Yosuke Kitanaka

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.

Argatroban, an attractive anticoagulant, for left heart bypass with centrifugal pump for repair of traumatic aortic rupture

Systemic heparinization often increases the risk of fatal bleeding from other injured organs in surgical repair of the aorta using extracorporeal circulation in patients with traumatic aortic rupture associated with multisystem injuries. We used an antithrombin agent, argatroban, as an alternative anticoagulant in left heart bypass with the Bio-Medicus centrifugal pump in 7 of 9 recent patients who underwent aortic repair using left heart bypass. All these patients survived without obvious evidence of systemic thromboembolization. Surgical treatments for other organ injuries were carried out in 3 patients concomitantly or immediately after aortic repairs without undue blood loss. Argatroban may have a complementary effect for preventing thrombus formation without aggravating bleeding tendency because of its monotarget specificity to thrombin. We believe intravenous administration (0.5 to 2 micrograms/kg/min) of argatroban is a safe anticoagulant for left heart bypass in repairs of traumatic aortic rupture associated with multiple organ injuries.

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.

Traumatic rupture of the false lumen in a patient with preexisting chronic dissection of the descending thoracic aorta

A 63-year-old man was transported to the emergency medical center due to blunt chest trauma combined with a fractured left leg caused by a motorcycle accident. He complained of severe dyspnea. Contrast-enhanced computed tomography revealed chronic aortic dissection DeBakey III, mediastinal hematoma of high density just above the diaphragm around the aorta, and an intimal flap-like shadow in the false lumen. Traumatic aortic rupture (TAR) with chronic aortic dissection was suspected. Aortography showed no clear sign of leakage, but a double-contour density was found in the outer wall of the false lumen of the descending aorta just above the diaphragm. He was therefore diagnosed with TAR and underwent an emergency operation. At the operation, rupture in the outer wall of the preexisting false lumen was found and was directly sutured. Acute renal failure developed immediately after surgery, which improved after several hemodialyses. We consider our case rare because no report has been so far made on TAR with chronic dissection.

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.

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.