Takashi Azami

Open Distal Anastomosis in Retrograde Cerebral Perfusion for Repair of Ascending Aortic Dissection

BACKGROUND In patients with aortic dissection, a patent distal false lumen at long-term follow-up leads to complications. We investigated the feasibility of performing an open distal anastomosis using retrograde cerebral perfusion. METHODS Over a 10-year period, 41 patients with acute type A aortic dissection underwent 43 surgical repairs. In 1991, an open distal anastomosis using retrograde cerebral perfusion (group 2) was introduced to replace the standard aortic cross-clamp method (group 1). The mean retrograde cerebral perfusion time was 47.3 minutes (range, 22 to 67 minutes), and there were no neurologic sequelae in surviving patients. RESULTS The operative mortality rate was 18.5% in group 1 and 18.7% in group 2. At long-term follow-up, dilatation of the false lumen (more than 50 mm in diameter) occurred in 9 of 18 patients (50%) in group 1, and 2 patients died of aortic rupture. There were no deaths in group 2, and dilatation of the distal false lumen occurred in only 15.4% of patients (p < 0.05). CONCLUSIONS The use of retrograde cerebral perfusion in patients with acute aortic dissection provides adequate time to perform a safe, open, distal anastomosis, and could decrease significantly the rate of enlarged, patent, false lumina.

Angiosarcoma causing cardiac rupture

We report the 7th known case in the literature of cardiac angiosarcoma resulting in cardiac rupture. A 34-year-old woman was admitted presenting chest pain and pericardial effusion. After the patient had been treated for 3 months under the diagnosis of pericarditis of unknown etiology, she became hypotensive. Doppler echocardiography showed increased pericardial effusion and a communication between the right atrium and the pericardial cavity. An emergency operation was undertaken to drain the effusion and explore the etiology. We found the ruptured right atrium and the irregularly shaped tumor extending from the pericardium near the inferior caval vein to the right ventricle. There was no apparent tumor on the right atrium, but its wall was extensively thin, which we replaced with autologous pericardium. The patient died on the 44th postoperative day. Clinical diagnosis of cardiac angiosarcoma is usually very difficult. If Doppler echocardiography demonstrates pericardial effusion and find a ruptured right atrium with or without mass formation, we should suspect cardiac angiosarcoma.

Acute Left Atrial Thrombus Causing Cardiogenic Shock Following Mitral Valve Replacement : Report of a Case

We report herein the rare case of a 53-year-old woman who developed cardiogenic shock due to an acute left atrial thrombus following replacement of the mitral valve. A definitive diagnosis was not able to be made using precordial echocardiography because of the broad, flat shape of the thrombus; however, transesophageal echocardiography imaged the thrombus in detail. The patient was initially stabilized by percutaneous cardiopulmonary support after which a thrombectomy was successfully performed.

Long-Term Results of Crossover Bypass for Iliac Atherosclerotic Lesions in the Era of Endovascular Treatment: The Re-ACTION Study ( Re trospective A ssessment of C rossover Bypass as a T reatment for I liac Lesi ON s)

Objective: The aim of this study was to elucidate the long-term results of crossover bypass (CB) for iliac atherosclerotic lesions in the era of endovascular treatment (EVT). Methods: A retrospective multicenter cohort study was performed. CB was performed in 242 patients between 2003 and 2014 by vascular surgeons at multiple medical centers in Japan. Results: Perioperative mortality was 1.7%. Primary patency rates were 86% at 5 years and 82% at 8 years. Univariate analysis showed that critical limb ischemia (Rutherford class 4–6), vein graft, and superficial femoral artery occlusion were significantly associated with low primary patency. In multivariate analysis, only critical limb ischemia influenced primary patency. The secondary patency rate was 87% at both 5 and 8 years. The limb salvage rate was 98% at both 5 and 8 years. The overall survival rates were 71% at 5 years and 49% at 8 years. Conclusion: The long-term results of CB were good in our study, compared with previous reports. Our results suggest that CB remains an option for the arterial reconstruction in unilateral iliac occlusive disease after EVT failed.

Penetrating Atherosclerotic Ulcer Causing Cardiac Tamponade — A Case Suggesting the Etiology of Intramural Hematoma

199 DOI: 10.1007/978-4-431-99237-0_33,

A Case of Two-Stage Operation for Distal Arch Aortic Aneurysm with Occluded Right Middle Cerebral Artery

症例は68歳,女性.嗄声を主訴に近医耳鼻咽喉科を受診し,精査により最大短径60mmの遠位弓部大動脈瘤を指摘された.術前検査で右中大脳動脈閉塞による安静時の脳血流低下および脳血流予備能の低下が認められたため,胸部大動脈瘤手術に先立って右浅側頭動脈-中大脳動脈吻合術を行った.脳外科手術後18日目の脳血流シンチにて脳血流の改善を確認したのち,22日目に全弓部大動脈人工血管置換術を施行した.術直後から24ヵ月後の現在まで神経学的合併症はなく良好に経過している.本症例では浅側頭動脈-中大脳動脈吻合術を先行させ,二期的に胸部大動脈瘤手術を行うことで胸部大動脈瘤の周術期の虚血性脳合併症を回避することができた.

Retrograde Cerebral Perfusion for Aortic Arch Operation

Deep hypothermic retrograde cerebral perfusion (RCP) has recently been the focus of interest as a simple new technique of brain protection during the operation for thoracic aneurysms. During the period from January 1991 to July 1994, 21 consecutive patients underwent operations on the various portions of the thoracic aorta with the use of deep hypothermic RCP. There were 10 men and 11 women, ages ranging from twenty-eight to seventy-eight (mean 61.4) years old. There were 9 cases with true aortic aneurysm, and 12 with dissecting aneurysm. In 8 patients (38.1%) the procedures were done on an emergency basis for ruptured/impending ruptured aneurysms or acute dissecting aneurysms. Four patients died before the adequate assessment of their neurologic function. One patient had a cerebral infarction probably due to dissection of the left common carotid artery. The remaining 16 patients showed clear consciousness and had no serious neuro logic complications postoperatively. Total perfusion time averaged 297 ± 110 minutes (ranging from 162 to 548 minutes). Rectal temperatures were 20.1 ± 1.4°C (ranging from 18.0 to 22.5°C). RCP time averaged 51.3 ± 13.9 minutes (ranging from twenty-seven to eighty minutes). Blood gas analysis of the returned blood sampled from the left common carotid artery or the innominate artery and the ophthalmoscopic findings demonstrated the insufficiency of blood and oxygen supply to the brain during RCP. Therefore, RCP time should be shortened and pharmacologic cerebral protection is recommended to reduce neurologic complications during operations on the thoracic aorta using RCP.