|Yusuke Kawasaki＊||Tatsuya Ozawa＊||Etsuro Suenaga＊|
（Division of Cardiovascular Surgery, Kansai Electric Power Hospital＊, Osaka, Japan）
A 73-years-old male with diabetes mellitus was referred for coronary artery bypass grafting（CABG). Preoperative coronary angiography（CAG）revealed total occlusion of proximal LAD#6, and a large diagonal branch supplied from collateral circulation. Because the patient required early recovery, we planned minimally invasive cardiac surgery（MICS). Preoperative chest CT showed dilatation of the ascending aorta, so the left axillary artery was used as the proximal inflow source for saphenous vein graft（SVG). Under general anesthesia, about an 8cm skin incision was made below the left nipple. The chest was entered through the 4th intercostal space. The left internal thoracic artery（LITA）was harvested using the Harmonic Scalpel in direct vision and thoracoscopy supported vision. SVG was harvested using the endoscopic harvesting technique（EVH). The bypass graft design was in situ LITA-LAD, and left axillary artery-SVG-D1. All coronary targets were directly accessed with the off-pump technique. There were no major postoperative complications. The patient was discharged 5 days after the operation. Postoperative coronary CT revealed all grafts patent. The axillary artery is an alternative inflow source for cases with an untouchable ascending aorta such as dilatation or severe atherosclerotic disease in MICS-CABG.
Jpn. J. Cardiovasc. Surg. 50:73-77（2021）
Keywords：MICS-CABG;SAXCAB（Subclavian/Axillary artery to coronary artery bypass）;dilatated ascending aorta
|Kenji Yoshida＊||Hideo Yoshida＊||Yoshimasa Kishi＊|
|Yuto Narumiya＊||Shohei Yokoyama＊||Munehiro Saiki＊|
|Atsushi Tateishi＊||Yu Ohshima＊||Keiji Yunoki＊|
（Department of Cardiovascular Surgery, Hiroshima City Hiroshima Citizens Hospital＊, Hiroshima, Japan）
A 75-year-old man who had maintenance hemodialysis for diabetic end-stage renal disease and had a history of coronary artery bypass grafting for angina pectoris was getting out of breath. Transthoracic echocardiography showed severe aortic stenosis（aortic transvalvular peak velocity（
Jpn. J. Cardiovasc. Surg. 50:78-81（2021）
Keywords：apico-aortic bypass;aortic stenosis（AS）;transcatheter aortic valve implantation（TAVI）;hemodialysis（HD）
|Yuika Kureyama＊||Hiroshi Nakanaga＊||Atsuhiko Sato＊|
|Shigefumi Matsuyama＊||Minoru Tabata＊|
（Department of Cardiovascular Surgery, Cardiovascular Center, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital＊, Tokyo, Japan）
In redo mitral and/or tricuspid valve operations after aortic valve replacement, the endoscopic right mini-thoracotomy approach provides the benefits of minimal tissue dissection and excellent exposure of mitral and tricuspid valves. Furthermore, on-pump beating surgery eliminates the need to cross-clamp the aorta and dissect the adhesion around the aorta. We report three cases of redo mitral and tricuspid valve operations after aortic valve replacement performed with a right mini-thoracotomy on-pump beating approach.
Jpn. J. Cardiovasc. Surg. 50:82-85（2021）
Keywords：redo surgery;mitral valve surgery;tricuspid valve surgery;minimally invasive cardiac surgery
|Wataru Kato＊||Yuki Goto＊||Ryota Yamamoto＊|
|Tsubasa Yazawa＊||Sho Akita＊||Hideyuki Okawa＊|
|Keisuke Tanaka＊||Kazuyoshi Tajima＊|
（Department of Cardiovascular Surgery, Japanese Red Cross Nagoya Daini Hospital＊, Nagoya, Japan）
A 49-year-old male was referred to our department for surgery because of uncontrollable congestive heart failure accompanied by severe liver dysfunction and acute renal failure. Echocardiography showed severe mitral regurgitation and reduced left ventricular ejection fraction（25%). Due to severe liver dysfunction, coagulopathy and reduced left ventricular function, intentional delay of surgery with interim IMPELLA 5.0 support was selected rather than an emergent surgery. The device was inserted through the right axillary artery to allow the patient to undergo a rehabilitation program before mitral valve surgery. After induction of the IMPELLA device, his multiple organ failure gradually improved. A mitral valve repair was successfully performed 14 days after the introduction of IMPELLA support. The postoperative course was uneventful except for minor complications. He was discharged 30 days after mitral valve surgery. IMPELLA 5.0 can offer effective support for the left ventricle and sufficient blood flow to damaged organs.
Jpn. J. Cardiovasc. Surg. 50:86-90（2021）
Keywords：subacute mitral regurgitation;multiple organ failure;IMPELLA
|Takuma Muraoka＊||Osamu Namura＊||Ryohei Kobayashi＊|
（Department of Cardiovascular Surgery, Niigata Prefectural Central Hospital＊, Joetsu, Japan）
We report a case of a 64-year-old man who obtained effective hemostasis with thoracic endovascular aortic repair（TEVAR）for massive hemoptysis due to bronchial tuberculosis. The patient presented to our hospital with massive hemoptysis. Contrast-enhanced computed tomography（CT）showed dilation of the right bronchial artery and obstruction of the right bronchus from the middle trunk due to hematoma, and sputum mycobacterial culture revealed M. tuberculosis, which led to the diagnosis of massive hemoptysis from the right bronchial artery by bronchial tuberculosis. Emergency bronchial artery embolization（BAE）was performed, but was discontinued due to a localized aortic dissection during the operation. Although respiratory management was started by separate lung ventilation, veno-venous Extra-corporeal Membrane Oxygenation（VV-ECMO）was introduced due to a rapid desaturation, and TEVAR was urgently performed for hemostasis. The patient passed the post-operative period without any clinically significant hemoptysis, and was discharged 47 days after the TEVAR.
Jpn. J. Cardiovasc. Surg. 50:91-95（2021）
Keywords：bronchial tuberculosis;massive hemoptysis;TEVAR
|Sho Mano＊||Yoshikazu Motohashi＊||Masafumi Morita＊|
（The Department of Cardiovascular Surgery, Kyoto Katsura Hospital＊, Kyoto, Japan）
Generally speaking, pararenal abdominal aneurysm（PRAAA）is not well suited to EVAR because the length of its proximal neck is too short for EVAR. Recently in Europe and America, PRAAA is treated with fenestrated EVAR, branched EVAR, or chimney EVAR. The purpose of this case was to evaluates the efficacy of the reverse VIABAHN sandwich technique for PRAAA. An 85-year-old man with a medical history of angina pectoris, diabetes mellitus, hypertension, dyslipidemia, intraductal papillary mucinous neoplasm, postoperative prostatic cancer, cholecystolithiasis, and postoperative inguinal hernia was indicated AAA in a health examination two years ago. CT showed that there was AAA with a diameter of 40mm under the right renal artery, and the left renal artery was branched from AAA. CT follow up at two years revealed AAA developed slowly expanding to a diameter of 47mm.
Jpn. J. Cardiovasc. Surg. 50:96-100（2021）
Keywords：PRAAA;VIABAHN;sandwich technique;chimney technique;EVAR
|Taishi Inoue＊||Atsushi Omura＊||Soichiro Henmi＊|
|Mari Hamaguchi＊||Takanori Tsujimoto＊||Yu Murakami＊|
|Hidekazu Nakai＊||Katsuhiro Yamanaka＊||Takeshi Inoue＊|
（Department of Cardiovascular Surgery, Kobe University＊, Kobe, Japan）
A 49-year-old man was referred to our hospital for surgical treatment of cerebral ischemia due to critical stenosis of aortic arch vessels;he had undergone coronary artery bypass grafting（CABG）using the bilateral internal thoracic artery for angina pectoris caused by left main trunk lesion due to Takayasu arteritis 9 years earlier. During follow-up after the CABG, asymptomatic total occlusion of the left common carotid artery was detected by surveillance imaging CT, and he started to complain of recurrent syncopal episodes along with progressive stenosis of the brachiocephalic artery. Since a bypass from the ascending aorta to the cervical artery seemed to be difficult due to the severely calcified and moderately dilated ascending aorta, partial arch replacement was then planned. Re-sternotomy was done without injury to patent internal thoracic arteries. Cardiopulmonary artery bypass was established with double inflow of an 8mm-graft anastomosed to the right axillary artery and left femoral artery. Brain protection was performed with the antegrade cerebral perfusion through direct cannulation to left subclavian artery, and right vertebral artery and right common carotid artery via the graft. Since reconstruction of the left common carotid artery was unnecessary because of long total occlusion, partial arch replacement with individual reconstruction of the right common carotid artery and right subclavian artery was successfully performed. The patient was discharged on postoperative day 20 without any complication.
Jpn. J. Cardiovasc. Surg. 50:101-105（2021）
Keywords：Takayasu’s arteritis;reoperation;coronary artery bypass grafting;aortic replacement
|Yosuke Ikeda＊||Yuhei Saitoh＊||Rikuto Nii＊|
|Naoki Sumi＊||Shingo Ishiguro＊||Takeshi Soeda＊|
（Department of Cardiovascular Surgery, Matsue Red Cross Hospital＊, Matsue, Japan）
An 83-year-old man with a 50mm infrarenal aortic aneurysm underwent an endovascular aortic repair（EVAR）under general anesthesia. The stent graft was positioned below the renal artery. During EVAR, the mean arterial pressure was maintained over 60mmHg and the activated whole blood clotting time was maintained over 240s. No neurological abnormalities were observed after extubation in the operating room, but paraplegia developed 5 h after surgery. Emergency cerebrospinal fluid drainage, steroid administration and arterial pressure augmentation were ineffective. Paraplegia after EVAR is rare;however, physicians should be aware of this possible complication.
Jpn. J. Cardiovasc. Surg. 50:106-109（2021）
Keywords：delayed paraplegia;abdominal aortic aneurysm;endovascular aortic repair
|Shinji Miyamoto＊||Takashi Shuto＊||Tomoyuki Wada＊|
|Kazuki Mori＊||Keitaro Okamoto＊||Takayuki Mizoguchi＊＊|
（Department of Cardiovascular Surgery, Faculty of Medicine, Oita University＊, and Department of Medical Engineering Center, Oita University Hospital＊＊, Yufu, Japan）
A 70-year-old man was hospitalized for the treatment of saccular aneurysm of the arch aorta and chronic dissecting aortic aneurysm with a history of type B dissection. Contrast-enhanced computed tomography showed many arteriosclerotic plaques protruding into the lumen of the arch and descending aorta. In order to prevent embolism caused by atheroma scattering, we performed total thoracic aortic replacement with selective cerebral extracorporeal circulation after cooling via an anterolateral thoracotomy with partial sternotomy at a blood flow rate of 1/2 standard flow. No postoperative organ damage was observed, and there was no brain/spinal cord complication;he was discharged from the hospital on foot on the 13th postoperative day. This “low-flow perfusion” method for preventing atheroma destruction by a blood flow jet is an effective method for preventing embolism without disturbing the balance of oxygen demand supply while maintaining the total circulation by continuing the cardiac output during the cooling process.
Jpn. J. Cardiovasc. Surg. 50:110-113（2021）
Keywords：cerebral complication;thoracic aneurysm;extracorporeal circulation;hypothermia;shaggy aorta
|Masahide Kawatou＊||Kazuhisa Sakamoto＊||Takuro Makiura＊|
|Jiro Sakai＊||Motoyuki Kumagai＊||Takahide Takeda＊|
|Hideo Kanemitsu＊||Kazuhiro Yamazaki＊||Tadashi Ikeda＊|
（Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine＊, Kyoto, Japan）
An 83-year-old female patient was referred to our hospital because of an aortic arch aneurysm. At the age of 78, she had undergone zone 1 TEVAR with bypass surgery from the right axillary artery to the left common carotid artery and left axillary artery in another hospital. After that, the proximal landing zone expanded, and the type 1 endoleak led to aneurysmal expansion. Therefore, open surgical repair was planned. In the operative findings, the proximal stent graft diameter was 40mm, and the diameter of the aorta was 45mm. We chose a Vascutek SienaTM Collared Branched Graft 26mm（Terumo, Japan）and anastomosed the trimmed collar to the proximal stent graft covered with the aortic wall. We successfully reconstructed the aortic arch.
Jpn. J. Cardiovasc. Surg. 50:114-118（2021）
Keywords：open conversion after TEVAR;collared branched graft
|Haruki Mikoshiba＊||Toshifumi Saga＊||Yuto Hori＊|
（Department of Cardiovascular Surgery, Shinkuki General Hospital＊, Kuki, Japan）
A 62-year-old woman with a history of 4 laparotomy procedures for lymph node metastasis after left hemicolectomy underwent left-sided nephrectomy and abdominal aortic repair. After discharge, as a sudden onset of intraperitoneal bleeding via the drain developed, the patient was transferred to our institution and diagnosed with abdominal aortic rupture（AAR）due to postoperative peritonitis induced by anastomotic leakage in rectal surgery. On admission, computed tomography revealed extravasation of contrast medium around the abdominal aorta. Judging from a case of aortic rupture with severe adhesions in the abdominal cavity, we adopted a policy that surgical management by endovascular aortic repair with the Chimney technique（Ch-EVAR）should be performed. The patient had an uneventful postoperative recovery without endoleaks or renal dysfunction. This case highlights the difficulty of managing AAR and provides insight into a successful Ch-EVAR for AAR without endoleaks or renal dysfunction.
Jpn. J. Cardiovasc. Surg. 50:119-123（2021）
Keywords：Chimney technique;EVAR;abdominal aortic rupture
|Yoshihiro Iwasaki＊||Masafumi Morita＊||Shuhei Azuma＊|
（Department of Cardiovascular Surgery, Kyoto Katsura Hospital＊, Kyoto, Japan）
We report a case of abdominal aortic aneurysm rupture after endovascular aortic repair（EVAR）caused by Capnocytophaga ochracea（C. ochracea). The case involved a 77-year-old man who underwent EVAR for an abdominal aortic aneurysm just below the renal artery 4 years earlier. The patient had been treated with antibiotics by his local doctor for fever of unknown origin and high C-reactive protein level, but his condition did not improve and he was referred to our clinic. Although the patient was hemodynamically stable and presented no symptoms other than fever, computed tomography-aortography showed a rapid expansion of the thrombosed abdominal aortic aneurysm, fluid retention outside the aneurysm, and destruction of the infected wall. Therefore, the patient immediately underwent emergency laparotomy. Intraoperative findings showed a large accumulation of pus within the aneurysm and a 4-cm rupture in the left posterior side of the aneurysm, as well as pus accumulation in the left retroperitoneum in the same area. Suspecting the presence of complicated stent graft infection, we removed all stent grafts. After removing the infected aneurysmal wall and careful debridement, we performed a Y-shaped vascular replacement and omental wrapping procedure. C. ochracea was detected in the wall of the infected aneurysm, and the patient was treated with antibiotics for 6 weeks after the surgery. The infection did not progress and the patient was discharged on day 49 after the surgery. C. ochracea should be kept in mind as a potential inflammatory organism in such cases because it can cause stent-graft and aneurysmal infections after EVAR.
Jpn. J. Cardiovasc. Surg. 50:124-127（2021）
Keywords：Capnocytophaga ochracea;ruptured mycotic abdominal aortic aneurysm;EVAR
|Yoshito Ito＊||Hitoshi Suhara＊||Satoshi Sakakibara＊|
（Department of Cardiovascular Surgery, Sakurabashi Watanabe Hospital＊, Osaka, Japan）
Both coronary malperfusion and paraplegia are fatal complications of type A aortic dissection. We report a rare case of successful surgical repair for type A aortic dissection simultaneously complicated with both right coronary malperfusion and paraplegia. A 44-year-old man was admitted to our hospital with sudden chest and back pain. ST elevation and atrioventricular block were shown in an electrocardiogram. The echocardiogram demonstrated asynergy of left ventricular wall motion in the inferior and posterior area. Enhanced computed tomography revealed type A aortic dissection with right coronary malperfusion. We performed emergent repair of the ascending aorta and aortic arch without implantation of a coronary stent prior to the surgical repair. After the operation, satisfactory right coronary revascularization was obtained. However, after the patient woke up from anesthesia, paraplegia was recognized. The paraplegia was successfully treated with acute administration of naloxone, acute cerebrospinal fluid drainage and subacute administration of a large dose of methylprednisolone. He was discharged without any neurologic deficits on the 49 th postoperative day.
Jpn. J. Cardiovasc. Surg. 50:128-132（2021）
Keywords：type A aortic dissection;coronary malperfusion;paraplegia;methylprednisolone
|Masayuki Nishiyama＊||Yoshimasa Seike＊||Yosuke Inoue＊|
|Kyokun Uehara＊||Hiroaki Sasaki＊||Hitoshi Matsuda＊|
（Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center＊, Suita, Japan）
An 84-year-old female with Marfan syndrome and a history of multiple aortic surgeries developed a triple-channel type B aortic dissection. A new entry was located at the proximal descending aorta and a false lumen was patent. Because of persistent back pain, her age, and a complicated surgical history, thoracic endovascular aortic repair（TEVAR）was conducted to close the new entry tear. Postoperative enhanced computed tomography revealed a thrombosed false lumen of the proximal descending aorta. There was no enlargement of the descending aorta four years post-surgery. TEVAR is an alternative procedure for treating aortic dissection in elderly patients, even with Marfan syndrome.
Jpn. J. Cardiovasc. Surg. 50:133-136（2021）
Keywords：TEVAR;Marfan syndrome;aortic dissection
|Daisuke Iwahashi＊||Yuki Ikegaya＊||Nao Kume＊|
|Shoichi Tsuda＊||Tatsuya Nakao＊|
（Department of Cardiovascular Surgery, New Tokyo Hospital＊, Matsudo, Japan）
Symptomatic aortic stenosis in adults causes complications such as secondary hypertension, heart failure, abdominal organ perfusion failure, and lower limb ischemia;therefore, medical management is difficult. Although there are reports of endovascular treatment using a catheter and surgery as treatment methods, there is no consensus on the treatment strategy. An 82-year-old woman was admitted to our hospital because of high blood pressure and heart failure. She underwent ascending-to-abdominal aortic bypass grafting with cardiopulmonary bypass. Proximal anastomosis was established during cardiac arrest. We performed the anti-anatomical anastomotic procedure using a large artificial graft, which was guided directly from the posterior pericardium to the retroperitoneal cavity. Although the surgery was highly invasive, the patient exhibited a favorable outcome. We report this case because the treatment method may be useful as one of the curative treatments for middle aortic syndrome.
Jpn. J. Cardiovasc. Surg. 50:137-141（2021）
Keywords：middle aortic syndrome（MAS）;adult aortic coarctation;surgical treatment