Yukiomi Fukumoto

Abdominal aortic aneurysm with arteritis in ankylosing spondylitis

Abdominal aortic aneurysm with arteritis in ankylosing spondylitis is described. An abdominal aortic aneurysm, 48-mm in diameter, in a 68-year-old woman with HLA-B27-associated ankylosing spondylitis was successfully replaced with a tube graft. The suture lines of the aortic wall were reinforced with Teflon felt strips. Pathologic examination of the aneurysmal wall revealed hyalinization of the connective tissue, with numerous lymphocytic infiltrates, remarkable calcification, and no elastic fibers. The original structure of the arterial wall was not recognized. These findings are compatible with aortitis reported in ankylosing spondylitis.

Abdominal aortic aneurysm related to Takayasu arteritis during pregnancy

Y. Umeda (*) · Y. Mori · H. Takagi · H. Iwata · Y. Fukumoto · H. Hirose First Department of Surgery, Gifu University School of Medicine, 40 Tsukasa-machi, Gifu 500-8705, Japan Tel. 81-58-267-2619; Fax 81-58-267-2955 e-mail: umeda@cc.gifu-u.ac.jp A cystic lesion in a 34-year-old woman was found incidentally at the dorsal side of the uterus during her pregnancy on ultrasound examination and magnetic resonance (MR) imaging (Fig. 1). Computed tomography (CT) was not performed at that time because of her pregnancy. An ovarian cyst was suspected and followed up by the obstetrician. After a natural delivery, a pulsatile mass was found in the left upper abdomen and she was then referred to our hospital. An infrarenal fusiform abdominal aortic aneurysm with a maximum diameter of 6cm was revealed on a CT scan (Fig. 2). She had no history of hypertension or abdominal trauma. The abdominal aortic aneurysm was repaired with a tube graft via a midline laparotomy. She recovered uneventfully after the operation and was discharged from the hospital. Histological examination revealed fibrous thickening of the intima, diffuse lymphohistiocytic infiltration and marked destruction of elastic fibers especially on the adventitial side of the media, and proliferation of the vasa vasorum with perivascular infiltration of lymphocytes in the adventitia. These changes corresponded with the pathologic finding of Takayasu arteritis. Takayasu arteritis is an idiopathic inflammatory arteriopathic disease that leads to stenotic or occlusive changes in the aorta and its main branches. However, aneurysmal formation has also been reported in 2%–30% of Takayasu arteritis patients. Therefore, even in young people, aortic aneurysm related to Takayasu arteritis should not be excluded from the diagnosis of abnormality in an aortic lesion.

Simultaneous Operations for Combined Thoracic and Abdominal Aortic Aneurysms

AbstractPurpose. To assess whether simultaneous operations are appropriate for combined thoracic and abdominal aortic aneurysms. Methods. Simultaneous operations were performed for combined thoracic and abdominal aortic aneurysms in nine patients. The thoracic aortic aneurysm (TAA) was repaired first, followed by repair of the abdominal aortic aneurysm (AAA). Selective cerebral perfusion was used in eight patients, after the exception of one who underwent replacement of the ascending aorta under hypothermic circulatory arrest. The abdominal organs were perfused during distal anastomosis in surgery for Stanford type A aortic dissection or aortic arch aneurysm; via the femoral artery with an aortic balloon occlusion catheter in one patient, and via an occlusion catheter with a perfusion lumen in two patients. Results. All patients underwent planned simultaneous repair of the AAA. One of the patients who underwent simultaneous replacement of both the descending thoracic and abdominal aorta was left with paraplegia, and one patient died suddenly of massive hemoptysis and melena on the 29th postoperative day. Autopsy revealed that the bleeding had been caused by aorto-broncho-esophageal fistulae. The overall operative mortality was 11%. Conclusions. Simultaneous repair of combined TAA and AAA can be safely performed; however, the risk of paraplegia should be considered, especially with simultaneous repair of concomitant aneurysms of the descending thoracic and abdominal aorta.

Surgical treatment of thoracoabdominal aortic mural and floating thrombi extending to infrarenal aorta

The case of a 49-year-old man with thoracoabdominal aortic mural and floating thrombi extending to the infrarenal aorta and occlusion of the common iliac artery is described. He had no factors promoting thrombosis, with a history of thrombectomy of the femoral artery. The thoracoabdominal aortic thrombi were successfully removed with a Forgaty catheter through a thoracotomy under simple aortic clamping and subsequent femoro-femoral cardiopulmonary bypass. Intravascular ultrasound performed through the femoral artery after thrombectomy revealed that little mural thrombi remained and that the celiac, superior mesenteric, and bilateral renal arteries were all patent.

Simultaneous operation of ischemic heart disease, abdominal aortic aneurysm, and rectal cancer

A 68-year-old man with ischemic heart disease, abdominal aortic aneurysm, and rectal cancer was referred. Coronary angiography indicated triple-vessel disease with jeopardized collaterals, and dipyridamole myocardial scintigraphy disclosed no viability in the inferior, posterior, and lateral walls. Abdominal computed tomography scanning revealed an infrarenal abdominal aortic aneurysm, 65 mm in diameter, with an expanding rate of 8 mm/year. Barium enema revealed stenosis 4 cm in length 5 cm inward from the anal verge, and an endoscopic finding was ulcerated type tumor with a clear margin and circumferential stenosis. Histological examination of a biopsy specimen revealed adenocarcinoma, and the clinical stage in the Japanese classification of colorectal carcinoma was II according to other examinations. Simultaneous operations were scheduled because of the jeopardized collaterals of the coronary arteries, rapid expansion of the aneurysm, and subileus due to the cancer. The patient underwent simultaneous off-pump coronary artery bypass grafting to the left anterior descending artery with the in situ internal thoracic artery through a median sternotomy, abdominal aortic aneurysm repair with a tube graft through a median laparotomy, and the Miles’ operation with total mesorectal excision. Although infection of the perineal wound was postoperatively recognized, it remained local and was healed with irrigation only. The patient is doing well 12 months after the operation, without myocardial ischemic symptoms or recurrence of the cancer.

Staged Hybrid Debranching and Thoracic Endovascular Aneurysm Repair for Multiple Aortic Aneurysms after Conventional Open Repair of the Descending Aorta: A Case Report

Endovascular repairs of thoracic and thoracoabdominal aortic aneurysm have recently been proposed as a less invasive alternative to conventional open surgical repair. In selective cases, adjunctive bypass surgery may be required to provide an adequate landing zone. We describe a case of staged hybrid debranching and thoracic endovascular aneurysm repair for distal aortic arch and thoracoabdominal aortic aneurysms after conventional open repair of the descending aorta.

A clinical renal-transplant case from a non-heart-beating donor using percutaneous cardiopulmonary support.

Organ procurement from non–heart-beating donors (NHBDs) has been considered as one technique to expand door pools. Experimental and clinical renal transplantation from NHBDs has been reported (1–3). Percutaneous cardiopulmonary support (PCPS) used in cardiopulmonary resuscitation can possibly maintain organ viability (4). We reported a renal transplant from a NHBD using PCPS. A 48-year-old man with cardiopulmonary arrest was admitted to our emergency department. An electrocardiogram (ECG) showed ventricular fibrillation, which was resistant to defibrillation and subsequent standstill and arrest. Fortynine minutes with cardiac massage after arrival, PCPS for rescuing the patient was indicated and performed successfully within 10 minutes. We used PCPS (CAPIOX EBS, TERUMO Corporation, Tokyo, Japan), consisting of oxygenator and centrifugal pump system, after insertion of arterial (16.5 F [5.5 mm] diameter) and venous (21 Fr [7 mm] diameter) catheters into the right femoral artery and vein using a percutaneous centesis method. ECG recovered to a normal sinus rhythm after the initiation of PCPS. The patient was admitted to intensive care unit (ICU) with dobutamine and dopamine. Bilateral pupils were 5.5 mm without light reflex. Spontaneous breathing was observed. However, 8 hours after admission to the ICU, a significant increase of urine output was observed (Fig. 1). However, serum creatinine and blood urea nitrogen (BUN) increased during PCPS and was affected by cardiac massage. Spontaneous breathing was disappeared and noradrenalin was required. Echocardiography showed severe hypokinetic wall motion of 15% ejection fraction that was suspicious for heart trouble such as coronary artery disease. The pupils were dilated to the size of 7.0 mm. Twenty-four hours later, clinical brain death was diagnosed. Blood pressure of the patient during PCPS was maintained at approximately 90 mm Hg at systole. Core temperature was maintained at 37°C during PCPS. Catecholamines were discontinued after the family’s agreement to donate the kidneys and cornea. Because Japanese law did not permit organ procurement under the criteria of brain death without a donor card that provided consent by both the donor and his family. After cardiac arrest, the bilateral kidneys and corneas were harvested. Through median laparotomy, topical cooling was performed with an ice slush. After clamping the descending thoracic aorta through the left diaphragm, abdominal organs were successfully perfused with 4°C cold lactate Ringer’s solution through the arterial canula of PCPS, with drainage through the venous canula. The duration from cardiac arrest to initiation of cold perfusion was 35 minutes. After harvesting, both kidneys were immersed in Euro-Collins’ solution for preservation. Two male recipients who were a 51 and 38 years old were selected. Kidney cold ischemic times were 17 hours, 58 min and 20 hours, 55 min, respectively. Histologic findings of specimens 1 hour postperfusion showed slight acute tubular necrosis. Both kidneys produced urine immediately after reperfusion. Initially, the amount of the urine at 1 day posttransplant was 650 mL; however, it increased to up to 1,000 mL/day at 3 days posttransplant. Finally, dialysis for both recipients was discontinued 15 days posttransplant. Weber et al. (1) reported significantly higher incidence of delayed graft function of the kidneys from NHBDs than those from donors with a heartbeat. However, long-term graft survival rates were similar. Sufficient blood perfusion of organs with PCPS in donors with insufficient cardiac output is an important issue for keeping organs viable. Warm ischemic time (WIT) is defined as the duration from the cardiac arrest to the perfusion with cold preservation solution. In our case, there was no WIT because of the use of PCPS after cardiac arrest. Kidneys were perfused with warm oxygenated blood during PCPS immediately before the perfusion with a cold preservation solution. Arterial and venous catheters of PCPS were useful for the cold perfusion and drainage. Fukushima et al. (5) reported a renal-transplant case from an NHBD using PCPS. They demonstrated that a donor with a single ventricle and massive pulmonary arterial venous shunt developed hypoxemic shock during their treatment. Our case was a patient case with cardiopulmonary arrest at

Mitral regurgitation without supravalvular aortic stenosis in Williams syndrome.

Abstract. Isolated mitral regurgitation without supravalvular aortic stenosis is rarely identified in Williams syndrome. We describe the case of a 24-year-old man with isolated mitral regurgitation in Williams syndrome. Severe regurgitation due to prolapse of the anterior leaflet was noted in an echocardiogram and color Doppler, and a left ventriculogram showed grade IV regurgitation. No pressure gradient between the left ventricle and the ascending aorta was found. Mitral regurgitation had been noted since his birth, and pediatricians suspected Williams syndrome because of postnatal growth deficiency, mental deficiency, unusual personality, and unusual facial features in his childhood. The diagnosis was confirmed by demonstration of the hemizygous deletion of 7q11.23 in the karyotype by the fluorescent in situ hybridization technique after his admission to our department. The patient underwent mitral valve replacement, and microscopic examination of the excised valve revealed myxomatous degeneration.

Morphological changes of the anterior spinal artery during aortic cross-clamping and effect of prostaglandin E1 with perfusion

This investigation was designed to evaluate the morphological changes of anterior spinal artery (ASA) and its reaction to prostaglandinE1 (PGE1) during aortic cross-clamping. ASA during 30 min cross-clamping was observed with charge-coupled device (CCD) and ASA diameter (ASAD) was measured. Group A: Infrarenal aorta was cross-clamped. Group B: Infrarenal aorta was cross-clamped and aorta above the bifurcation was snared. The aortic segment between clamp and snare was perfused with blood. Group C: PGE1 of 100 ng/kg/min was added to perfusate of Group B. The aortic segmental pressures in group B and C were about 30% of the proximal systolic arterial pressure and were significantly higher than distal pressure of group A. After cross-clamping, ASAD decreased about 80% of before cross-clamping in group A. By segmental perfusion of which pressure was about 30% of proximal systolic arterial pressure, ASAD remained almost 90% in group B. By administration of PGE1, ASAD was significantly increased in group C. The changes of ASAD were significantly different between group A and C, and between group B and C.

Simultaneous Endovascular Aneurysm Repair and Distal Gastrectomy in a Patient with Concomitant Abdominal Aortic Aneurysm and Advanced Gastric Cancer

The optimal surgical management of patients with concomitant abdominal aortic aneurysm (AAA) and gastrointestinal malignancy remains controversial. A 79 year-old man who presented with hematemesis was found to have advanced gastric cancer concomitant with infrarenal AAA. The patient underwent simultaneous endovascular aneurysm repair (EVAR) and distal gastrectomy. The postoperative course was uneventful. The present case illustrates the clinical utility of EVAR for the high-risk patient with concomitant AAA and gastrointestinal malignancy.