Teruyuki Koyama

Surgically treated Swyer-James syndrome

Because patients with Swyer-James syndrome have almost always been treated conservatively, few reports exist of pathological findings of the lung in this syndrome. We report a case of this rare disease treated surgically and discuss pathological findings. A 36-year-old woman repeatedly contracted bronchitis and pneumothorax since adolescence, until April 26, 1997, when she reported chest pain and dyspnea. Chest X-ray on admission showed left pulmonary collapse with a slight deviation of the mediastinum toward the right. Chest computed tomography showed an apical bulla and emphysematous change in the left upper lobe. Pulmonary arteriography at age 17 showed hypoplasia of left pulmonary artery branches in the left upper lobe. Based on a diagnosis of Swyer-James syndrome, we conducted left upper lobectomy on May 2, 1997. Pathological examination of the resected left upper lobe showed marked emphysematous change, including an emphysematous bulla with destruction of alveolar structure and peribronchiolar fibrosis. No vascular abnormality was recognized in histology. Emphysematous change secondary to repeated bronchiolitis is believed to have led to her repeated pneumothorax.

Continuous Monitoring of Short-Latency Somatosensory Evoked Potentials During Cardiac and Aortic Surgery

The effectiveness of monitoring somatosensory evoked potentials (SEPs) intraoperatively to detect brain damage early remains controversial. To assess the diagnostic accuracy of this modality, a study was conducted between 1991 and 1994, recording SEPs in 287 consecutive patients undergoing cardiac and aortic surgery using cardiopulmonary bypass (CPB) with moderate hypothermia or deep hypothermic circulatory arrest. From P1 to N2 of the SEPs occurring within 50 ms latency in response to electrical stimulation of the median nerve were recorded over the contralateral postcentral cortex at 5-min intervals using a Neuropack-2 (Nihon Koden, Tokyo, Japan). Normal SEPs were recovered in 247 patients postoperatively; however, 2 of these patients had suffered a cerebral infarction and 1, a transient stroke intraoperatively, demonstrating a false-negative incidence of 1.2%. On the other hand, three different types of abnormal SEPs were recorded postoperatively. P1 and N1 absence, probably caused by a subcortical lesion, was observed in 4 patients; P2 and N2 absence, probably caused by a cortical lesion, was observed in 8 patients; and a flat SEP, representing diffuse damage, was observed in 2 patients. Among these 14 patients with abnormal SEPs, 7 showed no neurologic disturbance at all, demonstrating a false-positive incidence of 50%. Thus, we concluded that when normal SEPs are recovered during weaning from CPB, the incidence of brain damage could be predicted at below 5%. Conversely, when abnormal SEPs are demonstrated, the incidence of brain dysfunction impeding a return to active life is estimated to be about 70%.

Traumatic ciardiac rupture with acute ascites

A rare accumulation of serous ascites following traumatic cardiac rupture is reported for a 21-year-old man transferred to the emergency center of our hospital from a community hospital suffering from severe shock due to a motorcycle accident. Computed tomography scan showed moderate pericardial and intrapelvic fluid accumulation strongly suggesting cardiac and visceral injuries. An emergency sternotomy disclosed a rupture of the right atrial appendage, successfully closed with primary sutures. A laparotomy was done to aspirate moderate serous fluid, which was clear and not bloody. Edema of the retroperitoneal space and hepatic congestion were noted with no accompanying organ injury. Ascites pathogenesis is unknown but appeared to be related to portal venous congestion induced by cardiac tamponade combined with massive intravenous fluid infusion done to correct the patients deteriorating hemodynamics.

A case of progressive saccular aneurysm caused by localized dissection of descending aorta

A fifty-three-year-old man was admitted because of chest pain. CT scan showed the localized dissection of the descending aorta which was partially thrombosed. The patient was followed by controlling of essential hypertension. He, however, complained of the second attack of chest pain after a year and 5 months. CT scan showed the increased dilatation of the false lumen as compared to that of previous examination. MR angiogram showed a saccular aneurysm localized in the middle portion of the descending aorta. An operation was performed through posterolateral thoracotomy in the 4th intercostal space with the aid of normothermic femoro-femoral bypass circulation. The aneurysm was located at the level of 5th thoracic vertebra with the size of 70 mm in length and 45 mm in diameter. Entry was observed in the posterior wall of the aorta, and the terminal end of the false lumen was occluded with the organized thrombus. The aneurysm was successfully replaced with a prosthetic graft. To the extent of our knowledge, only limited surgical cases of saccular aneurysm caused by localized dissection of the middle portion of the descending aorta have been reported.

RECURRENT CARDIAC TAMPONADE TREATED USING A PERICARDIO-VENOUS SHUNT

A 49-year-old woman was admitted because of recurrent cardiac tamponade. She had undergone radical mastectomy and radiotherapy for left breast cancer four years previously. In the following two years, she felt short of breath on exertion due to cardiac tamponade. Repeated conservative therapy with diuretics and pericardial drainage were ineffective in terminating pericardial effusion. The therapeutic procedure of a pericardio-venous shunt was then employed and was effective for improving the recurrent symptoms.

Arterial Reconstruction with Prosthetic Grafts in the Bilateral External Iliac Artery of Infant.

幼児の医原性両側外腸骨動脈閉塞の症例を経験した. 症例は6歳女児で, 主訴は間歇性跛行と寒冷時下肢痛であった. 既往歴として, 大動脈縮窄複合に対して生後1カ月と1歳3カ月時にそれぞれ右および左大腿動脈穿刺によるカテーテル検査を施行した. 4歳時に縮窄部切除端々吻合術と心室中隔欠損直接縫合閉鎖術を二期的に施行した. 今回血管造影検査時, 大腿動脈を穿刺したところ, 両側外腸骨動脈が閉塞しており, 内腸骨動脈の分枝を側副血行路として大腿動脈が造影された. 成長期に下肢虚血があり, 寒冷時下肢痛があるため, 下肢血行再建の適応とした. 手術は開腹し, 両側とも外腸骨動脈に伴走して, 6mmの expanded polytetrafluoroethylene (ePTFE) グラフトを用いて, 内腸骨動脈と総大腿動脈間に端側吻合によりバイパスを作成した. 術後, 両側とも足背動脈触知可能となり, 自覚症状は消失した. MR-angiogram でもグラフトはよく開存していた.

Early Diagnosis of Acute Aortic Dissection Associated with Aortic Root Lesions by Contrast-Enhanced CT Scanning.

急性大動脈解離の早期診断, 早期外科治療が可能になるにつれて大動脈基部外膜破裂, 冠動脈解離腔内断裂などの大動脈基部破壊例あるいは冠動脈解離による冠血行不全併発例に遭遇する機会が増加している. このような病変は大動脈造影検査が診断的であるが, 近年, 非侵襲的検査法によって診断が確定されたならば大動脈造影は除外される傾向にある. したがって, 初期診断上, もっとも利用度の高い造影CTにてこれらの病変を予知することは重要である. そこで, 49例の大動脈解離例の造影CT上の諸所見と大動脈造影像および術中所見から得られた所見とを比較した. 大動脈基部に intimal flap 像が同定しえた6例中4例 (66.7%), 大動脈基部径35mm以上でAAE例を除いた14例中2例 (14.3%) に大動脈基部再建あるいはCABGを要するような大動脈基部破壊例が含まれた. 大動脈基部破壊9例中8例は基部径40mm以上で有意に高値であった. 以上より, 造影CT上の大動脈基部内隔壁同定, 基部径の40mm以上の拡大所見は大動脈基部破壊を伴う基部病変合併例を示唆する重要所見であると結論した.

An Unusual Obstruction of the Left Renal Vein Caused by “Nutcracker” Phenomenon: Repair by Renocaval Bypass Procedure A Case Report

Compression of the left renal vein (LRV) between the superior mesenteric artery (SMA) and the aorta has been termed the nutcracker phenomenon. Although often asymptomatic, this phenomenon rarely results in hematuria and flank pain. The mechanisms of the compression found in the surgical cases have included a simple compression by the SMA, the fibrous tissue entrapping the LRV, and dorsal ptosis of the left kidney. Previous surgical approaches have thus included division of the fibrous band, renocaval reimplantation or external stenting procedures, and medial nephropexy. The authors report a case of a twenty-eight-year-old woman who had suffered from massive hematuria with resultant anemia and intractable flank pain caused by nutcracker phenomenon, which had resulted in unusual organic obstruction of the lumen of the LRV by intimal adhesion. Renocaval bypass with a prosthetic graft with supplemental nephropexy and resection of periureteral varices were successfully performed. The pathogenesis of the fibrous band and intimal adhesion could be considered to be the results of reactions to the mechanical stress by the SMA. Dorsal renal ptosis may be an additional contributing factor. Conclusion on the indications for excision of the pelviureteral varices awaits further surgical experiences.

Reconstructive Vascular Surgery for Intestinal Angina Associated with Renovascular Hypertension and Intermittent Claudication A Case Report

Calcified atherosclerosis producing occlusion of the suprarenal aorta with involvement of the celiac artery (CA), superior mesenteric artery (SMA), and renal artery is an extremely rare entity. The authors report a case of a fifty-five-year-old woman with this lesion who had suffered from renovascular hypertension, intestinal angina, and intermittent claudi cation of the lower extremities. Reconstructive vascular surgery was successfully performed including an aortic bypass from the lower descending thoracic aorta to the distal abdominal aorta and revascularization of the CA, SMA, and bilateral renal and external iliac arteries simultaneously. Only a few similar cases have been reported in the literature, and all the patients were female. It appears that there is an unusual predilection for females in this particular form of arteriosclerosis.