JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 53, No. 4, July 2024 CONTENTS

Preface

• Towards the Future of Academia　Y. Hiramatsu

Letter to Editor

• Safety of Minimally Invasive Cardiac Surgery in Japan　T. Sakaguchi 163
  Safety of Minimally Invasive Cardiac Surgery in Japan
  

  Taichi Sakaguchi＊

  
  

  (Department of Cardiovascular Surgery, Hyogo Medical University＊, Nishinomiya, Japan)
  

  Minimally invasive cardiac surgery （MICS） is rapidly gaining popularity in Japan, and its safety is attracting public attention. The Japanese Society for Minimally Invasive Cardiac Surgery （J-MICS） surveyed myocardial protection during MICS. Among the 97 institutions, blood CP is used in 60, crystalloid CP in 21, and a mixture in 16. Six percent of institutions using blood CP （other than del Nido CP） and 44% of those using crystalloid CP have CP administration intervals of 30 min or longer. De-airing of the aortic root to prevent air embolization into the coronary arteries is routinely performed at 94% of institutions during CP administration and 72% of institutions during water injection tests after mitral valve repair. According to the Japanese Cardiovascular Surgery Database （JCVSD）, MICS requires longer aortic cross-clamp time than median sternotomy, but the incidence of postoperative complications, including perioperative myocardial infarction, was similar. J-MICS starts the MICS registry in 2024, and we plan to conduct a detailed analysis of the MICS-specific complications. With our certification and proctorship programs, J-MICS will continue promoting MICS safely in Japan.

   

  Jpn. J. Cardiovasc. Surg. 53: 163-168（2024）

  Keywords：minimally invasive cardiac surgery; cardioplegia; complication; registry

  
  

Originals

• Clinical Outcomes of the Tricuspid Valve Replacement at Our Clinic　Y. Yokoyama and T. Emmoto　169
  Clinical Outcomes of the Tricuspid Valve Replacement at Our Clinic
  

  Yuichiro Yokoyama＊	Takeshi Emmoto＊

  
  

  （Yotsuba Circulation Clinic＊, Matsuyama, Japan）
  

  Background: Residual tricuspid regurgitation has recently been recognized as an adverse prognostic factor, for which reliable regurgitation control is required. Tricuspid valve repair with ring annuloplasty is the most common procedure for tricuspid regurgitation. However, if the rings are severely enlarged or the valves are strongly tethered by enlarged right ventricles, it is difficult to control the regurgitation by annuloplasty procedure only. The complex valvuloplasty procedures as required for mitral valve surgery are sometimes needed for these severe cases. Although tricuspid valve replacement （TVR） is sometimes chosen for simple and reliable regurgitation control in such cases, the procedure is uncommon and the long-term outcomes have yet to be clearly identified. In this study, the results of 17 TVR cases at our clinic are reviewed. Patients and Methods: Seventeen patients underwent TVR between February 2008 and May 2022. The operative outcomes and the echocardiographic changes of the implanted prosthetic valves were then retrospectively studied. Results: All the patients had implanted Carpentier-Edwards pericardial valves. Hospital mortality occurred in two cases. Among the survivors, three patients underwent re-operations for prosthetic valve dysfunction. One patient underwent tricuspid valvuloplasty using the Inoue balloon catheter, while the other two underwent re-tricuspid valve replacement using prosthetic tissue valves. The explanted valves showed severe adhesion between the leaflets and around the tissue, such as the patient’s own remaining tricuspid valves or the right ventricular organs. The timings of the re-operations were 6 to 8 years after the first TVR. Prosthetic valve function was studied by color Doppler echocardiography. Follow-up data were available only for twelve patients. Prosthetic valve regurgitation steadily worsened approximately three years after the operation, and the mean transprosthetic gradient gradually increased about 1.5 times in four years after implantation. These results suggest that the Carpentier-Edwards pericardial valve in the tricuspid position may begin to deteriorate in 3 to 4 years. Conclusion: The surgical outcomes of TVR with the Carpentier-Edwards pericardial valves are not satisfactory.

   

  Jpn. J. Cardiovasc. Surg. 53: 169-173（2024）

  Keywords：tricuspid valve replacement; Carpentier-Edwards pericardial valve; tissue valve

  
  
• Changes in the Infrarenal Residual Aorta after Open Repair for Abdominal Aortic Aneurysm（AAA）　T. Muraoka et al. 　174
  Changes in the Infrarenal Residual Aorta after Open Repair for Abdominal Aortic Aneurysm (AAA)
  

  Takuma Muraoka＊	Yuichiro Kaminishi＊	Mayumi Shinonaga＊
  Setsuo Kuraoka＊

  
  

  （Department of Cardiovascular Surgery, Mito Saiseikai General Hospital＊, Mito, Japan）
  

  Background: In abdominal aortic aneurysm （AAA） repair, European and the United States’ guidelines recommend performing proximal anastomosis as close to the renal arteries as possible. A long infrarenal residual aorta （IRA） raises concern about the risk of enlargement and aneurysmal formation in the future. There are no descriptions of proximal anastomosis in Japanese guidelines. Objective: To investigate the relationship between the length of the IRA and its long-term enlargement. Subjects: 100 patients who underwent open repair for AAA at our hospital between June 2002 and November 2016 were included. The mean age was 70.2±8.2 （SD） years, and the mean observation period was 8.5±3.3 years. Group S （n=24） consisted of patients whose IRAs were less than 2 cm in length, and Group L （n=76） consisted of patients whose IRAs were more than 2 cm in length. The preoperative diameter of the infrarenal aorta and the length and diameter of IRA in the immediately after surgery, in the early postoperative period （within 1 year）, in the mid-term （2 to 9 years）, and in the remote period （after 10 years） were measured. Results: There was no significant change in IRA diameter between preoperative and immediate postoperative periods. The preoperative diameter of the infrarenal aorta were 23.0 ［21.0-26.0］ mm in group S and 22.0 ［20.0-24.5］ mm in group L. There was no significant difference of the preoperative IRA diameter between the two groups. The IRA diameters in the postoperative period and thereafter were 22.0 ［20.0-26.0］ mm, 23.0 ［21.0-27.0］ mm, 24.0 ［22.0-28.0］ mm, 26.0 ［23.3-32.8］ mm in group L, showing a significant dilatation immediately after operation （p＜0.01）. In addition, although there was no statistically significant difference, the group with a preoperative infrarenal aorta diameter of 26 mm or greater showed a larger dilatation after the midterm postoperative period. Conclusions: An association was found between IRA length （≥2 cm） and postoperative IRA dilatation.

   

  Jpn. J. Cardiovasc. Surg. 53: 174-178（2024）

  Keywords：Infrarenal abdominal aortic aneurysm; bifurcated grafting; infrarenal residual aorta

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• A Case of Primary Pericardial Synovial Sarcoma Originating from the Epicardium with Cardiac Tamponade　Y. Hari et al. 179
  A Case of Primary Pericardial Synovial Sarcoma Originating from the Epicardium with Cardiac Tamponade
  

  Yosuke Hari＊	Noritsugu Naito＊	Yuhi Nakamura＊
  Hisaya Mori＊	Hisato Takagi＊

  
  

  (Department of Cardiovascular Surgery, Shizuoka Medical Center＊, Shizuoka, Japan)
  

  Primary cardiac synovial sarcoma is extremely rare, and approximately100 cases had been reported according to a literature review in 2019. We herein reported a case of primary pericardial synovial sarcoma originating from the epicardium with cardiac tamponade. Pericardiocentesis, subsequent complete tumorectomy under cardiopulmonary bypass and cardiac arrest, and adjuvant chemoradiotherapy was performed, and the patient survived for 3 years with neither recurrence nor metastasis.

   

  Jpn. J. Cardiovasc. Surg. 53: 179-182（2024）

  Keywords：primary pericardial synovial sarcoma; epicardial origination; cardiac tamponade

  
  
• Mitral and Aortic Valve Regurgitation Caused by Methotrexate-Associated Lymphoproliferative Disorder　Y. Sugita et al. 183
  Mitral and Aortic Valve Regurgitation Caused by Methotrexate-Associated Lymphoproliferative Disorder
  

  Yosuke Sugita＊	Hiroyuki Hara＊	Keita Yano＊
  Shinya Takimoto＊	Naoki Kanemitsu

  
  

  (Department of Cardiovascular Surgery, Japan Red Cross Wakayama Medical Center＊, Wakayama, Japan)
  

  We report on a rare case of valvular regurgitation caused by methotrexate-associated lymphoproliferative disorder （MTX-LPD）. A 60-year-old woman was on methotrexate （MTX） for rheumatoid arthritis. She had developed ulcerative lesions on her extremities, which were diagnosed as lymphoproliferative disorder （LPD） by skin biopsy. She had small intestinal perforation during the same time period, and underwent partial bowel resection. MTX was withdrawn perioperatively. The patient experienced congestive heart failure immediately after the operation and was diagnosed with severe mitral valve regurgitation and moderate-to-severe aortic valve regurgitation. She underwent mitral valve plasty and aortic valve replacement. We observed mitral valve perforation, surrounded by a cauliflower-shaped elevation. Meanwhile, the aortic valve leaflets degenerated into cauliflower-like structures. Pathological findings suggested infiltration of B lymphocytes and Epstein–Barr virus infection in the valve tissue. These findings were similar to those of the prior skin ulcer diagnosed as LPD, which healed spontaneously after MTX withdrawal. She was diagnosed with MTX-LPD based on the pathological findings and clinical history. The patient was discharged on postoperative day 19.

   

  Jpn. J. Cardiovasc. Surg. 53: 183-187（2024）

  Keywords：methotrexate-associated lymphoproliferative disorder; aseptic endocarditis; aortic valve regurgitation; mitral valve regurgitation

  
  
• A Case of Re-Do Aortic Valve Replacement for Early Bioprosthetic Valve Dysfunction due to a Large egetation of Nonbacterial Thrombotic Endocarditis　S. Kishimoto et al　188
  A Case of Re-Do Aortic Valve Replacement for Early Bioprosthetic Valve Dysfunction due to a Large Vegetation of Nonbacterial Thrombotic Endocarditis
  

  Satoru Kishimoto＊	Arudo Hiraoka＊	Genta Chikazawa＊
  Hidenori Yoshitaka＊

  
  

  (Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama＊, Okayama, Japan)
  

  A 73-year-old man underwent aortic valve replacement （AVR） with a bioprosthetic valve for severe aortic regurgitation at another hospital 18 months ago. He was referred to our department for treatment due to thickening of the bioprosthetic valve leaflets and restricted valve motion. Additionally, a 13×13 mm abnormal structure, suspected to be vegetation, was observed at the left ventricular outflow tract （LVOT）. Because this tissue could cause an embolism and the patient exhibited severe aortic stenosis due to constriction of the valve orifice area by the vegetation, the heart team decided that redo AVR was necessary. The patient underwent redo surgery via a re-median sternotomy. A fragile vegetation, characterized by a pale pink and black mixture, was adherent to the prosthetic valve leaflet and its inner surface. Upon removal of the prosthetic valve, the same type of tissue was observed at the LVOT under the right coronary cusp. The aortic valve was replaced with a sutureless bioprosthetic valve. The excised vegetation was culture-negative, as was the prosthetic valve. Histological examination revealed that the vegetation primarily consisted of fibrin, with small amounts of erythrocytes and histiocyte inclusions. Based on the tissue’s origin and histological findings, we diagnosed nonbacterial thrombotic endocarditis （NBTE） as the cause of the early prosthetic valve dysfunction. NBTE should be considered one of the differential diagnoses for early prosthetic valve dysfunction.

   

  Jpn. J. Cardiovasc. Surg. 53: 188-192（2024）

  Keywords：nonbacterial thrombotic endocarditis; early bioprosthetic valve dysfunction; aortic valve

  
  
• A Case of Aortic Valve Replacement after 20 Years of Aortic Root Replacement by Cryopreserved Homograft　H. Kuroki et al. 　193
  A Case of Aortic Valve Replacement after 20 Years of Aortic Root Replacement by Cryopreserved Homograft
  

  Hidehito Kuroki＊	Hironobu Sakurai＊＊	Kenji Yokoyama＊
  Satoshi Yamamoto＊	Takeshi Someya＊

  
  

  （Department of Cardiovascular Surgery, Ome Medical Center＊, Ome, Japan, and Department of Cardiovascular Surgery, Japanese Red Cross Musashino Hospital＊＊, Musashino, Japan）
  

  A 78-year-old man presented with back pain 20 years after aortic root replacement using a homograft and was admitted with a diagnosis of pyogenic spondylitis. The patient had a history of prosthetic valve infective endocarditis （PVE） 9 months after aortic valve replacement （AVR） at 57 years of age at another hospital, and had undergone aortic root replacement using a homograft. Streptococcus anginosus was detected in blood culture, and antibiotic therapy was commenced according to the treatment of PVE. During the course of the treatment, the diagnosis of PVE was confirmed due to worsening aortic regurgitation （AR） and a finding of suspected vegetation attachment to the right coronary cusp. Since there were no embolic symptoms or heart failure, antibiotic therapy was preceded by surgery on the 33rd day. Intraoperatively, the homograft showed a highly calcified sinus of Valsalva and each valve leaflet was very fragile. The aortic valve had a vegetation adherent to the tip of the right coronary leaflet, but the infection was localized and did not extend to the annulus. Although aortic root replacement had been considered, the patient was elderly and had impaired activities of daily living, so AVR was performed in order to reduce the invasiveness of the procedure. The annulus was so hard that the needle could not be passed through. It was possible to thread the annulus by inserting the needle through the autologous tissue below the suture line on the proximal side of the homograft at the previous surgery. A bovine pericardial patch was used to close the aortotomy line of sclerotic homograft. There was no recurrence of infection, and the patient was transferred to the hospital for rehabilitation on postoperative day 37. The optimal surgical technique should be considered according to the degree of calcification and the patient’s background in each case, as grafts are often highly calcified in cases of reoperation after homograft replacement.

   

  Jpn. J. Cardiovasc. Surg. 53: 193-197（2024）

  Keywords：homograft; prosthetic valve infective endocarditis; bovine pericardial patch

  
  
• Standby Surgical Repair for Ruptured Sinus of Valsalva Aneurysm in an Elderly Patient: a Case Report and Literature Review　T. Umeno et al　198
  Standby Surgical Repair for Ruptured Sinus of Valsalva Aneurysm in an Elderly Patient: a Case Report and Literature Review
  

  Tadashi Umeno＊

  Hirotsugu Hamamoto＊

  Shinji Miyamoto＊＊

  
  

  (Department of Cardiovascular Surgery, Almeida Memorial Hospital＊, Oita, Japan, and Department of Cardiovascular Surgery, Oita University Hospital＊＊, Oita, Japan)
  

  This case study reports the case of a 72-year-old man who was diagnosed with aortic regurgitation 20 years ago after a medical checkup and received treatment for edema and weight gain for approximately 2 months at the local hospital. The patient was diagnosed with a ruptured Valsalva aneurysm in the noncoronary sinus with right atrium shunting. Two and a half months after the onset, surgical repair was scheduled on a standby basis, and the patient was discharged 14 days postoperatively with a good course. The surgery was completed with fistula closure using a patch via the aortic valve and the right atrial side approaches as well as aortic valve replacement for aortic regurgitation due to uncinate valve leaflet degeneration. The ruptured sinus of the Valsalva aneurysm is an extremely rare disease, which forms a left-to-right shunt that progresses to severe heart failure. Moreover, congenital tissue fragility of the sinus of Valsalva causes this pathogenesis, and rupture prevalently occurs at a relatively young age, up to approximately 40 years. Herein, after a thorough literature review, we report an extremely rare case of an elderly onset at 72 years of age, and a rare disease course in which elective surgery could be performed without rapid heart failure progression.

   

  Jpn. J. Cardiovasc. Surg. 53: 198-202（2024）

  Keywords：sinus of Valsalva aneurysm; rupture into the right atrium; standby surgical repair; aortic insufficiency

  
  
• A Case of Mitral Stenosis due to Pannus Formation after Mitral Valve Plasty　T. Miyanaga et al　203
  A Case of Mitral Stenosis due to Pannus Formation after Mitral Valve Plasty
  

  Tatsuya Miyanaga＊	Ichiro Matsumaru＊	Shun Nakaji＊
  Kazuki Hisatomi＊	Yuichi Tasaki＊	Akihiko Tanigawa＊
  Shunsuke Taguchi＊	Yutaro Ryu＊	Yugo Murakami＊
  Takashi Miura＊

  
  

  (Depertment of Cardiovascular Surgery, Nagasaki University＊, Nagasaki, Japan)
  

  A 73-year-old man had been followed up in our hospital after surgery for mitral regurgitation. At the age of 67, he underwent mitral valve plasty through a right mini-thoracotomy approach for atrial functional mitral regurgitation at our hospital. The mean trans-mitral pressure gradient was 5 mmHg after surgery but no heart failure symptoms were observed. At the age of 72, he began to notice fatigue during exertion. Transthoracic echocardiography revealed that the mitral valve regurgitation was controlled to a trace level, but the mean trans-mitral pressure gradient increased to 10 mmHg. Transesophageal echocardiography and contrast-enhanced cardiac computed tomography revealed the restricted opening of the mitral valve and pannus formation around the prosthetic ring. We thus diagnosed mitral stenosis due to pannus overgrowth. He underwent pannus excision and removal of the artificial ring. Postoperative echocardiography revealed that the mean trans-mitral pressure gradient was reduced to 3 mmHg and no residual mitral regurgitation was observed. He was discharged on postoperative day 11 with no major symptoms. He was in New York Heart Association functional class I at 1 year after the surgery and continues to be an outpatient.

   

  Jpn. J. Cardiovasc. Surg. 53: 203-207（2024）

  Keywords：mitral valve plasty; pannus; mitral stenosis

  
  

［Aortic Disease］

• Usefulness of Gallium Scintigraphy in Follow up after Endovascular Aortic Repair for Mycotic Abdominal Aortic Aneurysm　Y. Ohtomo et al.　208
  Usefulness of Gallium Scintigraphy in Follow up after Endovascular Aortic Repair for Mycotic Abdominal Aortic Aneurysm
  

  Yuki Ohtomo＊	Yurie Ohtomo＊	Nobuyuki Inoue＊＊
  Nobuyuki Yamamoto＊

  
  

  (Department of Cardiovascular Surgery, Hokuto Hospital＊, Obihiro, Japan, and Cardiovascular Surgery, International Medical Center＊＊, Obihiro, Japan)
  

  Open surgery remains the treatment of choice for mycotic abdominal aortic aneurysm （MAAA）. However, open surgery for MAAA is often associated with a significant perioperative risk and there have been some reports in which MAAA was successfully treated with endovascular aortic repair （EVAR）. We report a case of MAAA treated with EVAR. Gallium scintigraphy was useful in postoperative evaluation of infection. A 61-year-old man presented with back pain. Computed tomography （CT） revealed a 50-mm saccular abdominal aortic aneurysm（AAA）. The patient underwent EVAR for symptomatic AAA but developed a high fever 5 days after surgery. Serum C-reactive protein level was elevated and blood culture was positive for Salmonella. Intravenous antibiotics were commenced with a diagnosis of MAAA and the fever and inflammatory parameters subsided with a decrease in the size of the aneurysm. Accumulation of gallium was observed on scintigraphy 1 month after surgery. The patient received intravenous antibiotics for 8 weeks after surgery and was discharged home with oral antibiotics. At 6 months after surgery, accumulation of gallium disappeared. Oral antibiotics were ceased when CT showed disappearance of the aneurysm 9 months after surgery. At present, the patient has been doing well without signs or symptoms of recurrent infection.

   

  Jpn. J. Cardiovasc. Surg. 53: 208-211（2024）

  Keywords：MAAA; EVAR; gallium scintigraphy

  
  
• A Rare Case of Ligation of Thoracic Duct for Lt. Cervical Chyle Leakage Diagnosed as Lt. Cervical Tumor after Total Arch Replacement and Aortic Valve Replacement　T. Mikoshiba et al.　 212
  A Rare Case of Ligation of Thoracic Duct for Lt. Cervical Chyle Leakage Diagnosed as Lt. Cervical Tumor after Total Arch Replacement and Aortic Valve Replacement
  

  Tohru Mikoshiba＊

  Hideo Tsunemoto＊

  
  

  （Department of Cardiovascular Surgery, Aizawa Hospital＊, Matsumoto, Japan）
  

  The patient was a 66-year-old man. He was following up after conservative treatment for type B acute aortic dissection. Computed tomography （CT） examination three months after the onset showed enlargement of the distal aortic arch and a new ulcer-like projection in the descending aorta. We judged them as indications for surgery. We were going to perform total arch replacement （TAR） and frozen elephant trunk （FET） for the distal arch aortic aneurysm, and thoracic endovascular aortic repair （TEVAR） for the processed aortic aneurysm in two stages. A CT scan 12 days after the TAR+ FET+AVR（aortic valve replacement） revealed a left cervical mass, and further examination revealed a left cervical lymphatic cyst. Conservative therapy involving drainage and a fat-restricted diet was initiated, but the drainage volume did not decrease. Therefore, we performed surgical thoracic duct ligation. We performed surgical thoracic duct ligation. We experienced a very rare case and report it here.

   

  Jpn. J. Cardiovasc. Surg. 53: 212-215（2024）

  Keywords：cervical chyle leakage; ligation of thoracic duct; post TAR

  
  
• Valve-Sparing Aortic Root Replacement and Total Arch Aortic Replacement for Aortic Regurgitation and Thoracic Aortic Aneurysm in Giant Cell Arteritis　S. Kubo et al.　216
  Valve-Sparing Aortic Root Replacement and Total Arch Aortic Replacement for Aortic Regurgitation and Thoracic Aortic Aneurysm in Giant Cell Arteritis
  

  Sara Kubo＊	Aya Tanaka＊	Atsushi Omura＊
  Kotaro Tsunemi＊	Takanori Oka＊	Yutaka Okita＊

  
  

  (Cardio-Aortic Center, Aijinkai Takatsuki General Hospital＊, Osaka, Japan)
  

  A 47-year-old woman was incidentally found to have a thoracic aortic aneurysm by CT scan. There was an aneurysm in the ascending aorta and aortic arch, and the Valsalva sinus was enlarged. Echocardiography showed a severe aortic regurgitation. Valve-sparing aortic root replacement and total arch replacement was performed. The pathology of the ascending aorta was consistent with giant cell arteritis. Her postoperative course was straightforward, and she was discharged 23 days after surgery. In Japan, there are few reports of valve-sparing surgery for patients with giant cell aortitis, and we report our experience of a rare case.

   

  Jpn. J. Cardiovasc. Surg. 53: 216-219（2024）

  Keywords：giant cell arteritis; valve-sparing aortic root replacement; arch aortic replacement

  
  
• Experience of Open-Heart Surgery for Idiopathic Thrombocytopenic Purpura (ITP) Refractory to Corticosteroids－Combined High-Dose Intravenous Gammaglobulin and Thrombopoietin Receptor Agonist 　M. Yamada et al.　220
  Experience of Open-Heart Surgery for Idiopathic Thrombocytopenic Purpura （ITP） Refractory to Corticosteroids－Combined High-Dose Intravenous Gammaglobulin and Thrombopoietin Receptor Agonist
  

  Masao Yamada＊	Jun Yokote＊	Masato Yamakawa＊
  Shinichi Ashida＊	Hiroki Hasegawa＊	Yukifusa Yokoyama＊

  
  

  (Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital＊, Ogaki, Japan)
  

  The patient was a 73-year-old man. We have performed an ascending aortic prosthesis replacement for a thoracic aortic aneurysm complicated by idiopathic thrombocytopenic purpura （ITP）. The platelet count was not sufficiently increased neither by preoperative Helicobacter pylori (H. pylori) eradication nor corticosteroid therapy. After treatment with high-dose intravenous gammaglobulin （400 mg/kg/day×5 days） and the use of thrombopoietin receptor agonists, the platelet count increased to 8.9×104/μl and the operation was safely performed. With a steady increase in platelet count, the patient continued to do well post-operatively. We report a case in which a stable platelet count was achieved throughout the perioperative period by the effective combination of high-dose intravenous gammaglobulin and a thrombopoietin receptor agonist in a patient with ITP refractory to corticosteroid therapy.

   

  Jpn. J. Cardiovasc. Surg. 53: 220-224（2024）

  Keywords：idiopathic thrombocytopenic purpura; open heart surgery; thoracic aortic aneurysm; intravenous immunoglobulin therapy; thrombopoietin receptor agonists

  
  
• A Case of Endovascular Revascularization for Visceral Malperfusion Associated with Acute Type A Dissection before Central Repair　A. Iwasaki et al.　225
  A Case of Endovascular Revascularization for Visceral Malperfusion Associated with Acute Type A Dissection before Central Repair
  

  Ayaka Iwasaki＊

  Hironori Baba＊

  Eisaku Nakamura＊

  
  

  (Miyazaki Prefectural Miyazaki Hospital＊, Miyazaki, Japan)
  

  We report a case of endovascular revascularization for visceral malperfusion associated with acute type A dissection. A 53-year-old man presented with chest pain, and contrast enhanced computed tomography revealed type A dissection with an occluded superior mesenteric artery （SMA）. No pericardial effusion or aortic valve insufficiency was detected. Due to concerns about the progression of bowel ischemia, we performed endovascular revascularization. Stenting the SMA resulted in improved blood flow. Additionally, a central repair（total arch replacement） was performed. The patient was discharged 20 days postoperatively without any complications.

   

  Jpn. J. Cardiovasc. Surg. 53: 225-229（2024）

  Keywords：acute type A aortic dissection; visceral malperfusion; superior mesenteric artery; endovasculer; malperfusion

  
  

［Peripheral Artery Disease］

• A Case of Popliteal Pseudoaneurysm Refractory to Treatment　M. Ohara and Y. Sekine　230
  A Case of Popliteal Pseudoaneurysm Refractory to Treatment
  

  Masato Ohara＊

  Yuki Sekine＊

  
  

  (Department of Vascular Surgery, Ishinomaki Red Cross Hospital＊, Ishinomaki, Japan)
  

  Popliteal pseudoaneurysms are often due to traumatic injury or are iatrogenic, such as from orthopedic surgery, and require urgent reconstruction. We report a case the onset of which was due to kneeling on the floor. The patient developed a large pseudoaneurysm because the symptoms did not manifest sooner. The patient was a 65-year-old man. He was referred to our department two months after the onset of the paralysis of the lower leg due to progressive swelling of the medial side above the knee. Computed tomography （CT） scan revealed damage to the popliteal artery. A 75×115 mm pseudoaneurysm was noted. We judged that a direct approach to the injured site was difficult, so we performed hematoma removal after hemostasis with a stent graft （SG）. Postoperatively, a pool formed in the open pseudoaneurysm, and an infection developed through the wound opening; therefore, we performed popliteal artery vascular bypass and SG removal. The treatment strategy for a popliteal pseudoaneurysm should be determined according to the extent and location of the injury and whether or not there is obstruction. Furthermore, when a large pseudoaneurysm is formed, the treatment of the hematoma is also an issue. It is important to understand the characteristics of the treatment and to choose appropriately.

   

  Jpn. J. Cardiovasc. Surg. 53: 230-235（2024）

  Keywords：popliteal pseudoaneurysm; infected hematoma; endovascular treatment

  
  
• A Case of Multiple Pancreaticoduodenal Artery Aneurysms Associated with a Splenic Artery Aneurysm, and the Celiac Axis Occlusion due to Median Arcuate Ligament Syndrome　Y. Oshima and O. Sogabe　236
  A Case of Multiple Pancreaticoduodenal Artery Aneurysms Associated with a Splenic Artery Aneurysm, and the Celiac Axis Occlusion due to Median Arcuate Ligament Syndrome
  

  Yu Oshima＊

  Osanori Sogabe＊

  
  

  （Department of Cardiovascular Surgery, Mitoyo General Hospital＊, Kannonji, Japan）
  

  Multiple pancreaticoduodenal artery aneurysms are occasionally reported, but there are few reports of three or more multiple pancreaticoduodenal artery aneurysms. In this case, we experienced a rare case of five multiple pancreaticoduodenal artery aneurysms and one splenic artery aneurysm associated with celiac axis occlusion due to median arcuate ligament syndrome. The four aneurysms located in the posterior aspect of the pancreas were treated with coil embolization. Prior to this, a superior mesenteric artery to gastroduodenal artery bypass was performed using the saphenous vein graft to prevent organ ischemia caused by occlusion of the major collateral vessels. Measurements of gastroduodenal artery pressure and systemic blood pressure before and after arterial occlusion and after bypass, as well as their ratios, are useful indicators of organ perfusion. No postoperative complications occurred. One posterior superior pancreaticoduodenal artery aneurysm was excised and showed pathologic findings of fibromuscular dysplasia. Although the aneurysm was 3 mm in size, the aneurysm wall was thinning, indicating a risk of rupture regardless of aneurysm size. Due to the presence of multiple artifacts on the CT scan, superior mesenteric artery angiography was performed in the post-operative period, confirming the patency of the bypass and the absence of recurrence of the pancreaticoduodenal artery aneurysm. In addition, no new changes were observed in a splenic artery aneurysm, confirming the efficacy of this approach. One of the pancreaticoduodenal artery aneurysms was re-evaluated using chest CT, which showed progressive calcification of the aneurysm wall over the previous 27 months, with no aneurysm enlargement observed. The coexistence of pancreaticoduodenal artery aneurysm and splenic artery aneurysm is rare, with only eight reported cases. All cases were in female patients, and among the eight cases, six were instances of multiple pancreaticoduodenal artery aneurysms, while four cases represented the uncommon occurrence of three or more multiple pancreaticoduodenal artery aneurysms.　Postoperatively, local complications such as pancreatic fistula were common. To clarify the characteristics of this condition, it is considered necessary to accumulate cases in the future.

   

  Jpn. J. Cardiovasc. Surg. 53: 236-241（2024）

  Keywords：median arcuate ligament syndrome; celiac axis occlusion; multiple aneurysms of the pancreaticoduodenal artery; splenic artery aneurysm

  
  
• Progress in Cardiovascular Surgery（2023） Recent Advances in Aortic Surgery in 2023 S. Shimura　242
• Development of Valve and Arrhythmia Surgeries 2023　S. Fukushima　247

• U-40 Column Becoming an Independent Cardiovascular Surgeon―10 Years Later H. Ueda et al. U1
  Becoming an Independent Cardiovascular Surgeon―10 Years Later
  

  Hideyasu Ueda＊	Daisuke Toritsuka	Yuji Nakamura
  Yusuke Imaeda	Toshihiko Nishi	Keita Yano
  Saki Bessho	Kohei Kitamura	Naohiro Akita
  Kazuki Matsuhashi

  
  

  （Department of Cardiovascular Surgery, Kanazawa University＊, Kanazawa, Japan）
  

  The U-40 generation of cardiovascular surgeons is receiving training as cardiovascular surgeons, including daily surgeries, ward responsibilities and other important tasks, young surgeons are on their way to becoming skilled cardiovascular specialists. However, it is said that it takes a long time to become a full-fledged surgeon, and in particular, the way to becoming a full-fledged cardiovascular surgeon varies greatly among individuals and is not standardized. Therefore, the U-40 generation is always concerned and worried about their future career development. At the 54th Annual Meeting of the Japanese Society for Cardiovascular Surgery, we will discuss what the U-40 generation needs to become full-fledged surgeons, what they are worried about, and how their seniors who are actually active as independent cardiovascular surgeons think and what their career paths have been like. I had an opportunity to reflect on the gap between the two. This time, we conducted a questionnaire survey to visualize the conditions and future prospects for becoming an independent surgeon as considered by the U-40 generation.

   

  Jpn. J. Cardiovasc. Surg. 53(4): U1-U5 (2024).

  Keywords：U-40; independent cardiovascular surgeon; career development

  
  

• H. Izutani