Toshio Baba

Examination of intercostal arteries with transthoracic Doppler sonography.

Objective: There has been no study on the measurement of blood flow of the intercostal artery (ICA) or lumbar artery (LA) with the use of transthoracic Doppler sonography. Here, the method of the ICA depiction and flow measurement were described, and we suggested the clinical usage of this method. Methods: Twelve healthy subjects were examined. The performance of transthoracic Doppler sonography was approached from the back on lateral decubitus position. The intercostal artery was depicted by two‐dimension mode with color flow, and the inner diameter was measured. Peak systolic velocity (PSV), end‐diastolic velocity (EDV), velocity‐time integral (VTI), and heart rate (HR) were measured with pulsed Doppler, and the blood flow was calculated. Results: Bilateral ICAs and LAs from Th4 to L4 were measurable with this method. The PSV of Lt Th9 was the fastest at 43.3 ± 10.1 cm/sec and the PSV of the ICAs gradually decreased as distance from Th9 increased. As for the flow volume, the left Th11 was the greatest at 99.7 mL/min, and the flow volume of the ICA gradually decreased as distance from Th11 increased. The velocity and blood flow of right ICA tended to be lower than the left in the same spinal level. Conclusions: Evaluation technique of serial ICAs and LAs was shown. We think that it may be a clinically useful method in the study of spinal cord circulation in the repair of cases of descending thoracic or thoracoabdominal aortic aneurysm. (Echocardiography 2010;27:17‐20)

Less-invasive management of left subclavian artery in stent-grafting for distal aortic arch disease

Simple coverage of the left subclavian artery (LSA) in thoracic endovascular aortic repair (TEVAR) is still a controversial procedure. We present our modified strategy dealing with LSA in TEVAR. Hand-made stent grafts were placed more proximal beyond the LSA for 104 patients. In elective 76, preoperative LSA occlusion test was performed on 31 patients, and preoperative computed tomographic angiography (CTA) of the vertebro-basilar artery was performed on the remaining 45. Head vessels were planned to be kept patent using fenestrated stent grafts, if possible. Stent grafts were placed from zone 0 in 23, zone 1 in 39, and zone 2 in 42. The LSA occlusion tests revealed harmful effects, such as loss of consciousness and vertigo in two out of 31 patients (6.5%). Vertebro-basilar arterial CTA revealed possible risks, if LSA covered, in three out of 45 patients (6.7%). Fenestrated stent grafts could successfully preserve 131 head vessels, except for one unintentional occlusion of the left carotid artery (0.75%). There was no LSA-related complication in any of the cases. A combination of preoperative vertebro-basilar arterial CTA and fenestrated stent grafts is useful to avoid possible LSA-related complications in TEVAR.

Re-replacement for prosthetic valve dysfunction : Analysis of long-term results and risk factors

BACKGROUND Prosthetic heart valve re-replacement still remains a challenging situation. Although some studies have examined the early results, the long-term survival has not yet been well analyzed. The aim of this study was to detect the factors that affect the long-term outcome of operation. METHODS Between April 1964 and September 1996, 231 prosthetic valve re-replacements were performed including 16 cases of third valve replacement. There were 100 men and 131 women with a mean age of 47 +/- 14 years. RESULTS The actuarial survival rate was 65% +/- 4% at 5 years and 41% +/- 7% at 10 years. Multivariate analysis revealed that New York Heart Association class IV and left ventricular ejection fraction were found to be independent predictors of late death. CONCLUSIONS Our study showed that advanced New York Heart Association functional class and lower left ventricular ejection fraction were found to be independent predictors of late death. If operation is performed before patients reach such a deteriorated condition, long-term results are excellent.

Fenestrated stent-graft facilitates emergency endovascular therapy for blunt aortic injury.

BACKGROUND Endovascular stent-grafting with intentional coverage of the left subclavian artery may be used to treat aortic isthmus injury, but this procedure may have serious neurologic sequelae and may not provide an adequate proximal landing zone. In 2005, in an effort to mitigate these problems, we began to use fenestrated stent-grafts for emergency repair of blunt aortic injury (BAI). METHODS Between 2005 and 2007, all patients in our practice with a BAI with mediastinal hematoma (except young patients without an associated critical injury) were treated with immediate endovascular stent-grafting, if anatomically possible. A fenestrated stent-graft was placed from the aortic arch, if the BAI was less than 20-mm distal of the left subclavian artery. The records of the 13 patients in the series were reviewed retrospectively. RESULTS The BAI treatment was successful in all 13 patients. Eight patients (61.5%) were given a fenestrated stent-graft, placed distal to either the ascending aorta (n = 2), brachio-cephalic artery (n = 4), or left common carotid artery (n = 2), without concomitant bypass grafting or transposition of the head vessels. Two patients died of an associated critical brain injury (hospital mortality rate, 15.4%). There were no perioperative complications related to stent-graft usage and no unintentional occlusions of the head vessels by a fenestrated device. One patient underwent open repair of a newly developed type Ia endoleak 7 months after placement of a nonfenestrated stent-graft. CONCLUSION Fenestrated stent-grafts can be used to treat BAI, without any concomitant procedures to provide an adequate proximal landing zone.

Physician-Modified Thoracic Stent-Grafts for the Treatment of Aortic Arch Lesions:

Purpose: To evaluate outcomes of physician-modified thoracic stent-grafts for the treatment of aortic arch aneurysms. Methods: A retrospective dual-center analysis was performed involving 36 patients (mean age 74.7±9 years, range 58–91; 27 men) with an aortic arch lesion who were treated between November 2013 and June 2016 using physician-modified thoracic stent-grafts. Half of the patients had a degenerative aneurysm; the remainder had type B dissection (n=9), traumatic transection (n=3), type Ia endoleak after previous endografting (n=5), or aortoesophageal fistula (n=1). All patients were considered to be at high surgical risk. Patients were treated using an aortic arch stent-graft with a single fenestration (n=24) or a proximal scallop (n=12); zone 0 was involved in 16 patients, zone 1 in 9, and zone 2 in 11. The modified thoracic stent-graft was deployed after supra-aortic branch revascularization in 24 (67%) patients. Results: Mean time required for stent-graft modifications was 18 minutes (range 14–21). Technical success was obtained in all cases with no type I endoleak. One (3%) patient had a stroke without permanent sequelae. The 30-day mortality was 6%. During a mean follow-up of 11.4±6 months (range 2–36), there were no conversions to open repair. The overall mortality was 14%; aorta-related mortality was 6%. Conclusion: Our experience suggests that physician-modified thoracic stent-grafts are feasible for aortic arch lesions and provide encouraging results in the short term. Durability concerns will need to be assessed.

Concomitant mitral and tricuspid valve infective endocarditis: report of a case.

A rare case of native valve endocarditis affecting both the normal mitral and tricuspid valves is presented. A 25-year-old woman with an acute ischemic stroke was found to have vegetation secondary to infective endocarditis as the embolic source. One month after the onset of embolic cerebrovascular intervention, a valve repair with the implantation of artificial chordae, sliding commissuroplasty, and ring annuloplasty resulted in a complete recovery.

Extended survival of a porcine mitral bioprosthesis for 23 years: Report of a case

Limited durability is the major drawback of bioprosthetic valves, few of which survive for as long as 20 years. We report herein the case of a patient we recently encountered in whom a bioprothesis lasted for 23 years. To our knowledge, this is only the second case of such long survival. The patient was a 56-year-old man who was urgently admitted to our hospital with acute mitral regurgitation, 23 years after undergoing mitral valve replacement with a porcine bioprosthesis. Acute leaflet tears were found to be the cause of the mitral incompetence and the xenograft was successfully replaced with a mechanical valve. We believe that when reoperation is thought to carry a low risk, prophylactic surgery might be justified, even in patients without symptoms.

Anatomical repair for Kommerell diverticulum with deep site in-situ fenestration:

An 83-year-old woman with a Kommerell diverticulum was treated by anatomical endovascular repair with a deep site in-situ fenestration instead of complex debranching techniques. The main component of the thoracic stent-graft was deployed just distal to the third cervical branch to completely exclude the Kommerell diverticulum. A deep site in-situ fenestration was made on the main component using a radiofrequency needle through the left subclavian artery, and a stent-graft was deployed to bridge the main component to the left subclavian artery. Six months postoperatively, the Kommerell diverticulum was completely excluded with excellent left subclavian artery patency.

Right parasternal minithoracotomy for repair of atrial septal defect.

Abstract  Various surgical approaches for repair of atrial septal defect (ASD) have recently been introduced for superior cosmetic and less invasive results. A technique for repair of isolated ASD through a small right parasternal minithoracotomy is described. In spite of the smaller incision, there is no need to use femoral cannulation or video‐assisted endoscopy. This approach is simple, less invasive, and cosmetic. We believe that right parasternal minithoracotomy is a suitable alternative to a median sternotomy for ASD closure, especially in young male patients.

A Case of Expansion of a Right Internal Iliac Artery Aneurysm after an Exclusion Operation

内腸骨動脈瘤に対しては症例によって瘤空置術が施行される.今回われわれは,瘤空置術後に瘤が拡大した症例を経験したので報告する.症例は72歳,男性.1995年11月に右内腸骨動脈瘤(最大径3.5cm)を合併した破裂性左内腸骨動脈瘤に対して,緊急手術を施行した.左内腸骨動脈瘤切除術および人工血管置換術,右内腸骨動脈瘤に対しては右外腸骨動脈人工血管置換術および右内腸骨動脈瘤空置術を施行した.術後順調に回復し,外来通院となっていた.他院でfollow-upされていたが,CT上,右内腸骨動脈空置瘤が2003年に8cmに拡大したため手術目的に当院紹介となった.2003年4月8日に瘤切除,人工血管置換術を施行し,良好な結果を得た.内腸骨動脈瘤に対しては瘤空置術のみ施行する術式もあるが,本症例のように空置瘤が拡大する可能性もあるため,症例によっては瘤切除,人工血管置換術を施行することも必要であると考えられた.右内腸骨動脈瘤空置術後瘤拡大した症例に対して瘤切除,人工血管置換術を施行し,良好な結果を得たので報告した.