（Department of Cardiovascular Surgery, Yotsuba Circulation Clinic＊, Matsuyama, Japan）
Anomalous origin of the left coronary artery from the pulmonary artery（ALCAPA）is a rare congenital anomaly. This anomaly occurs in approximately one in 300,000 live births. Of the children diagnosed with this syndrome, 90% die within the first year of life because of myocardial ischemia and left ventricular failure. Survival into adulthood is rare and depends upon pre-existing or rapidly developing collateral vessels between the right and left coronary artery. This report concerns the surgical case of anomalous origin of the circumflex coronary artery from the left pulmonary artery complicated with atrial septal defect（ASD). A 34-year-old woman was admitted because of dyspnea on exertion. Echocardiography revealed normal cardiac function with secondary ASD. Coronary catheterization revealed an anomalous origin of the left circumflex coronary artery from the left pulmonary artery. Direct closure of the ASD and coronary artery bypass grafting for the circumflex coronary artery using an internal thoracic artery were performed, and the orifice of the circumflex coronary artery was ligated. The postoperative outcome was excellent. Most of the ALCAPA cases shows the main trunk of the left coronary artery arising from the pulmonary artery. This case demonstrates only the left circumflex coronary artery originating from the left pulmonary artery. Moreover ASD coexisted in this case. To the best of our knowledge, this is a very rare case of its type to be diagnosed and reported.
Jpn. J. Cardiovasc. Surg. 46:1-5（2017）
Keywords：anomalous origin of the left coronary artery from the pulmonary artery（ALCAPA）;atrial septal defect
（Department of Cardiovascular Surgery, Kindai University Faculty of Medicine＊, Osaka-Sayama, Japan）
A 28-year-old woman with no underlying health issues was injured in a motorcycle accident and taken to our hospital by ambulance when she was 26 years old. Though she was diagnosed with multiple trauma, upon arrival at the hospital neither cardiac murmurs nor cardiac abnormalities on transthoracic echocardiography were detected. She was managed conservatively, and discharged on hospital day 16. She experienced dyspnea upon mild effort, and an early diastolic murmur appeared. She was again referred to our hospital, and diagnosed with severe aortic regurgitation. We scheduled an aortic valve replacement using an bioprosthetic valve because she intended to give birth. We also considered simultaneous aortic root enlargement as her aortic annulus was small. We performed the surgery 2 years after the initial motorcycle accident. Perioperatively, we noticed that her non-coronary cusp was torn. We converted the procedure to an aortic valve repair using an autologous pericardial patch. Her aortic regurgitation disappeared after the operation, and she was discharged on postoperative day 14. We successfully preserved the aortic valve cusps and avoided the need for anticoagulant therapy.
Jpn. J. Cardiovasc. Surg. 46:6-10（2017）
Keywords：blunt chest trauma;traumatic aortic regurgitation;aortic valve repair;young woman
（Division of Cardiovascular Surgery, Japanese Red Cross Narita Hospital＊, Narita, Japan, and Division of Cardiovascular Surgery, Chiba Cerebral and Cardiovascular Center＊＊, Ichihara, Japan）
ImmunoglobulinG4（IgG4)-related sclerosing disease can occur in various organs, rarely in cardiovascular lesions. We report a case of IgG4-related cardiac tumor which was concomitant with aortic dissection. A 72-year-old woman visited our hospital with chief complaints of difficulty swallowing and weight loss. A tumor was found in the pericardium adjacent to the left ventricle on echocardiography, and a dissecting aneurysm of the ascending aorta with a maximum of 60mm in the short diameter was noted on contrast CT. There had been no episodes related to the onset of aortic dissection such as chest pain, and chronic dissection was also identified on diagnostic imaging. A tumor biopsy was performed via a left lateral thoracotomy for tumor tissue diagnosis. Histopathologically, the tumor showed no malignant findings and we identified infiltration of IgG4-positive plasmacytes. The IgG4 level in blood exceeded the reference level, but no findings of IgG4-related disease were observed in other organs. Coronary artery CT showed the left circumflex branch of the coronary artery to run over the tumor. It was thus judged to be difficult to surgically resect the tumor. Oral steroid administration was started to reduce the size of the tumor. However, due to an enlarging trend of the aortic aneurysm involving the ascending aorta on CT at 1 month, the patient underwent ascending aorta replacement. Although infiltration of IgG4-positive plasmacytes was found in the outer lining of the resected arterial wall, the association between IgG4 and the onset of aortic dissection was unclear.
Jpn. J. Cardiovasc. Surg. 46:11-16（2017）
Keywords：IgG4-related disease;aortic dissection;autoimmune;cardiac tumor
（Department of Cardiovascular Surgery, Ise Red Cross Hospital＊, Ise, Japan）
Infected abdominal aortic aneurysm（IAAA）are rare, but life-threatening. This time we experienced six cases of infected abdominal aortic aneurysm. We measured the soothing of bacteremia by two weeks of antibiotic treatment before operation, if not in a state of impending rupture or rupture. The in situ prosthetic graft replacement surgery was the first choice. In five cases, we replaced by an in situ dacron graft with Rifampicin. However, one case that was by pondylitis caused by Helicobacter cinaedi was treated by extra-anatomical bypass. There was no post-operative infectious complication. In addition, surgery/hospital death was 0%.
Jpn. J. Cardiovasc. Surg. 46:17-20（2017）
Keywords：infected aneurysm;graft replacement;Helicobacter cinaedi
（Division of Cardiovascular Surgery, Saiseikai Fukuoka General Hospital＊, Fukuoka, Japan, and Fukuoka University Hospital Cardiovascular Surgery＊＊, Fukuoka, Japan）
We report an interesting case of thoracic vascular graft infection treated by in situ replacement using bovine pericardial roll. A 65-year-old man who had undergone graft replacement of ascending aorta for acute type A aortic dissection 9 months prior was admitted to our hospital with purulent discharge from his chest wound. Fluid accumulation surrounding the vascular graft was detected by chest CT, and methicillin-resistant Staphylococcus aureus（MRSA）was positive from his blood culture. These findings led to a diagnosis of aortic graft infection. We gave the antibiotics intravenously, opened the abscess cavity around the infected graft, and irrigated with 0.04% gentian violet solution for 6 months, but failed to control the graft infection. Then we did redo replacement of the ascending aortic vascular graft using a bovine pericardial roll graft with a concomitant omental flap wrapping and obtained successful healing of the graft infection. During follow-up, no recurrent infection occurred, however he died of acute subdural hematoma 8 months after surgery. In situ replacement of the infected vascular grafts using a bovine pericardial roll graft with a concomitant omental flap wrapping may be an option for treating infected aortic grafts.
Jpn. J. Cardiovasc. Surg. 46:21-24（2017）
Keywords：infected aortic graft;bovine pericardial roll graft;MRSA
（Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan）
A 42 year-old woman with Marfan syndrome, who had replacement of the ascending aorta for acute aortic dissection several years ago, was found to have distal aortic arch aneurysm. The aneurysm had small entries at cervical arterial branches and large re-entry at the left external iliac artery. It was necessary to perform two-staged operation Bentall procedure with total arch replacement and abdominal aortic replacement with re-entry closure. It was usually performed with a primary entry closure for chronic aortic dissection, but massive invasion was expected. We performed catheter angiography for entry and re-entry, and decided to perform preceding re-entry closure. First, we underwent replacement of the abdominal aorta, and then successfully performed the Bentall procedure with total aortic arch replacement. The catheter angiography was useful for decision-making for medical treatment.
Jpn. J. Cardiovasc. Surg. 46:25-28（2017）
Keywords：chronic aortic dissection;Marfan syndrome;re-entry closure;aortic remodeling;catheter angiography
（Department of Cardiovascular Surgery, Osaka General Medical Center＊, Osaka, Japan）
An aberrant right subclavian artery（ARSA）is a relatively rare congenital anomaly of arch branches, occurring in 0.5-2.0% of the population. Stanford type A acute aortic dissection involving an ARSA is rare, and is associated with difficult surgical planning in an emergency situation. We report a case of Stanford type A acute aortic dissection originating from an ARSA in a 50-year-old man. He was referred to our hospital with a chief complaint of chest and back pain. Contrast enhanced CT scan revealed type A aortic dissection involving an ARSA, with the entry located near the ARSA. Given the possible difficulty of performing distal anastomosis over the ARSA and ARSA reconstruction, total arch replacement was performed using the open stent-grafting technique. The postoperative course was uneventful, and a CT scan revealed a thrombosed false lumen and ARSA. The false lumen of the aorta next to the stent graft eventually disappeared at 1 year postoperatively. The open stent-grafting technique might be an effective alternative in the management of Stanford type A acute aortic dissection with ARSA.
Jpn. J. Cardiovasc. Surg. 46:29-34（2017）
Keywords：open stent grafting technique;aberrant right subclavian artery;type A acute aortic dissection;emergency operation
（Department of Cardiovascular Surgery, Aichi Medical University, Aichi, Japan）
A 79-year-old woman complained of chest pain during hemodialysis. At 65 years of age, she underwent total arch replacement for acute aortic dissection. The following year, she underwent thoracic endovascular aortic repair and Y-graft replacement of a thoracoabdominal aortic aneurysm. Since the age of 73 years, she has been on hemodialysis for chronic renal failure. At 77 years of age, she underwent a modified Bentall procedure and mitral valve annuloplasty for a huge pseudoaneurysm at the aortic root and for mitral regurgitation. One year after the surgery, computed tomography（CT）showed a pseudoaneurysm around the aortic root. Although asymptomatic at the time of her follow-up visit, she developed chest pain during hemodialysis 20 months following the Bentall procedure. CT revealed progressive dilatation of the aortic root pseudoaneurysm. Coronary angiography showed severe stenosis of the right coronary artery. During the redo operation, findings indicated the presence of oozing type of bleeding from the needle hole from the previous artificial graft. We experienced a rare case of a huge aortic root pseudoaneurysm due to oozing from the needle hole at the artificial graft.
Jpn. J. Cardiovasc. Surg. 46:35-38（2017）
（Department of Cardiovascular Surgery, Kakogawa East Hospital＊, Kakogawa, Japan, and Department of Cardiovascular Surgery, Kobe Rousai Hospital＊＊, Kobe, Japan）
A 76-year-old man was admitted to our hospital to receive optimal medical therapy for acute type B aortic dissection with a thrombosed false lumen. Eighteen days after admission, computed tomography（CT）was performed because of back pain and showed new retrograde acute type A aortic dissection. Emergency total arch replacement was performed with the aid of a J-graft open stent graft（JOSG). Postoperatively, the blood pressure in the lower extremities decreased to 70% of systemic blood pressure without symptoms. Enhanced CT showed severe stenosis from the non-stent part of the aorta to the proximal part of the JOSG. On postoperative day 2, thoracic endovascular aortic repair（TEVAR）was performed for stent graft stenosis. The blood pressure of the lower extremities promptly recovered after the procedure, and the patient was extubated without any neurologic deficits on the next day. Postoperative CT demonstrated that the stent graft stenosis had been effectively alleviated. The patient’s subsequent course was uneventful and he was discharged on postoperative day 24. A JOSG should only be deployed after precise evaluation of the anatomy of the target aorta and careful attention should be paid to the length of the non-stent part of the graft in order to prevent unpredictable graft retraction that could cause stent graft stenosis. TEVAR is considered to be a good option to treat complications related to open stent grafts.
Jpn. J. Cardiovasc. Surg. 46:39-44（2017）
Keywords：J-graft open stent graft（JOSG）;acute type A aortic dissection;total arch replacement;stenosis of JOSG;TEVAR
（Department of Endovascular Treatment for Structural Heart and Aortic Disease,＊ and Department of Cardiovascular Surgery＊＊, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan）
A 79-year-old man, who had a history of intravesical instillations of bacillus Calmette-Gue´rin（BCG）therapy for urinary bladder cancer, developed bloody sputum 4 years after BCG therapy. BCG was detected from the sputum by detailed examination. Medical therapy for tuberculosis（TB）was started, but bloody sputum continued. Computed tomography（CT）for the chest was performed to evaluate the state of TB, and surprisingly, found impending rupture of tuberculosis mycotic thoracic aneurysm. He was emergently transferred to our hospital. CT revealed that the aneurysm made a lump with surrounding lung and lymph nodes. It seemed to be quite difficult to dissect and to be quite high risk to perform graft replacement with pneumonectomy. On the other hand, TB infection was controlled with antibiotic therapy. Thus we chose debranch TEVAR for this complicated situation. His bloody sputum regressed soon after the procedure and disappeared during his hospitalization. He was discharged home on POD 13 without serious complication and continued to have antibiotic therapy under the instruction of his primary physician.
Jpn. J. Cardiovasc. Surg. 46:45-48（2017）
Keywords：intravesical instillations of bacillus Calmette-Gue´rin（BCG）therapy;tuberculous mycotic thoracic aortic aneurysm;TEVAR
（Department of Thoracic Cardiovascular Surgery, Tokyo Metropolitan Bokutoh Hospital＊, Tokyo, Japan and ＊＊Dr. Rokkaku passed away on February, 2016.）
A 69-year-old woman had dysphagia, hoarseness, and asthma-like symptoms such as cough and wheeze. Inhaled corticosteroids and long-acting β2 stimulants was not effective. Gastrointestinal endoscopy showed compression of the esophagus wall from outside. Enhanced computed tomography（CT）showed thoracic descending aortic aneurysm compressing esophagus and left lower lobe bronchus. Immediately thoracic endovascular aortic repair（TEVAR）was performed. After surgery, significant improvement of hoarseness and asthma-like attack was obtained at the time of 1 month after surgery. This is the first reported case of TEVAR which improved compression symptoms of both esophagus and bronchus due to thoracic aortic aneurysm in Japan.
Jpn. J. Cardiovasc. Surg. 46:49-53（2017）
Keywords：dysphagia;asthma-like attack;thoracic aortic aneurysm;TEVAR
（Department of Cardiovascular Surgery, Sapporo Higashi Tokushukai Hospital＊, Sapporo, Japan, and Department of Cardiac Surgery, Asahikawa Medical University＊＊, Asahikawa, Japan）
Persistent sciatic artery（PSA）is a rare congenital vascular anomaly with an incidence ranging from 0.025 to 0.06% of the general population. We report a 65-year-old male patient with bilateral PSA suffering from intermittent right-calf claudication. Peripheral pulsations could be palpated well at the right common femoral artery but not at the right popliteal artery. His ankle brachial index（ABI）was 0.79 on the right and 0.99 on the left. Computed tomographic（CT）angiography demonstrated that the bilateral PSAs were branched from the internal iliac arteries and the right PSA was completely occluded, whereas aneurysmal change was not evident. Both superficial femoral arteries were incompletely developed. Blood flow to the peroneal artery, anterior and posterior tibial arteries were maintained in both lower legs via a network of collateral arteries. Arterial bypass from right common femoral artery to the above-knee popliteal artery using knitted Dacron graft was performed and postoperative ABI of the right lower limb improved to 1.06. Ten months after the intervention, the patient was then suffered from intermittent left-calf claudication caused by complete occlusion of left PSA, therefore, above-knee femoropopliteal arterial bypass using knitted Dacron graft was performed. PSA is often asymptomatic until a complication develops and the careful monitoring to prevent the risk of thromboembolic and aneurysmal events are recommended.
Jpn. J. Cardiovasc. Surg. 46:54-56（2017）
Keywords：persistent sciatic artery;ASO;revascularization
（Department of Cardiovascular Surgery, St. Mary’s Hospital＊, Kurume, Japan）
A 23-year-old woman with mitral valve infective endocarditis complicated by embolism of the right common iliac artery underwent transfemoral embolectomy by a Fogarty catheter and mitral valve replacement. She developed occlusion of the right internal iliac artery, that was revealed by computed tomography on the 9th postoperative day. The occlusion was considered to result from migration of a part of the emboli from the right common iliac artery into the right internal iliac artery during the procedure of embolectomy. On the 16th postoperative day, she underwent repeat mitral valve replacement because of perivalvular leakage. Furthermore, after 2 weeks from the diagnosis of embolism of the right internal iliac artery, the embolic site showed aneurysmal formation finally requiring aneurysmectomy. Her recovery was uneventful. Our case is considered to be rare in that serial observations on computed tomography indicated the development of mycotic aneurysm at the site of septic embolism. In addition, care must be taken to prevent migration of emboli into branched arteries during the procedure of embolectomy for peripheral arterial septic embolism caused by infective endocarditis.
Jpn. J. Cardiovasc. Surg. 46:57-61（2017）
Keywords：mycotic aneurysm;septic embolism;infective endocarditis;embolectomy;Fogarty catheter