Takashi Shuto

Effect of Prostaglandin E1 on Ischemia–Reperfusion Injury During Abdominal Aortic Aneurysm Surgery

ObjectiveAbdominal aortic aneurysm (AAA) surgery subjects the lower extremities to ischemia and reperfusion. Although it is not extensive or prolonged, ischemia of the lower extremities during aortic cross-clamping is gradually and steadily induced. We studied the effects of prostaglandin E1 (PGE1) on ischemia–reperfusion injury of the lower extremities during AAA repair.MethodsDuring AAA surgery, two near-infrared spectroscopy probes were positioned on each calf muscle to monitor oxygen metabolism in the lower extremities. We also measured lactate concentration in both iliac veins.ResultsNear-infrared spectroscopy signals responded sensitively to aortic cross-clamping and declamping. Lactate increased time-dependently during aortic cross-clamping. The continuous venous administration of PGE1 (20u2009ng/kg per minute) inhibited the accumulation of lactate during aortic cross-clamping. Declamping of the first iliac artery resulted in a further but transient increase in ipsilateral venous lactate, which may be one component in the mechanism of declamping shock. Prostaglandin E1 eliminated the transient increase in ipsilateral lactate. The administration of PGE1 inhibited the contralateral accumulation of lactate after first declamping, and the lactate level decreased gradually before the second declamping.ConclusionsProstaglandin E1 seems to have a protective effect against ischemia–reperfusion injury of the lower extremities during AAA surgery.

A new method for protection from shower embolism during TEVAR on a shaggy aorta

The case of a patient with a thoracoabdominal aortic aneurysm accompanied by a shaggy aorta, in whom embolism was prevented by a graft used in debranching and placement of an extracorporeal shunt during thoracic endovascular aortic repair, called the “block and trap method”, is presented. Two-staged operations were performed using Y graft replacement, debranching bypass, and thoracic endovascular aortic repair during which a temporary shunt line with a blood filter was made involving the femoral artery and vein. The method of trapping emboli in a filter in an external shunt appears effective.

Perioperative management for iatrogenic aortocoronary dissection during percutaneous coronary intervention

Aortocoronary dissection is a rare but serious complication. We report the case of a 72-year-old female with angina. Percutaneous coronary intervention was performed for right coronary artery disease. Manipulation of the guiding catheter led to aortocoronary dissection. A drug-eluting stent was immediately implanted in the right coronary ostium to seal the entry of the dissection. Computed tomography (CT) showed ascending aortic dissection. The patient was observed without surgery. CT performed the following day and showed the contrast in the false lumen which had disappeared. Clinicians are more likely to avoid surgical treatment if stenting successfully seals the entry of the coronary dissection.

Intraoperative bronchoscopic resection of a papillary fibroelastoma in the left ventricular outflow tract after aortic mechanical valve replacement

We report the case of an 80-year-old man who 11 years previously had undergone aortic valve replacement (St. Jude Medical mechanical heart valve 23 mm) because of aortic stenosis. At the current presentation, a 7-mm pedunculated tumor was discovered along the septal wall in the left ventricular outflow tract. In an attempt to perform a less invasive procedure because of the patient’s advanced age, transaortic valve bronchoscopic resection was undertaken. A bronchoscope (Olympus BF P-200) was fed through a gap in the mechanical aortic valve. The entire tumor was removed using biopsy forceps, with histology revealing a papillary fibroelastoma. By using a bronchoscope, we avoided a second valve replacement.

A case of ruptured aneurysm of coronary-pulmonary artery fistula diagnosed after emergency thoracotomy

BackgroundCoronary fistulae are occasionally detected using echocardiography or coronary angiography. We report a patient with cardiac tamponade because of a ruptured aneurysm of a coronary artery fistula.Case presentationA 60-year-old man was referred to our hospital with sudden onset of chest pain and unconsciousness. He was initially diagnosed with cardiac tamponade for type A acute aortic dissection, and an emergency operation was performed. A large amount of bleeding was seen in the pericardium, but aortic dissection around the arch was not observed. Instead, a ruptured aneurysm of a coronary-pulmonary fistula was identified on the pulmonary artery root. The aneurysm was resected, and the fistula was closed by ligation. The patient’s postoperative progress was good, and he was discharged on postoperative day 12 without any abnormalities on the coronary arteriogram.ConclusionsPreoperative diagnosis of the rupture of the small coronary artery aneurysm is difficult in such an emergency case, and this possibility should be considered in differential diagnosis when the CT image does not show typical aortic dissection.

Ten-year experience of the thoraco-abdominal aortic aneurysm treatment using a hybrid thoracic endovascular aortic repair†

OBJECTIVESnThe treatment of thoraco-abdominal aortic aneurysm continues to have a high mortality and paraplegia rate. In superaging societies, the methods of performing less invasive operations remain a major issue. We reviewed our 10-year experience in the treatment of thoraco-abdominal aortic aneurysm using a hybrid procedure of combined visceral reconstruction and thoracic endovascular aortic repair.nnnMETHODSnSixty patients underwent a hybrid repair for the treatment of the thoraco-abdominal aortic aneurysm between 2007 and 2016. The mean age was 72.7u2009years. A true aneurysm was found in 43 (72%) patients and a chronic dissection in 17 (28%) patients. The standard operative procedure involved replacing the abdominal aorta with an artificial graft, and the visceral arteries were reconstructed using a quadrifurcated graft. Renovisceral debranching and stent grafting were performed as a 2-stage procedure.nnnRESULTSnThe hospital mortality rate was 5%. Two (3%) patients died due to an aneurysmal rupture in the hospital just after renovisceral debranching. The other 2 patients died due to an aneurysmal rupture in the long-term period after preventive renovisceral debranching. Two (3%) patients experienced spinal cord ischaemia after the stenting procedure. Four (7%) patients required additional treatment during the follow-up period. The overall survival was 75.9% at 2u2009years, 65.2% at 5u2009years and 43.5% at 8u2009years. The rates of freedom from aorta-related events were 92.9% at 2u2009years, 80.5% at 5u2009years and 72.5% at 8u2009years.nnnCONCLUSIONSnThe hybrid repair is considered to be a good option for elderly and high-risk patients. Further long-term follow-up is necessary to extend the indication in younger patients.

Difficult preoperative diagnosis in a case of rapidly progressive carcinomatous pericarditis.

A 54-year-old woman initially diagnosed with stage IIIb squamous cell carcinoma of the uterine cervix was treated with chemotherapy and radiation therapy. After 8xa0months, she developed dyspnea, leg edema, pleural effusion, pericardial effusion, and liver congestion. Her cardiac ejection fraction was normal and cardiomegaly was not evident. Metastatic carcinomatous pericarditis or pleurisy was suspected, but laboratory findings, including tumor markers, were normal. She was transferred to our hospital for the repair a cardiac injury caused by a pericardial drainage procedure. Emergency surgery was performed for the misplaced drainage catheter in the right atrium and for an abnormal mass in her right and left atria. The clinical diagnosis of carcinomatous pericarditis was made; however, her condition rapidly deteriorated, and she died 6xa0days postoperatively. At autopsy, metastasis was identified in a large area of the pericardium and myocardium.

Unique Technique for Open Surgical Repair after Failed Endovascular Aneurysm Repair with Proximal Anastomoses.

Endovascular aortic aneurysm repair (EVAR) has revolutionized the management of abdominal aortic aneurysms (AAAs), with lower perioperative morbidity and mortality compared to conventional surgical repair. However, late secondary re-interventions after EVAR are still needed before aneurysm rupture in many cases. A patient with impending rupture of an AAA associated with a type I endoleak 7 years after EVAR who was successfully treated with a unique technique of fixation of the proximal aortic neck taking into account the structure of the stent graft is reported. This technique offers a safe solution to late open conversion after failed EVAR.

Simultaneous inflammatory pseudotumors of the coronary arteries and abdominal aorta.

We herein report a rare case of cardiac and abdominal aortic inflammatory pseudotumors (IPTs). A 64-year-old male presented with a loss of appetite, abdominal distension and general fatigue. A cardiac tumor was suspected on the basis of computed tomography scans. A needle biopsy was performed, but it did not lead to a definitive diagnosis. At the same time, a 70-mm abdominal aortic aneurysm (AAA) was also detected. A full sternotomy was performed, and a huge, elastic hard tumor was found around the bilateral coronary arteries, anterior side of the right atria, ascending aorta and pulmonary artery. The pathological diagnosis was IPT, which was judged to be inoperable because of its anatomical location and the fact that the patient was a Jehovah’s Witness, which precluded the administration of heterologous blood transfusions. The AAA was surgically treated, and the pathological diagnosis of the aneurysmal tissue also revealed IPT. Perioral steroid therapy was initiated, and the size of the tumor did not change for 1–2xa0years, but then gradually increased. The patient eventually died 8xa0years later, and the cause of his sudden death was considered to be heart failure caused by the pressure on the right atrium and ventricle due to the enlarged cardiac tumor.