Japanese Journal of Cardiovascular Surgery Vol.41, No.3

Preface

• Y. Ueda

Original

• Endovascular Abdominal Aortic Aneurysm Repair with on Excluder for Proximal Neck Angulation A. Aoki et al.…107
  Endovascular Abdominal Aortic Aneurysm Repair with on Excluder for Proximal Neck Angulation

  （Division of Cardiovascular Surgery, Kagawa Prefectural Central Hospital, Takamatsu, Japan）

  Atsushi Aoki	Takanori Suezawa	Mitsuhisa Kotani
  Jun Sakurai	Mamoru Tago

  The results of endovascular abdominal aortic aneurysm repair（EVAR）for severe neck angulation with an Excluder were evaluated. We performed EVAR in 51 patients, using an Excluder, from September 2007 to September 2011. The angle between proximal neck and the aneurysm（Angle）was less than 61° in 31 patients（Group I), 61-90° in 13 patients（Group II）and more than 90° in 7 patients（Group III). In Groups I and II, the angled proximal neck was straightened with a stiff guide wire and a Trunkipsilateral device was deployed slowly（aortic modification technique). In Group III, the device modification technique was applied. In this technique, the stiff guide wire was inserted in the aortic root. The Trunkipsilateral device was bent to the contra lateral limb side and was inserted into the aorta. The stiff guide wire was pushed in with a fulcrum at the aortic valve. This procedure resulted in bending of the wire and the trunk-ipsilteral device became parallel to the proximal neck. The renal artery position was confirmed on angiographys and the main body was deployed slowly. We performed angiography after planned device deployment to evaluated Type Ia endoleak, and if it was observed, an additional procedure such as Aortic Extender or Palmaz XL stent deployment was performed and the Type Ia endoleak was evaluated during the procedure by completion angiography. The Angle change was measured by enhanced CT at 7 days and 6 month after EVAR. The Angle were 97-137° in Group III. The frequency of Type Ia endoleak after planned device deployment（35% in Group I, 55% in Group II and 17% in Group III), additional procedure for Type Ia endoleak（29% in Group I, 23% in Group II and 14% in Group III）and Type Ia endoleak by completion angiography（0% in Group I, 8% in Group II and 14% in Group III）did not differ significantly between the 3 groups. When Group I was sub divided into those with Angle less than 41°（Group Ia, 15 patients）and those with an Angle from 41 to 60°（Group Ib, 16 patients), Type Ia endoleak after planned device deployment（18% in Group Ia, 63% in Group Ib）was significantly more frequent in Group Ib and the additional procedure for Type Ia endoleak（7% in Group Ia, 50% in Group Ib）was more frequent in Group Ib. The Angle significantly decreased 7 days after EVAR and did not change thereafter in all 3 groups. EVAR with an Excluder for severe neck angulation was feasible by device modification with the bending technique. This technique might be useful for patients with an Angle of more than 41°.
    Jpn. J. Cardiovasc. Surg. 41:107-112（2012）
  
  Keywords：abdominal aortic aneurysm, endovascular surgery, stent graft

Case Reports

• Total Arch Replacement with Frozen Elephant Trunk Technique for Aortic Arch Aneurysm Complicated with Left Subclavian Artery Aneurysm T. Nakazato et al.…113
  Total Arch Replacement with Frozen Elephant Trunk Technique for Aortic Arch Aneurysm Complicated with Left Subclavian Artery Aneurysm

  （Division of Cardiovascular Surgery, National Hospital Organization Kure Medical Center, Kure, Department of Cardiovascular Surgery, Hiroshima University Graduate School of Medicine* Hiroshima, Japan, and Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine**Osaka, Japan）

  Taro Nakazato	Teruya Nakamura	Naosumi Sekiya
  Naomichi Uchida*	Yoshiki Sawa**

  A 61-year-old man who had hypertension and renal dysfunction（serum creatinine:1.5-2.0mg/dl）was referred to our hospital for an abnormal shadow on chest roentgenogram. Chest CT scan with contrast revealed a distal aortic arch aneurysm（maximum diameter 52mm）and left subclavian artery aneurysm（maximum diameter 30mm). For the surgical treatment of the aneurysms, left hemi-collar incision and left subclavian incision followed by median sternotomy were performed. After the left subclavian artery was secured distal to the aneurysm, a ringed dacron graft was anastomosed with the distal left subclavian artery. Cardiopulmonary bypass was commenced, and selective cerebral perfusion was instituted at 25℃. The aorta was transected at the origin of the left common carotid artery. A 30mm stent graft（length 13cm）was inserted and was fixed on the transected aorta using 4-0 Prolene continuous suture. Then a branched dacron graft was sewn onto the transected aorta and the stent graft. The left common carotid artery and the brachiocephalic artery were anastomosed onto side branches of the graft. The left subclavian artery was reconstructed by anastomosing the ringed bypass graft onto one of the side branches. The left subclavian artery was ligated between the aneurysm and the origin of the vertebral artery, thereby interposing the subclavian artery aneurysm. After proximal anastomosis was done and the heart was reperfused, the patient was weaned from cardiopulmonary bypass. The patient was discharged without any major complication. Two years after the operation, the patient is doing well and there is no evidence of aneurysmal dilatation or endoleak. In conclusion, frozen elephant trunk technique provides an alternative to conventional graft replacement, resulting in complete exclusion of these aneurysms in a single stage. However, long-term follow up is warranted in order to ensure the durability of the stent graft.
    Jpn. J. Cardiovasc. Surg. 41:113-116（2012）
  
  Keywords：subclavian artery aneurysm, thoracic aortic aneurysm, frozen elephant trunk technique
• A Case of Postoperative Paraparesis after Ascending Aortic Replacement for Type A Acute Aortic Dissection Y. Sakasai et al.…117
  A Case of Postoperative Paraparesis after Ascending Aortic Replacement for Type A Acute Aortic Dissection

  （Department of Cardiovascular Surgery, Ibaraki Seinan Medical Center Hospital, Ibaraki, Japan）

  Yoshie Sakasai

  Motoo Osaka

  Tadashi Koishizawa

  Although paraplegia following descending thoracic and thoracoabdominal aortic repair is well known, paraplegia after repairing ascending aorta has been rarely reported. We describe a very rare case of postoperative paraparesis after repairing type A acute aortic dissection. A 64-year-old man with type A acute aortic dissection whose aortic false lumen was all thrombosed, was treated with rest and his blood pressure was strictly controlled. The follow-up computed tomography revealed that blood flow in the false lumen was recognized in the ascending aorta 8 days after admission. At the same time the diameter of the ascending aorta was enlarged. We performed emergency ascending aortic replacement under deep-hypothermic circulatory arrest and selective cerebral perfusion. We recognized that he showed paraparesis 4 days after operation and magnetic resonance imaging showed high signals in the spinal cord, which indicated spinal cord infarction. He received rehabilitation for 5 months, and fully recovered neurologically. The causes of paraplegia after repairing type A acute aortic dissection have not been clarified. In our case, we presumed the causes included over 60 min circulatory arrest which invoked low spinal perfusion, the anterior spinal artery was thrombosed by selective cerebral perfusion, some intercostals arteries were occluded by postoperative change of the descending aortic false lumen pressure. This case is very rare, and we had to take all possible precautions.
    Jpn. J. Cardiovasc. Surg. 41:117-120（2012）
  
  Keywords：repair of type A acute aortic dissection, paraplegia, spinal cord infarction
• A Case of Solitary Inferior Mesenteric Artery Aneurysm M. Okamoto and M. Tanaka…121
  A Case of Solitary Inferior Mesenteric Artery Aneurysm

  （Department of Cardiovascular Surgery, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan）

  Minoru Okamoto	Mutsuo Tanaka

  A 74 year-old man visited our hospital complaining of increasing sensory disorder of the left lower extremity. On physical findings, a pulsatile mass was detected in abdomen, but he had been aware of it for 5 years. Further examination revealed on inferior mesenteric artery aneurysm 8cm in diameter. It had no communication with other visceral arteries or veins. Surgical treatment was performed to resect the aneurysm without revascularization. The postoperative course was uneventful. The pathological examination of the aneurysm showed atherosclerotic change. The chief complaint on admission was unchanged following surgery and was thought to have no relation to the aneurysm. It was thought that to derive from lumbar vertebral disease. After operation, regular follow-up is necessary to check for pseudoaneurysms formation at the surgical margin and development of other visceral artery diseases.
    Jpn. J. Cardiovasc. Surg. 41:121-123（2012）
  
  Keywords：Inferior Mesenteric Artery Aneurysm, surgical treatment of visceral artery aneurysm
• Emergency Operation for an Unconscious Patient Caused by Stanford Type A Acute Aortic Dissection with Occlusion of the Right Common Carotid Artery H. Yamabi et al.…124
  Emergency Operation for an Unconscious Patient Caused by Stanford Type A Acute Aortic Dissection with Occlusion of the Right Common Carotid Artery

  (Department of Cardiovascular Surgery, Saitama Medical Center, Kawagoe, Japan）

  Hideaki Yamabi	Kazuhito Imanaka	Takahiro Matsuoka
  Mitsuhiro Kawata

  A 65-year old unconscious man with left hemiplegia was found to have acute Stanford type A aortic dissection（AAD）and occlusion of the brachiocephalic and right carotid artery. He underwent emergency surgery. Before midline sternotomy, arterial cannulas were inserted into the femoral artery and the true lumen of the right carotid artery and were connected thorough a Y-shaped extracorporeal circulation circuit to restore the cerebral perfusion. During the aortic procedure, both arteries were used as arterial inflow sites.The patient regained consciousness 6 h later and was extubated on the next day. He suffered infarction of the right cerebral hemisphere, but neurologic deficits were totally resolved. He was given an ambulatory discharged 46 days later and has been reinstated in his former job 6 months after the operation. The indications for emergency surgery for AAD complicated by stroke or coma remains controversial. Especially soon after the onset, surgery may be applicable for such AAD patients if neurological deficits are not obviously irreversible.
    Jpn. J. Cardiovasc. Surg. 41:124-127（2012）
  
  Keywords：Stanford type A aortic dissection, unconscious, cerebral malperfusion, carotid artery occlusion
• A Surgical Case for Acute Heart Failure in a 1-month-old Infant with a Right Cervical Aortic Arch K. Nomura et al.…128
  A Surgical Case for Acute Heart Failure in a 1-month-old Infant with a Right Cervical Aortic Arch

  （Department of Cardiovascular Surgery, Saitama Children’s Medical Center, Saitama, Japan）

  Koji Nomura	Takayuki Abe	Yoshihiro Ko

  A 2-day-old male baby was referred to our hospital because of a heart murmur. We diagnosed as a right cervical aortic arch, and coarctation between the right carotid and right subclavian artery. On echocardiography, the velocity at the coarctation was 1.8m/s, the left ventricular ejection fraction（LVEF）was 53%, and he was asymptomatic during the neonatal period. A chromosome examination showed a deletion of 22q11 syndrome. At 1 month, he weighted 3.8kg and was readmitted to our hospital for wheezing. Echocardiography showed a left ventricular dysfunction with LVEF of 24%. The coarctation velocity increased to 5.1m/s. An urgent operation was performed because of a severely depressed cardiac function. His LVEF increased to 67%, and the velocity was less than 1m/s postoperatively, and he was discharged on postoperative day 32. We report a rare neonatal surgical case of a right cervical arch with a coarctation.
    Jpn. J. Cardiovasc. Surg. 41:128-131（2012）
  
  Keywords：right cervical aortic arch, 22q11 deletion, coarctation, ventricular dysfunction, infant
• Stanford Type A Acute Aortic Dissection with Left Extra-pleural Hematoma and Lung Hemorrhage Y. Kuroda et al.…132
  Stanford Type A Acute Aortic Dissection with Left Extra-pleural Hematoma and Lung Hemorrhage

  （Department of Cardiovascular Surgery, Nihonkai General Hospital, Yamagata Prefectural and Sakata Municipal Organization, Sakata, Japan）

  Yoshinori Kuroda	Tetsuro Uchida	Kazue Nakashima
  Hideaki Uchino	Takao Shimanuki

  A 68-year-old woman with a sudden onset of back pain was brought to our hospital by ambulance. Computed tomography（CT）showed Stanford type A（DeBakey type II）acute aortic dissection, left hemothorax, and hematoma extending along the pulmonary artery;therefore, the patient underwent emergency operation. We performed a median sternotomy. Pericardial effusion was not observed;however, a hematoma was found around the ascending aorta. Preoperative CT showed left hemothorax, but pleural effusion was not observed in the left pleural cavity. The left hemothorax, which was detected on preoperative CT, was diagnosed as an extrapleural hematoma. The dissection entry site was located at the proximal aortic arch;therefore, ascending aorta-hemiarch replacement was performed. After weaning from cardiopulmonary bypass, the patient experienced sudden airway bleeding. The bleeding was attributed to the hematoma extending along the pulmonary artery. Here, we have reported a rare case of Stanford type A acute aortic dissection with the left extrapleural hematoma and lung hemorrhage.
    Jpn. J. Cardiovasc. Surg. 41:132-134（2012）
  
  Keywords：Stanford type A acute aortic dissection, extra-pleural hematoma, lung hemorrhage
• Three Cases of Lambl’s Excrescence N. Yamamoto et al.…135
  Three Cases of Lambl’s Excrescence

  （Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan）

  Nobuko Yamamoto	Yoshitaka Okamura	Yoshiharu Nishimura
  Shunji Uchita	Koji Toguchi	Kentaro Honda
  Takeo Nakai

  Lambl’s excrescences are the fibrous structures which are attached to the heart valve, and usually the presence of Lambl’s excrescences alone is not an indication of operation. The operative indications of isolated Lambl’s excrescence is still controversial, because some reports indicated cross relationship between Lambl’s excrescences and cerebral embolism. Based on these facts, we discussed our 3 cases of Lambl’s excrescences. Two of the cases had been complicated with severe mitral regurgitation and Lambl’s excrescences were resected at the time of mitral valve plasty. In another case, Lambl’s excrescence was found with echocardiography during chronic heart failure therapy. This patient had a past history of cerebral infarction, but no relationship of cerebral infarction was suggested. In this case, cardiac surgery was not required, so we followed isolated Lambl’s excrescence without resection in this case. One operated case, which had infective endocarditis was suspected by echocardiography, had slighted inflammatory reaction but blood culture was negative. Diagnosis of Lambl’s excrescence was made by histopathological examination. One report suggested that the cause of the cerebral infarction is not Lambl’s excrescence itself but the thrombi around Lambl’s excrescence. However, we hesitate to operate on isolated Lambl’s excrescence. Based on some reports, it is useful to resect Lambl’s excrescence when a concurrent cardiac operation is carried out to avoid cerebral embolic events.
    Jpn. J. Cardiovasc. Surg. 41:135-138（2012）
  
  Keywords：Lambl’s excrescence, cerebral infarction
• Reoperation in Two Patients with SJM Toronto SPV and Medtronic Freestyle Stentless Bioprosthetic Valves Y. Ichihara et al.…139
  Reoperation in Two Patients with SJM Toronto SPV and Medtronic Freestyle Stentless Bioprosthetic Valves

  （Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan, and Department of Cardiovascular Surgery, Senpo Tokyo Takanawa Hospital*, Tokyo, Japan）

  Yuki Ichihara	Akihiko Kawai*	Satoshi Saito
  Kenji Yamazaki

  Stentless bioprosthetic valves have been implanted for treatment of aortic valve disease, especially in elderly patients;these valves have the advantage of durability and excellent hemodynamics compared with stented bioprosthetic valves. Although good long-term results in patients with stentless bioprosthetic valves have been reported recently, reoperation has been gradually increasing. We performed reoperation for the SJM Toronto SPV and Medtronic Freestyle valves in one patient each. The SJM Toronto SPV was used in a 30-year-old woman;however, 8 years later, the valve showed severe calcification and adhesions, and could not be completely removed（Case 1). The other reoperation case, wherein a 69-year-old man underwent aortic valve replacement with the Medtronic Freestyle 4 years previously, showed no adhesion around the implanted valve, which could be easily removed from the autologous aortic annulus. Consequently, the first patient required reimplantation of a small mechanical valve（SJM #19). In contrast, we were able to use a stentless bioprosthetic valve（Prima Plus #23）for the second patient. Further observations on stentless bioprosthetic valves are required.
    Jpn. J. Cardiovasc. Surg. 41:139-143（2012)
  
  Keywords：bioprosthetic valve, stentless Toronto SPV, Freestyle valve, reoperation
• Successful Endovascular Treatment of Ureteroarterial Fistula and Anastomotic Pseudoaneurysms A. Mikuriya et al.…144
  Successful Endovascular Treatment of Ureteroarterial Fistula and Anastomotic Pseudoaneurysms

  （Department of Cardiovascular Surgery, Kokura Memorial Hospital, Fukuoka, Japan, Department of Vascular Surgery, The University of Tokyo Hospital*, Tokyo, Japan, and Department of Cardiovascular Surgery, Morinomiya Hospital**, Osaka, Japan）

  Akiyoshi Mikuriya	Katsuyuki Hoshina*	Masaaki Kato**
  Nobukazu Ohkubo**

  A 79-year-old man who had undergone aneurysmectomy and graft replacement for an abdominal aortic aneurysm developed abdominal distension and massive hematuria. A computed tomography（CT）scan revealed the presence of anastomotic pseudoaneurysms and an ureteroarterial fistula between the ureter and iliac artery（distal anastomotic pseudoaneurysm). On admission, the patient’s vital signs were stable. The patient was considered a high-risk case for open surgery because of his renal dysfunction which required dialysis, chronic heart failure and hostile abdomen. We initially recommended open surgery because of possible graft infection, however, the patient refused to undergo the high-risk open surgery. We performed emergency surgery for the ureteroarterial fistula via coverage with off-label use of the stent-graft leg. Intraoperative angiography revealed that there was no leakage. After 1 month, we confirmed that the inflammatory laboratory data was normalized, subsequently, we performed endovascular re-intervention for the proximal aortic anastomotic pseudoaneurysm. The endoleak was finally repaired after off-label use of the stent-graft（aortic cuff exclusion）twice within 2 months. The patient did not develop any operation-related adverse events for 4 months, but subsequently he died of pneumonia that developed from a common cold. Thus, we successfully performed endovascular treatment for a high-risk patient with an ureteroarterial fistula and pseudoaneurysms, without any surgery-related infection.
    Jpn. J. Cardiovasc. Surg. 41:144-147（2012）
  
  Keywords：ureteroarterial fistula, stent graft, endovascular repair
• A Case of Disseminated Intravascular Coagulation Complicating Thoracic Aortic Aneurysm for Which Recombinant Human Soluble Thrombomodulin Was Effective K. Nakamura et al.…148
  A Case of Disseminated Intravascular Coagulation Complicating Thoracic Aortic Aneurysm for Which Recombinant Human Soluble Thrombomodulin Was Effective

  （Cardiovascular Surgery, Tokyo Jikeikai University, Kashiwa Hospital, Kashiwa, Japan, Cardiovascular Surgery, Jichi Medical University Hospital* Shimotsuke, Japan, and Cardiovascular Surgery, Tokyo Jikeikai University Hospital**, Tokyo, Japan）

  Ken Nakamura	Koji Kawahito*	Hirokuni Naganuma
  Kei Tanaka	Yoko Matsumura	Noriyasu Kawada
  Norimasa Haijma	Kazuhiro Hashimoto**

  Chronic disseminated intravascular coagulation（DIC）complicates 5.7% of thoracic aortic aneurysm. DIC with thoracic aortic aneurysm is characterized by hyperfibrinolysis, but usually shows a stable condition in a state of compensated non-overt DIC with limited hemorrhagic symptoms. However, in some cases, hemorrhage caused by external factors may induce uncompensated overt DIC and lead to serious hemorrhagic tendencies. In the present study, we report a patient with a thoracic aortic aneurysm complicated by DIC who exhibited marked hemorrhagic tendencies. DIC remarkably improved following administration of recombinant human soluble thrombomodulin.
    Jpn. J. Cardiovasc. Surg. 41:148-151（2012）
  
  Keywords：recombinant human soluble thrombomodulin, disseminated intravascular coagulation, thoracic aortic aneurysm
• Simultaneous Off-pump Coronary Artery Bypass Grafting and Ascending Aorto-bifemoral Bypass in Leriche Syndrome N. Takashima et al.…152
  Simultaneous Off-pump Coronary Artery Bypass Grafting and Ascending Aorto-bifemoral Bypass in Leriche Syndrome

  （Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Japan）

  Noriyuki Takashima	Tomoaki Suzuki	Soh Hosoba
  Takeshi Kinoshita	Hiromitsu Nota	Atsushi Kambara
  Yasuhiro Nagayoshi	Tohru Asai

  In the presence of Leriche syndrome, the lower extremities are perfused by collateral flow from internal mammary arteries. If an internal mammary artery graft is used in coronary artery surgery, an acute ischemic limb will develop postoperatively. A 52-year-old man was admitted to our department with bilateral claudication. Multidetector row computed tomography with contrast showed total occlusion of the infrarenal abdominal aorta and rich collateral flow to the lower extremities from internal mammary arteries. Cardiac angiography revealed three-vessel disease. Simultaneous coronary artery bypass grafting and an ascending aorto-bifemoral bypass were performed without cardiopulmonary bypass. Postoperative computed tomography angiography showed that grafts to the coronary and bifemoral arteries were patent. This combined procedure is useful for patients with coronary artery disease and aortoiliac occlusive disease. This procedure without cardiopulmonary bypass has not previously been reported.
    Jpn. J. Cardiovasc. Surg. 41:152-155（2012）
  
  Keywords：Leriche syndrome, ischemic heart disease, coronary artery bypass grafting
• A Surgical Case of Acute Aortic Dissection in a Patient with Rheumatoid Arthritis Being Treated with Tacrolimus K. Matsuzaki et al.…156
  A Surgical Case of Acute Aortic Dissection in a Patient with Rheumatoid Arthritis Being Treated with Tacrolimus

  （Department of Cardiovascular Surgery, Tsukuba Medical Center Hospital, Tsukuba, Japan）

  Kanji Matsuzaki	Akito Imai	Tomohiro Imazuru
  Tomoaki Jikuya

  We report a rare case of acute type A aortic dissection in a patient with rheumatoid arthritis（RA）being treated with tacrolimus. The patient was a 77-year-old woman, who had received implantation of 6 artificial joints and was treated with 3mg/day of tacrolimus and 10mg/day of prednisolone. Tacrolimus, one of the immunosuppressive drugs for severe RA, had been applied to her to reduce the amount of prednisolone. An emergency surgery was performed successfully and 20mg/day of prednisolone was administered for RA instead of her preoperative regimen. Such simplification of RA medication was actually useful to us for managing her difficult postoperative care. Respiratory insufficiency with persistent preural effusion was regulated by non-invasive positive pressure ventilation（NPPV）and pleural drainage. Disuse syndrome was treated with enteral nutrition and rehabilitation. Such care was also useful for her recovery.
    Jpn. J. Cardiovasc. Surg. 41:156-159（2012）
  
  Keywords：tacrolimus, immunosuppressant, aortic dissection, rheumatoid arthritis