Toru Uezu

Emergency off-pump complete arterial revascularization in a patient with dextrocardia

We describe complete emergency arterial coronary artery bypass grafting performed on the beating heart of a 73-year-old man with situs inversus totalis and triple-vessel disease. The right internal mammary artery was anastomosed to the left anterior descending artery in situ. The first and second obtuse marginal branches of the circumflex coronary and the posterior descending branch of the right coronary artery were sequentially revascularized using the left internal mammary and radial arteries in situ. The only abnormality was that the position of the heart mirrored that of a normal heart. Beating heart surgery appears to be as safe in patients with dextrocardia as in the general population. However, the position of the surgeon must be reconsidered for optimal handling of stabilizers and to facilitate access to anastomosis sites. Understanding mirror-image coronary arterial anatomy is important for successful surgical outcomes among patients with dextrocardia.

Type B Dissection Complicated with Subacute Visceral Ischemia

A 63-year old man presented with back pain and abdominal pain that worsened after eating. Contrast-enhanced computed tomography revealed type B aortic dissection. Arteriography 20 days after dissection revealed celiac trunk stenosis and the superior mesenteric artery did not arise from the true lumen. Saphenous vein bypass grafting from the right common iliac artery to the superior mesenteric and gastroduodenal arteries was performed. The postoperative course was uneventful and the abdominal symptoms completely disappeared.

Coronary Artery Bypass Grafting for Patients in Whom Preoperative Angiography Determined That the In Situ Left Internal Thoracic Artery Could Not Be Used.

1998年1月から2001年8月までに当科で施行したCABG274例中,術前血管造影検査にて左内胸動脈(LITA)使用不能と判断された7例(7/262=2.7%)を対象として検討した.全例男性で,平均年齢は68.6歳,4例が鎖骨下動脈閉塞あるいは狭窄,3例がLITA閉塞あるいは狭窄であった.3例でRITAに橈骨動脈を端側吻合しcomposite Y graftとして使用,ほかの3例で橈骨動脈をsequential graftとして使用し,バイパス枝数は2.7±1.0であった.グラフト開存率は94.7%(18/19)で,1例にPMIを合併したが,対症療法にて軽快しており,ほかの症例に合併症はなく全例軽快退院した.冠動脈疾患を有する患者は高脂血症,末梢血管病変を有することが多く,このような症例においてはLITAの動脈硬化が有意に高率に認められるとの報告も見受けられ,有茎動脈グラフトに対する術前の十分な検討が重要であると考える.

Successful surgical treatment of impending rupture of thoracoabdominal aortic aneurysm in an elderly patient with severe pulmonary emphysema

In a case of successful surgery for impending thoracoabdominal aortic aneurysmic rupture, an 83-year-old man with severe pulmonary emphysema was transferred to our hospital diagnosed with impending aneurysmic rupture. The aneurysm had been pointed out 2.5 years ago but surgical repair was not undertaken due to the patients severe pulmonary emphysema. After admission, computed tomography showed an enlarging saccular thoracoabdominal aortic aneurysm. Emergency surgery was conducted because of severe pain below the left costal margin. We resected the wall of the saccular aortic aneurysm and reconstructed the aorta with an on-lay patch under femoro-femoral bypass and selective visceral organ perfusion. Tracheostomy provided respiratory care on the day following surgery. The patient was weaned from respiratory support 6 days after surgery. Postoperative aortography showed that the reconstructed thoracoabdominal aorta functioned satisfactorily. The patient remains in good health 18 months after surgery.