（Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine＊, Sapporo, Japan）
Background:Persistent endoleak is a major cause of aneurysmal enlargement or rupture after endovascular aneurysm repair（EVAR). Although several reports have described ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy as useful strategies, treatment for type II endoleak after EVAR is controversial. Objectives:We investigated the early results in 5 patients who underwent ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy for type II endoleak. Methods:A＞10mm increase in aneurysm diameter after primary EVAR or a maximum diameter＞65mm serve as indications for intervention for type II endoleak. Under general anesthesia, following transperitoneal exposure of the abdominal aorta, the infrarenal aorta was banded using a tape at the proximal landing zone. After the aorta was opened without clamping, the lumbar arteries were ligated, and a stent graft-conserving aneurysmorrhaphy was performed. Results:The mean interval from the primary EVAR was 47±17 months. The mean operation time was 215±76 min. Blood transfusion was necessary in 4 patients（estimated blood loss 1,260±710ml). No in-hospital deaths were observed, and the mean postoperative hospital stay was 26±20 days. One patient developed aspiration pneumonia and 1 developed surgical site infection post-surgery. The diameter of the aneurysm changed from 68±8 to 47±5mm during hospitalization and decreased further to 36±7mm at the last follow-up. Conclusions:The early results of ligation of lumbar arteries and stent graft-conserving aneurysmorrhaphy were favorable. Although this strategy could be useful for aneurysmal dilatation secondary to persistent type II endoleak after EVAR, the indications for this approach should be determined following careful evaluation of the patient’s status considering the invasiveness of the procedure.
Jpn. J. Cardiovasc. Surg. 47:257-262（2018）
Keywords：abdominal aortic aneurysm;aneurysmorrhaphy;Type II endoleak
（Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan）
A 17-days-old-girl with pulmonary artery（PA）sling, patent ductus arteriosus（PDA), and persistent left superior vena cava was admitted to our hospital. Despite good respiratory status just after birth, the respiratory status gradually worsened, and tracheal intubation was performed on 13th day after birth. Emergency division of the PDA was conducted on day 16. Although preoperative computed-tomography did not demonstrate tracheal stenosis, bronchoscopy after tracheal intubation revealed progression of tracheal stenosis with difficulty for stable anesthetic management. Therefore, operation was postponed to re-evaluate tracheal stenosis. Bronchoscopy and computed-tomography revealed the worsening of tracheal stenosis. Eventually, we performed total correction of the PA sling and tracheal stenosis on day 17. Cardiopulmonary bypass was established after median sternotomy. After transection of the PDA, the left PA originating from the right PA was also transected, and transplanted to the main PA. Then, sliding tracheoplasty was performed following the division of the tracheal stenotic region. Her respiratory condition improved after operation, and postoperative computed-tomography showed successful correction of tracheal stenosis. Although few such cases were reported for neonatal PA sling requiring concomitant tracheoplasty, this case suggests that total correction of PA sling and tracheal stenosis is feasible and useful surgical procedure for such cases.
Jpn. J. Cardiovasc. Surg. 47:263-266（2018）
Keywords：pulmonary artery sling;tracheal stenosis;slide tracheoplasty
（Cardiovascular Center, Ageo Central General Hospital＊, Ageo, Japan）
SOLO SMART is a stentless bioprosthesis that comprises a larger effective orifice area and reduced pressure gradient, exhibiting a better hemodynamic profile than a stented bioprostheses. Currently, SOLO SMART finds application in patients with aortic valve diseases. However, patients with bicuspid aortic valve disease may present Valsalva sinus asymmetry. Recently, some studies have considered SOLO bioprosthesis as contraindicated in patients with a bicuspid aortic valve. Here, we report the case of a 79-year-old female with bicuspid aortic stenosis and Valsalva sinus asymmetry. We preoperatively assessed the aortic root of the patient using a novel 3D workstation that creates virtual reality（VR）images from cardiac CT data. After creating three symmetric commissures at the wall of the Valsalva sinus, we evaluated the distance from the coronary orifices. We determined the appropriate suture line of bioprosthesis avoid coronary orifice occlusion. Aortic valve replacement with SOLO SMART was successful, and the postoperative clinical course was uneventful. Hence, preoperative evaluation of the aortic root using VR images could be a precise and useful method for the assessment of the operative indication for SOLO SMART.
Jpn. J. Cardiovasc. Surg. 47:267-271（2018）
Keywords：stentless bioprosthesis;aortic valve replacement;bicuspid aortic valve;sinus of Valsalva;virtual reality
（Maebashi Red Cross Hospital Department of Cardiovascular Surgery＊, Maebashi, Japan）
The patient was a 57-year-old man who, in 1973, at 19 years of age, had undergone mitral valve replacement for mitral valve stenosis using a Bjo¨rk-Shiley Delrin（BSD）valve. When the patient visited our hospital, he was living in an assisted-living facility due to paresis of the right side of the body, dysarthria, and other sequelae of cerebral infarction. The patient was referred to and visited our hospital with a chief complaint of chest pain in 2011, 38 years after the BSD valve was implanted. In 2012, mitral valve re-replacement, aortic valve replacement, and tricuspid annuloplasty were performed for congestive heart failure associated with prosthetic valve failure, combined aortic stenosis and insufficiency, and tricuspid insufficiency, which were identified by transesophageal echocardiography. The patient’s postoperative course was generally favorable. The disc of the resected prosthetic valve showed a groove and bidirectional cracks caused by wear, and its condition suggested a risk of potential rupture. Transthoracic echocardiography on admission showed mild to moderate prosthetic transvalvular regurgitation, and the symptoms were therefore unlikely to have resulted from the prosthetic valve failure alone at this time. Consequently, it was considered that the heart failure was attributed to the prosthetic transvalvular regurgitation caused by the disc abnormalities in addition to the combined valvular disease by transesophageal echocardiography. In this case, detailed investigation of the heart failure by transesophageal echocardiography led to the discovery of prosthetic valve abnormalities, thus enabling the prevention of a serious cardiac accident due to disc rupture. Detailed examination by transesophageal echocardiography is essential, and early surgical intervention should also be considered if transthoracic echocardiography suggests even a minor prosthetic valve abnormality in a patient who has had this prosthetic valve implanted for such a long time.
Jpn. J. Cardiovasc. Surg. 47:272-275（2018）
Keywords：Bjo¨rk-Shiley Delrin valve;prosthetic valve malfunction;reoperation
（Department of Cardiovascular Surgery, Nagano Chuo Hospital＊, Nagano, Japan）
A 65-year old man with a diagnosis of aortic regurgitation from childhood referred to our hospital due to palpitations and dyspnea on exertion. Transthoracic echocardiography showed severe aortic regurgitation, but the form of left coronary aortic cusp was not detected clearly. Trans esophageal echocardiography revealed small left coronary aortic sinus covered with a rudimentary left coronary cusp. Right coronary angiography showed retrograde flow to left coronary artery, and pooling of contrast material in the aortic cusp. Cannulation into the left coronary ostium could not be performed, aortography revealed no antegrade left coronary blood flow. The patient underwent aortic valve replacement with mechanical valve after resection of the rudimentary left coronary cusp, and ascending aorta replacement using selective cerebral perfusion. The post operative course was uneventful. We report on a rare case of occlusion of left coronary ostium with a rudimentary aortic cusp.
Jpn. J. Cardiovasc. Surg. 47:276-279（2018）
Keywords：occlusion of left coronary ostium;rudimentary aortic cusp;aortic valve replacement;ascending aorta replacement
（Cardiovascular and Gastrointestinal Surgery, Kagoshima University Graduate School of Medical and Dental Sciences＊, Kagoshima, Japan, and Kagoshima University Hospital＊＊, Kagoshima, Japan）
A 67-year-old man with dilated cardiomyopathy was admitted to our hospital for treatment of cardiac failure. After using heparin because cerebral infarction developed during hospitalization, in acknowledgment of thrombocytopenia, we reach the diagnosis of HIT. We judged surgery to be necessary because heart failure had difficulty with catecholamine secession and the left ventricular dilation progressed rapidly, and performed left ventriculoplasty, mitral valve plasty. There were no complications such as the thrombosis during cardiopulmonary bypass, and the postoperative course was good without leading to re-thoracotomy due to bleeding. He passes without a heart failure symptom by the follow of one year 6 months after surgery at home.
Jpn. J. Cardiovasc. Surg. 47:280-283（2018）
Keywords：heparin-induced thrombocytopenia;surgical ventricular restoration;argatroban
（Department of Cardiovascular Surgery, Fujimoto General Hospital＊, Miyakonojo, Japan）
Gerbode defect is a communication between the left ventricle and right atrium. It is usually congenital rather than acquired, but can occur as a complication of endocarditis, myocardial infarction, trauma, or cardiac surgery. We report a case of surgical repair of acquired Gerbode defect resulting from infective endocarditis. A 69-year-old woman with aortic regurgitation due to infective endocarditis was referred to our hospital with a diagnosis of congestive heart failure. She was hospitalized and underwent medical treatment（intensive antibiotic therapy). Preoperative transthoracic and transesophageal echocardiography were performed and revealed a mobile mass（vegetation）on the aortic valve. The patient also had severe aortic regurgitation and a communication between the left ventricle and right atrium. The communication was visualized in the atrioventricular membranous septum. Due to the mobility of the mass（vegetation）and uncontrollable congestive heart failure caused by severe aortic regurgitation, surgical treatment was advised. Surgery was performed through a median sternotomy with the patient on cardiopulmonary bypass. After aortic cross-clamping, the vegetation was approached through a horizontal incision in the ascending aorta and a right atriotomy. The communication site from the left view was below the commissure between the right coronary and non-coronary cusps;from the right view, it was just above the tricuspid annulus of the septal leaflet. The defect was closed with two 0.4-mm thick Gore-Tex cardiovascular patches:one was placed on the LV side and the other on the RA side. The aortic valve was replaced with a bioprosthetic valve（SJM Epic 21 mm). The operation was finished and her clinical course was almost uneventful.
Jpn. J. Cardiovasc. Surg. 47:284-288（2018）
Keywords：left ventricular-right atrial communication;patch closure;infective endocarditis
（Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital＊, Tsuchiura, Japan）
Anti-inflammatory therapy is generally considered to be prior to surgery for Takayasu disease to achieve better outcomes. We report two Takayasu arteritis patients with thoracic aneurysm. Case 1 was a 19-year-old woman who presented acute trachyphonia for one month. CT revealed aortic arch aneurysm of which maximal diameter was 64 mm with partial cystic protrusion. We performed urgent total arch replacement before anti-inflammation therapy was induced. Postoperative course was uneventful and the patient discharged on steroid therapy. Case 2 was a 35-year-old woman who complained chest pain for two weeks. CT revealed a Valsalva aneurysm with maximal diameter 54mm and the aortic wall of the arch including its branches was surrounded by thick low density area. As the FDG-PET confirmed inflammatory arteritis, initial steroid therapy was planned. However, one day before admission, the patient presented acute aortic dissection and did not respond to any resuscitation. We conclude that the right time of surgery or the initial induction of anti-inflammatory therapy for anuerysmal dilation by Takayasu arteritis is to be determined based not only on the inflammation level but also on aneurysmal size and the patient’s severity of complaints.
Jpn. J. Cardiovasc. Surg. 47:289-292（2018）
Keywords：Takayasu arteritis;aneurysm;surgery;anti-inflammatory therapy
（Department of Cardiovascular Surgery, Kyoto Katsura Hospital＊, Kyoto, Japan）
This case report aimed to evaluate the efficacy of applying VIABAHN endoprosthesis at the dissection re-entry of the right renal artery after thoracic endovascular aortic repair（TEVAR）in a patient with a chronic type B dissected thoracoabdominal aneurysm. A 78-year-old man was given a diagnosis of type B aortic dissection 5 years ago and underwent a successful TEVAR operation. Two years later, he developed complications such as chronic expanding aortic dissections;thus, he underwent a second endovascular repair. Enhanced computed tomography（CT）scanning at the five-year follow-up after initial endovascular repair showed a 58-mm diameter thoracoabdominal dissected aneurysm. It also showed an apparent entry point dissection arising from the lower thoracic aorta and a re-entry point at the base of the right renal artery. Although the right renal artery was affected by the dissecting false lumen, all other abdominal branches were intact. He was treated with VIABAHN via occlusion of the re-entry of the dissection and reconstruction of the right renal artery. The patient recovered uneventfully and was discharged 10 days after the operation. Postoperative enhanced CT scanning showed that the aortic false lumen was completely thrombosed, and the right renal arterial flow had significantly improved. Although TEVAR is the standard treatment in acute complicated type B dissections, its role in chronic type B dissections remains controversial. Our technique of using VIABAHN for the reconstruction of the right renal artery showed promising results for patients with chronic type B dissections.
Jpn. J. Cardiovasc. Surg. 47:293-297（2018）
Keywords：re-entry;VIABAHN;chronic type B thoracoabdominal dissected aneurysm;TEVAR
（Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital＊, Aomori, Japan）
A 92 year-old-female with melena was admitted to our hospital. She underwent Y-graft replacement of the abdominal aorta at the age of 65. Gastroduodenal fiberscopic examination and computed tomography（CT）confirmed the diagnosis of aortoduodenal fistula. The fistula in the proximal anastomotic site was occluded with a suture ligature and omentopexy was performed. On the 15th post-operative day she developed high-grade fever. CT revealed a pseudoaneurysm formation at the proximal anastomosis site. She underwent emergency endovascular aneurysmal repair（EVAR). Her postoperative course was uneventful. She is doing well without symptoms of recurrent infection.
Jpn. J. Cardiovasc. Surg. 47:298-302（2018）
Keywords：secondary aortoenteric fistula;AAA;graft infection;EVAR
（Department of Cardiovascular Surgery, Uji-Tokushukai Medical Center＊, Uji, Japan）
Acute pulmonary embolism（PE), usually secondary to deep venous thrombosis（DVT), is a serious disease which may cause sudden death. An inferior vena cava filter（IVCF）is placed in certain circumstances to prevent recurrence of PE. However, some complications of IVCF have been reported and the indications of IVCF should be reviewed. We encounted a case of IVCF migration which required surgical removal through right intercostal thoracotomy. The patient was a 53-year-old woman. She had undergone the placement of IVCF for DVT followed by anticoagulant therapy. Eight days after, CT revealed IVCF migrated above renal veins. As percutaneous extraction was attempted unsuccessfully, the direct approach to remove IVCF between the hepatic vein and renal vein was indicated. Through the right side thoracotomy at the seventh intercostal space with the division of costal arch, the inferior vena cava（IVC）was exposed near the right atrium. The diaphragm was longitudinally divided straight to IVC and the liver was retraced anteriorly after the careful dissection of the venous plexus on the back of the liver. IVCF could be palpated and just below the branch of the caudate rami and above the right renal vein. After systemic heparinization, IVC and branches were clamped simply and IVC was incised longitudinally. The proximal tip of the IVCF dug into the intima and the distal hook penetrated the vein. IVCF was carefully removed and incision and penetration of IVC were repaired. Her postoperative course was unremarkable, and the patient was discharged without any complications.
Jpn. J. Cardiovasc. Surg. 47:303-306（2018）
Keywords：inferior vena cava filter;deep vein thrombosis;pulmonary embolism;complication
（Department of Cardiovascular Surgery, Tenri Hospital＊, Tenri, Japan）
Most renal artery aneurysms are asymptomatic and the indication of surgery for renal artery aneurysm is controversial. We encountered 3 cases of renal artery aneurysms that were found incidentally during imaging studies. We used urological approach to undergo renal or adrenal surgery and we injected renal protection solution into the kidney after clamping the renal artery, later we underwent renal artery aneurysmectomy. In all cases, we got good operative field, and they went an uneventful postoperative course without deterioration of renal function. In surgical treatment of renal artery aneurysm, this approach method, reconstructive procedure, and renal protection are satisfied enough.
Jpn. J. Cardiovasc. Surg. 47:307-311（2018）
Keywords：renal artery aneurysm;hypochondriac transverse incision;Chevron incision;lumbar oblique incision;renal protective solution
（Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine＊, Aomori, Japan）
A 75-year-old man with underlying arteriosclerosis obliterans presented with acute heart failure secondary to rest pain of the right lower extremity. Echocardiogram showed severe mitral regurgitation, moderate tricuspid regurgitation and a low cardiac function（ejection fraction:27%). Right toe gangrene developed in association with continuous acute heart failure. He underwent mitral valve replacement, tricuspid annuloplasty, right common femoral artery-posterior tibial artery bypass and amputation of the right toes in single-stage surgery. There were no major complications during his hospital stay. After surgery, his symptoms significantly improved.
Jpn. J. Cardiovasc. Surg. 46:325-329（2017）
Keywords：mitral valve replacement;tricuspid annuloplasty;critical limb ischemia;distal bypass;arteriosclerosis obliteration