Acute Limb Ischemia Caused by Embolus of Primary Lung Cancer Complicating Trousseau’s Syndrome

Limb ischemia caused by tumor embolus is rare. In this study, we report the case of a 77-year-old woman who suffered from acute ischemic limb. Computed tomography showed a tumor in the right bronchus invading the left atrium. The tumor fragments scattered resulting in the occlusion of the right iliac artery. The excluded embolus was revealed as a squamous cell carcinoma. Regarding the popliteal venous thrombus, Trousseau’s syndrome was complicated. The patient was discharged without any complications. We believe that advanced lung cancer is a differential diagnosis of acute ischemic limbs and that successful limb rescue contributed to a patient’s quality of life.

Reconstruction for rupture of profunda femoris artery aneurysm in a patient with sarcopenia

Profunda femoris artery aneurysm (PFAA) is rare and has a high incidence of rupture. Herein, we report the case of an 80-year-old man who developed sarcopenia after gastric surgery. The patient presented to our hospital with a reddish thigh and was diagnosed with PFAA rupture. We performed aneurysmectomy and graft interposition in emergency. Postoperative enhanced computed tomography revealed an interposed graft, and the patient was discharged on postoperative Day 7. We considered that the PFAA patients with sarcopenia has a high risk of rupture because the muscles surrounding the profunda femoris artery became weak, and should be followed-up closely.

Autologous G-CSF-mobilized peripheral blood CD34+ cell therapy for diabetic patients with chronic nonhealing ulcer

Recently, animal studies have demonstrated the efficacy of endothelial progenitor cell (EPC) therapy for diabetic wound healing. Based on these preclinical studies, we performed a prospective clinical trial phase I/IIa study of autologous G-CSF-mobilized peripheral blood (PB) CD34(+) cell transplantation for nonhealing diabetic foot patients. Diabetic patients with nonhealing foot ulcers were treated with 2 × 10(7) cells of G-CSF-mobilized PB CD34(+) cells as EPC-enriched population. Safety and efficacy (wound closure and vascular perfusion) were evaluated 12 weeks posttherapy and further followed for complete wound closure and recurrence. A total of five patients were enrolled. Although minor amputation and recurrence were seen in three out of five patients, no death, other serious adverse events, or major amputation was seen following transplantation. Complete wound closure was observed at an average of 18 weeks with increased vascular perfusion in all patients. The outcomes of this prospective clinical study indicate the safety and feasibility of CD34(+) cell therapy in patients with diabetic nonhealing wounds.

Case of ischemic optic neuropathy developed eleven days after an aortic arch replacement

We present a case of ischemic optic neuropathy (ION) developed 11 days after an aortic arch replacement in a 59 year-old male who had a history of untreated hypertension. Thoracic CT revealed severe stenosis of the right common carotid artery with poor blood flow. Aortic clamping time was 96 minutes, and selective cerebral perfusion time was 48 minutes. The lowest hemoglobin concentration of venous blood during cardiopulmonary bypass was 8.1 g/dl and the lowest arterial pressure was 60 mmHg. Due to pulmonary congestion, artificial ventilation was required until 11 post-surgical days. After removal of ventilator, the patient's consciousness was clear with no motor paralyses evident. However, the patient complained of blurred vision on that day. Bilateral papillae of the optic fund were pale. Atrophy of the papillae was also noted. Visual evoked potential was bilaterally flat suggesting bilateral optic nerve disturbance. The diagnosis of ION was made by ophthalmologist and neurologists. We speculated that low hemoglobin level during cardiopulmonary bypass was not the sole etiology of ION. Untreated hypertension, low blood flow through internal carotid artery and prolonged mechanical ventilation were also deteriorating factors of ION in this patient. We should be alert to prevent ION in such a complicated case.

Minimal inspiratory flow from dry powder inhalers according to a biphasic model of pressure vs. flow relationship

Inhalation therapy using the dry powder inhaler (DPI) is now the first choice for obstructive pulmonary diseases. We previously measured relationships between inspiratory pressure (PI) and flow rate of almost all of the DPIs available in Japan, and described an importance of inspiratory efforts. In the present study, we further analyzed the data obtained in the previous study. Although there were linear relationships between PI and flow2, the slope became steeper when PI was less than a certain value (critical PI, existed between 15-20 cmH2O). When PI was less than critical PI, linear rather than parabolic regression between PI and flow yielded better fits (r > 0.90, p < 0.001). Inspiratory flows at the critical PI were 53.9 (Diskus), 65.8 (Diskhaler), 45.9 (Turbuhaler for Pulmincort), 48.6 (Turbuhaler for Symbicort) and 38.0 l/min (Twisthaler). These findings suggested that flow through the DPI becomes laminar rather than turbulent flow in the range below critical PIs. We suggest that patients should inhale from the DPIs with inspiratory pressure higher than critical PI.

The efficacy of an oxygen mask with reservoir bag in patients with respiratory failure

BACKGROUND

Oxygen masks with reservoir bags (OMR) are widely used for oxygen therapy in patients with severe respiratory failure. The purpose of the present study was to determine whether OMRs are effectively used in clinical practice.

METHODS AND RESULTS

In the first phase of the study on the patients with severe respiratory failure, no apparent respiratory motions of the reservoir bag were noted, and the oxygen saturation level as determined by pulseoximetry (SpO2) did not decrease even after shrinkage of the reservoir bag. In the second phase, when a healthy female volunteer wore an OMR, pressure swings in the reservoir bag were less than 0.1 cmH2O, even when she was breathing with her maximal respiratory efforts (tidal volume, 1.14 L and respiratory frequency, 19.2 bpm). These pressure swings provoke a less than 50 mL oxygen supply from the reservoir bag. The decreased efficacy of OMR in oxygen therapy may be primarily due to the large space between the OMR and the nose but this space is inevitable in sitting or orthopneic subjects.

CONCLUSIONS

Fixing an OMR very tightly to the face is mandatory for its effective use. It should also be kept in mind that there are limitations to the efficacy of OMR, even when they are used with such careful management.

[Patient with innominate artery steal accompanied with cerebral infarction]

A 49-year-old man suddenly suffered left hemiplegia, and was brought to our hospital by ambulance at the beginning of August, 2006. He had a history of hypertension, and had received replacement of a synthetic graft in the ascending aorta and aortic arch with innominate artery for dissecting aneurysm in the aorta 2 years before. On diffusion-weighted magnetic resonance images obtained after admission, cerebral infarction was detected at the right corona radiata, and MR angiography (MRA) showed obstruction of the right middle cerebral artery. He was given intravenous tissue-plasminogen activator (t-PA) a few hours after arrival, and his hemiplegia was improved on the following day. At 11 days after onset, recanalization of the right middle cerebral artery was seen by MRA. On Doppler ultrasonographic examination, obstruction and thrombus in the innominate artery were observed. Retrograde flow of the right vertebral artery was demonstrated by both pulse-Doppler ultrasonography and velocity-coded color MRA. This patient is a rare example of innominate artery steal and ischemic cerebrovascular disease with obstruction of the innominate artery. Cerebral infarction in this patient might have developed via artery-to-artery embolism, with the thrombus in the innominate artery, rather than through a hemodynamic mechanism with innominate artery steal.

Primary cardiac angiosarcoma: presenting with cardiac tamponade followed by cerebral hemorrhage with brain metastases

A 49-year-old man presented with palpitation and shortness of breath. He was seen to have a massive pleural and pericardial effusion on radiography and echocardiography. Computed tomography (CT) scanning showed that cardiac tumors arose from the right atrium with epicardial and endocardial extension. Pathology examination of samples at pericardiotomy revealed them to be angiosarcoma. Two days after the surgery, he developed left hemiparesis. CT scans showed a large cerebral hemorrhage on the right temporal lobe with midline shift by brain metastases. He died 37 days after the surgery. At autopsy, he had metastases in the brain, multiple bones, and soft tissues but no lung or left-side heart involvement. Primary cardiac angiosarcoma is rare, and mostly arises from the right side of the heart. Common metastatic sites are the lungs and liver. There are only a few reports of brain metastases. In conclusion, this is a rare report of cardiac angiosarcoma presenting with pericardial tamponade. There were rapid brain and multiple bone metastases but no lung or left-side heart lesions.

Surgical treatment of chronic atrial fibrillation: Report of 8 cases

Since February 2003, we have conducted surgical treatment on 8 patients complicated with chronic atrial fibrillation during cardiac surgery. A radial procedure was conducted on 7 patients, and pulmonary vein isolation was conducted on 1 patient. Underlying diseases included mitral regurgitation (MR) in 5 patients, mitral stenosis (MS) in 1 patient, aortic stenosis (AS) + MS in 1 patient and chronic type A dissociation in 1 patient. Simultaneous procedures included mitral valve plasty (MVP) in 3 patients, mitral valve replacement (MVR) in 3 patients, aortic valve replacement (AVR) + MVR in 1 patient, and aortic root reconstruction by reimplantation procedure + total arch replacement in 1 patient. The operation time was 320 to 840 minutes and 458.1± 171.1 minutes on average. The cardiopulmonary bypass time was 204 to 404 minutes and 266.7 ± 62.7 minutes on average. The aortic cross-clamp time was 142 to 271 minutes and 171± 41.5 minutes on average. One patient died in hospital. Six patients returned to sinus rhythm, and 1 patient required pacemaker implantation. The follow-up period was 2 to 37 months and 13.6 ± 15 months on average. When cryoablation was changed to radiofrequency ablation to assist preparation of the block line, a tendency toward shortening of the aortic clamping time was observed.

Search for appropriate experimental methods to create stable hind-limb ischemia in mouse

OBJECTIVE

Stable animal models for refractory peripheral arterial disease are not established. A standardized animal model of hind-limb ischemia is required upon searching effective treatment for this condition. The aim of the study is to verify previously used hind-limb ischemia models to find a standard method.

METHODS

Using Balb/ca mice six various methods of inducing hind-limb ischemia were applied and two weeks after operation degree of ischemic damage were examined. Six methods include V group, A group, AV group, A-strip group, AV-strip group and Prox-A group (refer the text).

RESULTS

Degree of ischemia was evaluated macroscopically by judging toes, foot, knee, and total hind-limb necrosis. We found that severity of damage was markedly different among different methods. Furthermore the severity of necrosis was not uniform even in the same method group.

CONCLUSIONS

The A-strip group in which the femoral artery from the bifurcation of the deep femoral artery to the saphenous artery was stripped appears to be suitable as a stable severe ischemia model. The A group in which the femoral artery were cut just below the bifurcation of the deep femoral artery appears to be suitable as a chronic mild ischemia model.

Recent surgical outcomes of acute type-A aortic dissection

The aim of this study is to assess the early outcome of the surgical treatment of acute type-A aortic dissection using recent improvements in antegrade selective cerebral perfusion. This study included 38 patients who had undergone surgery for acute type-A aortic dissection from October 2003 through March 2006. The surgery results were evaluated in 2 groups: group A was composed of those who had undergone the surgery before the procedures of antegrade selective cerebral perfusion was changed in December 2004, and group B consisted of those who had the surgery after the change. Operations were performed with hypothermic cardiopulmonary bypass, antegrade selective cerebral perfusion during the arch repair, and open distal anastomosis. Times to awakening after the surgery were 27.6±26.2 hours in group A and 19.8±22.3 hours in group B (p= 0.5). Intubation times were 8.55±7.09 days in group A and 5.11±2.56 days in group B (p=0.06). Permanent neurologic dysfunction was observed in 3 patients in group A and 1 in group B (p=0.6). Transient neurologic dysfunction was observed in 4 patients each in groups A and B (p=1). Mortality rates were 21.1% in group A and 10.5% in group B (p=0.65). There were no significant differences in mortality or morbidity between the two groups, but the intubation time tended to be shorter in group B.

Aortic root reconstruction by aortic valve-sparing operation (David type I reimplantation) in Marfan syndrome accompanied by annuloaortic ectasia and acute type-A aortic dissection

To reconstruct the aortic root for aneurysm of the ascending aorta accompanied by aortic regurgitation, annuloaortic ectasia (AAE) and acute type-A dissection with root destruction, the Bentall operation using a prosthetic valve still is the standard procedure today. Valve-sparing procedures have actively been used for aortic root lesions, and have also been attempted in aortic root reconstruction for Marfan syndrome which may have abnormalities in the valve leaflets. We conducted a valve-sparing procedure in a female patient with Marfan syndrome who had AAE accompanied by type-A acute aortic dissection. The patient was a 37-year-old woman complaining of severe pain from the chest to the back. The limbs were long, and funnel breast was observed. Diastolic murmurs were heard. On chest computed tomography, a dissection cavity was present from the ascending aorta to the left common iliac artery, and the root dilated to 55 mm. Grade II aortic regurgitation was observed on ultrasound cardiography. Regarding her family history, her father had died suddenly at 54 years of age. She was diagnosed with type-A acute dissection concurrent with Marfan syndrome and AAE. The structure of the aortic valve was normal, and root reconstruction by a valve-sparing operation and total replacement of the aortic arch was conducted. On postoperative ultrasound cardiography, the aortic regurgitation was within the allowable range, and the shortterm postoperative results were good.

Surgical outcome of stentless aortic valve replacement for calcified aortic stenosis

We have conducted aortic valve replacement (AVR) using a stentless bioprosthesis (Medtronic Freestyle valve) on 10 patients with calcified aortic stenosis since March 2004. There were 64-84 years of age and 75 ± 5.5 years old on average, and included 4 males. Implantation was conducted by a modified subcoronary method in all the patients. The preoperative New York Heart Association class was class II in 80% of the patients. The preoperative left ventricular mass and the left ventricular mass index (LVMI) were 193.1-524.1 g and 144.1-299.5 g/m2 and, on average 328.4 ± 104.7 g and 217.3 ± 55.7 g/m2, respectively. The annulus dimension was 18-24 mm and, on average, 20.3 ± 1.7 mm. The size of implanted valve was 19-25 mm and, on average, 21 ± 2.2 mm. The maximum pressure gradient of the aortic valve remained at 14.2-46.5 mmHg, 25.2 ± 10.2 mmHg on average, 1 or 2 months after surgery, but the LVMI significantly improved to 153.2 ± 33.9 g/m2 (p = 0.018). The hospitalization period were 24.7 ± 16.9 days for all the patients and 19.3 ± 5.1 days for patients undergoing the AVR alone. These results show that LVMI is significantly reduced by using a stentless bioprosthesis in the early phase after surgery, and early discharge from hospital can be expected by concurrently using minimally invasive cardiac surgery.

A case report of papillary fibroelastoma attached to chorda tendineae of mitral valve

The case was a Japanese man of 62 years old. A bulbar mass attached to mitral valve anterior leaflet was discovered in an echocardiography within detailed examination of ischemic heart disease accidentally. We diagnosed him as ischemic heart disease and doubt of heart tumor. We thought about the danger of future embolism, surgical treatment was decided. We dissected the tumor together with one chorda tendineae of mitral valve, and a performed aorta - coronary bypass surgery. We diagnosed the tumor as papillary fibroelastoma by pathological diagnosis. Papillary fibroelastoma is extremely rare with 7-9% of benign tumor of heart primary. Most of the papillary fibroelastoma is incidentally discovered by echocardiography or autopsy. Or it is discovered for systemic embolism. The tumor is benign, but there is a problem to cause embolism. Therefore, when we discovered papillary fibroelastoma, surgical resection of the tumor is the first-line therapy. A problem on surgical therapy is the range of resection area. Papillary fibroelastoma is benign tumor, but the pathological characteristic is still unidentified. Further epidemiological and pathological studies are necessary to determine the extent of surgical excision in associated with characteristics of papillary fibroelastoma.

Aortic root reconstruction in two patients with chronic aortic dissection by aortic valve-sparing procedures using a new aortic root conduit with the sinuses of valsalva (De Paulis Valsalva graft)

The durability of the aortic valve after aortic root reconstruction by an aortic valve-sparing procedure is of particular concern because of the absence of the sinuses of Valsalva in the David type-I reimplantation method. Various improvements have been made to the David-I method. In particular, a new aortic root conduit with the sinuses of Valsalva was developed recently and is expected to improve the long-term follow-up results of the aortic valve-sparing procedures. We used a Valsalva graft in two patients with aortic root dilation accompanied by aortic regurgitation and obtained good short-term results.

Expression of CD44 in primary lung carcinomas using histological and cytological analyses

CD44 is a family of transmembrane glycoproteins expressed in hematopoietic and epithelial cells, and associated with diverse physiological functions such as cell-cell and cell-matrix interactions. CD44 exists in a standard form, CD44s, and in multiple isoforms which are produced by alternative splicing of the variant exons (exon v1 to exon v10) encoding parts of the extracellular domain. Recently, CD44 was shown to play a role in the invasive and metastatic properties of tumor cells. In this study, we demonstrated CD44 immunoreactivities in 74 primary lung carcinomas. CD44s was noted in 38% (28 out of 74) of primary lung carcinomas. CD44v3 (38%, 28 out of 74) and CD44v6 (41%, 30 out of 74) were less frequently expressed in the primary lung carcinomas, compared with non-neoplastic lung tissues (CD44v3, 100%, p < 0.001; CD44v6, 73%, p < 0.05), respectively. CD44v3 and CD44v6 were more frequently found in squamous cell carcinomas than the other histological types (p < 0.05. CD44s, CD44v3 and CD44v6 were noted in 33% (6 out of 18), 44% (8 out of 18) and 33% (6 out of 18) of cytology-positive cases, and in 46% (6 out of 13), 38% (5 out of 13) and 31% (4 out of 13) of cytology-negative cases, respectively. It is suggested that decreased CD44v3 and CD44v6 might be correlated with sputum cytology-negative cases of lung adenocarcinoma.

[Surgical treatment of acute aortic dissections--a clinical study using a ringed intraluminal graft]

From 1984 to 1994, surgery was performed using a ringed intraluminal graft (RIG) in 75 patients with acute aortic dissection (DeBakey's type I in 37 cases, type II in 10 cases and type III in 28 cases). The operative death rate was 24% for type I, 30% for type II and 21% for type III. The average time from onset to surgery was short (47 +/- 67 hours for type I, 34 +/- 36 hours for type II and 47 +/- 77 hours for type III). The outcome of these cases indicated that this technique was effective for saving the lives of patients in the acute early stage of aortic dissection. No characteristic complications developed after this surgery. The postoperative course of patients was followed by using CT scans, MRI, angiography. No patients developed aneurysmal formation in the ligated area or dislocation of the RIG. There were no deaths directly attributable to the RIG. Patients who were autopsied in the late postoperative period showed no aneurysm of the ligated area or necrosis of the aortic wall. In conclusion, RIG surgery effectively saved the life of patients with acute aortic dissection and the RIG could be used as prosthetic graft for long-term periods.

Surgical treatment of infective endocarditis

From February, 1975 through October, 1990, 26 patients underwent surgical treatment for infective endocarditis at Tokai University Hospital. The overall operative mortality rate was 11.5% (3/26). The three patients who died were suffering from aortic prosthetic valve endocarditis (PVE) in the active stage. Among 16 patients in the active stage, the mortality rate was 18.7% (3/16) Among 10 patients with native valve endocarditis (NVE) in the healed stage, all survived. Among the total of 21 patients with NVE, the mortality rate was zero and among those with PVE, the rate was 60% (3/5). Various species of streptococci were the most common organisms encountered, followed by Staphylococcus epidermides. The two PVE patients with S. epidermides died. Nine of the 11 NVE cases in the active stage were of the localized type. Only one case of the localized type of PVE suffered from an infected mitral bioprosthetic valve. The 6 extensive-type cases had aortic valve endocarditis (2NVE, 4PVE). Three patients with the extensive type of PVE died. We conclude that patients with infective endocarditis who develop progressive congestive heart failure, recurrent embolization, or progressive sepsis despite antimicrobial treatments, should undergo prompt valve replacement within 7 days after institution of therapy.

Nephrotic syndrome associated with subacute bacterial endocarditis (SBE): a case report

We experienced a female nephrotic patient associated with subacute bacterial endocarditis. Her proteinuria was completely normalized after antibiotic therapy and valve replacement. Immunofluorescence and an electron microscopic study of a renal biopsy specimen showed little evidence of immune complex in the glomeruli. Marked deposition of properdin in the glomeruli and the reduced level of serum complement may indicate involvement of the complement system in the pathogenic mechanism of massive proteinuria in this case.

Artificial valve replacement for congenital bicuspid aortic valves

The congenital bicuspid aortic valve functions almost normally provided degeneration does not occur, but complications of infective endocarditis and calcification of the cusps with aging are indications for surgical intervention. We compared 22 cases with an incompetent bicuspid aortic valve (14 cases with stenosis and eight with regurgitation) with 96 cases of acquired tricuspid aortic valve (30 cases with stenosis and 66 with regurgitation) who were treated by aortic valve replacement (AVR) during the same period. Compared with the stenotic tricuspid aortic valve cases, the stenotic bicuspid aortic valve cases: 1) were older at AVR (59.3: 51.7 years, P < 0.05), 2) had a smaller diameter of preoperative valve orifice (6.9: 9.2 mm, P < 0.05), 3) had a smaller valve ring diameter (23.0: 24.3 mm, P < 0.05), 4) used artificial valves of almost identical size (22.0: 22.5), and 5) included no operative deaths (0: 10%). In contrast, compared with the tricuspid aortic valve cases with regurgitation, the bicuspid aortic valve cases with regurgitation: 1) were younger at AVR (39.5: 45.8 years), 2) had a higher incidence of infective endocarditis (62.5: 19.6%, P < 0.02) as a complication, and 3) showed a higher operative death rate (25.0: 6.1%), although this difference was not statistically significant. Suture repair of the incised portion of the aorta must be performed meticulously in patients with prominent poststenotic dilatation of the ascending aorta.

Surgical treatment of non-penetrating injury to the aorta

During a 17-year period, eight cases of blunt traumatic injury to the aorta were surgically treated at our hospital. The locations of the lesions were the descending thoracic aorta in four cases, abdominal aorta in two cases, and traumatic DeBakey type IIIb dissection in two cases. Surgical repairs were carried out during the acute or subacute period in four cases and others were electively treated during the chronic period. One patient suffering from acute traumatic dissection of the aorta died of acute renal failure following acute ischemia in the lower extremities 10 days after surgery. Accordingly, the overall mortality rate was 12.5% in this series. We believe that elective operations should be carefully considered if they are possible.

[An experimental study on the relation between lung volume and pulmonary blood flow]

The purpose of this study was to elucidate whether or not the reduction of lung volume is related to the mechanism of blood flow reduction in the atelectatic lung. In adult mongrel dogs, whose main stem bronchus in the thoracotomized lung was obstructed, the change of blood flow in the lung containing N2 was compared with that in the collapsed lung. 1) Under a low partial pressure of O2 in the broncho-alveolar system by obstruction of the main stem bronchus, the blood flow did not change, even when the N2 volume in the lung was varied. Therefore, the change of blood flow in the collapsed lung is not attributable to the reduction of lung volume. 2) The lung blood flow increased when the partial pressure of O2 in the broncho-alveolar system was elevated by infusion of O2 into the collapsed lung, and it decreased with the subsequent O2 absorption leading to lung collapse. Therefore, the change of lung blood flow is due to the change of intraalveolar partial pressure of O2. 3) The reduction of blood flow in the atelectatic lung is caused by hypoxic pulmonary vasoconstriction, and is not influenced by the reduction of lung volume due to the lung collapse.

[Combined medical and surgical treatment of 74 cases of acute type III aortic dissection]

In the early period up to 1986, our treatment of acute type III dissection was anti-hypertension drug therapy as a rule, and Collins operations were performed in two cases of progressive hemothorax. Among 21 patients receiving medical therapy, five died of rupture, and three operated cases died of multiple organ ischemia, and then the hospital mortality was 40%. Since 1987, we have selected hypotensive treatment of strictly maintaining blood pressure less than 120mmHg for the completely thrombosed type of the dissected lumen, and the emergency operation of ringed intraluminal graft insertion (RIG operation) for the blood-flow type and aneurysm formation type of the dissected lumen, diagnosed by the emergency cine-angiography. As the result, among 51 cases having hypotensive therapy, one died of respiratory failure. In the 23 operated cases, in which RIG operation and/or arterial reconstruction was performed, four died of multiple organ ischemia. The hospital mortality was 8%, which was significantly improved compared with that of the early period.

[Torsion after left lower lobectomy and cerebral infarction following the re-exploratory thoracotomy: a case report]

A 38-year-old man had a left lower lobectomy for pulmonary carcinoid. Following the operation, torsion of the left residual upper lobe occurred. Re-explosive thoracotomy was performed on the second postoperative day. The left upper lobe showed a clockwise 180-degree rotation. Pneumonectomy was not done. After the re-thoracotomy, the patient developed right hemiplegia. Head CT showed a cerebral infarction due to the thrombus of pulmonary vein that was released after the repair of the torsion.

[Fontan-type operation in a 14-month-old patient with tricuspid atresia who had [I, D, D], pulmonary atresia and right pulmonary artery stenosis]

A 14-month-old male with tricuspid atresia who had [I, D, D], pulmonary atresia, right pulmonary stenosis and a Blalock-Taussig shunt successfully underwent a Fontan-type operation accomplished by making a direct right atrial-pulmonary arterial connection with a Gore-Tex roof patch. The patient had an uneventful postoperative course without development of the heart failure.

[Pathological findings of the aortic wall at the site of ligation against the rigid rings of an intraluminal graft for acute DeBakey type I aortic dissection]

A ringed intraluminal graft has been utilized in the surgical treatment for dissecting aneurysm since 1978. Histological findings of the aortic wall long after surgery, however, have not been described in detail, and concern remains about possible pressure necrosis at the point of encirclement. The following report is for a case of acute type I aortic dissection which required the use of an intraluminal surgical graft in a patient who died eight months postoperatively of a disease unrelated to previous surgical management. The pathological findings at autopsy were as follows. At the site of circumferential ligations around the aorta, 1) discontinuity of the elastic fibers in the media was found only at the outer surface, 2) there was no compression necrosis in the outer half of the media, although a dark shade of elastic fibers was recognized, 3) there were no pathological changes in the inner half of the media. In addition, complete repair of the intimal tear as well as closure of the false lumen replaced by collagen fibers was confirmed histologically in the whole length of aorta where the intraluminal graft had been placed. We conclude that concerns about the fragility of the aortic wall at the site of circumferential ligation, the migration of prosthesis, and the formation of thrombi is alleviated by these pathological observation.

[A case of a 10-year survivor with squamous cell carcinoma of the lung, treated with radiation after an exploratory thoracotomy]

We have experienced a rare case of an unresectable lung cancer in a male patient who has survived 10 years after radiation therapy. The patient was aged 58 at the time of diagnosis. In May 1978, he was hospitalized because of an abnormal shadow in the upper left lung filed, and the diagnosis of squamous cell carcinoma was made by TBLB. Since subsequent surgery revealed an extensive tumor invasion to the large blood vessels, an exploratory thoracotomy was performed. Following postoperative 60 Gy radiation therapy, tumor regression was observed on examination of chest x-ray films. In July, 1988, 10 years and 3 months after this surgery, a back pain developed due to the recurrence of the tumor, and radiation therapy was given again. This relieved the pain. As of December 1988, he receives treatment on an outpatient basis and his performance status has been excellent.

[Diffuse B-cell lymphoma of anterior mediastinum cured by short-term administration of CDDP-containing regimen]

The following report is of a case of diffuse B-cell lymphoma of the anterior mediastinum that was originally treated by resection and radiation in a patient who had pleural and subcutaneous metastases four months after operation. A total dose of 120 mg of CDDP, 60 mg of BLM, and 15 mg of VBL was administered in five weeks. The metastases completely disappeared by this dose alone, and the patient is alive and well seven and a half years after the chemotherapy.