Norifumi Ohtani

Stanford type A acute dissection developing acute myocardial infarction

A 75-year-old female, exhibiting epigastric pain and vomiting, underwent treatment for acute gastritis. She also experienced incontinence of urine and chest pain. A diagnosis of acute myocardial infarction was made upon examination of electrocardiographic findings and the patient was transferred to our hospital. Diffuse infarction of the left ventricle and acute aortic dissection (Stanford type A) were diagnosed by electrocardiographic and echo-cardiography. An emergency operation was performed. After induction of anesthesia, elevation of pulmonary artery pressure and fall of pulse pressure were observed, indicating acute cardiac tamponade. Transesophageal ultrasonography disclosed the entry of dissection in the descending aorta. Dissection of the aorta extended proximally up to the annulus of the aortic valve and the right and left coronary arteries were compressed by its aneurysm. As aortic insufficiency was mild, only reconstruction of the ascending aorta was carried out. The patient was discharged in fair condition one month after operation under use of postoperative long-term administration of catecholamines.

Evaluation of an internal thoracic artery as a coronary artery bypass graft by intercostal duplex scanning ultrasonography

OBJECTIVES Although angiography is often used to determine whether the internal thoracic artery is appropriate as a coronary bypass graft, but use of duplex scanning ultrasonography for this purpose is not yet widespread. METHODS The internal diameter and flow of the internal thoracic artery were measured using intercostal duplex scanning in 100 patients during April 1995. The ultrasonographic device (sonos 2000, Hewlett Packard) used had a linear probe delivering a frequency of 7.5 MHz. Bilateral internal thoracic arteries and their blood flow were imaged clearly in all subjects. Diameter was compared by angiography and duplex scanning ultrasonography in 20 patients. RESULTS The average internal diameter of internal thoracic artery was 2.19 +/- 0.46 mm (right) or 2.13 +/- 0.32 mm (left) in men and 2.05 +/- 0.44 mm (right) or 2.09 +/- 0.42 mm (left) in women. The gender difference was statistically significant (p = 0.05). The maximum systolic blood flow velocity through the internal thoracic artery was 0.85 +/- 0.34 m/s (right) or 0.84 +/- 0.36 m/s (left) in men and 0.87 +/- 0.28 m/s (right) or 0.82 +/- 0.28 m/s (left) in women. The average internal thoracic arterial blood flow (F) was 54.6 +/- 29.0 ml/min (right) or 50.9 +/- 28.8 ml/min (left) in men and 56.8 +/- 38.2 ml/min (right) or 58.2 +/- 33.4 ml/min (left) in women. Duplex scanning ultrasonography using an intercostal approach enables easy imaging of bilateral internal thoracic arteries and visualizes entire internal thoracic artery structure by simply changing the probe position. CONCLUSION Intercostal duplex scanning ultrasonography is thus recommended for reliable evaluation of the internal diameter and blood flow of the internal thoracic artery.

Thoracic aortic aneurysm complicated with severe coronary arterial occlusive disease.

The patient was a 77-year-old female who had been treated medically for angina pectoris since 5 years ago. Expanded aneurysms in the distal aortic arch and in the descending thoracic aorta were seen during follow-up. She presented continuous back-pain at rest along with increasing size of the aneurysms despite antihypertensive therapies after admission. First, two saphenous vein grafts were anastomosed to the left anterior descending artery and obtuse marginal artery under beating heart. Next, the proximal portion of the left subclavian artery was clamped and divided. To this graft, the proximal ends of the coronary bypassed vein grafts were anastomosed and coronary perfusion was established and maintained until this artery was anastomosed to the aortic graft. Then, the aneurysms in the distal arch and descending thoracic aorta were excised and the aorta and its two pairs of intercostal arteries were reconstructed. The Postoperative course was uneventful with favorable cardiac function.

Two Cases of Endovascular Abdominal Aortic Aneurysm Repair with Iliac Aneurysm Using a Zenith Iliac Bifurcation Graft

We report on treatment of an abdominal aortic aneurysm with common iliac artery aneurysm using an iliac branch device. We performed 2 cases because of a large common iliac artery aneurysm or a complication of an internal iliac artery aneurysm. Both cases had a good postoperative course and progressed without embolizing the iliac branch device during follow-up period. Though there is a drawback, it is not covered by the national insurance program in Japan and cannot be used in all applicable cases. However, use of a unilateral or bilateral iliac branch device allows us to maintain the bloodstream of the internal iliac artery, thus suggesting it to be effective in such cases.

Poststernotomy mediastinitis treated by rectus muscle flap plugging

The current standard treatment of mediastinitis following median sternotomy is radical sternal curettage and plugging of the anterior mediastinal dead space with muscle flap or omentum. This paper will report our experience with a pediculated flap of the rectus muscle after mediastinal irrigation and drainage. The patient was a 75-year-old man diagnosed as having aortic arch aneurysm. The patient underwent a total aortic arch replacement with the bovine-collagen sealed vascular prosthesis (Hemashield). As an early postoperative complication, he was diagnosed with mediastinitis which was the result of infection of the drainage fluid. Mediastinal curettage and plugging of the rectus muscle flap was successfully performed. Without recurrence of infection, the wound healed completely. We conclude that early curettage and rectus muscle flap plugging are the most effective treatment of the poststernotomy mediastinitis.

Tube device for facilitating distal anastomosis in aortic arch replacement

The technique of placing an inverted graft into the descending thoracic aorta facilitates and secures the distal anastomosis in aortic arch replacement, especially in the anastomosis beyond the transverse arch. We developed a simple technique using a pair of thin-walled tubes to enable the arch graft, with its four branches, to be smoothly inserted into the flaccid, normal-caliber descending aorta. The use of these tubes simplified the procedure, resulting in time saving.

Importance of duplex scanning ultrasonography evaluation of the proximal internal thoracic artery as a coronary artery bypass graft

Importance of Duplex Scanning Ultrasonography Evaluation of the Proximal Internal Thoracic Artery as a Coronary Artery Bypass Graft. To the Editor: We read with great interest “Evaluation of an Internal Thoracic Artery (ITA) as a Coronary Artery Bypass Graft by Intercostal Duplex Scanning Ultrasonography (DSU)” by Ohtani et al.1 We agree in recommending intercostal DSU to reliably evaluate ITA internal diameter and blood flow. We reported a similar DSU evaluation of the ITA (n = 77) in 1998.2 Few differences exist between our measurement of diameter in 2-dimensional B-mode imaging and our operative findings. We feel, however, that Ohtani et al. overlooked the need for particular evaluation of the proximal ITA via supraclavicular imaging. They position the probe only at the intercostal space. Some radiological studies have shown that almost all atherosclerotic stenoses in the ITA (incidence; 0.95–5.0%) are located in just proximally or at the subclavian part. Intercostal DSU thus is no substitute for conventional angiography. We carefully apply ultrasonic waves from bilateral supraclavicular spaces rather than from bilateral intercostals, and emphasized in our paper the importance of proximally evaluating the ITA via a supraclavicular approach. In our experience, the internal diameter of the ITA can be measured in intercostal Bmode imaging, but ITA stenosis, though rare, rules out the ITA for use as a coronary bypass graft. Hence, all ITA stenosis should be screened via a supraclavicular approach using both Doppler spectrum and B-mode imaging. We did find 1 case of proximal stenosis, appearing as turbulent Doppler spectra via a supraclavicular approach, and avoided using this ITA as a pedicled graft. We concluded that supraclavicular DSU is sensitive and reliable in preoperatively examining the ITA. We believe that if physicians examine the ITA using DSU, they should also apply supraclavicular approach to detect any stenotic lesions. Findings specific to the proximal portion are equally as important as findings for the middle portion for preoperatively evaluating the ITA. Yuichiro Kaminishi, MD Division of Cardiovascular Surgery Jichi Medical School, 3311–1 Yakushiji, Minami-Kawachi Tochigi 329–0498, Japan REFERENCES