to have an aneurysm of the right-sided descending thoracic aorta, was referred to our hospital for surgical treatment. Contrast computed tomography scan revealed a left-sided aortic arch with an aberrant right subclavian artery, a descending thoracic aorta passing downward behind the esophagus, and an aneurysm of the right-sided and distal (level between the 8th and 10th vertebral bodies) descending thoracic aorta. With a right posterolateral thoracotomy, the patient underwent descending thoracic aorta replacement using an 18-mm woven Dacron prosthesis. The patient had an uneventful postoperative course and was discharged 24 days after surgery. Histological microscopic examination of the resected aneurysmal wall revealed an arteriosclerotic aneurysm. The postoperative computed tomography scan 18 days after surgery revealed no anastomotic aneurysm or abnormal fluid collection.

Fetal Echocardiography in Japan

わが国における胎児心臓超音波検査の普及は,日本胎児心臓病学会が,2006年 9月に『胎児心エコー検査ガイド ライン』1)を作成したことから飛躍的に進み,現在に至っている.このガイドラインによると,胎児心エコー検査はレ ベル I (胎児心臓スクリーニング)とレベル II (胎児心精査)に分けられ,レベル Iは原則としてすべての妊婦が対象と なり,通常の検診の際に産科医,胎児スクリーニング経験を有する超音波検査士等が行うことになっている.このレ ベル Iの検査項目としては,〔1〕胎児の左右の確認,〔2〕腹部断面,〔3〕四腔断面(1心臓の位置,2心臓軸,3心臓の 大きさ,4心臓の左右差),〔4〕流出路の観察(1大血管が 2本存在し,サイズがほぼ同じである,2 2本の大血管が 空間的に交差する,3それぞれの心室から 1本ずつの大血管が出る)が記載されている. これらの観察項目で多くの先天性心疾患のスクリーニングが可能であるが,大動脈縮窄症,離断症,総肺静脈還流 異常症といった新生児期に治療介入を要する疾患に関してはスクリーニングから外れてしまう可能性があり,山下 論文ではこの点に着目し,施設独自でスクリーニングプログラムを作成し,本来であれば,レベル IIの検査項目に含 まれている Three-vessel viewと Three vessel trachea viewをレベル Iに加えていることは評価に値する.さらに,検査 時期,回数をガイドラインでは在胎 18~ 20週台前半までと 30週前後の 2回としているが,18週前後,28週前後, 36週前後の 3回として検出率向上に努めており,今後のわが国における胎児スクリーニングの方向性を導く報告と いえる. 大動脈縮窄症,総肺静脈還流異常症は胎児診断が難しい疾患であり,かつ新生児期に治療介入が必要な疾患であ る.まず,大動脈縮窄症に関してであるが,大動脈縮窄症の胎児診断は大動脈弓が描出されたとしても,大動脈弓部 の狭窄が明確ではない場合がある.大動脈縮窄症の間接的所見として心室サイズの左右差があげられるが,これは 大動脈縮窄症に特異的な所見ではない.故に胎児診断が難しい.大動脈縮窄症の胎児診断に関しては,Matsui2)らが その詳細を報告している.これによると,四腔断面の左右差,大動脈弓の不均等の両方あるいはどちらかを肉眼的に 認 め,大 動 脈 縮 窄 症 が 疑 わ れ た(normal situs, concordant atrioventricular and ventriculoarterial connections, and a biventricular atrioventricular connection)胎児 44例を対象とし Three vessel trachea viewで aortic isthmusと ductの径を測 定し isthmal-to-ductal-diameter ratioを算出している.対象胎児44例のうち,40例で isthmal-to-ductal-diameter ratioは0.74 未満であり,この 40例には,出生後,手術介入あるいは経過観察を要すると診断された大動脈縮窄症 27例全例が含 まれていた.0.74以上の症例 4例には出生後の確定診断にて大動脈縮窄症の症例は認めなかった.この指標がその ままわが国のスクリーニングに取り入れられるとは思わないが,数値化された指標を用いることでレベル Iでのス クリーニングがより明瞭化する可能性があると思われる. また,総肺静脈還流異常症も胎児診断が極めて難しい疾患である.診断は 4本の肺静脈が左房に還流しないこと で確定されるが,肺静脈血流が少ない胎児において同定は簡単ではない.また,パルスドプラ法やカラードプラ法で の計測が,わが国ではレベル Iの検査項目に含まれていないため,スクリーニングから外れる可能性が高い.総肺静 脈還流異常症の胎児診断率は Seale3)らの報告では 1.9%,Laux4)らの報告では 10.5%と報告により差がある.Sealeら の報告は,イギリス,アイルランド,スウェーデンのデータを解析した報告であるが,それぞれの国でスクリーニン

Right retroperitoneal approach for repair of an abdominal aortic aneurysm involving bilateral iliac arteries in a patient with a left-side stoma after abdominoperineal resection.

A 78-year-old woman, who had a history of abdominoperineal resection with the associated left-side stoma for rectal cancer, was diagnosed with an infrarenal abdominal aortic aneurysm involving both common and right internal iliac arteries. She underwent in situ graft (bifurcated Dacron) replacement through a right retroperitoneal approach because of limited accessibility to the aorta and iliac arteries due to the left-side stoma. The distal anastomosis of the bifurcated graft was placed to the right external iliac artery and left femoral artery, and the left common iliac artery was excluded by ligating the branching arteries. The patient had an uneventful postoperative course, and the computed tomography scanning at 13 months after surgery revealed thrombosed occlusion of the excluded left common iliac aneurysm. In conclusion, a right retroperitoneal approach may be an option for abdominal aortic aneurysm patients who had a history of transperitoneal abdominal surgery and an associated left-side stoma.

Ligation-and-bypass technique through the posterior approach for bilateral popliteal aneurysms.

A 56-year-old man with a painful, progressively enlarging pulsatile mass in the bilateral popliteal fossae was diagnosed with a bilateral popliteal artery aneurysm (PAA) and referred to our hospital to undergo surgical therapy. Computed tomographic scanning demonstrated a large, middle-type PAA with a rich mural thrombus in the bilateral popliteal arteries. Following aneurysm exclusion posteriorly, the patient underwent bypass surgery using a ringed polytetrafluoroethylene graft bilaterally. This procedure was chosen to prevent nerve injury caused by mobilization of the adherent nerves and aneurysmal resection. The patient had a satisfactory postoperative course. This procedure may be recommended for large, middle-type PAAs because (1) the adherent tibial nerve trunk and its branch nerves can be protected by aneurysm exclusion with arterial branch ligation and (2) frequently occurring postexclusion expansion of the aneurysm caused by insufficient branch ligation using the medial approach can be avoided.