Yuji Morishima

A three-decade experience of radical open endvenectomy with pericardial patch graft for correction of Budd-Chiari syndrome

BACKGROUND We previously reported the value of our operative procedure for Budd-Chiari syndrome (BCS) that comprised reconstruction of the occluded or severely stenosed inferior vena cava (IVC) using an autologous pericardium patch and reopening as many occluded hepatic veins as possible. Here, we present the long-term durability and efficacy of the autologous pericardium patch for reconstruction of the IVC in BCS. METHODS We retrospectively analyzed a series of 53 consecutive patients (mean age, 48.4 +/- 12.8 years; range, 24-76 years; 34 men) who underwent surgical treatment for BCS at our institution from 1979 to 2008. Patency of the IVC and hepatic veins was examined by venography at discharge. Patients attended an outpatient clinic every 1 or 2 months for follow-up. The reconstructed IVC was evaluated by enhanced computed tomography every 1 or 2 years. RESULTS Two in-hospital (operative mortality, 3.7%) and 15 late deaths occurred. During a mean follow-up of 7.6 +/- 6.5 years (range, 0.08-24.1 years), the reconstructed IVC became totally obstructed in three patients, of whom two underwent reoperation, and severely stenosed in two patients, who required percutaneous transvenous balloon venoplasty (PTV). The 5- and 10-year patency rates without reoperation or PTV for the reconstructed IVC were 90.5% and 84.3%, respectively. The cumulative 5- and 10-year survival rates were 89.8% and 70.7%, respectively. CONCLUSION The autologous pericardium patch is effective and durable for reconstructing a diseased IVC in BCS.

Aortic Replacement via Median Sternotomy with Left Anterolateral Thoracotomy

Prevention of cerebral injury is an important consideration during repair of aortic arch aneurysm, and the major goal of cerebral protection techniques. We describe our surgical strategy for treatment of extended thoracic aortic aneurysms. Between January 2001 and June 2008, 17 men and 6 women, with a mean age of 67.9 ± 8.3 years, underwent total replacement of the arch and descending aorta. Six (26.1%) patients required emergency surgery. A median sternotomy with a left anterolateral thoracotomy provided a good visual field, and bilateral axillary arteries were preferentially used for systemic as well as selective cerebral perfusion. Two (8.7%) patients died in hospital. Prolonged mechanical ventilation was required for 7.3 ± 8.4 days after surgery in 17 patients who all recovered uneventfully. Permanent neurological dysfunction developed in 1 (4.3%) patient who died of sepsis 2 years after the operation. Our results suggest that total arch replacement through a median sternotomy plus a left anterolateral thoracotomy is helpful for extended replacement of the thoracic aorta as well as distal reoperation for dissecting type A aortic aneurysm. Perfusion via bilateral axillary arteries may improve cerebral protection.

One-stage thoracic aortic aneurysm treatment and coronary artery bypass grafting.

OBJECTIVE The treatment of thoracic aortic aneurysm accompanied by ischemic heart disease presents a surgical challenge and has up to now shown a high hospital mortality rate. This report discusses the factors contributing to improved results in these cases. METHODS We conducted a retrospective analysis of the records of 24 consecutive patients who had undergone replacement of thoracic aorta with combined coronary artery bypass grafting (CABG) between May 1991 and October 1998. Fifteen patients received total arch replacement (Arch-with-CABG Group), and the other 9 patients received the Bentall operation (Bentall-with-CABG Group). These results were compared with those patients who had undergone replacement of the thoracic aorta without CABG (Without-CABG Group). RESULTS In the combined CABG groups, the overall operative mortality rate was 16.7%. In comparison with the Arch-without-CABG Group, there was a significantly longer cardiopulmonary bypass time and longer selective cerebral perfusion time in the Arch-with-CABG Group. However, no significant difference was observed in postoperative complications between the two groups. In addition, there was no significant difference in either actuarial survival or the cardiac-event-free rate at 5 years between the replacement of thoracic aorta with- and without-CABG Groups (83.1% vs. 90.4%, and 78.5% vs. 77.7%, respectively). No reoperation and no late death were observed during the follow-up period (mean 21.3 months). CONCLUSIONS We concluded that replacement of the thoracic aorta combined with CABG can be carried out safely, and that revascularization for coronary artery disease is useful for preventing any occurrence of cardiac event.

Post-sternotomy hemorrhage due to left internal thoracic artery pseudoaneurysm.

We describe a case of pseudoaneurysm of the internal thoracic artery, which was probably caused by infection. Four weeks after aortic valve replacement and coronary artery bypass surgery, an 84-year-old woman suddenly developed painful sternal instability and hypotension, with active hemorrhage from a left parasternal swelling. Selective arteriography revealed a pseudoaneurysm of the left internal thoracic artery. It was surgically excised, and the patient recovered uneventfully.

Long-term results of root reconstruction using the Carrel patch.

OBJECTIVE The treatment of annuloaortic ectasia in patients, including those with Marfan syndrome, ascending aortic dissection, and other disorders of the ascending aorta and aortic valve presents a surgical challenge that has, unfortunately, shown high hospital mortality up to now. Improvements in graft materials and advanced surgical techniques have, however, begun to reduce hospital mortality. SUBJECTS AND METHODS We retrospectively analyzed the records of 47 consecutive patients who undergoing aortic root reconstruction using the Carrel patch between January 1991 and March 1999. RESULTS Postoperative complications included myonephrotic metabolic syndrome caused by femoral artery cannulation in 2 patients. Reexploration was done to halt bleeding in 2 patients. In 1 of 4 acute dissection patients, retrograde filling of the false lumen was demonstrated postoperatively. Overall surgical mortality in this series was 2.1% (1 of 47). The cardiac-event free rate was 98% at 5 years and 88% at 8 years. Actual survival is 97.8% at 8 years. No anastomosis complications were seen during follow-up (average: 32.7 months) (about 2.73 years). CONCLUSION Surgery is considered feasible in any anatomic variation of aortic root disease, even in coronary ostial minimal dislocation, and the Carrel patch holds hope in preventing of anastomotic pseudaneurysm and ensuring long-term survival. Our experience suggests that modified Bentall operation, or aortic root remodeling using the Carrel patch, has few late-term complications, even in Marfan patients.