Mamoru Tago

Effect of type II endoleaks and antiplatelet therapy on abdominal aortic aneurysm shrinkage after endovascular repair

OBJECTIVE Endovascular repair of abdominal aortic aneurysm (EVAR) has been shown to be safe, and its use is increasing rapidly, but the long-term results of this procedure remain unclear. A decrease in the diameter of the aneurysm sac is considered to represent successful exclusion of the aneurysm from the circulation, but it has been reported that aneurysm shrinkage occurs in only about 60% of patients who have undergone EVAR. We analyzed several factors to determine whether they were related to aneurysm shrinkage after EVAR. METHODS From March 2007 to January 2010, EVAR was performed in 65 patients, 58 of whom underwent an enhanced computerized tomographic evaluation 6 months after the procedure. One patient was found to have a type Ia endoleak and was excluded from the study. In the remaining 57 patients, univariate and multiple regression analyses were used to determine whether there was a relationship between aneurysm shrinkage and various patient characteristics, aneurysm dimensions, and procedural outcomes. Aneurysm shrinkage was defined as a decrease in diameter of at least 4 mm. RESULTS On univariate analysis, a lack of aneurysm shrinkage by 7 days and 6 months after EVAR was significantly associated with hyperlipidemia, ongoing multiagent antiplatelet therapy with clopidogrel, ticlopidine, or cilostazol as well as aspirin, length of the proximal neck of the aneurysm, preprocedure maximum aneurysm diameter, and the presence of a type II endoleak. On multiple regression analysis, only multiagent antiplatelet therapy and type II endoleak were significantly related to a lack of aneurysm shrinkage 6 months after EVAR. Multiagent antiplatelet therapy and type II endoleak 6 months after EVAR were not significantly associated with each other. CONCLUSION Patients with a persistent type II endoleak and patients undergoing multiagent antiplatelet therapy are at an increased risk of a lack of aneurysm shrinkage 6 months after EVAR.

Forty-Year Survival With Smeloff-Cutter and Starr-Edwards Prostheses

This case study describes a 40-year follow-up of a man who had a double valve replacement with Smeloff-Cutter aortic (Cutter Laboratories, Berkeley, CA) and Starr-Edwards mitral prostheses (Edwards Laboratories, Santa Ana, CA) when he was 34 years old. Double valve replacement was performed for aortic and mitral valve stenosis and insufficiency. To date, no surgical treatment has been required except a pacemaker implantation. The patient presented with a New York Heart Association functional class of I to II. Echocardiography revealed intact prostheses.

Bronchial and cardiac ruptures due to blunt trauma

Tracheobronchial and cardiac injuries following blunt thoracic trauma are uncommon but can be life-threatening. We report a case in which the patient with bronchial and right atrial ruptures due to blunt trauma survived after emergent repairs. An 18-year-old female driver was transported to our hospital after a traffic accident and was hemodynamically stable on arrival. Chest computed tomography revealed cervicomediastinal emphysema and hemopericardium, and fiberoptic bronchoscopy showed a tear in the right main bronchus. She was intubated with a double-lumen endotracheal tube guided by bronchoscopy. A median sternotomy was undertaken, and a laceration of the right atrium was oversewn without the use of cardiopulmonary bypass. After that, right-sided thoracotomy was performed. The tear in the membranous portion of the right main bronchus was repaired with interrupted sutures, and the suture lines were wrapped with a pedicled flap of intercostal muscle.

Endovascular repair and pharmacotherapy of an inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula.

An inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula was successfully treated by stent grafting. Pharmacotherapy with octreotide after endovascular aneurysm repair was also performed with the expectation of spontaneous and rapid closure of the fistula. Gastrointestinal endoscopy performed 10 days after endovascular aneurysm repair showed closure of the large aortoduodenal fistula, and oral intake was started on the operative day 16. To date, 16 months after the initial operation, the patient is doing well without any symptoms or signs of infection and without any antibiotic therapy.

Primary Cardiac Chondrosarcoma with Large Cell Pulmonary Carcinoma

A 55-year-old man was transferred to our hospital for removal of cardiac and pulmonary tumors. Transesophageal echocardiography demonstrated a large echogenic mass in the left ventricle. The mass was attached to the posterior wall of the left ventricle and the mitral valve. Chest computed tomography showed a solitary, well-defind nodular lesion in the right upper lung. We performed concomitant resection of cardiac and pulmonary tumors through a midline sternotomy. The pathological diagnosis was cardiac chondrosarcoma with pulmonary large cell carcinoma. Postoperatively pelvic computed tomography, bone and gallium scintigrams did not identify any other active lesion, hence the cardiac tumor was considered to be of cardiac origin. He is alive 20 months after the operation and findings from the cardiac and pulmonary examination are unremarkable. Primary cardiac chondrosarcoma is extremely rare, and to our knowledge, only 13 cases have been recorded. We summarize herein these 14 cases.

Endovascular management for ruptured Stanford B acute aortic dissection

Surgery for a complicated Stanford B acute aortic dissection, such as rupture or malperfusion, is still a challenge. We undertook endovascular therapy for ruptured Stanford B acute aortic dissection in two patients. A homemade stent graft was deployed in an 84-year-old woman with a massive mediastinal hematoma; and an aortic extender of Excluder was used for a 76-year-old man with left hemothorax. Both patients recovered without major complications. Careful follow-up is mandatory. Endovascular therapy for a ruptured Stanford B acute aortic dissection seems feasible and efficient.

Operation with Cardiopulmonary Bypass Using Heparin and Nafamostat Mesilate for a Patient with Protamine Allergy

症例は77歳,女性.平成14年2月6日上行大動脈瘤(最大径7.0cm)に対して手術を行うため,全身麻酔を導入したところ,アナフィラキシーショックとなった.同日の手術を中止し,皮内テストを行ったところ,ベクロニウム,パンクロニウム,プロタミン,ファモチジンが陽性であった.5月22日あらためて上行大動脈人工血管置換術を行った.体外循環時の抗凝固剤は,ヘパリンとメシル酸ナファモスタット(FUT)を併用した.体外循環直前にヘパリンを投与し,体外循環中はFUTを持続投与した.プロタミンによる中和は行わず,体外循環を終了した.体外循環中,抗凝固のモニターとして,活性化凝固時間(ACT)だけではなく,適宜,プロトロンビン時間(PT)も測定した.手術時間は4時間30分,体外循環時間は1時間26分であった.ICU帰室後一時的に出血量が増加したため,MAP4単位,FFP8単位を投与した.その後,経過は良好で術後35日目に退院した.

A Case of One-Stage Operation for Brachiocephalic Aneurysm and Aortic Regurgitation Associated with Aortitis Syndrome

な症例は31歳,女性.大動脈炎症候群に伴い,右総頸動脈,鎖骨下動脈まで及ぶ腕頭動脈瘤(最大径25mm)と大動脈弁閉鎖不全症(Sellers分類IV度)を認めた.CRPが27.5mg/dlと高値であったため,ステロイドによる治療でCRPが陰転化したのち,腕頭動脈人工血管置換術,大動脈弁置換術を一期的に施行した.術中,脳内局所酸素飽和度(rSO2)をモニターし,脳虚血に注意しながら頸部の動脈を遮断したが,rSO2は低下しなかった.術後,Horner症候群が出現したものの,そのほかの経過は良好で術後28日目に退院した.将来,出産を希望する患者であったが,本人が再手術を希望しないため,妊娠・分娩時に抗凝固療法を考慮することとし,機械弁を用いて大動脈弁置換術を行った.

Myocardial protection of only the left coronary artery perfusion in patients with isolated aortic valve replacement.

Effectiveness of only left coronary perfusion on myocardial protection was assessed by measuring serially cardiac functions such as cardiac index(CI), stroke index(SI), left ventricular minute work index(LVWI) and left ventricular stroke work index (LVSWI) in 22 consecutive patients with isolated, scheduled aortic valve replacement. The cardiac functions were determined 2,4 and 6 hours after open heart surgery. Correlation coefficients(r) between coronary perfusion time and the cardiac functions were less than 0.23, such being statistically insignificant. SI and LVSWI were in statistically significant inverse correlation to the preoperative NYHA classification and extracorpreal circulation(ECC) time for 4 hours following open heart surgery, and CI and LVWI for 2 hours. The correlation coefficients were highest at the 2nd postoperative hour and then decreased with passage of time. Therefore, the cardiac dysfunctions occurring in the postoperative period correlated either to the preoperative NYHA classification or ECC time, or both. It does, however, seem likely that the dysfunctions were correlated to ECC time as the recovery time of 4 hours from the dysfunctions is too short for preoperatively existing dysfunction. Therefore, it was concluded that the continuous perfusion of only the left coronary artery was not the determinant factor of the postoperative dysfunctions and that the ECC time afforded detrimental effects, although such continued for 4 hours in terms of SI and LVSWI, and 2 hours in term of CI and LVWI.

Prediction of prognosis in open-heart-surgery by regional difference in leg surface temperature.

Change of the surface temperature of the leg during open-heart-surgery was determined in five patients, in whom either side of the femoral artery was ligated for cannulation. While the surface temperature at the patella was least influenced, that at the ankle paralleled closely the changes in the core body temperature and blood supply to the leg. Their difference(P-A difference) was studied to see if they can be used to predict prognosis of patients undergoing open-heart surgery. The P-A difference was followed for several hours after the open-heart surgery. It was marked positive when the surface temperature at the patella was higher than that at the ankle. Total of 54 patients were studied. Only one out of 29 patients with negative P-A difference succumbed. This is in sharp contrast to the 25 remaining patients with positive P-A difference, from whom as many as 12 died. In addition, the postoperative course of the 13 survivors from the latter group was more eventful. Since P-A difference seemed to indicate accurately cardiac output by reflecting the state of the peripheral circulation, it can be used as a useful parameter in prediction of the prognosis in open-heart surgery.