Japanese Journal of Cardiovascular Surgery Vol.32, No.6

Originals

  • Limited Incision through a Retroperitoneal Approach in Abdominal Aortic Surgery 　　H. Kiyama, et al.…325
    Limited Incision through a Retroperitoneal Approach in Abdominal Aortic Surgery

    (Department of Cardiovascular Surgery, Dokkyo University Koshigaya Hospital, Koshigaya, Japan and Department of Cardiovascular Surgery, Sayama Hospital*, Sayama, Japan)
    Hiroshi Kiyama* Takao Imazeki Yoshihito Irie
    Noriyuki Murai Nobuaki Kaki Shigeyoshi Gon
    Masahito Saito Souichi Shioguchi
    To reduce surgical invasion, we recently used a limited incision through a retroperitoneal approach in the abdominal aortic surgery. Between May 2001 and March 2002, 18 patients who had infrarenal aortic aneurysm, iliac aneurysm, or aortoiliac occlusive disease were surgically treated using a new approach at Dokkyo University Koshigaya Hospital. Although 1 patient with a short aortic neck had to be converted to conventional surgical incision, the remaining 17 patients were successfully treated with the limited incision (range, 6 -10cm). Operative time and intraoperative blood loss were 275.2±62.9 min and 968.5±473.8 ml, respectively. None of these patients required homologous blood transfusion in the perioperative period. All patients were extubated in the operation room. Oral feeding and mobilization started on day 1.6±0.5 and 1.4±0.9, respectively. Furthermore, all patients were discharged home without serious complications such as postoperative ileus and perioperative death. These results show that the limited incision through a retroperitoneal approach is safe and effective in the abdominal aortic surgery. This technique maintains quality outcome while reducing surgical invasion.
    　Jpn. J. Cardiovasc. Surg. 32: 325 -328 (2003)
  • Comparison of the Impact of Skeletonization and Semi-Skeletonization by Harmonic Scalpel on the Left Internal Thoracic Artery Graft Flow 　　A. Aoki and S. Oosaki…329
    Comparison of the Impact of Skeletonization and Semi-Skeletonization by Harmonic Scalpel on the Left Internal Thoracic Artery Graft Flow

    (Department of Cardiovascular Surgery, Kure Kyousai Hospital, Kure, Japan)
    Atsushi Aoki Satoru Oosaki
    Intraoperative graft flow, measured by a BF1001 CardioMed Flowmeter and the postoperative graft diameter of the left internal thoracic artery, measured by coronary angiogram were compared in the semi-skeletonization method group (23 patients) and the skeletonization method group (29 patients). There was no significant difference between 2 groups in terms of age, gender, body surface area, diabetes mellitus, LAD lesion, preoperative ejection fraction, operation time, cardiopulmonary bypass time and aortic cross-clamp time. Graft flow was significantly larger in the skeletonization method group than in the semi-skeletonization method group (50.4±21.7ml/min vs 36.9±12.8ml/min, p=0.019). However graft diameter did not differ significantly between the 2 methods (2.46±0.44mm in the skeletonization method group and 2.38±0.42mm in the semi-skeletonization method, p=0.991). These results suggested that left internal thoracic artery could be used longer by either 2 methods than by pedicled harvesting technique, however skeletonization method caused less spasm during graft harvesting than the semi-skeletonization method.
    　Jpn. J. Cardiovasc. Surg. 32: 329 -332 (2003)
  • Perioperative Change of Atrial Natriuretic Peptide and Brain Natriuretic Peptide in Relation to the Surgery for Abdominal Aortic Aneurysm 　　Y. Nishimura, et al.…333
    Perioperative Change of Atrial Natriuretic Peptide and Brain Natriuretic Peptide in Relation to the Surgery for Abdominal Aortic Aneurysm

    (Department of Cardiovascular Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Japan and Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University*, Wakayama, Japan)
    Yoshiharu Nishimura* Shinichi Higashiue Toshifumi Mori
    Masahiro Iwahashi Atsutoshi Hatada
    Perioperative changes of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) in surgically treated cases of abdominal aortic aneurysm (AAA) were investigated. A retrospective review of 34 patients of AAA who underwent operation was carried out. All patients received cardiac catheterization before the AAA operation. ANP and BNP were measured on the preoperative day, postoperative day (POD) 1 and POD2, respectively. Twenty-two cases were complicated by ischemic heart disease (IHD). In all cases of AAA, ANP and BNP increased significantly at POD1 and POD2. The levels of ANP and BNP in the AAA with IHD group were significantly higher than those in the AAA without IHD group at all points. These results suggest that postoperative care for cardiac overload during the AAA operation is especially needed for patients with IHD.
    　Jpn. J. Cardiovasc. Surg. 32: 333 -336 (2003)
  • Treatment of Elderly Patients with Aneurysm of Abdominal Aorta 　　H. Fujiwara, et al.…337
    Treatment of Elderly Patients with Aneurysm of Abdominal Aorta

    (Department of Cardiovascular Surgery, Musashino Red Cross Hospital, Tokyo, Japan)
    Hitoshi Fujiwara Takahiko Sugano Takeshi Someya
    Between December 1994 and December 2002, surgical repair of aneurysm of the abdominal aorta (AAA) was performed in 139 patients, 32 of whom had ruptured AAA. Thirty-nine patients were 80 years old or older (O) and 100 patients were younger (Y) than 80. The ratio between ruptured and unruptured AAA was significantly higher among older patients（O: 41.0% versus Y: 16.0%, p=0.002). Surgical mortality was identical in those receiving elective repair (O: 0% versus Y: 0%) and similar in those receiving repair following rupture (O: 13.3% versus Y: 28.5%, p=0.314). A diagnosis of AAA had been made before rupture in only 10 patients, whose survival rate was relatively higher (100%) than that of patients without known AAA (66.7%). Ten patients died of ruptured AAA without surgery. Four of them had intractable cardiopulmonary arrest despite attempts at resuscitation. Four other patients were debilitated due to other disease even before rupture of AAA. Another 2 patients were diagnosed as ruptured AAA at autopsy. In conclusion, elective surgical repair is safe in elderly patients with AAA. The survival rate of elderly patients following rupture of AAA is comparable to that of younger patients. Some patients, however, should be excluded from aggressive treatment because of associated conditions such as marked debilitation prior to rupture or uncorrectable cardiopulmonary arrest on arrival. Patient selection is a sensitive but important issue in the era of society being composed of many elderly people.
    　Jpn. J. Cardiovasc. Surg. 32: 337 -342 (2003)

Case Reports

  • Ruptured Pancreaticoduodenal Artery Aneurysm 　　T. Shibuya and T. Kawasaki…343
    Ruptured Pancreaticoduodenal Artery Aneurysm

    (Division of Vascular Surgery, Department of Surgery (E2), Osaka University Graduate School of Medicine, Suita, Japan and Division of Vascular Surgery, Higashi Takarazuka Satoh Hospital*, Takarazuka, Japan)
    Takashi Shibuya* Tomio Kawasaki
    A 59-year-old man was admitted with sudden onset of back pain and abdominal discomfort. There was no history of pancreatitis, abdominal injury, or abdominal surgery. Enhanced abdominal computed tomography (CT) showed retroperitoneal hematoma behind the head of the pancreas, and emergency angiography demonstrated retroperitoneal bleeding due to rupture of a superior pancreaticoduodenal artery aneurysm. Embolization was tried unsuccessfully, because of difficulty in selective cannulation of the vessel feeding the aneurysm. Emergency laparotomy was performed. We inserted a finger behind the pancreas via the lateral side of the duodenum by Kocher's maneuver, then ligated the ruptured portion of the superior pancreaticoduodenal artery. We did not reconstruct the artery because blood supply to the peripheral tissue was good. The patient's postoperative course was uneventful, and he was discharged from the hospital in good condition 1 month after surgery. CT proved to be useful in revealing the voluminous retroperitoneal hematoma, and angiography proved to be necessary for the definitive diagnosis of pancreaticoduodenal artery aneurysm.
    　Jpn. J. Cardiovasc. Surg. 32: 343 -346 (2003)
  • Successful Treatment with Percutaneous Catheter Drainage and Irrigation for Methycillin-Resistant Staphylococcus aureus Graft Infection Following Abdominal Aneurysm Repair 　　F. Fukumura, et al.…347
    Successful Treatment with Percutaneous Catheter Drainage and Irrigation for Methycillin-Resistant Staphylococcus aureus Graft Infection Following Abdominal Aneurysm Repair

    (Department of Cardiovascular Surgery and Department of General Medicine*, Aso-Iizuka Hospital, Iizuka, Japan)
    Fumio Fukumura Hiromi Ando Masayoshi Umesue
    Ichiro Nagano Noriko Boku Kenichiro Taniguchi
    Satoshi Kimura Jiro Tanaka Kenichi Nakamura*
    We report 2 cases of successful treatment by percutaneous catheter drainage and irrigation for methycillin-resistant Staphylococcus aureus (MRSA) prosthetic graft infection after abdominal aortic aneurysm (AAA) repair. Case1 was a 71-year-old man in whom MRSA graft infection was diagnosed on the basis of high fever and CT-guided taps of the perigraft fluid 11 days after AAA repair, and a percutaneous catheter was inserted into the perigraft space by the CT-guided method. Case2 was a 77-year-old man in whom MRSA graft infection was diagnosed because of high fever and purulent discharge from the wound of retroperitoneal drainage 5 days after AAA repair. A percutaneous catheter was placed into the retroperitoneal space via an extraperitoneal route. In both cases, intermittent irrigation by 0.5% Povidone-iodine solution and saline was performed as well as systemic and local antibiotic administration. The graft infection was well controlled and both patients were discharged after 4 months. Percutaneous catheter drainage and irrigation can be one of the choices for critically ill patients with graft infection after AAA repair.
    　Jpn. J. Cardiovasc. Surg. 32: 347 -349 (2003)
  • A Case of Valve Repair in Mitral Valve Regurgitation Associated with Acromegaly and a Review of the Literature during the Last 2 Decades 　　H. Kunishige, et al.…350
    A Case of Valve Repair in Mitral Valve Regurgitation Associated with Acromegaly and a Review of the Literature during the Last 2 Decades

    (Department of Cardiovascular Surgery, Hokkaido University Postgraduate School of Medicine, Sapporo, Japan)
    Hideyuki Kunishige Toshifumi Murashita Tomonori Ohoka
    Hirotaka Kato Yasuhiro Kamikubo Keishu Yasuda
    Cardiovascular manifestations of acromegaly include cardiomegaly and very often hypertension, coronary atherosclerosis, and diabetes. Primary valvular disease is less commonly observed. A 62-year-old woman had acromegaly associated with mitral regurgitation (MR) resulting from prolapse of the posterior mitral leaflet, which was successfully repaired. At the age of 57 years, the patient was admitted due to heart failure without valvular disease. Acromegaly was diagnosed and a pituitary tumor was removed surgically. At the age of 62, a heart murmur was found, and moderate to severe MR was diagnosed. MR was successfully corrected by quadrangular resection of the posterior leaflet, including the prolapsed portion, and prosthetic ring annuloplasty. Histological examination showed myxomatous degeneration. The patient recovered uneventfully. During the last 2 decades, only 21 surgical cases of valvular disease associated with acromegaly were reported in the literature; mitral valve lesions in 10 patients (all with regurgitation), aortic valve lesions in 10 patients (7 with regurgitation and 3 with stenosis), and one with combined lesions of mitral and aortic valves. Since histology did not show specific changes in many reports, it is still unclear whether valve lesions are caused by a high GH hormone level. Although mitral valve replacement was recommended in the 1990s due to the fragility of valvular rings and their apparatus, mitral repair was performed in 5 recent cases and no recurrence has been reported.
    　Jpn. J. Cardiovasc. Surg. 32: 350 -354 (2003)
  • A Case of 1-Stage Replacement of the Ascending Aorta, Coronary Artery Bypass Grafting and Revascularization of the Lower Extremities 　　T. Mizumoto, et al.…355
    A Case of 1-Stage Replacement of the Ascending Aorta, Coronary Artery Bypass Grafting and Revascularization of the Lower Extremities

    (Department of Thoracic and Cardiovascular Surgery, Shingu Medical Center, Shingu, Japan and Department of Thoracic Surgery, Anjo Kosei Hospital*, Anjo, Japan)
    Toru Mizumoto Katsutoshi Adachi Katsumoto Hatanaka
    Toshihiko Kinoshita*
    An 86-year-old woman was transferred to our hospital because of chest pain and left incomplete paralysis. CT-scan revealed a dissecting aortic aneurysm (DeBakey type2) 6cm in diameter. Coronary angiography and aortography were perfomed to assess the coronary artery disease and ASO, they showed occluded LAD, 90% stenosis of CX and occluded left external iliac artery. We planned a 1-stage operation. Coronary artery bypass grafting with the beating heart was carried out prior to replacement of the ascending aorta. Then we performed femoro-femoro bypass. The postoperative course was uneventful and the patient was discharged 23 days after the operation.
    　Jpn. J. Cardiovasc. Surg. 32: 355 -357 (2003)
  • A Case of Tracheoinnominate Artery Fistula That Required 2 Operations and Which Developed a Subcutaneous Abscess 2 Years after the Operations 　　T. Ohto, et al.…358
    A Case of Tracheoinnominate Artery Fistula That Required 2 Operations and Which Developed a Subcutaneous Abscess 2 Years after the Operations

    (Department of Cardiovascular Surgery, National Chiba Hospital, Chiba, Japan)
    Toshiaki Ohto Yoshihisa Tsukagoshi Hideo Ukita
    The patient was an 18-year-old man with congenital cerebral palsy who had undergone a tracheotomy at the age of 12. He underwent 2 emergency operations for massive endotracheal bleeding due to a tracheoinnominate artery fistula. At the first operation, the tracheal and tracheoinnominate artery fistulas were each closed directly, with median sternotomy. The second operation was due to recurrence of bleeding on the 20th postoperative day. The innominate artery was transected to avoid recurrence of bleeding. We only used an autologous pericardium but no artificial materials other than sutures, because of operative field contamination. Although a subcutaneous abscess developed at the operative wound 2 years after the operation, it was cured by incisional drainage and administration of antibiotics. In the case of tracheoinnominate artery fistula, it is impossible to save life without surgical treatment. However, the surgery involves a risk of repeated hemorrhaging and infections, resulting in a very poor prognosis. In our case, transection should have been performed at the first operation to avoid a recurrence of bleeding. The surgical method, using an autologous pericardium but no artificial materials, appeared to be effective in preventing infections. The surgical method should be selected with careful consideration to prevent repeated hemorrhaging and infection.
    　Jpn. J. Cardiovasc. Surg. 32: 358 -361 (2003)
  • A Case of Abdominal Aortic Aneurysm Associated with Postoperative Paraplegia 　　M. Oshiumi, et al.…362
    A Case of Abdominal Aortic Aneurysm Associated with Postoperative Paraplegia

    (Department of Cardiovascular Surgery, Jikei University Kashiwa Hospital, Chiba, Japan and Department of Cardiovascular Surgery, Jikei University School of Medicine*, Tokyo, Japan)
    Motohiro Oshiumi Shinichi Ishii Hirokuni Naganuma
    Makoto Sumi Kazuhiro Hashimoto*
    We present a very rare case of abdominal aortic aneurysm associated with paraplegia. A 68-year-old man developed paraplegia following resection of a infrarenal abdominal aortic aneurysm. The aorta was clamped just below the renal arteries. In this case interruption of the radicular artery magna (RAM; Adamkiewicz artery) might have caused serious ischemia of the spinal cord. Spinal cord ischemia is a very rare and unpredictable complication in surgery of infrarenal abdominal aortic aneurysms because the spinal cord is generally protected from irreversible ischemia during infrarenal aortic occlusion by the presence of the RAM which arises above the renal artery (Even if RAM interruption might arise, the lower renal artery, and other radicular arteries are usually present above the renal arteries). We feel that reducing aortic cross-clamping time as short as possible and avoiding intra- and postoperative hypotensive episodes to keep adequate blood flow of collaterals seem to be the most important factors to prevent spinal cord ischemia.
    　Jpn. J. Cardiovasc. Surg. 32: 362 -365(2003)
  • Occlusion of the Left Coronary Artery Caused by Fusion of the Aortic Cusp to the Aortic Wall 　　Y. Yokoyama, et al.…366
    Occlusion of the Left Coronary Artery Caused by Fusion of the Aortic Cusp to the Aortic Wall

    (Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Gifu, Japan)
    Yukifusa Yokoyama Shuji Tamaki Noriyuki Kato
    Jun Yokote Masato Mutsuga Norihisa Ohata
    A 75-year-old woman suffered from chest compression on effort. Detailed examinations showed aortic valve stenosis and unusual separation of the left coronary artery from the aorta. Surgical exposure revealed that the aortic valve was composed of 3 cusps. Two of 3 cusps were calcified, and another small cusp had fused to the aortic wall. Fusion of the cusp produced a cyst with a hole that was 1.5 mm in diameter. Excision of the cyst disclosed the normal orifice of the left coronary artery. The aortic valve was resected and replaced with an artificial valve. Her postoperative course was uneventful, without any angina pectoris.
    　Jpn. J. Cardiovasc. Surg. 32: 366 -369 (2003)
  • A Case of Obturator Foramen Bypass for Infected Femoral Artery after Use of an Arterial Closure Device 　　S. Uchikawa, et al.…370
    A Case of Obturator Foramen Bypass for Infected Femoral Artery after Use of an Arterial Closure Device

    (Department of Cardiovascular Surgery, Kawasaki Social Insurance Hospital, Kawasaki, Japan and Kikuna Memorial Hospital*, Yokohama, Japan)
    Shin Uchikawa Noboru Murata* Kazuhide Hayashi
    A 52-year-old man with a 10-year history of severe diabetes was referred to our hospital with hemorrhage from a methicillin-resistant Staphylococcus aureus-infected femoral artery following the use of an arterial closure device (Prostar XL: Perclosure, Co., Ltd., Redwood, CA, USA). At surgery, the common femoral artery showed a circular area of disintegration, 9 mm in diameter, due to massive infection. One month after femoral angioplasty with a saphenous vein patch, re-hemorrhage occurred as a result of uncontrollable infection. Next, an obturator foramen (OF) bypass was performed and the infected femoral artery was removed. Two months after OF bypass, the wound healed and the patient was well. We conclude that OF bypass is a satisfactory method of treatment for compromised patients with an infected femoral artery.
    　Jpn. J. Cardiovasc. Surg. 32: 370 -373 (2003)
  • A Case of Traumatic Injury to the Thoracic Descending Aorta Complicated with Intracerebral Hemorrhage 　　H. Nishida, et al.…374
    A Case of Traumatic Injury to the Thoracic Descending Aorta Complicated with Intracerebral Hemorrhage

    (Division of Cardiovascular Surgery, Funabashi Municipal Medical Center, Funabashi, Japan)
    Hirofumi Nishida Yoshiharu Takahara Kenji Mogi
    Manabu Sakurai
    A semicomatose 53-year-old woman who had been injured in an automobile accident was admitted. Injury to the thoracic descending aorta was suspected because of widening of the upper mediastinum on a chest X-ray film and confirmed by chest contrast-enhanced computed tomography (CT). We postponed surgical treatment because brain CT showed traumatic intracerebral hemorrhage. She was maintained in an intensive care unit and had pharmacological treatment and medical support. Two days later, brain CT showed that the intracerebral hematoma was a stable and inactive lesion, so she underwent aortic repair 3days after the accident. Left thoracotomy was performed and an artificial vascular prosthesis was interposed under hypothermic circulatory arrest (open proximal method). The postoperative course was uneventful and the patient was discharged 44 days after the operation. Hypothermic circulatory arrest may be a valuable adjunct for traumatic injury of the thoracic aorta at risk for impending rupture.
    　Jpn. J. Cardiovasc. Surg. 32: 374 -377 (2003)
  • A Surgically Treated Case of Acute Type A Dissection Subsequent to Chronic Dissection with 3-Channeled Descending Aorta Dissection 　　J. Murayama, et al.…378
    A Surgically Treated Case of Acute Type A Dissection Subsequent to Chronic Dissection with 3-Channeled Descending Aorta Dissection

    (Department of Cardiovascular Surgery, Fukuoka Wajiro Hospital, Fukuoka, Japan)
    Junichi Murayama Masakatsu Hamada Hideyuki Fumoto
    A 41-year-old woman was admitted suffering from chest pain and dyspnea. We performed an emergency operation under a diagnosis of type A acute aortic dissection combined with type B chronic 3-channeled dissection on CT scan. The ascending aorta was replaced with woven Dacron graft under deep hypothermic circulatory arrest. Atrial inflow for cardiopulmonary bypass was initiated only through the femoral artery because the right axillary artery was stenotic. Neither cystic medial necrosis nor aortitis were recognized in pathological examination of the ascending aorta. Postoperative recovery was smooth and uneventful. Three-channeled aortic dissection tends to enlarge the false lumen, and has a high risk of rupture compared with the more common 2-channeled aortic dissection, therefore careful follow-up is needed in this patient. When acute type A dissection is complicated with 3-channeled chronic dissection, it is important to preoperatively assess the route of visceral blood supply, and to carefully select the cannulation site of extracorporeal circulation to prevent malperfusion.
    　Jpn. J. Cardiovasc. Surg. 32: 378 -381 (2003)
  • Aortic Valve Replacement in a 92-Year-Old Woman 　　K. Gan, et al.…382
    Aortic Valve Replacement in a 92-Year-Old Woman

    (Department of Cardiovascular Surgery, Kobe Rosai Hospital, Kobe, Japan)
    Kunio Gan Noboru Wakita Masahiro Sakata
    Kyouzou Inoue
    A case of aortic valve replacement in a 92-year-old woman is reported. Severe aortic valve stenosis was pointed out when she suffered from congestive heart failure (CHF). After medical treatment for CHF, she complained of leg edema even with only mild exercise. Aortic valve replacement was performed, because her general condition and her left ventricular contraction on UCG were good. Her postoperative course was good except for a transient rapid atrial fibrillation. We think that surgery should not be withheld on the basis of age alone.
    　Jpn. J. Cardiovasc. Surg. 32: 382 -384 (2003)