Japanese Journal of Cardiovascular Surgery Vol.31, No.5

Originals

Surgical Treatment of Abdominal Aortic Aneurysm in Octogenarians 　　N. Hibino, et al.…321

Surgical Treatment of Abdominal Aortic Aneurysm in Octogenarians

(Department of Cardiovascular Surgery, Yamanashi Prefecture Central Hospital, Kofu, Japan)

Narutoshi Hibino Koji Tsuchiya Masato Nakajima

Hideki Sasaki Harunobu Matsumoto Yuji Naito

We reviewed 223 cases of surgical treatment for abdominal aortic aneurysm in octogenarians in this hospital between 1981 and 2000, and investigated the characteristic features, complications, and indications of the operation. The cases were divided into two age groups. Group O included 23 cases of octogenarians, and Group Y included 200 cases of patients under 80 years old. The average age was 68.6 years old in group Y (33-79 years old), and 83 years old in group O (80-93 years old). The hospital mortality rate was 0% in elective operation cases. In emergency operation case, Group O had a hospital mortality rate of 57.1%, significantly higher than the 6.1% for group Y. The hospital mortality rate was 17% in group O and 0.5% in group Y. The rate of emergency operation case was significantly higher in group O (30.4%) compared to group Y (16.5%). As for the preoperative complications, group O had more cases of renal dysfunction, COPD and gastrointestinal complication. As for the coronary artery disease and other cardiovascular complications, there were no significant differences between the groups. In the postoperative complication, group O had more cases of ileus, pneumonia, and cardiovascular disease. These complications were fatal in group O. These results suggest that surgical treatment for abdominal aortic aneurysm was performed safely in both groups for elective operations. Because the results of emergency operations are poor, early diagnosis and treatment seem to be important for the improvement of operative results.
　Jpn. J. Cardiovasc. Surg. 31：321-324 (2002)

Prognosis of Aortic Dissection (Type A) with a Thrombosed False Lumen 　―CT Findings and Operative Timing― 　　K. Tamura, et al.…325

Prognosis of Aortic Dissection (Type A) with a Thrombosed False Lumen―CT Findings and Operative Timing―

(Department of Cardiovascular Surgery, Tokyo Metropolitan Hiroo General Hospital, Tokyo, Japan)

Kiyoshi Tamura Hideki Nakahara Hitoshi Furukawa

Several investigators have reported that aortic dissections with thrombosed false lumens has a better prognosis than those with open false lumens. However, the method of treating dissecting aorta with a thrombosed false lumen has not yet been clearly determined. The purpose of the present study is to determine the factors that would indicate surgical treatment for dissecting aorta with thrombosed lumen. Sixteen consecutive cases of type A dissecting aorta with a thrombosed lumen were classified into two groups: event-free group (group R, n=10), recanalization or ulcer-like projection group (group P, n=6). The maximum aortic diameter and thrombosed lumen diameter in group P were significantly greater than in group R (45.00±1.78 vs. 36.00±2.16mm: p=0.0182, 8.00±0.00 vs. 4.00±0.40mm: p=0.0004). In group P, the thrombosed lumen diameter significantly decreased after 1 month. In conclusion, the maximum aortic diameter (＞45mm), the maximum lumen diameter (＞8mm), and no decrease of the thrombosed lumen diameter are useful predictors for the risk of recanalization or ulcer-like projection. These cases would require surgical treatment.
　Jpn. J. Cardiovasc. Surg. 31：325-327 (2002)

Early and Late Results for Primary Malignant Tumors of the Heart 　　R. Kunitomo, et al.…328

Early and Late Results for Primary Malignant Tumors of the Heart

(First Department of Surgery, Kumamoto University School of Medicine, Kumamoto, Japan and Division of Cardiology, Kumamoto City Hospital*, Kumamoto, Japan)

Ryuji Kunitomo Shigeyuki Tsurusaki Shuji Moriyama

Ryusuke Suzuki Koji Hagio Kentaro Takaji

Yoichi Hokamura* Michio Kawasuji

Primary malignant tumors of the heart are rare and are associated with very poor survival. We retrospectively analyzed early and late results for five primary malignant tumors of the heart. There were two operative deaths and two late deaths, and the mean survival of patients who survived operation was 18.3 months. No operative survivors had symptoms of congestive heart failure during follow up period. One patient who underwent histologic biopsy received postoperative chemotherapy and is alive without recurrence 36 months after operation. The operative mortality of primary malignant tumors of the heart was high and unsatisfactory, however, surgical treatment prevented congestive heart failure during follow up and contributed to the selection of postopeative therapeutic options, with or without complete resection of the tumors.
　Jpn. J. Cardiovasc. Surg. 31: 328-330 (2002)

Coronary Artery Bypass Grafting for Patients in Whom Preoperative Angiography Determined That the In Situ Left Internal Thoracic Artery Could Not Be Used 　　S. Yamashiro, et al.…331

Coronary Artery Bypass Grafting for Patients in Whom Preoperative Angiography Determined That the In Situ Left Internal Thoracic Artery Could Not Be Used (Second Department of Surgery, School of Medicine, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan) Satoshi Yamashiro Yukio Kuniyoshi Kazufumi Miyagi Mitsuyoshi Shimoji Toru Uezu Katsuya Arakaki Katsuto Mabuni Kageharu Koja Use of the internal thoracic artery for myocardial revascularization has regained general acceptance because it offers better long-term results than do venous conduits. However, according to angiographic studies, it has been reported that atherosclerotic changes in the internal thoracic artery occurred in 1-5% of patients with coronary artery disease, although, generally, it is considered that atherosclerotic changes in internal thoracic artery are rare. From January 1998 to August 2001, of the 274 patients who underwent coronary artery bypass grafting, it was estimated that the left internal thoracic artery could not be used for coronary revascularization by preoperative angiography in 7 patients (7/262＝2.7%). Two hundred sixty-two patients underwent preoperative angiography to evaluate the grafts for coronary revascularization. All were men and age at the time of operation ranged from 62 to 81 years (mean, 68.6 years). The reason for the left internal thoracic artery being useless were occlusion or stenosis of the subclavian artery in 4 and stenosis or occlusion of the left internal thoracic artery in 3. One patient needed an emergency operation. Four patients had a history of myocardial infarction, 3 patients had hypertension, 2 patients had diabetes mellitus, 4 patients had hyperlipidemia, 1 patient had aortitis and 3 patients had a history of percutaneous transluminal coronary angioplasty. There were 4 patients with peripheral vascular disease. Four right internal thoracic arteries, 9 radial arteries and 6 gastroepiploic arteries were used for coronary revascularization. A composite Y graft (right internal thoracic artery-radial artery) was used in 3 patients, and sequential bypass was performed in the other 3 patients. The total number of distal anastomoses was 2.7±1.0/patient. The angiographic patency of the distal anastmoses was 94.7% (18/19). One patient required intra-aortic balloon pumping postoperatively for perioperative myocardial infarction (Max CK-MB 200 IU/l). All other patients had an uneventful postoperative course. In conclusion, although the internal thoracic artery is a protective vessel, there is a certain extent of atherosclerosis, which correlates with known risk factors. Our observations should not preclude use of the internal thoracic artery, but they should be considered for patients who are at risk for atherosclerotic changes of the internal thoracic artery. We considered that it is important to evaluate condition of in situ arterial grafts for patients with coronary artery disease preoperatively. Although further studies are required, in situ arterial grafting with sequential arterial conduit and composite arterial graft were associated with excellent results and achieved complete revascularization. Jpn. J. Cardiovasc. Surg. 31: 331-336 (2002)

Case Reports

A Case of Graft Duodenal Fistula Occurring after Operation for Thoracoabdominal Aortic Pseudoaneurysm Associated with Behçet's Disease 　　T. Ohto, et al.…337

A Case of Graft Duodenal Fistula Occurring after Operation for Thoracoabdominal Aortic Pseudoaneurysm Associated with Behçet's Disease

(First Department of Surgery, Chiba University School of Medicine, Chiba, Japan)

Toshiaki Ohto Masahisa Masuda Naoki Hayashida

Yoko Pearce Mitsuru Nakaya Hitoshi Shimura

Kenji Mogi Nobuyuki Nakajima

A 41-year-old woman was given a diagnosis of Behçet's disease at age 25. When she was 31, a large aortic pseudoaneurysm developed near the left renal artery. Isolation of the aneurysm and anatomical grafting and ancillary bypass were performed. Ten years later, a graft duodenal fistula developed. Extra-anatomical reconstruction was done after complete resection of the original graft and the infectious lesion. It was found that the intra-abdominal organs were receiving blood supply only from the inferiol mesenteric artery. Moreover, severe ischemia of the intra-abdominal organs was a concern during surgery. Therefore, hepatic vein oxygen saturation was monitored continuously with a Swan-Ganz catheter for ischemia of the intra-abdominal organs. It proved to be a very effective indicator and we could perform this operation safely. Reoperation of grafting is often inevitable in patients with Behçet's disease. Also, two stumps of abdominal aorta were left in this patient because of the extra-anatomical reconstruction. Pseudoaneurysm may later occur at the site of the stumps, thus necessitating careful follow-up observations.
　Jpn. J. Cardiovasc. Surg. 31：337-340 (2002)

A Case of Large Anastomotic Pseudoaneurysms at Both Sites Following Prosthetic Graft Replacement between Aorta and Left External Iliac Artery 　　S. Takano, et al.…341

A Case of Large Anastomotic Pseudoaneurysms at Both Sites Following Prosthetic Graft Replacement between Aorta and Left External Iliac Artery

(Department of Surgery II, Ehime University School of Medicine, Ehime, Japan)

Shinji Takano Kanji Kawachi Yoshihiro Hamada

Tatsuhiro Nakata Hiroyuki Kikkawa Nobuo Tsunooka

Yoshitsugu Nakamura

A 84-year-old man was admitted with an abdominal tumor. Prosthetic graft replacement between the aorta and the left external iliac artery was performed 17 years previously. CT scan and angiography showed a large anastomotic pseudoaneurysms at the sites of proximal and distal anastomosis. A Y graft prosthesis replacement was performed. The size of the proximal anastomotic pseudoaneurysm was 7×6×5cm, and that of the distal anastomotic pseudoaneurysm was 15×10×10cm. They resulted from cutting at anastomosis. Large anastomotic pseudoaneurysms at both sites is rare.
　Jpn. J. Cardiovasc. Surg. 31：341-343 (2002)

Combined Coronary Artery Bypass Grafting, Abdominal Aortic Repair and Aortic Valve Replacement in a Case with Porcelain Aorta 　　K. Kawachi, et al.…344

Combined Coronary Artery Bypass Grafting, Abdominal Aortic Repair and Aortic Valve Replacement in a Case with Porcelain Aorta

(Department of Surgery II, Ehime University School of Medicine, Ehime, Japan)

Kanji Kawachi Tatsuhiro Nakata Yoshihiro Hamada

Shinji Takano Nobuo Tsunooka Yoshitsugu Nakamura

Atsushi Horiuchi Katsutoshi Miyauchi Yuuji Watanabe

A 73-year-old woman was admitted to undergo three simultaneous operations: aortic valve replacement (AVR), coronary artery bypass grafting (CABG) and abdominal aortic aneurysm repair. She had previously undergone percutaneous catheter intervention in the left coronary anterior descending artery. Computed tomography revealed an abdominal aortic aneurysm 5 cm in diameter. Aortic valve stenosis (AS) was shown with a pressure gradient of 60 mmHg, and 90% stenosis of the distal right coronary artery was also shown. CT scan and aortography revealed porcelain ascending aorta. The patient underwent simultaneous operations because of severe AS, coronary artery disease and abdominal aortic aneurysm. An aortic cannula was placed in a position higher in the ascending aorta with no calcification. Cardiopulmonary bypass was started using a two-staged venous cannula through the right atrium. At first, AVR was performed with cardioplegic solution and ice slush. Because it was difficult to inject the cardioplegic solution into the coronary artery selectively due to the calcified orifice of coronary artery, we closed it immediately by removing the calcified intima of the porcelain aorta after completion of AVR. The second cardioplegic solution was injected through the ascending aorta. Next, CABG to RCA was performed using the right gastroepiploic artery without anastomosis to the ascending aorta. Cardiac surgery was first performed, followed by abdominal aortic aneurysm repair after discontinuation of cardiopulmonary bypass. The patient was extubated the next day and stayed for two days in the intensive care unit. She is very well now one year after the operation.
　Jpn. J. Cardiovasc. Surg. 31：344-346 (2002)

Successful Treatment of Acute Type A Aortic Dissection with Intestinal Necrosis 　　Y. Nakamura, et al.…347

Successful Treatment of Acute Type A Aortic Dissection with Intestinal Necrosis

(Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan)

Yoshitsugu Nakamura Motomi Ando Osamu Tagusari

Hitoshi Ogino Hiroaki Sasaki Yuji Hanafusa

Soichiro Kitamura

A 59-year-old man presented with severe abdominal pain. CT scan showed a type A aortic dissection and pericardial effusion. As cardiac tamponade was present, emergency total arch replacement was performed. Because of his symptom, we added an exploratory laparotomy, which revealed intestinal necrosis. Therefore, necrotic intestine 4.5m in length was resected. After intensive care, he began oral feeding on the 25th day and was discharged on the 76th day postoperatively.
　Jpn. J. Cardiovasc. Surg. 31: 347-349 (2002)

A Surgically Treated Case of Stanford Type B Acute Aortic Dissection Extending through Atherosclerotic Abdominal Aortic Aneurysm 　　H. Nakata, et al.…350

A Surgically Treated Case of Stanford Type B Acute Aortic Dissection Extending through Atherosclerotic Abdominal Aortic Aneurysm

(Department of Cardiovascular Surgery, University Hospital of Tsukuba, Tsukuba, Japan and Department of Surgery, Institute of Clinical Medicine, University of Tsukuba*, Tsukuba, Japan)

Hiroko Nakata Tomoaki Jikuya* Motoo Osaka

Toshio Mitsui*

A 72-year-old man presented with chief complaints of back pain. Medical workup discovered infrarenal abdominal aortic aneurysm (AAA) with Stanford type B acute aortic dissection on CT. The dissection originated distal to the left subclavian artery and extended to the right commom iliac artery. All visceral arteries branched from the false lumen. The maximum diameter of the thoracic aneurysm was 4.8 cm and that of the abdominal aneurysm was 6.5 cm. Multiple renal infarcts were noted and the right kidney function was decreased. Initial surgery was performed 3 months after presentation using a graft technique. Advanced atherosclerosis and dissection were noted in the aneurysm making the arterial wall quite vulnerable. Hemorrhage was extensive and hemostasis difficult in the defective arterial wall. The patient became unstable so the aneurysm was closed and the surgical procedure was changed to right axillo-bifemoral bypass rather than the original surgical plan of anatomic reconstruction of the AAA. The patient tolerated the procedure well. We report a rare case of acute aortic dissection which extended through the AAA.
　Jpn. J. Cardiovasc. Surg. 31：350-352 (2002)

A Case of Infective Endocarditis and Osteomyelitis 　　Y. Tezuka, et al.…353

A Case of Infective Endocarditis and Osteomyelitis

(Department of Surgery, Division of Cardiovascular Surgery, Jichi Medical School, Tochigi, Japan)

Yasuhiro Tezuka Hiroaki Konishi Yoshio Misawa

Katsuo Fuse

A 53-year-old man was admitted to Jichi Medical School Hospital because of low back pain and respiratory distress. Echocardiography revealed mitral valve regurgitation and mitral vegetations, and MR imaging showed destructive change in the lumbar vertebrae. The low back pain and inflammatory activity subsided with administration of antibiotics, but regurgitation-induced heart failure was medically intractable. The patient underwent mitral valve replacement with a bicarbon valve. The mitral valve showed destructive change with infective vegetation. Microbiologic study of preoperative blood samples and resected valve did not show any organism. Antibiotics were given for another 6 weeks. As of the last follow-up observation at 18 months, the patient was doing well.
　Jpn. J. Cardiovasc. Surg. 31：353-355 (2002)

Left Atrial Free-Floating Ball Thrombus Moving from the Left Appendage 　　H. Hamamoto, et al.…356

Left Atrial Free-Floating Ball Thrombus Moving from the Left Appendage

(Department of Cardiovascular Surgery, Oita Medical University, Oita, Japan)

Hirotsugu Hamamoto Shinji Miyamoto Hirohumi Anai

Hidenori Sako Eriko Iwata Osamu Shigemitsu

Tetsuo Hadama

A free-floating ball thrombus in the left atrium is a rare occurrence. Few patients who developed a ball thrombus after mitral valve replacement have been reported. Our patient was a 58-year-old man who had undergone mitral valve replacement in 1981. Since bleeding gastric cancer had been diagnosed anticoagulant therapy had been 4 days before admission. On admission, echocardiography revealed a large thrombus in the left appendage. First, he underwent total gastrectomy for gastric cancer. After the operation, he developed aspiration pneumonia, and was intubated. We observed that a large thrombus had moved from the left appendage to the left atrium. Emergency operation was successfull.
　Jpn. J. Cardiovasc. Surg. 31: 356-358 (2002)

A Case of Celiac Artery Aneurysm with Type IIIb Aortic Dissection 　　H. Matsumoto, et al.…359

A Case of Celiac Artery Aneurysm with Type IIIb Aortic Dissection

(Second Department of Surgery, Yamanashi Medical University, Yamanashi, Japan)

Harunobu Matsumoto Shunya Shindo Okihiko Akashi

Kenji Kubota Atsuo Kojima Tadao Ishimoto

Keiji Iyori Masahiro Kobayashi Yusuke Tada

Celiac artery aneurysm (CAA) is very rare. We report a case of CAA with type IIIb aortic dissection (DA) which was treated surgically. A 60-year-old man who had an abnormal enlargement of the aorta on abdominal ultrasonography was admitted to our hospital. Angiography and CT scan revealed CAA with type IIIb DA. His general condition was stable and surgery was performed electively. The CAA was exposed through a median laparotomy. It was found to be about 3cm in diameter. As vascular reconstruction seemed difficult and the proper hepatic artery showed good pulsation after clamping the common hepatic artery, we decided to perform celiac artery aneurysmectomy without vascular reconstruction. Except for transient liver dysfunction, there was no other complication and he was discharged on the 24th postoperative day. During surgery for CAA, when collateral perfusion from the SMA to the liver is adequate, it seems that vascular reconstruction is not always necessary as shown by this case.
　Jpn. J. Cardiovasc. Surg. 31: 359-362 (2002)

A Case of Aortic Anastomotic False Aneurysm Associated with a Graft-Duodenal Fistula 　　Y. Sasaki, et al.…363

A Case of Aortic Anastomotic False Aneurysm Associated with a Graft-Duodenal Fistula

(Department of Cardiovascular Surgery, Osaka National Hospital, Osaka, Japan)

Yasuyuki Sasaki Fumitaka Isobe Seiji Kinugasa

Keiji Iwata Kenu Fumimoto Yasuyuki Kato

Hideki Arimoto Hiroki Hata

We report a case of successful surgical treatment for an aortic anastomotic false aneurysm associated with a graft-duodenal fistula after abdominal aortic aneurysm repair. A 63-year-old man was admitted with melena and an aortic anastomotic false aneurysm after prosthetic graft replacement 8 years previously. CT scan demonstrated an aneurysm with a maximum diameter of 70 mm at the proximal anastomosis of the prosthetic graft. Gastroduodenoscopy revealed no bleeding site in the stomach or the first and second portions of the duodenum. Therefore, we performed an emergency operation under a diagnosis of an aortic anastomotic false aneurysm associated with a graft-duodenal fistula. The aneurysm was replaced with interposition of a new prosthetic graft via a thoracoabdominal approach. The fistula was repaired by covering the duodenum with the jejunum through a left pararectal laparotomy. The postoperative course was uneventful, and there was no evidence of graft infection at 14 months after the operation.
　Jpn. J. Cardiovasc. Surg. 31：363-366 (2002)

Ruptured Abdominal Aortic Aneurysm with Left-Sided Inferior Vena Cava: A Case Report 　　K. Yamane, et al.…367

Ruptured Abdominal Aortic Aneurysm with Left-Sided Inferior Vena Cava: A Case Report

(Department of Cardiovascular Surgery, National Nagasaki Medical Center, Omura, Japan and Department of Cardiovascular Surgery, Nagasaki University School of Medicine*, Nagasaki, Japan)

Kentaro Yamane Masayoshi Hamawaki Kouji Hashizume

Katsuo Nishi Kiyoyuki Eishi*

We present a successful case of ruptured abdominal aortic aneurysm with left-sided inferior vena cava (IVC). A 74-year-old man, with complaints of abdominal pain and loss of consciousness, was referred to our hospital. Computed tomography revealed a ruptured aneurysm of the abdominal aorta, and the operation was performed immediately. At the operation, left-sided IVC was recognized to cross anteriorly over the abdominal aorta at the usual level of the left renal vein. Proximal anastomosis was safely performed with careful mobilization of the IVC in the appropriate direction. The patient was in acute renal failure after this procedure, with 9 days of continuous hemodiafiltration, but he recovered to discharge on the 46th postoperative day with normal renal function. The cardiovascular surgeon should be familiar with anomalies of the IVC in performing procedures of the abdominal aorta, especially in emergency operations, even if they are rare.
　Jpn. J. Cardiovasc. Surg. 31：367-370 (2002)

A Case of Iliac Artery Occlusion due to Abdominal Blunt Trauma 　　T. Ishiyama and K. Inazawa…371

A Case of Iliac Artery Occlusion due to Abdominal Blunt Trauma

(Department of Surgery, Yamagata Prefectural Shinjo Hospital, Shinjo, Japan)

Tomoharu Ishiyama Keitaro Inazawa

A 54-year-old male driver suffered abdominal injuries from the steering wheel in a collection and was admitted. Twelve days later, contrast CT demonstrated stenosis of the abdominal aorta and occlusion of the left common iliac artery. Aorto-biiliac bypass, using a bifurcated knitted Dacron graft, was performed without incident. The left common iliac artery was completely occluded by a thrombus. The case of an iliac arterial occlusion due to blunt abdominal trauma is rare. Adequate and prompt diagnosis is thus required in such cases of blunt abdominal trauma.
　Jpn. J. Cardiovasc. Surg. 31：371-373 (2002)