Mitsuyoshi Shimoji

Coronary Artery Bypass Grafting for Patients in Whom Preoperative Angiography Determined That the In Situ Left Internal Thoracic Artery Could Not Be Used.

1998年1月から2001年8月までに当科で施行したCABG274例中,術前血管造影検査にて左内胸動脈(LITA)使用不能と判断された7例(7/262=2.7%)を対象として検討した.全例男性で,平均年齢は68.6歳,4例が鎖骨下動脈閉塞あるいは狭窄,3例がLITA閉塞あるいは狭窄であった.3例でRITAに橈骨動脈を端側吻合しcomposite Y graftとして使用,ほかの3例で橈骨動脈をsequential graftとして使用し,バイパス枝数は2.7±1.0であった.グラフト開存率は94.7%(18/19)で,1例にPMIを合併したが,対症療法にて軽快しており,ほかの症例に合併症はなく全例軽快退院した.冠動脈疾患を有する患者は高脂血症,末梢血管病変を有することが多く,このような症例においてはLITAの動脈硬化が有意に高率に認められるとの報告も見受けられ,有茎動脈グラフトに対する術前の十分な検討が重要であると考える.

Impact of Segmental Aortic Clamp and Distal Aortic Perfusion on Postoperative Paraplegia During Thoracoabdominal Aortic Graft Replacement

A variety of different measures have been instituted to decrease spinal cord injury during thoracoabdominal aortic aneurym surgery. However, paraplegia is still a most devastating complication. During the past twelve years, 40 consecutive patients were operated on for thoracoabdominal aortic aneurysms at our hospital. The mean age was 56.7 years and the range 22 to 82 years. Eighteen patients had dissecting aneurysms (DeBakey type III in fourteen patients and type I in four patients). Eight patients (20%) had had prior surgical aortic reconstruction. According to Crawford’s classification, 15 patients were type I, 5 were type II, 11 were III and 9 were type IV. A temporary left heart bypass (PA-FV or FA-FV) to maintain an adequate distal organ perfusion pressure and monitor of sensory evoked spinal cord potentials for detection of intraoperative cord injury was used in all patients. The mean number of cross-clamped aortic segments during surgery was 2.5 (range 1 to 5) in the nondissecting group and 3.4 (range 2 to 5) in the dissection group. Reimplantation of intercostal or lumbar arteries was performed in 18 patients (81.8%) in the nondissection group and in 17 patients (94.4%) in the dissection group. During surgery, selective visceral artery perfusion was undergone in 18 patients for organ preservation. The hospital mortality was 10% (4/40), 6.1% for elective cases (2/33) and 28.6% for emergency operations (2/7). Temporary paraparesis occurred in one patient who underwent emergency operation. No neurologic deficit was observed in the remaining patients.

Surgical Treatment of Traumatic Aneurysm of the Ascending Aorta

Traumatic aneurysm of the ascending aorta is a rare event. This case describes a patient with such an aneurysm, resulting from injuries received in a motorcycle accident. The patient was admitted to the emergency room of a local hospital complaining of chest pain, and was subsequently referred to our institution. On admission, a chest x-ray showed mediastinal widening. Computed tomography and aortography revealed an ascending aortic aneurysm and contusion of the upper lobe of the right lung. Due to concerns about bleeding from the lung contusion, surgery was delayed for one week. During surgery, intimal tears were detected at two sites in the ascending aorta. The wall of the ascending aorta was subsequently resected and a prosthetic graft inserted. The postoperative period was uneventful and a postoperative aortogram showed that the graft had molded well.

Successful surgical treatment of impending rupture of thoracoabdominal aortic aneurysm in an elderly patient with severe pulmonary emphysema

In a case of successful surgery for impending thoracoabdominal aortic aneurysmic rupture, an 83-year-old man with severe pulmonary emphysema was transferred to our hospital diagnosed with impending aneurysmic rupture. The aneurysm had been pointed out 2.5 years ago but surgical repair was not undertaken due to the patients severe pulmonary emphysema. After admission, computed tomography showed an enlarging saccular thoracoabdominal aortic aneurysm. Emergency surgery was conducted because of severe pain below the left costal margin. We resected the wall of the saccular aortic aneurysm and reconstructed the aorta with an on-lay patch under femoro-femoral bypass and selective visceral organ perfusion. Tracheostomy provided respiratory care on the day following surgery. The patient was weaned from respiratory support 6 days after surgery. Postoperative aortography showed that the reconstructed thoracoabdominal aorta functioned satisfactorily. The patient remains in good health 18 months after surgery.