Shinji Shimokawa

Intramural hematoma of the thoracic aorta

OBJECTIVE This study was designed to clarify the optimal treatment mode of patients with intramural hematoma (IMH) of the thoracic aorta. METHODS From 1992 through 1997, 51 patients underwent surgical repair or medical treatment of IMH of the thoracic aorta. There were 36 male and 15 female patients, aged between 49 and 79 years with a mean of 67 years. The ascending aorta and/or aortic arch was involved in 18 patients (group I), whereas the descending thoracic aorta was affected in 33 (group II). The presence of intimal disruption in IMH was confirmed in 10 of group I and 13 of group II patients. RESULTS For group I patients 13 required aortic arch repairs and the remaining 5 underwent conservative therapy including anti-hypertensive medication. Primary indications for immediate surgery were: cardiac tamponade in 5 patients, aortic dissection superimposed on IMH in 2, and persistent pain with an aortic arch aneurysm in 1, respectively. Early elective operations were done for enlarged ulcer in 3 patients and aneurysmal dilatation in 2 of which 1 had a coexisting aortic arch aneurysm. The 2-year survival rate after diagnosis was 94% with an operation-free rate of 25%. Nine of the group II patients experienced surgical intervention of which 8 had intimal disruption, 4 patients received urgent replacement of the descending thoracic aorta for massive pleural effusion and 1 had the aortic arch replaced for a coexisting aneurysm with persistent pain. All other patients underwent conservative treatment and 4 of them had to be shifted to early surgery during the initial hospitalization because of an enlarged ulcer. The 5-year survival rate in group II patients was 63% with an operation-free survival rate of 66%. CONCLUSIONS On the basis of our experience early operation is recommended for almost all patients with ascending aortic IMH, and medical therapy for those with descending aortic involvement unless complication developed. However, the presence of intimal disruption may require early surgical treatment even in the patients with descending thoracic IMH.

The use of a dumon stent for the treatment of a bronchopleural fistula

We report the successful management of a bronchopleural fistula with bronchial stent placement combined with irrigation of the empyema cavity. A bronchopleural fistula occurred in a 67-year-old man after a right upper lobectomy for lung cancer. Resuturing of the bronchial stump plus omental wrapping and subsequent closure of the open stump with a pedicled flap of intercostal muscle were not effective. Consequently, we placed a Dumon stent in the right main bronchus to close the stump.

Clinical Experience with Temporary Vena Cava Filters

An experience with temporary filter placement, which seems to be safe and effective for temporarily preventing pulmonary embolism, is reported. Since October 1997, six patients had temporary filters. There were two men and four women, with a mean age of 37 years. Three filters were placed at the infrarenal inferior vena cava, two at the suprarenal inferior vena cava, and one at the superior vena cava. All filters were placed before various surgical interventions. During filter placement, anticoagulation therapy was routinely performed. There were no complications at and during filter placement. No pulmonary emboli occurred during surgical intervention. All filters were successfully removed, two of which were exchanged for permanent filters. All patients are alive and well without recurrent deep vein thrombosis and/or pulmonary emboli during a follow-up period of 11 to 25 months. Although this experience is small, temporary filter placement is safe and effective for short-term prevention of pulmonary emboli even in older patients or those with malignant disease. Veins of the upper part of the body may be more favorable than the femoral vein for insertion of a temporary filter. Temporary filters can be safely placed not only at the infrarenal inferior vena cava, but also at the suprarenal inferior vena cava or superior vena cava.

Acute aortic dissection in a patient with osteogenesis imperfecta

A case of osteogenesis imperfecta complicated with acute type A aortic dissection is presented. Emergency graft replacement of the ascending aorta was performed successfully despite the anticipated difficulties with tissue friability. Therefore, such an operation is suggested to be worthy of consideration and feasible in patients with osteogenesis imperfecta.

Successful application of hypothermia combined with intra-aortic balloon pump support to low-cardiac-output state after open heart surgery.

The authors report a successful application of hypothermia, along with intra-aortic balloon pump (IABP) support, to postcardiotomy ventricular failure. Surface-cooling hypothermia was applied in 8 patients after open heart surgery. The original cardiac procedure consisted of 3 aortocoronary bypass graftings (ACBGs), 2 aortic valve replace ments (AVRs), 1 repair for left ventricular (LV) rupture after mitral valve replacement (MVR), 1 MVR+ACBG, and 1 MVR+AVR+tricuspid valve annuloplasty (TAP). Their ages ranged from fifty-two to sixty-eight years with a mean of sixty-one years. Hemodynamic criteria for induction of hypothermia included cardiac index (CI) less than 2.0 L/min/m2 with left atrial pressure greater than 18 mmHg despite the use of IABP and maximum pharmacologic support. Blood temperature was maintained at around 33°C. By six hours after induction of hypothermia the tissue oxygen consumption decreased significantly with no hemodynamic deterioration as compared with that before cooling. The duration of hypothermia ranged from thirty-six to one hundred fifty-nine hours with a mean of seventy-eight hours. All 8 patients finally discontinued IABP support with a mean driving time of one hundred thirty-two hours. Five of them were ultimately discharged from the hospital and returned to their previous life-style. The authors believe that, from the perspective of monetary and personal resources, the use of hypothermia with IABP support could be a therapeutic option for patients with postcardiotomy ventricular failure.

Ruptured bronchial artery aneurysm associated with pleural telangiectasis and tortuous portal obstruction : report of a case

A 25-year-old woman presenting with an emergent condition of massive hemothorax due to a ruptured bronchial artery aneurysm was successfully treated by transcatheter arterial embolization. She had previously undergone portosystemic shunt splenopneumopexy for hepatic portal hypertension at 6 years of age. When undergoing right thoracotomy for the removal of a clot, a prominent telangiectasis on the pleural surface was noted. The lesion appeared to be a rare systemic vascular abnormality although this could not be confirmed.

Superior Vena Caval Placement of a Temporary Filter A Case Report

Placement of permanent filters in the superior vena cava (SVC) for preventing pulmonary embolism (PE) arising from thrombi superior to the right atrium has rarely been performed. The authors report the first case of temporary filter insertion in the SVC because of upper extremity thrombosis accompanied with PE. After thrombectomy, the temporary filter was successfully removed. It is recommended to use a temporary filter, especially in young patients with upper extremity thrombosis requiring temporary prophylaxis against PE.

The surgical treatment of 30 patients with cardiac myxomas: a comparison of clinical features according to morphological classification.

Thirty patients with cardiac myxomas whose main clinical symptoms included congestive heart failure, tachyarrhythmia, chest pain and emboli, were successfully treated with surgery. The cardiac myxomas were found in the left atrium in 23 patients, the right atrium in 6, and the right ventricle in 1. Complete follow-up was conducted from 1 month to 15 years (mean 5.4 years) on 28 patients, 24 of whom were in New York Heart Association (NYHA) Class I, and 2 of whom were in NYHA Class II. The actuarial survival rate was 89% 15 years after surgery and no recurrent myxomas have been identified clinically or by echocardiography in any of the patients. Thus, an aggressive surgical approach is recommended prior to the development of heart failure or other complications whenever cardiac tumors are detected.

Penetrating atherosclerotic ulcers in an abdominal aortic aneurysm: Report of a case

We report the case of a 74-year-old man found to have an extensive intramural hematoma (IMH) in the infrarenal abdominal aorta during a follow-up imaging study performed after repair of a DeBakey type II aortic dissection with an aortic arch true aneurysm. Enhanced computed tomographic scan and angiography revealed an extensive IMH and multiple penetrating atherosclerotic ulcers in the abdominal aorta. The patient underwent a successful replacement of the affected abdominal aorta using a collagen-impregnated woven Dacron graft. Atheromatous ulcers are known to occur frequently in patients with advanced atherosclerosis. Hence, the elderly hypertensive patient, being at high risk of developing a variety of aortic disorders, requires careful follow-up imaging studies to assess the aorta on a regular basis.

Impalement injury of the thorax: Report of a case

We report herein the case of a 33-year-old man who survived an impalement injury of the thorax involving the heart, esophagus, and spinal cord. The patient was transported to our hospital with the impalement object left in situ and it was extracted under cardiopulmonary bypass in an operating room. The important principles of surgical management contributing to the successful outcome of such patients are discussed following the presentation of this case.