Tokuo Koshino

Does the adamkiewicz artery originate from the larger segmental arteries

OBJECTIVE The Adamkiewicz artery supplies most of the blood to the anterior spinal artery, which perfuses the anterior two thirds of the spinal cord. During operations for thoracoabdominal aortic aneurysm, detailed anatomic knowledge of the Adamkiewicz artery and its correlation with the intercostal and/or lumbar arteries is important to prevent postoperative paraplegia. METHODS Minute dissection was performed on 102 formol-fixed adult cadavers without any history of circulatory disorders. The Adamkiewicz artery was found in the epidural space after laminectomy of the vertebrae. The entire course between the Adamkiewicz artery and the intercostal and/or lumbar artery was dissected carefully. The vertebral level, laterality, and mean diameter of all Adamkiewicz arteries were investigated. The correlation between the diameter of the Adamkiewicz artery and that of the intercostal and/or lumbar arteries was also determined. RESULTS The mean number of Adamkiewicz arteries per cadaver was 1.3 +/- 0.65, and the mean diameter was 0.77 +/- 0.24 mm (range, 0.50 to 1.49 mm). Approximately 70% of the Adamkiewicz arteries originated from the intercostal and/or lumbar arteries on the left side, frequently at the T8-L1 vertebral level. There was no statistically significant correlation between the diameter of the Adamkiewicz artery and that of intercostal and/or lumbar arteries. CONCLUSION This study provides evidence that, during operations on the thoracoabdominal aorta, the intercostal and/or lumbar arteries should be preserved, regardless of their diameter, to prevent postoperative paraplegia.

Successful surgical treatment of giant coronary artery aneurysm with fistula

Giant coronary artery aneurysm with fistula formation is a rare entity. We report a giant coronary artery aneurysm with a maximum diameter of 70 mm with fistula, in which a favorable course was obtained after surgical treatment. We also review the literature on giant coronary artery aneurysms exceeding 50 mm in maximum diameter.

Selective visceral and renal perfusion in thoracoabdominal aneurysm repair.

OBJECTIVE Whether or not selective visceral and renal perfusion during thoracoabdominal aortic aneurysm (TAAA) repair has a protective effect on visceral and renal function remains unknown. The aim of this study was to clarify if selective perfusion has such an effect. METHODS From May 1982 to December 1997, 82 consecutive patients underwent TAAA repair. Patients receiving hypothermic circulatory arrest or cooling of the kidney using Ringers lactate solution were excluded, thus 73 patients were enrolled into this study. They were divided into three groups: those in whom selective visceral and renal perfusion was performed using a roller pump (n = 41), those in whom it was performed using a centrifugal pump with a reduced heparin regimen (n = 22) and those who underwent simple aortic clamping alone (n = 10). RESULTS Serum creatinine, total bilirubin and alanine aminotransferase levels were elevated postoperatively in patients undergoing simple cross-clamp repair, but remained almost within normal limits in patients undergoing TAAA repair with selective visceral and renal perfusion. Urine output was more in selective perfused patients than in non-perfused patients. Renal dysfunction, defined by requirement of hemodialysis or by a serum level of creatinine above 3 mg/dl, occurred in four patients (10%) of the roller pump group and in two patients (9%) of the centrifugal pump group, while in four patients (40%) of the simple cross-clamping group. CONCLUSION Our experience suggests that selective visceral and renal perfusion has a protective effect on hepato-renal function during TAAA repair.

Comparison of clinical outcome between histidine-triptophan-ketoglutalate solution and cold blood cardioplegic solution in mitral valve replacement.

Abstract Background: This study was conducted to compare the effect of histidine‐triptophanketoglutalate solution (HTK) with that of cold blood cardioplegic solution (CBC) in mitral valve surgery. Method: Forty‐six patients who underwent mitral valve replacement between January 1994 and December 1996 were enrolled in this study. Twenty patients received HTK (HTK group), while 27 patients had CBC (CBC group) as myocardial protection. HTK was given as a single high dose, whereas CBC was used in the usual multidose format. Result: The doses of inotropic agent at the end of extracorporeal circulation did not differ between the HTK group and the CBC group. Creatine kinase values (units) on day 1 and day 2 were 1140 ± 412, 921 ± 436 for the HTK group and 904 ± 335,816 ± 420 for the CBC group, respectively (p = NS). Spontaneous defibrillation occurred in 26% of the CBC group and 90% of the HTK group (p < 0.05). Pacing was temporarily used in 20% of the HTK group and 44% of the CBC group after extracorporeal circulation (p < 0.05). Conclusions: These results suggest that HTK provided more adequate myocardial protection in mitral valve surgery. (J Card Surg 1998; 13:43–47)

Simultaneous Cardiac Operations With Pulmonary Resection for Lung Carcinoma

OBJECTIVES A procedure remains to be established for managing patients with both cardiac and pulmonary diseases requiring surgical interventions. We review our experience with 6 patients having cardiac disease and lung cancer surgically treated simultaneously to determine whether simultaneous surgery is safe and effective. METHODS Subjects were 6 men with a mean age of 64 +/- 10 years undergoing cardiac surgery combined with pulmonary lobectomy from January 1986 through June 2000. Cardiac procedures consisted of coronary artery bypass in 3, coronary artery bypass plus left ventricular aneurysm repair, aortic valve replacement, and minimally invasive direct coronary artery bypass surgery in 1 patient each. All underwent lobectomy. RESULTS No early deaths occurred. Bleeding complications occurred in 2 patients and lymph node dissection was incomplete in 3. Two died of carcinoma-related events, 1 at 28 and the other at 84 months after surgery. One died suddenly from a cardiac-related event 42 months after surgery. Only 1 patient is currently alive and disease-free at 104 months after surgery. CONCLUSION Simultaneous surgery can be conducted with acceptable mortality. The occurrence of bleeding complications and incomplete lymph node dissection, however, indicates combined procedures only in patients requiring simultaneous surgery due to their disease or unable to tolerate a second operation.

Posterior pulmonary lobe: Segmental and vascular anatomy in human specimens

The posterior pulmonary lobe (PPL) is defined by an aberrant fissure running horizontally on the costal surface of the lower lobe. We studied the frequency of the PPL, and the ramification of bronchi and vessels in the PPL, and so describe mainly these differences compared to the normal lung. Nineteen PPL cases (15 right and 4 left) were found in 273 (116 right and 157 left) human lung specimens. The incidence of PPL was 13% on the right side and 3% on the left side. The PPL frequently (right 87%, left 50%) corresponded to S6 (superior segment). Analysis of the ramification of bronchi revealed that B7 (medial basal bronchus) tended to form a common trunk with B* (subsuperior bronchus) or B8 (anterior basal bronchus). Analysis of the ramification of veins revealed that V6 (superior vein) tributaries were often double, and V6 tended to disperse widely. Anomalies in which the segmental artery and vein communicated with other segments were found in seven cases (37%) (4 arteries and 3 veins, 6 right and 1 left) in PPL. These results show that the PPL does not always correspond to S6 and frequently has an anomalous vessel from other segments. This is valuable surgical information, particularly in S6 segmentectomy. Clin. Anat. 13:257–262, 2000.

Combined Medical and Surgical Treatment for Pulmonary Mucormycosis

A 40-year-old woman with primary pulmonary mucormycosis was successfully treated with combination therapy involving administration of amphotericin B and surgery.

Impending rupture of the descending aorta by enlargement of the false lumen after graft replacement with the elephant trunk technique: report of a case.

We report herein a case of an impending rupture of the descending aorta caused by an enlargement of the false lumen after a graft replacement using the elephant trunk technique. The patient was a 51-year-old woman who had received a graft replacement of the ascending aorta for an acute Stanford type A aortic dissection 6 years previously. An enhanced computed tomographic scan and digital subtraction angiography revealed pseudoaneurysms at the proximal and distal anastmotic site, and a residual dissection of the aortic arch. A graft replacement of the ascending aorta to the aortic arch was performed with the distal site using the elephant trunk technique. Five days after the operation, massive bleeding from the drainage tube occurred. A chest enhanced computed tomographic scan suggested an impending rupture of the descending aorta caused by an enlargement of the false lumen. A graft replacement of the descending aorta was carried out. Postoperatively she had no complications, and digital subtraction angiography showed an excellent reconstruction of the thoracic aorta. One month after the second operation, she was discharged from hospital.

Total Arch Replacement with an Aortic Arch Aneurysm Due to Chronic Interstitial Pneumonia: Report of a Case

Abstract: The case of a 66-year-old man who had rheumatoid arthritis, chronic interstitial pneumonia (IP) with honeycomb lung, and an aortic arch aneurysm is described. He complained of left chest pain in April 1998 and chest computed tomography revealed an enlargement of a thoracic aneurysm whose maximum diameter reached 7 cm. He was urgently transferred to our institution to undergo immediate surgery for an impending rupture of the aneurysm. His PaO 2 with 80 Torr with oxygen therapy. The operation included a median sternotomy, extracorporeal circulation with selective cerebral perfusion, the use of cold blood cardioplegic solution, and open distal anastomosis. Although an acute exacerbation of IP occurred 2 months after the surgery, he successfully received intensive care including high-dose steroid therapy and artificial ventilation. He was successfully weaned from the ventilator and is now being followed up with medical treatment.

Enlargement of ulcer-like projections after repair of acute type A aortic dissection

We treated two cases of enlargement of ulcer-like projections in the descending thoracic aorta, which were recognized after emergency graft replacement from the ascending aorta to the aortic arch for acute type A aortic dissection. The intimal tear, which was near the left subclavian artery, was resected during the initial operation. Graft replacement of the descending thoracic aorta was successful.