Masahiko Ikebuchi

Pulmonary embolism in patients with isolated soleal vein thrombosis

This study investigated the features of calf deep vein thrombosis (DVT) as a pulmonary embolic source. Fifty-eight lower limbs in 29 patients who were suspected of having DVT distal to the popliteal vein were screened by ultrasonography. Then, ascending venog raphy was performed to confirm the diagnosis. Pulmonary embolism (PE) was diagnosed in suspected patients by use of pulmonary perfusion scanning or pulmonary angiography. Venography revealed calf DVT in 33 limbs in 28 patients. Of 28 patients, six had symp tomatic PE. Thrombosis was found in the muscle veins in 18 limbs, the trunk veins in 11, and both veins in four. Isolated single vein thrombosis was found in the soleal vein in 14 limbs (42%), the posterior tibial vein in eight, the peroneal vein in two, and the gastroc nemius vein in two. The overall percentage of soleal vein thrombi was 61%. All six patients with symptomatic PE had isolated soleal vein thromboses. Calf DVT was a pulmonary embolic source when isolated thrombosis of the large soleal vein was more than 7 mm in diameter. Soleal veins were the most frequent and important location of calf DVT, suggesting that these were an occasional embolic source of critical PE.

Mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer: report of a case.

We report a case of mycotic abdominal aortic pseudoaneurysm caused by a penetrating atherosclerotic ulcer (PAU). An 81-year-old woman was admitted to a local hospital with fever and abdominal pain, and when her symptoms were not improved by antibiotics, she was referred to our department. Computed tomography (CT) and angiography showed a saccular aneurysm below the renal arteries, and an emergency laparotomy was performed because we suspected a mycotic abdominal aortic pseudoaneurysm. An abscess was found on the proximal side of the jejunum, caused by an aneurysm penetrating the serosa. We diagnosed a mycotic pseudoaneurysm after finding the anterior wall of the aorta penetrated by intense calcification. The pseudoaneurysm was resected with the abscess and the area was covered with a pedicled omental flap to prevent infection. An axillofemoral bypass was also done. The patient recovered well.

Postinfarct cardiac free wall rupture detected by multidetector computed tomography

Cardiac free wall rupture after myocardial infarction is one of the life-threatening complications, which often results in sudden onset of cardiogenic shock caused by cardiac tamponade. Multidetector computed tomography (MDCT) provides valuable information in any clinical setting. There have been a few case reports on detecting cardiac rupture by means of CT. We report here a rare case of postinfarct cardiac free wall rupture, whose myocardial tear could be detected by MDCT.

Exploration of Pulmonary Embolic Sources in the Lower Limbs by Ultrasonography

We demonstrate our method for detecting deep vein thrombosis in the lower limbs, the most frequent source of thrombosis, and we investigate the pathogenesis of critical pulmonary embolic sources. The subjects were 157 patients who underwent either pulmonary perfusion scanning or pulmonary angiography from 1987 to 1998. Unilateral thrombosis was found in 128 cases and bilateral thrombosis in 29. Among them, 42 patients exhibited symptomatic pulmonary embolism: 31 acute and 11 chronic. For exploration of deep vein thrombosis, the duplex with color Doppler was mainly used. Both sitting position and compression technique were necessary to diagnose calf vein thrombosis. Compared with the proximal occlusive levels and the incidence of symptomatic pulmonary embolism, the frequency of symptomatic pulmonary embolism was higher in the femoral vein or soleal vein than in other areas. In particular, most patients with chronic pulmonary embolism had bilateral soleal vein thrombosis. The frequency was significantly higher in bilateral thrombosis than in unilateral thrombosis. The duplex with color Doppler is the first choice of noninvasive testing methods to explore pulmonary embolic sources in the lower limbs. Both femoral vein thrombosis and soleal vein thrombosis are critical pulmonary embolic sources, and bilateral soleal vein thromboses may be a specific embolic source for chronic pulmonary embolism.

Comprehensive arrhythmic surgery for sustained ventricular tachycardia revisited

A 68-year-old woman with a history of old inferior myocardial infarction was admitted because of sustained ventricular tachycardia. Double vessel coronary disease was found with subtotal obstruction of the right coronary artery (#1) and severe stenosis of the left circumflex coronary artery (#13). Dilated left ventricle with a large ventricular aneurysm at the inferior wall and severely reduced systolic function were also present. A comprehensive surgical ablation using subendocardial resection and cryoablation was performed in combination with aneurysmectomy, left ventricular reconstruction, and coronary bypass grafting to the circumflex coronary artery. An implantable cardioverter-defibrillator was also implanted. She has remained well without recurrence of sustained ventricular tachycardia for one year. Although radiofrequency catheter ablation is nowadays considered a first-line therapy for patients with sustained ventricular tachycardia, surgical ablation remains a valuable option for selected patients, particularly for those requiring left ventricular aneurysmectomy and coronary artery bypass grafting, in order to gain a better long-term prognosis through total cure of ventricular tachycardia. <Learning objective: Although radiofrequency catheter ablation is nowadays considered a first-line therapy for patients with sustained ventricular tachycardia, surgical ablation remains a valuable option for selected patients, particularly for those requiring left ventricular aneurysmectomy and coronary artery bypass grafting, in order to gain a better long-term prognosis through total cure of ventricular tachycardia.>.

Rehabilitation on the day of cardio-aortic surgery

Fast-track strategy in cardio-aortic surgery has been known to have advantages in minimizing post-operative complications, shortening hospital stay and lowering costs.

A Case of Endovascular Stent-Graft Treatment for Traumatic Thoracic Aortic Dissecting Aneurysm Complicated with Multiple Injuries.

症例は65歳,男性.約6m高の屋根より転落し,深昏睡,ショックで入院した.頭蓋底骨折,右全肋骨骨折,血気胸を含む多発外傷を保存的に治療し,約2週間で意識障害と呼吸不全が軽快したが,経過中に下行大動脈瘤を生じ6.5cmに増大した.合併病変による危険を考え,ステントグラフト内挿術を施行し,瘤径は3ヵ月で4.6cmに縮小した.

Long-Term Results after Surgery for Abdominal Aortic Aneurysm.

1980年から1997年に手術した腹部大動脈瘤(AAA)191例(非破裂161例,破裂30例)の遠隔期予後を検討した.30日死亡は非破裂群1.2%,破裂群36.6%,在院死亡はおのおの3.1%,53.3%であった.耐術例の累積生存率は5年76.3%,10年42.3%で,一般人口より低かった.非破裂群と破裂群に有意差はなかった.遠隔期の死因は心臓関連死が28.8%,脳血管障害19.2%,悪性腫瘍17.3%,大動脈腸管瘻や再発した真性動脈瘤(真性瘤),吻合部動脈瘤(吻合部瘤)など中枢側吻合部周囲大動脈病変の破裂が9.6%であった.遠隔期に中枢側吻合部周囲の大動脈病変を10%,胸部大動脈瘤を3.7%,大動脈解離を4.2%に認めた.グラフト累積開存率は10年97.4%,15年90.9%であった.AAA患者では術後遠隔期において,冠動脈疾患や大動脈瘤の再発などを早期に発見するために,長期的な経過観察が必要である.

Multiple External Iliac and Femoral Aneurysms that Developed After Closure of a Traumatic Arteriovenous Fistula: A Case Report

A 65-year-old man who underwent closure of a traumatic arteriovenous fistula presented with pulsating masses in the right femoral region. A diagnosis of multiple aneurysms from the right external iliac artery to the superficial femoral artery complicated by ipsilateral varicosis of the short saphenous vein was made. Stripping of the short saphenous vein and iliopopliteal bypass with reimplantation of the profunda femoris artery were performed in two stages. Hemodynamic factors are considered to be involved in the mechanism of aneurysm formation following treatments for traumatic arteriovenous fistula, and long-term follow-up is needed after their closure.