Yuji Hanafusa

Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion

OBJECTIVE Right axillary artery (AxA) perfusion, which can prevent cerebral embolism caused by retrograde perfusion via the femoral artery (FA), was used for selective cerebral perfusion (SCP) as well as cardiopulmonary bypass (CPB) in aortic arch repair. We review the outcome of aortic arch surgery using SCP with right AxA perfusion to clarify its efficacy. METHOD Between 1998 and 2002, 120 patients underwent aortic arch repair using SCP with right AxA perfusion. The mean age was 69+/-10 years. Aneurysms were atherosclerotic in 79, dissecting in 32, and others in nine patients. Twenty of them (16.7%) required emergency surgery. CPB was initiated with right AxA and FA perfusion, and following SCP was established using right AxA and left common carotid artery perfusion. RESULTS With right AxA perfusion, hospital mortality was 5.8%. Multivariate analysis showed only ruptured aneurysm was an independent determinant for hospital mortality. Permanent neurological dysfunction developed in one patient (0.8%), while seven (5.8%) suffered from temporary one. In univariate analysis, SCP time, stenosis of the carotid arteries, past history of cerebrovascular events, and atherosclerotic aneurysm were not related to temporary neurological deficits CONCLUSION Right AxA perfusion in conjunction with SCP is a safe and useful alternative for brain protection in total arch replacement.

Total arch replacement with elephant trunk procedure for retrograde dissection.

BACKGROUND The surgical management of type A dissection with the intimal tear in the descending aorta--retrograde dissection--has some challenging aspects because the standard approach through a median sternotomy for ascending aortic dissection is difficult in these cases in which the intimal tear is located in the descending aorta. METHODS From January 1995 to December 2001, 12 (8.6%) consecutive patients aged 40 to 71 years underwent total arch replacement with an elephant trunk procedure through a median sternotomy for retrograde dissection of the ascending aorta (acute: 10, chronic: 2) among 139 patients with type A dissection. The intimal tear was located in the descending aorta in all patients. Dissection extended proximally to the aortic root in 7 patients and to the ascending aorta in 5, and extended distally to the abdominal aorta in 4 and to the common iliac artery in 8. RESULTS Hospital mortality occurred in 1 patient (8%) owing to multiple organ failure after malperfusion of the renal arteries. Postoperatively the false lumen in the descending aorta was closed in all patients who survived but the false lumen in the abdominal aorta was patent in 9. The thoracic and abdominal aorta had slight dilatation in 2 patients. CONCLUSIONS These data suggest that total arch replacement with an elephant trunk procedure through a median sternomy should be recommended in patients with type A dissection and the intimal tear in the descending aorta. This procedure induces thrombosis of the remaining false lumen in the distal aorta postoperatively.

Ruptured left ventricular pseudoaneurysm penetrating into the left pleural cavity

We experienced a rare case of ruptured left ventricular pseudoaneurysm penetrating into the left pleural cavity. A 77-year-old woman was first diagnosed with unstable angina due to sudden chest pain onset and abnormal electrocardiographic findings. In 2 days, massive left pleural effusion was recognized by chest X-ray, though subsequent computed tomographic scans did not show any aortic pathology. We observed her with left thoracentesis alone. Two days later, cardiac arrest suddenly occurred and emergency surgery was undertaken after resuscitation by percutaneous cardiopulmonary support. In surgery, a moderate amount of intrapericardial hematoma caused by rupture of a left ventricular pseudoaneurysm penetrating into the left pleural cavity was found and successfully repaired. This rare rupture of a left ventricular pseudoaneurysm penetrating into the left pleural cavity generated massive hemo-hydrothorax.

The Elephant Trunk Procedure for Aortic Dissection

大動脈解離手術において,吻合部の補強ならびに解離腔の血栓化を期待し,末梢側吻合にelephant trunk(ET)法を応用した手術を行った.対象は1995年1月から1999年12月までの24例で,術後解離腔内血栓化の有無および大動脈径の推移について検討した.手術はStanford A型19例には弓部全置換術を,Stanford B型5例には下行大動脈置換術を施行した.術後全例でET外側の解離腔内血栓化を認め,吻合部での解離腔への血流リークを認めなかった.また18例(75.0%)では横隔膜部の下行大動脈までの解離腔内血栓化を認め,さらに瘤縮小傾向がみられた.このことから吻合部の補強として有用であるとともに,遠隔期に下行大動脈以下の追加手術が減少する可能性があり,本法は大動脈解離における有用な手術法であると思われた.

Valve-Sparing Operation Versus Bentall Operation: Comparison at Medium-Term Follow-Up

The valve-sparing operation has been proposed for aortic regurgitation (AR) in the setting of aortic root dilatation. This method has several advantages over the Bentall operation. Since 1994 a total of 37 patients have undergone either reimplantation of the aortic valve (12 patients) or remodeling of the aortic root (25 patients) in our institution (group R). During the same period 33 patients have had the Bentall operation (group B) as elective surgery. The mean follow-up periods were 323 days (17–1457 days) in group A and 712 days (15–1620 days) in group B. In group R seven patients had Marfan syndrome, five had aortic dissection, and three had aortitis syndrome. In group B nine patients had Marfan syndrome, two had aortic dissection, and eight had aortitis syndrome. There were no differences in preoperative New York Heart Association class or age at operation between the two groups. There was one hospital death in each group and one late death in group B. Two patients in group R required reoperation but none in group B. Actuarial survivals at 4 years were 96.7% in group R and 94.0% in group B. The event-free rates at 4 years were 94.6% in group R and 93.9% in group B. The reoperation-free rates at 4 years were 94.6% in group R and 100% in group B. There was no statistical difference between the two groups for all rates. The valve-sparing operation maintains valve competence during the early postoperative course in our experience, but follow-up data showed deterioration of the valve competence after reimplantation or remodeling, particularly when aortic regurgitation, even mild, was seen after operation. The medium-term survival and cardiac event rates for the valve-sparing operation showed no statistical difference from those of the Bentall operation, although the long-term results of valve competence after the valve-sparing operation are still not known. The aortic root replacement technique should be selected in each clinical setting.

Successful Surgical Treatment of a Case of Ruptured Thoracoabdominal Aortic Aneurysm Associated with Liver Cirrhosis.

肝硬変を合併した胸腹部大動脈瘤破裂に対して人工血管置換術後に, 難治性腹水が遷延し, 腹腔-大腿静脈シャント術を施行し, 良好な成績を得たので報告する. 症例は52歳, 男性で, 以前より肝硬変, 食道静脈瘤の治療を受けていた. 4カ月前より39℃台の発熱が持続し, 2カ月間で瘤径が60mmから80mmに拡大した. 腰背部痛も出現したため, 感染性胸腹部大動脈瘤破裂と診断した. 術前の評価では Child 分類は grade Bで, 食道内視鏡, 臨床所見などより総合的に耐術と判断し, 胸腹部大動脈人工血管置換, 腹部4分枝, 肋間動脈再建, 大網充填を施行した. 術後難治性腹水が出現し, 新鮮凍結血漿の投与でも, 低蛋白血症は改善せず, 腹水貯溜が遷延するため, 第29病日に腹腔-大腿静脈シャント術を施行した. 術後, 腹水貯溜と臨床症状は消失し, 第49病日に退院した. Child 分類 grade Bの肝硬変を合併する大血管術後の難治性腹水に対し, 腹腔-大腿静脈シャント術を施行し良好な結果を得た.