Yuji Maruyama

Repair of an Abdominal Aortic Aneurysm with a Remarkably Dilated Meandering Artery: Report of a Case

A 73-year-old man on dialysis for chronic renal dysfunction was referred to our hospital for surgical treatment of an abdominal aortic aneurysm (AAA). Preoperative angiography showed a remarkably developed meandering artery branching from the inferior mesenteric artery (IMA). The superior mesenteric and celiac arteries were occluded at the origin, and all blood flow to the abdominal organs was apparently supplied by collateral circulation from the IMA. Considering the risk of mesenteric ischemia after aortic clamping in conjunction during surgery, we used a perfusion catheter with a 12-F balloon to create a shunt to the IMA from the subclavian artery. The operation was successful and the patient recovered uneventfully. We describe this surgical procedure for its effectiveness in preventing postoperative mesenteric ischemia in a rare case of an AAA with complex branching lesions.

Long-Term Outcomes of Pediatric Coronary Artery Bypass Grafting and Down-Sizing Operation for Giant Coronary Aneurysms

There are several concerns regarding surgical revascularization for Kawasaki coronary disease, including the choice of conduit, optimal timing, and indications for coronary artery bypass grafting (CABG). The internal thoracic artery is the best conduit for pediatric CABG because of its favorable growth potential and long-term patency. Use of a saphenous vein graft should be avoided unless the internal thoracic artery is unavailable. Indications for CABG for Kawasaki coronary disease have not yet been established. In principle, coronary aneurysms should be observed continuously for 1–2 years under restrictive anticoagulation therapy, because coronary aneurysms regress in 50 % of patients within 1–2 years. Presence of severe ischemia with giant coronary aneurysms involving obstructive lesions of the left main trunk or left anterior descending artery (LAD) is an unequivocal indication for CABG. In addition, a giant aneurysm with recurrent thrombosis under restrictive anticoagulation therapy or with severely delayed flow without significant localized stenosis may be an indication for CABG. However, determining surgical indications is difficult, especially for younger children, because of technical challenges. To prevent fatal complications, CABG might be indicated at a young age for patients with severe ischemia, because a history of myocardial infarction and impaired cardiac function affect prognosis. Down-sizing operation for giant aneurysms of non-LAD lesions without significant stenosis and severe calcification may be a good choice to improve coronary circulation and allow discontinuation of warfarin, if indications for this procedure can be established.

Acute Type-A aortic dissection with patent false lumen through to the abdominal aorta: effects of a conventional elephant trunk on malperfusion syndromes and narrowed true lumen

Background: Narrowed true lumen and patent false lumen through to the terminal aorta is a high-risk condition for malperfusion syndromes (MS) in acute type-A aortic dissection. It is important to ascertain how the true and false lumens behave after surgery. Patients and Methods: We retrospectively investigated 45 patients with this pathology. The true lumen sizes at the narrowest levels above and below the superior mesenteric artery were followed by computed tomography after surgery (0-36 months). Results: Thirty-seven MS were seen in 23 patients. Hospital mortality was 8.9%. The narrowed true lumen was not enlarged in the first 6 months with a patent false lumen. The elephant trunk procedure did not improve the true lumen size. An extremely narrowed (≤3mm) true lumen was associated with a significantly high incidence of MS and mortality. Conclusions: High incidences of MS were observed in this particular pathology. An extremely narrowed true lumen was accompanied by a high incidence of MS and mortality.

Preoperative evaluation of the saphenous vein by 3-D contrastless computed tomography

Volume-rendering computed tomography (CT) without contrast medium has clearly demonstrated the 3-D mapping of the saphenous vein (SV). Contrastless volume-rendering CT was used to preoperatively evaluate the SV anatomy before coronary artery bypass grafting (CABG). This technique was useful for atypical anatomical variations, such as partial duplication of SV (Case 1) or varicose veins (Case 2). Volume-rendering CT may also help with redo CABG (to determine remaining SV) or during endoscopic SV harvesting with restricted view. Volume-rendering CT is an objective, less time-consuming modality to evaluate the SV preoperatively and may be less invasive in terms of avoiding unnecessary skin incision.

Two-Patch Repair for Atrioventricular Septal Defect With Mitral Aneurysm

We experienced an unusual case of partial atrioventricular septal defect in an elderly patient. A preoperative ultrasonic cardiogram revealed the mitral leaflet pouching toward the right atrium and suggested the presence of a ventricular septal defect underneath the atrioventricular valve. The mitral aneurysm was diagnosed as a septal aneurysm on preoperative ultrasonic cardiogram. A crescent-shaped Dacron patch (InterVascular S. A., La Ciotat Cedex, France) was placed beneath the atrioventricular valve to prevent rupture of the mitral aneurysm and support the anterior mitral leaflet by creating a new annulus. We believe that this is the first report describing this type of mitral aneurysm and its surgical repair.