Masakazu Goshima

Primary infected abdominal aortic aneurysm: Surgical procedures, early mortality rates, and a survey of the prevalence of infectious organisms over a 30-year period

PurposeThe purpose of this study was to analyze the surgical procedures, culture results, and outcomes, and to survey the prevalence of the infectious organisms over a 30-year period in patients with a primary infected abdominal aortic aneurysm (PIAAA).MethodsA total of 11 patients (1.8%) with PIAAA were surgically treated between 1982 and June 2009. All patients had back pain, leukocytosis, and elevated C-reactive protein level. All of the patients underwent either urgent or emergency operations.ResultsCultures of aortic wall specimens and blood were positive in 10 patients and included Salmonella in 2, Streptococcus in 2, Campylobacter fetus in 2, and Listeria, Haemophilus influenzae, Serratia marcescens, Bacteroides thetaiotaomicron, and an unknown organism in 1 patient each. The 10 patients underwent in situ prosthetic grafting with excision of the infected tissue and lavage using 10 l saline solution; omentum plasty was required in four patients. An axillofemoral bypass was performed in one patient with pus surrounding the AAA. All 10 patients with in situ replacement survived and were administered intravenous antibiotic therapy for 1 month postoperatively. All of these patients left the hospital without any further complications. However, one patient who underwent an axillofemoral bypass died of overwhelming sepsis.ConclusionIn situ replacement with excision of infected tissue, lavage using 10 l saline solution, and omentum plasty for PIAAA successfully resolved the condition. High local concentrations of rifampin-soaked grafts or superficial femoral vein may also be an alternative for an in situ replacement conduit.

Surgery for Ruptured Abdominal Aortic Aneurysm with an Aortocaval and Iliac Vein Fistula

The purpose of this study was evaluate the operative procedure and outcome of abdominal aortic aneurysm (AAA) patients with aortocaval fistula (ACF) and iliac vein fistula. From 1982 through 2004, we experienced five AAA patients associated with spontaneous aortocaval and aortoiliac venous fistula who underwent repair of AAA. Three patients were in hypovolemic shock, including one patient with cardiopulmonary arrest on admission who required cardiopulmonary resuscitation before surgery. These three ACF patients with hypovolemic shock underwent emergency operation and two patients with stable hemodynamic state underwent urgent operation. One of two ACF patients with stable condition was associated with unstable angina. One AAA patient with ACF-complicated angina underwent AAA repair with coronary artery bypass grafting; the remaining four patients underwent 3 bifurcated graft and 1 tube graft implantation. All surgical treatment of the fistula included direct closure within the aorta under digital compression in four patients and inferior vena cava clamp in one. The mortality rate was 25%. One ACF patient with retroperitoneal hematoma died of bleeding. Survival for ACF depends on early diagnosis and prompt surgical repair. Aortocaval fistula complicated with a rupture of aneurysm into retroperitoneal space had a severe fatal prognosis compared with uncomplicated ACF.

An impending rupture of a celiac artery aneurysm in a patient with Behçet’s disease — Extra-anatomic aorto-common hepatic artery bypass: Report of a case

A celiac artery aneurysm associated with Behçet’s disease is extremely rare. We herein present the case of successful surgical treatment for an impending rupture of a large celiac artery aneurysm with a wide proximal neck in a patient associated with Behçet’s disease. To our knowledge, this is the first report of a procedure involving extra-anatomic aorto-common hepatic artery (CHA) bypass through the retroperitoneal space implanting a 6-mm expanded polytetrafluoroethylene graft. An 18-month postoperative magnetic resonance angiography scan showed a good patency of the aorto-CHA graft without an anastomotic pseudoaneurysm in a closure of aorta and anastomoses.

Evaluation of Catheter-Directed Thrombolysis for Acute Deep Vein Thrombosis

近年,急性期深部静脈血栓症に対するカテーテル血栓溶解療法(CDT)や血栓吸引療法を含めた血管内治療の有効性が報告されている.今回,2003年1月より2004年8月までに当科で経験した深部静脈血栓症のうち,血管内治療を行った20例について検討した.血管内治療の適応は,発症から2週間以内,腸骨大腿静脈血栓閉塞型の深部静脈血栓症を対象とした.内訳は男性11例,女性9例,平均年齢56.4(30～78)歳,発症からの治療開始までの期間は平均4.4(1～12)日であった.血栓存在部位は左側15例,右側5例であり,血栓が存在する最も中枢側の静脈は下大静脈5例,腸骨13例,大腿2例であった.一時型下大静脈フィルターを留置したのちに,膝窩静脈よりシース挿入,カテーテルは多孔式を用い,ウロキナーゼは24万単位を1日量としてdrip infusion法と1日3～5回のpulse-spray法を併用とした.抗凝固療法はヘパリンを使用し,また,間欠的マッサージ(IPC)で患肢血流うっ滞を予防した.再造影にて血栓が残存する場合には機械的血栓吸引療法を施行し,iliac vein compression syndrome (IVCS)や器質化血栓に対しては金属ステントを留置した.治療前後の静脈造影にてvenographic severity score(VSスコア)と四肢周囲径にて治療効果判定とした.治療期間は5.0±0.28(2～9)日,総ウロキナーゼ使用量は102.5±5.7(36～168)万単位であった.総腸骨静脈にIVCSで1例,器質化血栓に対して2例に金属ステントを留置した.治療中2例に一時下大静脈フィルター内に血栓を捕捉したことが確認されたが,肺塞栓症は認めなかった.血栓性素因は2例に認められ,1例に抗リン脂質抗体症候群,もう1例にプロテインS欠乏症がみられた.早期再発を1例に認め,再度血管内治療を要した.VSスコアは術前26.2±6.3から治療後6.2±2.5と有意に(p<0.0001)低下した.急性期深部静脈血栓症に対して血管内治療は有効であり,満足しうる結果であると思われた.