Graft for mycotic thoracic aortic aneurysm: omental wrapping to prevent infection

Nine cases of mycotic thoracic aortic aneurysm were treated surgically between July 1995 and March 2003. The aneurysms were located in the ascending aorta in 1 patient, the descending thoracic aorta in 5, and the thoracoabdominal aorta in 3. Preoperatively, 3 patients were in shock due to rupture of the aneurysm. All patients underwent aneurysmectomy and in-situ graft placement. In 5 patients, the graft was covered with a pedicled omental flap to prevent postoperative graft infection. There were 2 hospital deaths: one patient died of multi-organ failure, and the other died from intrathoracic bleeding. After discharge, one patient died from intrathoracic bleeding 3 months after surgery. These 3 patients had not received omental wrapping. Postoperative graft infection did not occur in the 6 surviving patients during a mean follow-up period of 4.0 +/- 3.1 years. It was concluded that covering the prosthetic graft with a pedicled omental flap may help prevent postoperative graft infection and improve the surgical results.

Improvement of Liver Function After Surgery for Budd-Chiari Syndrome

PURPOSE

We evaluated the relationship between liver histology and postoperative improvement of liver function after surgery for Budd-Chiari syndrome (BCS).

METHODS

Over a period of 23 years, we operated on 46 patients with BCS by reconstructing the occluded inferior vena cava (IVC) and reopening as many occluded hepatic veins as possible. We divided the patients into a liver cirrhosis group (group I, n = 30) and a hepatic fibrosis or liver congestion group (group II, n = 16), and compared the ages, duration of illness, preoperative liver function, changes in liver function, and changes in esophageal varices (EV).

RESULTS

There were no hospital deaths. In group I the patients were older, and the duration of illness was longer. The group I patients also had a lower thrombotest percentage and a higher serum ammonia. The indocyanine green clearance (ICG) test showed more remarkable improvement in liver function in group II. The rate of disappearance of EV was also higher in group II.

CONCLUSION

Surgery during the early stage of BCS is important in improving postoperative liver function.

The prevention of nerve injury in aortic arch aneurysmal surgery

In a case of aortic arch aneurysm associated with adhesion to the surrounding structures, we devised an operative technique to avoid nerve injury during the surgical procedure. By preserving the adventitial layer of the aortic arch aneurysm to which the phrenic and recurrent nerves were attached, injury to the nerves was avoided, and the aneurysmectomy was completed with the distal anastomosis being performed intraluminally.

Selective visceral perfusion during thoracoabdominal aortic aneurysm repair

PURPOSE

To evaluate the effectiveness of selective visceral perfusion during repair of an thoracoabdominal aortic aneurysm (TAAA), we compared the postoperative renal and hepatic functions (blood urea nitrogen, serum creatinine, total bilirubin, glutamate pyruvate transaminase) between the two groups with and without perfusion.

PATIENTS AND METHODS

We operated on 52 patients with TAAA. Among them, the visceral vessels were reconstructed in 22 patients with selective visceral perfusion and in 12 patients without perfusion. The average selective perfusion time was 49.5+/-25.5 min. in the celiac and superior mesenteric arteries and 32.8+/-18.8 min. in the renal arteries. The average perfusion flow rate per each visceral vessel was 155.4+/-97.4 ml/min.

RESULTS

There were five hospital deaths. There was no significant difference between the groups in the postoperative value of four factors. The selective perfusion time for vessel reconstruction in the selective visceral perfusion group was significantly longer than the arterial clamp time for vessel reconstruction in the non-perfusion group (49.5+/-25.5 min. vs. 25.6+/-13.4 min.).

CONCLUSION

Our selective visceral perfusion method is not only beneficial for organ protection, but also provides us with the necessary time to reimplant the visceral as well as intercostal or lumbar arteries.

Direct cannulation of the common carotid artery during the ascending aortic or aortic arch replacement

OBJECTIVE

To evaluate cerebral perfusion using direct cannulation into the common carotid artery. A new technique is needed to protect brain ischemic injury during ascending aortic or aortic arch replacement.

METHODS

This technique was evaluated for patients who would have difficulty maintaining adequate cerebral perfusion during surgery. The procedure was performed when patients had the following diagnoses: pseudoaneurysm formation in contact with the sternum with the risk of aneurysmal rupture (n = 5), acute aortic dissection with compression of the true lumen of the innominate artery by the pseudolumen (n = 3), or a large volume of thrombus in the lumen of the aneurysm with the risk of cerebral thromboembolism if standard extracorporeal circulation was used (n = 2). The perfusion catheter was cannulated into one side of the common carotid artery (right side: n = 6, left side: n = 4) and mean perfusion flow rate was found to be 175 mL/min. The operative procedures consisted of ascending aortic and aortic arch replacement with coronary artery bypass grafting in six patients, ascending aortic replacement in 2 patients, and innominate artery reconstruction/innominate artery and right subclavian artery reconstruction in one patient.

RESULTS

No cerebral accidents or deaths occurred while patients were hospitalized. We have followed up patients for a mean of 2.1 years (maximum 3.6 years), with no complications noted from the surgical procedure.

CONCLUSIONS

Direct cannulation of the common carotid artery is a simple, safe, and acceptable cerebral protection for patients undergoing aortic or aortic arch replacement procedures in the patients with these specific conditions.

[Spinal cord protection during thoracoabdominal aortic aneurysm repair; efficacy of distal aortic perfusion and segmental aortic clamping]

Despite improvement in adjuncts for thoracoabdominal aortic aneurysms (TAAA) repairs, many devastating complications remains after the surgery. Our experience with these aneurysms has been reviewed in order to identify those methods at risk of major morbidity, as well as which further improvements required. During last 16 years, 53 consecutive patients were operated on TAAA. The mean age was 58 years. Twenty patients had dissecting aneurysms and 13 patients had had prior aortic surgery. A femoro-femoral bypass was used to maintain distal aortic perfusion in most patients. Reimplantation of intercostal or lumbar arteries under the multi-segmental aortic clamping is consistent in our technique. Motor evoked potentials (MEP) were measured to monitor spinal cord protection since 2000. The hospital mortality was 9.4% (5/53), 22.2% (2/9) for emergency operation and 15.4% (2/13) for patients with prior aortic surgery. The mortality for the first and elective operations was 3.2% (1/31). No any neurologic dysfunction was observed in all patients including the hospital deaths. In view of clinical results, our adjuncts and techniques are useful for prevention of spinal cord ischemia during the TAAA surgery.

Pannus formation in aortic valve prostheses in the late postoperative period

We present three patients who underwent repeat aortic valve replacement for prosthetic valve dysfunction caused by tissue ingrowth in the late postoperative period. These patients (three women aged 48-51 years, mean 49.3 +/- 1.53 years) underwent operations for restriction of prosthetic valve leaflet movement by pannus in the left ventricular outflow tract. The interval from the previous operation ranged from 8.0 to 9.6 years (mean 9.6 +/- 2.0 years). The symptoms of the patients were New York Heart Association functional class I, II, and IV in one patient each. Diagnosis was made by cinefluoroscopy in two patients and aortography in one patient. The operative procedures consisted of aortic valve replacement ( n = 1) and aortic valve replacement with mitral valve replacement ( n = 2). Pannus was found at the left ventricular aspect of the prosthetic valve in all patients. In two patients, the pannus directly restricted movement of the leaflet and also severely narrowed the inflow orifice of the prosthetic valve. In the other patient, the pannus had grown at a distance of 7 mm from the valve and narrowed the left ventricular outflow tract circularly. The postoperative course was uneventful and all three patients were discharged in a good condition. One patient died of pneumonia 8 months after surgery and the other two patients have remained well and have been followed up for one and a half years. In conclusion, there may be a discrepancy between the clinical symptoms and the grade of subvalvular stenosis caused by pannus. Therefore, it is essential for satisfactory operative results that early diagnosis be made by various means.

Prevention of postoperative paraplegia during thoracoabdominal aortic surgery1This article has been selected for the open discussion forum on the CTSNet Web site: http://www.ctsnet.org/discuss1

BACKGROUND

We present data showing the impact of sequential multisegmental aortic clamping accompanied by reimplantation of as many segmental arteries as possible on the prevention of postoperative paraplegia or paraparesis during thoracoabdominal aortic graft replacement.

METHODS

Since 1987 we have performed graft replacements in 51 individuals undergoing thoracoabdominal aortic surgery using the technique of normothermic partial bypass with sequential multisegmental aortic clamping. The procedure was performed emergently in 10 patients and electively in 41 patients. The patients ranged in age from 22 to 82 years (mean, 57.6 +/- 13.8 years). Indications for surgery included dissecting thoracoabdominal aortic aneurysm (n = 19) and nondissecting thoracoabdominal aortic aneurysm (n = 32). The extent of aneurysm was Crawford type I in 19 patients, type II in 7 patients, type III in 12 patients, and type IV in 13 patients. Along the entire extent of aneurysm to be replaced, we reimplanted as many of the patent segmental arteries as feasible.

RESULTS

Five patients died during hospitalization, for an in-hospital mortality rate of 9.8%. The number of aortic clampings per patient ranged from one to five (median, three). A total of 124 segmental arteries were reimplanted in 44 (86.3%) of 51 patients. Of the 124 arteries, 90 (72.6%) were distributed between T9 and L2. Postoperative paraplegia or paraparesis did not develop in any of the patients.

CONCLUSIONS

Our results demonstrate that extensive reimplantation of segmental arteries using sequential multisegmental aortic clamping, accompanied by adequate intraoperative distal aortic perfusion, is effective in preventing spinal cord ischemia.

Blood distribution to the anterior spinal artery from each segment of intercostal and lumbar arteries

AIM

Prevention of paraplegia, a serious complication of surgery for thoracoabdominal aortic aneurysm, has been well documented. However no assured prophylaxis against this complication has yet been found. Spinal ischemia is believed to be the major cause of paraplegia. We conducted an experimental study to define the development of paraplegia with regard to the blood supply to the spinal cord.

METHODS

A porcine model was used to evaluate blood distribution to the anterior spinal artery. Colored silastic agent was selectively injected into the intercostal and lumbar arteries, and distribution to the anterior spinal artery was evaluated on 50 animals. The intercostal and lumbar arteries were ligated in the segments where the blood supply to the anterior spinal artery would be interrupted. Whether or not paraplegia developed was checked 2 days later.

RESULTS

Colored silastic agent arrived at the anterior spinal artery from all segments of the 8th intercostal to 4th lumbar arteries. Two of 9 pigs (22.2%) that underwent ligation of the segments from the 9th intercostal to 2(nd) lumbar artery suffered paraplegia. In 3 non-paraplegic pigs, colored silastic agent injected into the preserved arteries was found to have covered a wider range.

CONCLUSION

All the intercostal and lumbar arteries supplied blood to the anterior spinal artery. When large segments of intercostal and lumbar arteries were ligated, the blood flow from the preserved segments acquired increased dominance. The possibility exists that any intercostal and lumbar artery can supply blood to the spinal cord and become collateral circulation to the anterior spinal artery.

Myocardial protective effect of hypothermia during extracorporeal circulation -- by quantitative measurement of myocardial oxygen consumption -

OBJECTIVE

To evaluate the effect of systemic temperature on myocardial protection during extracorporeal circulation, we quantitatively evaluated the relationship between myocardial oxygen consumption and rectal temperature.

MATERIALS AND METHODS

Myocardial oxygen consumption during cardiac arrest was calculated via blood gas analysis of venous blood samples collected from the coronary sinus. The rectal temperatures of the patients during extracorporeal circulation ranged from 16.0 degrees C to 33.5 degrees C. The patients were classified into three groups according to their rectal temperature: group I (n=10; rectal temperature: 20.3+/-1.80 degrees C), group II (n=24; rectal temperature: 29.4+/-0.97 degrees C), and group III (n=29; rectal temperature: 31.7+/-0.72 degrees C). The myocardial oxygen consumption of each group was then compared.

RESULTS

The average of the myocardial oxygen consumption of all cases was 62.5+/-64.0 O(2) ml/min/100 mm(3) left ventricle volume, and the averages of the individual groups were 26.9+/-28.8 in group I, 72.2+/-71.8 in group II, and 69.3+/-62.6 in group III. There was a significant difference in the oxygen consumption between group I and the other two groups. There was a positive correlation between the rectal temperature and myocardial oxygen consumption, as reflected in the following formula: Y=-0.3 x X +1.10 x X(2)-0.02 x X(3) (Y, myocardial oxygen consumption; X, rectal temperature; R(2)=0.533; P<0.0001).

CONCLUSION

This study suggested that rectal temperature below 22.5 degrees C is advantageous due to the resultant myocardial protection such hypothermia affords.

Surgical treatment of Budd-Chiari syndrome induced by Behcet's disease

OBJECTIVE

Although Budd-Chiari syndrome in Japanese is usually chronic, and of unknown etiology and idiopathic, Behcet's disease is rare as an underlying disorder of Budd-Chiari syndrome in Japanese. To clarify the Behcet-induced Budd-Chiari syndrome, the clinical course and pathologic findings of patients with Behcet-induced Budd-Chiari syndrome were compared with those of patients with idiopathic Budd-Chiari syndrome.

PATIENTS AND METHODS

We treated 45 patients (15 women and 30 men) with our devised surgical procedure. With normothermic partial bypass, the occluded vena cava and hepatic veins were reopened. The age of the patients ranged from 24 to 76 years (mean, 48.9 13.0 years). In two patients, Budd-Chiari syndrome was induced by Behcet's disease (Behcet group). The other 43 patients (control group) had no distinct underlying disorder. The Behcet group was compared to the control group with regards to (1) onset of symptoms and duration of illness prior to medical treatment, (2) preoperative laboratory data including liver function, (3) intraoperative findings, (4) microscopic findings of liver tissue, and (5) postoperative course.

RESULTS

(1) In the Behcet group, duration of illness from diagnosis to surgical treatment was markedly shorter (P=0.027, 8.5 months vs. 10.1 10.6 years). (2) The preoperative laboratory data of liver function were similar in both groups with moderately impaired hepatic function. (3) The Behcet group had no patent hepatic vein (P=0.025 vs. 1.22 0.57). (4) Microscopic examination of the liver tissue showed liver cirrhosis or liver fibrosis in the control group, and centrilobular marked congestion only in the Behcet group. (5) During hospitalization, one patient of the control group died due to preoperative severe hepatic failure. One patient with Behcet's disease underwent reoperation due to reocclusion by Behcet-induced vasculitis, and the other died of peritonitis by intestinal Behcet's disease.

CONCLUSION

In Budd-Chiari syndrome in Japanese, the Behcet-induced Budd-Chiari syndrome had an acute clinical course, and its postoperative prognosis depends on the prognosis of the Behcet's disease.

Surgical treatment of aortic arch aneurysm combined with coronary artery stenosis

OBJECTIVE

We present operative results of aortic arch aneurysm associated with coronary artery stenosis, and evaluate the operative risk of graft replacement of the aortic arch and concomitant coronary artery bypass grafting (CABG).

PATIENTS AND METHODS

From January 1991 to December 2001, we treated 16 patients with aortic arch aneurysm and coronary artery stenosis. The patients, 3 women and 13 men (study group) ranged from 58 to 79 years of age, average 68.1 5.3 years. With the aid of deep hypothermic cardiopulmonary bypass, we performed graft replacement of the aortic arch aneurysm and concomitant CABG. We bypassed 31 coronary arteries. The bypass grafts included saphenous vein (n=16), left internal thoracic artery (n=4), right internal thoracic artery (n=1), right gastroepiploic artery (n=5) and inferior epigastric artery (n=2). The number of bypassed coronary arteries per patient ranged from 1 to 3, average 2.1 0.8/patient. A comparative study was performed between the study group and a control group of patients (n=39) who had undergone only graft replacement of the aortic arch.

RESULTS

There was no significant difference between the two groups regarding: operation time, cardiopulmonary bypass time, cardiac arrest time, intraoperative bleeding volume, and early mortality rate. However, in the patients (n=4) of the study group who had undergone total arch graft replacement with three vessel CABG, the cardiopulmonary bypass time was significantly longer than that of the patients in the control group who underwent total arch graft replacement (n=19, P<0.05). Two of the 16 study group patients died in the early postoperative period, resulting in 12.5% early mortality rate. In the control group, four of 39 patients (10.3%) died in the early postoperative period.

CONCLUSIONS

CABG combined with graft replacement of the aortic arch does not increase operative risk when the number of bypassed vessels is within two vessels, but may increase risk when three or more vessels are bypassed.

Early diagnosis and radical surgical treatment of Budd-Chiari syndrome

We report a 26-year-old woman who was diagnosed with Budd-Chiari syndrome following consultation for a skin nodule in the lower extremity. Histopathological examination of a biopsy specimen showed features of erythema induratum. As part of the diagnostic work-up, chest roentgenography performed to rule out possible tuberculosis showed enlarged right lower mediastinum. Computed tomography identified a dilated azygos vein and obstruction of the inferior vena cava near the liver. Liver function tests and blood cell counts were all within normal limit and no sign of portal hypertension was noted except for mild splenomegaly. Although angioplasty by balloon catheter resulted in recanalization of the obstructed inferior vena cava, obstruction of the inferior vena cava appeared again 2 months later. One-stage surgical reconstruction of the vascular abnormalities affecting inferior vena cava and hepatic vein using autologous pericardial patch was performed 11 months after angioplasty, which resulted in normalization of blood flow. Examination of a liver biopsy obtained intraoperatively revealed hepatic fibrosis compatible with early-stage Budd-Chiari syndrome. No complications were noted postoperatively and the nodular lesion in the lower extremity disappeared after surgery.

Cooling device for bradycardia based on Peltier element for accurate anastomosis of off-pump coronary artery bypass grafting

Upon introducing off-pump coronary artery bypass grafting (CABG), the indications for CABG were expanded to include patients who previously had no operative indications. For accurate anastomosis, various devices and methods have been developed. Bradycardia is easily induced by drug administration. However, this method of achieving bradycardia also has adverse effects on cardiac function. We have developed a new device to decrease the heart rate by regional cooling of the sino-atrial node. The new device is incorporated with Peltier's element, which uses an electric charge to create a temperature gradient on both of its surfaces. In terms of the cooling ability of this device, its cooling surface is chilled from 25 degrees C to 0 degrees C within 30 s. During in vivo animal experiments, this device has been shown to decrease the myocardial temperature around the sino-atrial node to 15 degrees C and suppress sino-atrial node activity, resulting in bradycardia to 60 beats/min level. In summary, the simple and easily applicable device for local cooling in combination with the application of diltiazem for effective heart rate reduction may be very helpful for the surgeon and may avoid disadvantages for critically ill patients.

[Impact of multi-segmental aortic clamping and distal aortic perfusion on the prevention of postoperative paraplegia during thoracoabdominal aortic graft replacement]

OBJECTIVE

We present the impact of multisegmental aortic clamping under distal aortic perfusion and segmental artery reimplantation on the prevention of postoperative paraplegia during thoracoabdominal aortic graft replacement.

PATIENTS

During the last 14 years in 47 patients (age range: 22 to 82 years; average: 57,9 +/- 13,2 years; 16 females and 31 males) with thoracoabdominal aortic aneurysm a graft replacement was performed with adjuncts of normothermic partial bypass and multisegmental aortic clamping. As many patent segmental arteries as possible were reimplanted.

RESULTS

Five patients died during hospitalization, for an in-hospital mortality rate of 10,6 %. In the elective patients (n = 40), the hospital mortality rate was 7,5 %. The average number of segmental aortic clampings per patient was 2,83 +/- 1,19 times. In 39 patients (82,9 %), 117 segmental arteries were reimplanted or preserved by beveled anastomosis. Eighty-three out of 117 segmental arteries (70,9 %) were located between TH9 and L2. Postoperative paraplegia/paraparesis did not occur in any patient.

CONCLUSION

In view of our results reimplantation of as many segmental arteries as possible under multisegmental aortic clamping with adequate distal aortic perfusion can be recommended for effective prevention of spinal cord ischemia in TAAA surgery.

Management of the heart rate during coronary artery bypass grafting on the beating heart: newly devised methods of decreasing heart rate--a preliminary report-

BACKGROUND

To develop new methods for achieving bradycardia, we studied the feasibility of producing transient, reversible bradycardia with atrial stimulation and cooling of the sinoatrial node.

METHODS

In an animal study, the atrium was stimulated electrically during the refractory period of the atrioventricular node. Alternatively, an area of the sinoatrial node was cooled regionally. The two methods were also performed in combination. In a clinical study, atrial stimulation was applied in seven consecutive patients who underwent coronary artery bypass grafting (CABG).

RESULTS

In the animal study, atrial stimulation was effective only when 2 mg/kg of diltiazem was administered. Such atrial stimulation decreased heart rate (beats/minute) from 95.8+/-16.9 to 64.2+/-20.0 (the average reduction from the control value 66.1+/-10.3%). Cooling the sinoatrial node decreased heart rate, and was effective with or without administration of diltiazem. Heart rate was decreased from 156.6 31.7 to 110.7+/-21.7 (average reduction from control value 71.3+/-9.2%) before using diltiazem and from 102.0+/-11.9 to 63.5+/-13.9 (average reduction from control value 62.0+/-10.4%) after administration of diltiazem. By combining the two methods, heart rate was decreased from 102.0+/-12.3 to 44.6+/-9.1 (average reduction from control value 43.5+/-6.3%). In our clinical study, the atrial stimulation method was effective.

CONCLUSION

Atrial stimulation or regional cooling of the sinoatrial node slowed the heart rate. By combining the two methods, the heart rate was slowed to 40. Clinically, atrial stimulation was effective in CABG patients.

One-stage operation for descending thoracic aortic aneurysm and left lung cancer: a case report

We performed concomitant graft replacement for descending thoracic aortic aneurysm and pulmonary resection for squamous cell carcinoma of the left upper lobe in a 79-year-old man. The tumor reached the parietal pleura. No distance metastasis was found, and the tumor was diagnosed preoperatively as a stage IIB (N0, M0, T3) tumor. The descending thoracic aortic aneurysm was saccular, with greatest diameter being 55 mm, and extending from TH5 to TH8. A left upper lobectomy was performed, and after irrigation with a large volume of saline diluted with povidone iodine, graft replacement for the aortic aneurysm was performed under femoro-femoral partial bypass. To prevent postoperative graft infection, the greater omentum was dissected and placed over the resected pulmonary hilum and the graft. The patient's postoperative course was uneventful. There was no sign of infection, and the patient was discharged 1 month after surgery. Artificial graft wrapping with the greater omentum was useful for the prevention of the postoperative graft infection in this case of surgical treatment of lung cancer and descending thoracic aortic aneurysm.

Successful surgical treatment of impending rupture of thoracoabdominal aortic aneurysm in an elderly patient with severe pulmonary emphysema

In a case of successful surgery for impending thoracoabdominal aortic aneurysmic rupture, an 83-year-old man with severe pulmonary emphysema was transferred to our hospital diagnosed with impending aneurysmic rupture. The aneurysm had been pointed out 2.5 years ago but surgical repair was not undertaken due to the patient's severe pulmonary emphysema. After admission, computed tomography showed an enlarging saccular thoracoabdominal aortic aneurysm. Emergency surgery was conducted because of severe pain below the left costal margin. We resected the wall of the saccular aortic aneurysm and reconstructed the aorta with an on-lay patch under femoro-femoral bypass and selective visceral organ perfusion. Tracheostomy provided respiratory care on the day following surgery. The patient was weaned from respiratory support 6 days after surgery. Postoperative aortography showed that the reconstructed thoracoabdominal aorta functioned satisfactorily. The patient remains in good health 18 months after surgery.

Two-stage operation for multiple aneurysms of the thoracic aorta, abdominal aorta, and left common iliac artery in an octogenarian

Multiple aortic aneurysms are well described in the surgical literature. However, there are many problems related to surgical treatment of elderly patients with such aneurysms. This report presents the case, an octogenarian with multiple aortic aneurysms that were successfully treated by graft replacement. An 82-year-old man with a descending aortic aneurysm was referred to our institution for surgery. In addition to the previously diagnosed aneurysm, computed tomography and aortography showed an abdominal aortic aneurysm and a left common iliac aneurysm. Since the patient was an elderly man with chronic obstructive pulmonary disease, a two-stage operation was performed. The abdominal aortic aneurysm and left common iliac aneurysm were resected first due to the risk of thromboembolism from the abdominal aortic aneurysm during surgery involving replacement of the descending aorta under femoro-femoral (F-F) bypass. Fifty-two days after the first operation, a second operation was performed to repair the descending aortic aneurysm. The postoperative course was uneventful. Angiography after the operation showed satisfactory replacement of the multiple aortic aneurysms. The patient was discharged 25 days after the second operation.

A new devised skirted elephant trunk technique

A simple and effective new elephant trunk technique was devised and applied to two patients with a successful result. In advance before the operation, an arch graft with a skirted elephant trunk was made. This was done by inserting a smaller, 22 mm diameter sized graft into the arch graft at the distal end and suturing it so as to leave a skirt extending over the smaller graft. This configuration facilitates the distal anastomosis and effectively shortens anastomotic time.

Successful treatment of bilateral deep femoral aneurysms and multiple iliac aneurysms associated with severe aortic valve disease: report of a case

We report herein the case of a patient in whom aneurysms of the bilateral deep femoral arteries (DFA) and multiple iliac aneurysms associated with severe aortic valve disease were successfully treated by a two-staged operation. The patient was a 74-year-old man who had dense calcification of the ascending aorta and aortic arch. Prior to aortic valve replacement (AVR), the aneurysms of the DFA and internal iliac arteries were resected. The terminal end of the abdominal aorta and bilateral common iliac arteries were then reconstructed with a Y graft to be used as a possible alternative arterial input route in place of the ascending aorta for extracorporeal circulation during the AVR. The inferior mesenteric artery (IMA) was well developed, and the external iliac arteries and their branches were preserved at aneurysmectomy. Postoperatively, there was no ischemia of the pelvic organs or the hip muscles. The AVR was subsequently performed 5 weeks after the first operation, and the patient was discharged after an uneventful postoperative course.

Improvement in esophageal varices and liver histology postoperatively in Budd-Chiari syndrome

BACKGROUND

In the past 17 years, 32 patients with Budd-Chiari syndrome were treated by reconstruction of the occluded inferior vena cava and reopening of the hepatic veins under femoro-femoral normothermic extracorporeal partial bypass. The mean follow-up was 8 years (range, 1.5 to 17 years).

METHODS

To evaluate the benefits of our operative procedure, we compared the preoperative, early postoperative, and late postoperative endoscopic appearance of the esophageal varices and the histologic findings of the liver tissue obtained intraoperatively and at a later date.

RESULTS

The esophageal varices found preoperatively in 29 patients (90.6%) had disappeared in 7 patients by the time of discharge, and in 2 patients they disappeared 4 to 7 years after surgery. In the remaining 20 patients, the grade of the esophageal varices was reduced markedly. Histologic examination of the liver showed cirrhosis in 22 patients, fibrosis in 9 patients, and severe congestion in 1 patient. Inspection of the liver in the late postoperative period (in 10 patients) showed improvement in centrilobular congestion and no increase in interlobular fibrosis.

CONCLUSIONS

Gradual and steady improvement of esophageal varices and hepatic fibrosis can be achieved after our operative procedure.

A ruptured syphilitic descending thoracic aortic aneurysm. The characteristic findings on computed tomography for the etiological diagnosis of aneurysm

We report the case of a 72-year-old man with a ruptured syphilitic descending thoracic aneurysm who underwent an emergency operation and successful graft replacement. Preoperative physical examination showed a pulsative mass on the left back. Preoperative computed tomography showed bone destruction in the TH6 to TH10 thoracic vertebrae and ribs and penetration (or rupture) of the aneurysm into the subcutaneous tissue. During the period of preoperative evaluations, free wall rupture of the aneurysm occurred and emergency operation for graft replacement was performed. The microscopical examination of the aneurysmal wall revealed the syphilitic changes. In literature, the vertebral destruction by atherosclerotic aneurysm is usually located at the TH12 to L3 of vertebral bodies. From the findings of this patient and a study of existing literature, we concluded that the finding of vertebral bone beyond TH12 to L3 region on CT examination of the aneurysm could be a etiological characteristic finding for syphilitic aortic aneurysm.

[Cerebral complication during open heart surgery in relation to cerebral arterial stenosis documented by angiography]

To determine the cause of a cerebral lesion after open heart surgery, a cranial 4-vessel-study was performed prior to an elective operation in 89 patients, who were over 70 years of age and/or had a previous history of cerebro-vascular diseases (CVD). Patients with arterial stenosis over 75% to complete obstruction were categorized as the significant stenosis group and the others as the normal findings group. Of the 89 cases, 19 (21.1%) showed significant stenosis, among which six patients were found to have complete occlusion of the internal carotid artery. Seven patients (7.9%) developed postoperative neurological complications, with four patients having single or plural significant stenosis. Angiograms of three of those four patients revealed complete obstruction of their internal carotid arteries. The stenotic group showed a tendency toward neurological complications in comparison with the non-stenotic group although the incidence was not significant (p = 0.054). However analysis of the group with complete occlusion of the internal carotid artery indicated significant increased risk for cerebral complication (p < 0.013). Besides the 89 patients studied, an additional 479 patients who had not undergone preoperative angiography were subjected to this study whether the patient's age, previous history of CVD and extracorporeal circulation (ECC) time or aortic cross-clamp time were of the risk factors for postoperative cerebral complications or not. There was significant correlation between age (p = 0.044) and/or the previous history of CVD (p < 0.001) and neurological complications. Although there was no correlation between either the duration of ECC or aortic cross-clamp time and neurological problems within the whole study population, when only the patients over 70 years old and/or having history of CVD were studied, an increased tendency towards neurological complications was seen when the ECC time was longer than 120 minutes (p = 0.045).

[Study of pulmonary function after CABG with pleurotomy]

We studied the influence of pleurotomy during harvesting IMA for CABG on postoperative pulmonary function. Ninety nine cases underwent CABG surgery from January 1991 to July 1992, were divided into three subgroups, 45 patients (subgroup AY 2) having bilateral IMAs graft with pleurotomy, 45 patients (subgroup AY 1) having unilateral IMA graft with pleurotomy, 9 patients (subgroup AN) having unilateral IMA graft or vein grafts without pleurotomy. Frequencies of chest X-rays abnormality such as elevation of diaphragm and accumulation of pleural effusion before discharge around 2 weeks after surgery, were not significantly different among three subgroups. 58 cases without chest X-rays abnormalities were divided into three subgroups in the same way. There was no case with late extubation or with postoperative pulmonary complication. At first we compared pre-with postoperative pulmonary function in each subgroups. Pulmonary function (VC, FEV1.0, peak flow, MMF, V50, V25) was significantly deteriorated in the patients with pleurotomy, while VC, FEV1.0, peak flow significantly decreased, and MMF, V50 and V25 tended to decrease in the patients without pleurotomy. Moreover, magnitude of change of pulmonary function from pre- to postoperative period were not different significantly among three subgroups. In conclusions pleurotomy itself didn't appear to influence postoperative morbidity.