Minoru Hosaka

Treatment for Aortic Graft Infection

Abstract Nine patients with an aortic graft infection presented after undergoing aortic grafting. Seven of 9 patients underwent an initial aortic reconstruction in our hospital. The incidence of aortic graft infection was 1.5% (7/456). There were 6 cases of paraprosthetic infection and 3 cases of aortointestinal fistulas. The treatments consisted of a complete graft excision and an axillofemoral bypass in 6 patients, a complete graft excision alone, a partial graft excision and a femorofemoral bypass, and the preservation of the graft with omental wrapping and irrigation in 1 each. Broad-spectrum antibiotics were intravenously administered to all patients and were then replaced by selective antibiotics for the responsible organisms. All surviving patients received antibiotics orally for 3–6 months. The early postoperative mortality rate was 11.1%. Aortoduodenal fistula occurred in 1 patient with graft excision alone. Graft thrombosis occurred in 2 patients with an axillofemoral bypass. No late graft infection or stump blowout occurred in any patient. We believe that a complete excision of the infected graft as well as the maintenance of distal tissue perfusion is necessary. However, based on the condition of the patient, the appearance of the operating field, and the difficulty of a repeat operation, we would like to stress the importance of selecting the best and safest treatment plan for each case.

LIMB SALVAGE AND SURVIVAL RATES AMONG ELDERLY PATIENTS WITH ADVANCED LIMB ISCHEMIA

The purpose of this study was to clarify the incidence of limb salvage and patient survival rates among elderly patients with advanced leg ischemia. We reviewed the records of 159 patients treated for advanced ischemia over a 15-year period at Aichi Medical University, 74 of whom were aged over 75 years and 85, between 65 and 74 years. There was a collective total of 186 limbs; 82 in the older group and 104 in the younger group. The older group had a greater proportion of women, and a higher incidence of coronary heart disease, pulmonary dysfunction, and acute onset of advanced ischemia than the younger group. Limb salvage was achieved in 73% of the affected limbs in the older group and in 92% of the limbs in the younger group. The poor limb salvage rate in the older group was mainly related to the high initial amputation rate. Early recognition of the sentinel ischemic signs before the ischemia is essential, especially in the elderly. Timely revascularization should be attempted whenever possible, and it should not be abandoned simply because the patient is deemed too old. The 1-, 3-, and 5-year survival rates in the older group were 59%, 28%, and 23%, respectively, which were markedly poorer than the expected survival rates of the age- and sex-matched Japanese population at 1, 3, and 5 years, which were 93%, 79%, and 65%, respectively. Thus, advanced limb ischemia carries a poor prognosis to the point of being life-threatening, and further continuous systemic management with the collaboration of physicians and surgeons must be provided even after the patient has left the hospital.

Indications for and limitations of exercise training in patients with intermittent claudication

BACKGROUND The selection of candidates for exercise training among patients with intermittent claudication is still a matter of debate. PATIENTS AND METHODS Forty-nine patients with intermittent claudication due to arteriosclerosis obliterans were tested. Forty-six patients were men and 3 were women, with an average age of 65 years (range, 46 to 76 years). The patients walked on a treadmill at 2.4 km/h on a 12% upgrade followed by an appropriate period of rest for 30 minutes twice a day during a 3-week hospitalization. Programs were individualized for each patient. Four parameters were assessed after exercise training: (1) Ankle-brachial index (ABI) at rest, (2) Fall in ABI after 40 m of treadmill walking (ABI Fall 40), (3) the recovery time (RT 40) required for the ABI to return to resting levels after 40 m of walking, and (4) the maximal walking distance (MWD) on the treadmill. RESULTS The average ABI at rest before the 3-week training period was 0.60 +/- 0.02 (mean +/- SE), and after training it was 0.62 +/- 0.02. There was a small although not statistically significant increase in the ABI after training. This increase in the ABI did not exceed 0.21. The average ABI Fall 40 before training was 0.36 +/- 0.01, and after training it was 0.30 +/- 0.02. The average RT 40 before training was 9.9 +/- 0.8 min, and after training it was 6.2 +/- 0.6 min. There were significant decreases in the ABI Fall 40 and RT 40 after training (p < 0.01 and p < 0.001, respectively). The MWD increased after training in 48 of the 49 patients. The average MWD increased from 134 +/- 13 m to 226 +/- 32 m after training (p < 0.001). The occlusion levels did not influence the results as training effects and hemodynamic parameters. Fourteen of 49 patients desired arterial reconstruction after exercise training. CONCLUSIONS Patients with shorter RT 40s before training achieved greater increases in the MWD after training. In patients with an RT 40 under 12 min, exercise training is indicated. However, there is some discrepancy between the increase in MWD and the degree of satisfaction in individual patients.Background: The selection of candidates for exercise training among patients with intermittent claudication is still a matter of debate. Patients and methods: Forty-nine patients with intermittent ...

Gluteal compartment syndrome after abdominal aortic aneurysm repair.

A 66-year-old man underwent emergency surgery for a ruptured abdominal aortic aneurysm associated with right common and internal iliac aneurysms. Postoperatively, his right buttock was distended and tender to compression. A CT scan revealed an extremely swollen right gluteus maximus with decreased density. Macromyoglobinuria was noted, and creatine kinase and myoglobin were elevated: 87,800 IU/l and 144,300 ng/ml, respectively. Renal function had deteriorated and he was treated with hemodialysis until the 15th postoperative day. The patient recovered without any discomfort to the buttock or intermittent claudication. To our knowledge this is the first documented case of gluteal compartment syndrome after the repair of an abdominal aortic aneurysm.

Simultaneous Open and Endoluminal Repair of Ruptured Abdominal and Thoracic Aortic Aneurysms: Report of a Case

A 66-year-old woman was transferred to our hospital for emergency treatment of a ruptured abdominal aortic aneurysm (AAA) and impending rupture of a descending thoracic aortic aneurysm (TAA) caused by a Stanford type-B dissection. She had severe coronary artery disease and a highly calcified aorta, and had been taking long-term steroids for rheumatoid arthritis. Endovascular repair of the TAA failed because the femoral artery was too small, so we performed simultaneous repair of the TAA and the AAA. A temporary axillofemoral bypass was constructed and the AAA was replaced with a bifurcated prosthetic graft. A thoracic stent graft was delivered successfully through a chimney graft of the abdominal graft. About 4 months later, the TAA extended proximally, causing hemoptysis, which was stopped by placing a new stent graft proximal to the previous one. This case report shows that a combination of open and endovascular repair is useful for treating a TAA with an AAA, especially in a small or frail patient.

Disruption of externally supported knitted Dacron graft three years after implantation—A case report*

A knitted Dacron velour externally supported prosthesis was broken in two pieces at the supported portion 3 years after femoroposterior tibial bypass grafting. This type of graft problem has never been reported. Details of the clinical course, angiogram, CT scan, and scanning electron micrograph of a portion of the graft are shown. The externally supported Dacron prosthesis broke into two pieces along the broken coil of the middle portion. A possible cause of this failure may have been due to damage of the Dacron fibers in the process of heat fusing the coil. This presentation emphasizes the possibility of this rare externally supported graft complication, and the necessity for careful follow-up not only of the graft patency but also for the mechanical defects of the implanted externally supported Dacron graft itself.

Venous malformation of the vulva

Case reportA 27 year old, nulliparous woman presented with athree-year history of a painless swelling in the left labiummajus of the vulva. This was thought to be a Bartholin’scyst and was treated by aspiration at another hospital, butit soon recurred. The swelling increased on standing anddid not change with the menstrual cycle. On examinationa soft oval swelling was present in the subcutaneoustissue of the left labium majus of vulva. It measured2.5 by 2 cm, had an indistinct border, and was reducedby compression. No pulsation or thrill was palpable.Ultrasonography showed that the swelling was subcuta-neous, contained fluid but had no septa. Following aspira-tion of about 10mL of blood, the size of the swelling wasnot reduced. There were no varices, venous dilatation,oedema, or pigmentation of the vulva (Fig. 1). X-raystudies after direct injection of contrast material intothe swelling indicated two lobular lesions and with retro-grade flow into both external iliac veius (Fig. 2). Thelarger labule was located in the vulva, while the smallerone was situated in the deeper tissues. These findings ledto a diagnosis of venous malformation. At resection, theswelling was quite easily separated from the surroundingtissues, and was extirpated after ligation of the supplyingand departing veins. The pathological specimen showeddilated veins of various sizes throughout the swelling.Hypercellularity of the vessel walls and endothelial cellmultiplication were not seen (Fig. 3). Her post-operativecourse was satisfactory, and she was discharged on thefourth day after the operation.DiscussionAlthough venous malformations may appear anywherein the body, our literature search over the last 20 yearsrevealed no reports of vulvar venous malformation.Only one case of a capillary-venous malformation in thelabiummajoraofa12yearoldgirlwasreportedbyKempi-naire et al.

Benefits of arterial reconstruction in claudication

We conducted a midterm follow-up of 150 claudicants who underwent surgical reconstruction by assessing cumulative patency, survival, and palliation (graft patency in live patients) rates. Eighty-nine claudicants (group I) underwent direct (in situ) proximal revascularization, 33 (group II) had indirect (ex situ) proximal revascularization, while 28 (group III) had distal revascularization. The secondary patency rates at 3 years were 97.5% in group I, 97.0% in group II, and 75.0% in group III, respectively. Only one patient with limb graft thrombosis required below-knee amputation. There were 3 perioperative deaths (2 in group I and 1 in group II). The survival rates at 3 years were 86.0% in group I, 69.5% in group II, and 95.8% in group III, respectively. The palliation rates at 3 years were 84.8% in group I, 70.0% in group II, and 77.9% in group III, respectively. These findings indicate the midterm benefits of supra- and infrainguinal arterial reconstructions, and also suggest that the preoperative assessment of risks in individual patients, the selection of the appropriate operative procedure and graft material, and intensive postoperative follow-up and management of any associated disease are all important aspects in the treatment of claudicants.

Operative Mortality and Long-Term Relative Survival Rate Following Surgery for Abdominal Aortic Aneurysms.

腹部大動脈瘤 (AAA) 240例を破裂群 (31例) と非破裂群 (209例) に分け, 非破裂群をASO合併群 (48例) とASO非合併群 (161例) に分けて検討した. 追跡期間は最長15年10か月, 平均4年2か月, 遠隔期追跡率は97%であった. 手術死亡率は破裂群41.9%, 非破裂群2.9%, ASO合併群6.3%, ASO非合併群1.9%であった. 遠隔期死亡原因は心疾患32%, 悪性腫瘍22%, 脳血管障害10%, 腎疾患10%などであったが, 手術時リスクファクターと関連したのは腎不全のみであった. 術後相対生存率は破裂群5年79%, 10年0%, 非破裂群5年90%, 10年70%で, 同年代一般人より低く, ASO非合併群は5年95%, 10年78%, ASO合併群は5年74%, 10年52%であり, ASO合併群ではさらに低値であった. ASO合併群は手術時, 虚血性心疾患, 糖尿病の合併が多く, 全体の遠隔期死亡原因は心疾患, 腎不全が多かった. これらを念頭においた遠隔期フォローアップが重要である.