Post-traumatic giant thrombosis of inferior vena cava induced right-sided blunt traumatic diaphragmatic injury: a case report

BACKGROUND

Inferior vena cava thrombosis is a severe disease as it carries a higher risk of developing pulmonary embolism associated with a high mortality rate. The incidence of inferior vena cava thrombosis is extremely low and is commonly associated with outflow obstruction of the inferior vena cava. The frequency of traumatic diaphragmatic injuries is less than 1% of all traumatic injuries. In addition, it was not a typical cause of inferior vena cava obstruction. We report the case of the patient who presented with giant thrombosis of the inferior vena cava, which required surgical treatment-induced right-sided blunt traumatic diaphragmatic injury.

CASE PRESENTATION

A 60-year-old male presented to the emergency department with pelvic and lower leg pain. He was working on a dump truck with the bed raised position. Suddenly, the bed came down, and his body was crushed and injured. Primary CT showed a right lung contusion and elevation of the right diaphragm but no apparent liver injury. The right pleural effusion gradually worsened after admission, as the traumatic diaphragmatic injury was highly suspected. Repeat CT showed aggravation of elevation of the right-sided diaphragm, narrowing of the inferior hepatic vena cava due to left cephalic deviation of the liver, and formation of a giant thrombus in the inferior vena cava. No adverse hemodynamic effects were observed due to thrombus formation, and we performed thrombolytic therapy. The day after starting thrombolytic therapy, the patient developed pulmonary embolism due to a dropped in SpO₂ needed oxygen, and dyspnea triggered by coughing. Thrombolytic therapy was continued after the diagnosis of pulmonary embolism. However, thrombolytic therapy was ineffective, so we decided on surgical thrombectomy and inferior vena cava filter placement. The postoperative course was not eventful, and an anticoagulant was started. The patient was transferred to the hospital on the 62nd day for rehabilitation.

CONCLUSIONS

When a diaphragmatic hernia is suspected of causing hepatic hernia and narrowing of the inferior vena cava, it may be necessary to consider emergency surgical treatment to prevent secondary inferior vena cava thrombosis and fatal pulmonary embolism.

[The Role of Corrugated Bioresorbable Sheet for Bone Fixation after Median Sternoto]

OBJECTIVES

Performing sternal reconstruction after a median sternotomy using a corrugated bioresorbable sheet composed of poly-L-lactide acid and hydroxyapatite can improve the safety and efficacy of the treatment outcome and promote bone healing.

METHODS

We compared treatment outcomes of 53 patients who underwent sternal closure using a corrugated sheet (group P) from October 2018 with retrospectively evaluated outcomes of 57 patients who underwent sternal closure using a sternal pin-type device( group C).

RESULTS

Sternal wound infection was not observed in either group. Significant sternal dehiscence was not observed in group P, but it was seen in three cases in group C( p=0.0449). Incomplete approximation by wire cutting was observed in 3% of patients in group P and 15% of patients in group C( p=0.0645). Displacement in the antero-posterior direction was 1.35 mm in group P and 1.67 mm in group C (p=0.0707). The drain discharge volume during 12 hours after operation was 175 ml for group P and 220 ml for group C (p=0.1958), while the total drain discharge volume was 380 ml for group P and 622 ml for group C( p=0.0068). The mean hospital stay was 23.9 days for group P and 26.3 days for group C( p=0.3637).

CONCLUSIONS

The total volume of drain discharge significantly decreased when a bioresorbable corrugated sheet was used for sternal closure. We also consider that the bioresorbable corrugated sheet may improve repair of the split sternum and could result in decreased sternal dehiscence.

[Effects of Olmesartan Medoxomil on Patients with Thoracic and Thoracoabdominal Aortic Aneurysm;Evaluation of Anti-hypertensive Effect and Possible Suppression of Aneurysmal Dilation( OLM 40 Study)]

We evaluated the blood pressure( BP) lowering effect and possible suppression of aortic enlargement by olmesartan (OLM) in patients with thoracic and thoracoabdominal aortic aneurysm. In this single center prospective, forced titration study, 50 patients were registered between 2008 and 2011. After all patients received any of OLM 10, 20, and 40 mg/day as an initial dose, the dosage of OLM was titrated up to 40 mg as needed during follow-up period. Home BP (HBPs), aortic aneurysm size assessed by computed tomography (CT) scan, indices of renal function were recorded at 3- and 6-months follow-up. Depending on whether 40 mg/day of prescription was continued for more than 4 months or not, the patients were divided into 2 groups:less than 40 mg (<40 mg) and 40 mg groups. Morning HBPs tended to decrease in both groups, and the percent changes in BPs were essentially the same regardless of dosage. The absolute value of aortic diameter tended to slightly enlarge only in <40 mg group. Also in the <40 mg group, the absolute differences in aortic diameter between those at the time of study registration and each follow-up were 0.5±1.8 mm at 3-month and 1.2±2.3 mm at 6-month (p=0.047),whereas the percent changes were 0.9±3.3% and 2.2±4.5% at 3 and 6 months, respectively( p=0.058). As for 40 mg group, the absolute differences and percent changes did not reach statistically significant increase during the follow-up period. No severe renal dysfunction related to OLM 40 mg prescription was observed. Our results imply that OLM 40 mg may suppress aortic aneurysmal dilation independently of blood pressure lowering effect. Further study with larger number of sample size is warranted to assure this observation.

Marchiafava-Bignami disease with haemophagocytic lymphohistiocytosis as a postoperative complication of cardiac surgery

Marchiafava-Bignami disease (MBD) is a rare complication of chronic alcoholism; however, MBD in a non-alcoholic diabetic patient has rarely been reported. The aetiology or pathophysiology of MBD is still unknown. A 50-year-old man with a history of untreated diabetes mellitus underwent on-pump beating coronary artery bypass graft surgery (CABG) surgery for three-vessel and left main coronary disease. 3 days after the surgery, he developed a fever over 40°C and entered a coma state. MRI revealed multiple lesions, including in the corpus callosum, globus pallidus, brain stem and upper cervical spinal cord, which suggested MBD. The patient did not respond to thiamine therapy, but partly responded to steroid therapy. He ultimately died of respiratory failure. The autopsy revealed MBD and haemophagocytic lymphohistiocytosis. It is rare, but systemic inflammatory response syndrome induced by on-pump beating CABG could develop these complication.

Differential selective hypothermic intercostal artery perfusion: a new method to probe spinal cord perfusion during thoracoabdominal aortic aneurysm repair

OBJECTIVE

To prevent paraplegia in patients undergoing thoracoabdominal aortic aneurysm repair, the importance of preoperative identification of the Adamkiewicz artery and reconstruction of critical intercostal artery have been advocated. Conversely, significance of collateral network for spinal cord perfusion has been recognized. We invented a new system consisting of a direct monitoring of cerebrospinal fluid temperature (CSFT) and differential selective hypothermic intercostal artery perfusion (D-HIAP).

METHODS

After exposing a critical intercostal artery, a 10-mm prosthetic graft was anastomosed in an end to side fashion. A balloon-tipped catheter was inserted into the graft to perfuse with 15 °C blood. Neighboring intercostal arteries were also perfused in the same fashion. Serial monitoring of CSFT was performed. Between January 2011 and January 2015, D-HIAP was employed in 50 patients with Adamkiewicz artery that located within a reconstructed area.

RESULTS

Significant CSFT drop was recorded after initiation of D-HIAP in 42 (84%) patients. Of those, 34 (68%) patients showed significantly lowered CSFT with D-HIAP into a single critical intercostal artery. Perfusion into plural intercostal arteries was necessary for CSFT drop in 2 cases (4%), and plural intercostal artery perfusion further enhanced CSFT drop that had been modestly achieved by single intercostal artery perfusion in 6 cases (12%). Eight (16%) patients did not exhibit a significant drop in CSFT even when D-HIAP was employed for the critical and neighboring intercostal arteries.

CONCLUSIONS

The detection of a disparity in temperature between the intrathecal space and blood generated by D-HIAP revealed individual variability in CSFT changes, which may imply a complexity in spinal cord perfusion. Intraoperative D-HIAP may help to identify a major blood supply for spinal cord perfusion and underlying collateral network.

Suppressive effect of pitavastatin on aortic arch dilatation in acute stanford type B aortic dissection: analysis of STANP trial

OBJECTIVES

Medical therapy for patients with uncomplicated acute type B aortic dissection (ABAD) is essentially accepted for its excellent early outcome; however, long-term outcomes have not been satisfactory due to aorta-related complications. This trial was performed to investigate the efficacy of a statin as an additive that may enhance the effectiveness of conventional medical treatment in patients with ABAD.

METHODS

This was a multi-center, prospective, and randomized comparative investigation of patients with uncomplicated ABAD. Fifty patients with ABAD compatible with inclusion criteria were randomly assigned to two groups and then received administration of pitavastatin (group P) or not (group C). We followed up the patients for 1 year from study onset.

RESULTS

Two patients demised during the follow-up period (both were in group C). In addition, aorta-related interventions were performed in two patients (entry closure for aortic dissection by endovascular repair in one patient in each group). Aortic arch diameters at 1 year in group P tended to be smaller than in group C (P = 0.17), and the rate of change of the aortic arch diameters from onset to 1 year was significantly lower in group P (P = 0.046). Multivariate analysis identified patency of the false lumen was detected as a risk factor for aortic arch dilatation (P = 0.02), and pitavastatin intake was a negative risk factor (P = 0.03).

CONCLUSIONS

Pitavastatin treatment, in addition to the standard antihypertensive therapy, may have a suppressive effect on aortic arch dilatation in patients with ABAD.

Predictors of the need for pacemaker implantation after the Cox maze IV procedure for atrial fibrillation

PURPOSE

The Cox maze IV (CMIV) procedure is being used increasingly frequently for surgical ablation of atrial fibrillation (AF). This study aimed to identify the risk factors of the need for postoperative pacemaker implantation (PMI) after CMIV.

METHODS

Preoperative, intraoperative, and postoperative data were retrospectively collected from 67 consecutive patients who underwent CMIV at our institution; 7 (10.4%) required PMI (as a treatment of brady AF or sick sinus syndrome).

RESULTS

Patients who needed PMI tended to have lower preoperative heart rates than those who did not on a 12-lead electrocardiogram (ECG; 68.7 ± 11.6 vs. 79.1 ± 18.5 bpm, p = 0.07) and a 24-h ECG (94,772 ± 9800 vs. 109,854 ± 19,078 beats/day, p = 0.03). A multivariate analysis identified a low amplitude of the fibrillatory wave on preoperative ECG as a risk factor of PMI necessity after CMIV [odds ratio = 14.7; 95% confidence interval (CI) 1.9-324.7; p = 0.007] and internal use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) as a negative risk factor (odds ratio = 0.16; 95% CI 0.02-0.99; p = 0.049).

CONCLUSIONS

A low amplitude of the fibrillatory wave was identified as a risk factor of PMI necessity, whereas the internal use of ACEIs/ARBs diminished the need for PMI. These factors should be considered before CMIV is performed.

Surgical removal of calcified amorphous tumor localized to mitral valve leaflet without mitral annular calcification

A cardiac calcified amorphous tumor (CAT) localized to the mitral valve leaflet without mitral annular calcification (MAC) is a rare entity. We report a case of a 69-year-old woman with such a condition, who underwent successful excision of the tumor and mitral valvuloplasty using a glutaraldehyde-treated autologous pericardium. During 38 months of follow-up, no recurrence of a cardiac mass has been recognized. This report addresses questions on the surgical indication for CAT, particularly in cases without MAC, and reviews CATs of the mitral valve.

Contemporary outcome of the surgical management of prosthetic graft infection after a thoracic aortic replacement: is there a room to consider vacuum-assisted wound closure as an alternative?

Objective

Once a replaced prosthetic graft is infected, it is usually necessary to re-replace the thoracic aorta to achieve complete resolution of the infection. It is, however, an exceedingly invasive approach to perform such a repeat surgery on patients in a poor condition. We have managed both re-replacement of an infected prosthetic graft and conservative therapy with vacuum-assisted wound closure (VAC) without re-replacement. These two treatment modalities were retrospectively assessed.

Methods

Retrospective clinical chart review was undertaken on 21 patients with prosthetic graft infection after thoracic aortic replacement between December 1999 and December 2012. Surgical outcomes were evaluated between the two groups: re-replacement group (group R, n = 14) and no-replacement group (group NR, n = 7).

Results

In-hospital survival rates were 64.3 % in group R and 85.7 % in group NR. Mortality in group R included five patients, sepsis in two patients, and intraoperative aortic rupture, heart failure, and cerebral infarction in one. Mortality in group NR included one patient (sepsis). In terms of long-term outcome, one patient in group R and one patient in group NR died of rupture of a residual aortic aneurysm, and one patient in group NR died of renal disease during follow-up (52.8 ± 41.5 months for R and 43.2 ± 28.5 months for NR; mean ± standard deviation).

Conclusions

Re-replacement of an infected prosthetic graft after a thoracic aortic operation still carries a significant risk for mortality. VAC therapy may provide an acceptable option for such a subgroup of patients with this serious condition.

[Successful treatment using recombinant thrombomodulin for disseminated intravascular coagulation associated with recurrent prosthetic valve endocarditis]

Prosthetic valve endocarditis(PVE)occasionally evokes sepsis and disseminated intravascular coagulation(DIC). A 46-year-old man developed relapsing active PVE with an annular abscess and suffered from exacerbating sepsis and DIC. Despite the administration of antibiotics, his DIC score increased. Anti-DIC treatment with recombinant thrombomodulin (rTM) was initiated, and his DIC was remarkably resolved. Accordingly, the abscess cavity was closed by using a homograft anterior mitral leaflet, and the aortic root was replaced with the homograft. He is doing well without an evidence of recurrent endocarditis 18 months after the operation. rTM is a new and promising drug for the treatment of DIC with infective endocarditis.

[Atheromatous aorta: clinical pitfall in cardiovascular surgery]

A highly atheromatous aorta has been reported to bring about devastating complications such as endorgan ischemia with or without aortic manipulation. One of the complications has been perioperative stroke known that almost the halves suffered have been dead even in recent era. The other of the devastating complications has been called cholesterol crystal embolization or blue toe syndrome, meaning scattered embolization by small cholesterol crystals towards splanchnic organs or lower extremities respectively, which has also known to be critical. Nowadays, new devices have encouraged cardiovascular clinician to have a plan for a safe cardiovascular intervention including aortic manipulation even with highly atheromatous aorta. Before the manipulation, modern powerful modalities such as transesophageal echocardiography, epiaortic ultrasonography and computed tomography (CT), have already become common based on many evidences. During operation, evolving techniques and technologies such as off-pump coronary artery bypass grafting (OPCAB) and axillary artery cannulation both of which are aorta non-touch techniques, which are technically demanding, has proved to reduce perioperative stroke recently even though severe complications still occur in lower percentages.

[Is emergency aortic root replacement combined with arch replacement safe?]

BACKGROUND

Aortic root replacement (ARR) combined with aortic arch replacement (AAR) is an invasive procedure even in elective cases. Nevertheless, such combined operations are often mandatory in acute type A aortic dissection. We examined whether emergency operation might have further incremental risks compared with elective surgery in this type of operations.

METHODS

Forty-six cases of ARR combined with AAR were divided into 2 groups, the emergency (EM) group and the elective (EL) group. The EM group consisted of 10 cases of acute type A aortic dissection, whereas the EL group of 36:23 of chronic aortic dissection and 13 of true aneurysm.

RESULTS

There were no statistical differences between the 2 groups in the durations of aortic crossclamp, selective cerebral perfusion and cardiopulmonary bypass. The incidences in the EM and EL groups were as follows:in-hospital death; 0 vs 3( 8%), respiratory failure; 4 (40%) vs 14 (39%), renal failure; 0 vs 6 (17%), IABP requirement; 1 (10%) vs 3 (8%), and cerebral infarction; 0 vs 1 (3%), respectively.

CONCLUSION

Early surgical results of emergency ARR combined with AAR were almost equal to those in elective surgery.

Modified cuffed anastomosis technique to treat pseudoaneurysms following thoracic endovascular aortic repair

Pseudoaneurysm after thoracic endovascular aortic repair (TEVAR) is very rare. We report a case of thoracic aortic pseudoaneurysms due to flares at the proximal end of a stent graft after TEVAR for ductal aneurysm. We describe a total aortic arch replacement in this case using a modified cuffed anastomosis technique with an elephant trunk procedure leaving the partial stent graft in situ.

[Successful repair of sealed-ruptured pararenal abdominal aortic aneurysm with left-sided inferior vena cava employing the technique for thoracoabdominal aortic aneurysm repair]

We describe a case with pararenal abdominal aortic aneurysm associated with anomalous inferior vena cava. We applied the technique similar to that employed in the thoracoabdominal aneurysm repair consisting of mild hypothermic cardiopulmonary bypass and selective visceral perfusion. Replacement of the abdominal aorta and reconstruction of the left renal artery were completed without an injury to the anomalous vein.

[Successful preoperative respiratory rehabilitation in patients with aortic valve stenosis associated with severe respiratory dysfunction]

We describe 2 cases of aortic valve stenosis with severe pulmonary dysfunction. Preoperative respiratory rehabilitation programmed by the rehabilitation doctors was cautiously undertaken to improve their exercise tolerance and respiratory reserve. These 2 patients underwent aortic valve replacement eventually. Postoperative course in each patient was uneventful without respiratory complication. Preoperative respiratory rehabilitation can be performed in the high risk patient with severe pulmonary dysfunction as long as careful risk management is guaranteed.

[Distal aortic repair after aortic arch replacement]

BACKGROUND

It is crucial to expose the proximal aorta in distal aortic repair, i.e., replacement of the descending thoracic aorta (DTA) or the thoracoabdominal aorta (TAA), after aortic arch replacement. With the elephant trunk (ET), it is usually easy to expose and clamp it. On the other hand, without the ET, it may be difficult or impossible to expose the proximal aorta and deep hypothermic circulatory arrest (DHCA) will be required.

METHODS

Between April 1989 and March 2007, 17 patients underwent distal aortic repair after aortic arch replacement. Five patients underwent replacement of DTA and 12 of TAA. Five patients without the ET needed DHCA and open proximal anastomosis [OP (+) group], while in 12 patients, the ET or proximal aorta was successfully clamped [OP (-) group].

RESULTS

The mean extracorporeal circulation time in OP (+) group was significantly longer than that in OP (-) group (415 +/- 131 min v.s. 267 +/- 109 min, p < 0.05). There was no hospital death, cerebral infarction, fatal arrhythmia or low output syndrome in either group, and paraplegia in 2 patients and renal failure requiring hemodialysis in one were found only in OP (+) group.

CONCLUSION

The ET procedure enables to avoid DHCA and may contribute to improving operative results in distal aortic repair after aortic arch replacement.

Efficacy of perfusion cooling of the epidural space and cerebrospinal fluid drainage during repair of extent I and II thoracoabdominal aneurysm

AIM

The aim of this study was to evaluate spinal cord injury and mortality resulting from repair of extent I and II thoracoabdominal aneurysm. The authors compared patients operated under mild hypothermia with or without epidural perfusion cooling (EPC) and cerebrospinal fluid drainage (CSFD).

METHODS

From 1988 to 2007, 116 patients underwent replacement of the thoracoabdominal aorta; the procedure was performed in 38 patients with the aid of mild hypothermia alone (group A), and in 78 patients with the aid of EPC, mild hypothermia and CSFD (group B). Two catheters for epidural perfusion cooling were inserted in group B, in which one catheter was inserted into the epidural space to infuse chilled saline, and the other was inserted into the subdural space to drain the cerebrospinal fluid and to measure temperature and pressure. There were no significant differences in mean age, etiology of aortic disease, and aneurysm extent between the two groups.

RESULTS

There were no significant differences in cardiopulmonary bypass time, the lowest nasopharyngeal temperature and operation time between the two study groups. The incidence of spinal cord injury in group A (16.2%) was significantly higher than in group B (3.8%, P=0.03). Hospital mortality in groups A and B was 10.5% and 2.6%, respectively (P=0.08). There was no significant difference in postoperative complications between the two study groups.

CONCLUSION

The combination of EPC and CSFD was effective in lowering the incidence of postoperative spinal cord injury in the repair of extent I and II thoracoabdominal aortic aneurysm.

Axillary Artery Cannulation Improves Operative Results for Acute Type A Aortic Dissection

BACKGROUND

This study was undertaken to identify preoperative and postoperative predictors of hospital death of patients with acute type A aortic dissection.

METHODS

Between May 1,1992, and July 31, 2004, 106 consecutive patients (59 male and 47 female, mean age 62.2 +/- 12.1 years) with acute type A aortic dissection underwent surgery with open technique and cerebral protection by antegrade selective cerebral perfusion. The external iliac artery or femoral artery alone was used for arterial cannulation in 37 patients; however, the right axillary artery was cannulated in 69 patients. Univariate analysis of potential risk factors was performed to identify risk factors for hospital death and was followed by multivariate analysis by a stepwise logistic regression model to identify independent risk factors.

RESULTS

Sixteen patients died postoperatively, and the overall hospital mortality rate was 15.1%. Univariate analysis revealed shock (p = 0.020), visceral ischemia (p = 0.007), root replacement (p = 0.041), and absence of axillary artery perfusion (p = 0.003) as significant risk factors for hospital death. Multivariate analysis revealed visceral ischemia (p = 0.0028, odds ratio 18.4) and absence of axillary artery perfusion (p = 0.0014, odds ratio 8.2) as independent preoperative and intraoperative predictors of hospital death.

CONCLUSIONS

Achievement of greater success in the surgical treatment of acute type A dissection will require axillary artery cannulation and measures to prevent visceral malperfusion.

[Spinal cord protection during most or all of descending thoracic or thoracoabdominal aneurysm repair]

OBJECTIVES

The purpose of this study is to evaluate usefulness of perfusion cooling for regional spinal cord hypothermia during most or all of thoracic or thoracoabdominal aneurysm repair.

METHODS

From 1987 to 2003, 103 patients underwent most or all of thoracic or thoracoabdominal aneurysm repair. Forty-eight patients underwent operation using distal aortic perfusion, mild hypothermia and segment sequential repair (group MH). Fifty-five patients underwent the same operation as group MH except epidural perfusion cooling and drainage of cerebrospinal fluid (CSF) [group EC & CSFD]. The aorta was replaced sequentially in segment and several paris of intercostal and lumbar arteries were reconstructed in 2 groups.

RESULTS

Cardiopulmonary bypass time of group MH and group EC & CSFD was averaged 235 and 241 minutes, respectively. The lowest CSF temperature in group EC & CSFD was averaged 24.7 degrees C, and the difference between nasopharyngeal and CSF temperature was averaged 6.4 degrees C. The rate of spinal cord injury of group MH and EC & CSFD was 10.4% and 3.6%, respectively. Hospital mortality of group MH and EC & CSFD was 8.3% and 5.5%, respectively. The incidence of spinal cord injury and hospital mortality of group EC & CSFD were decreased compared to them of group MH.

CONCLUSION

We conclude that the perfusion cooling of epidural space and CSF drainage are effective method in reducing postoperative spinal cord injury.

Clinical features and long-term outcome of type A and type B intramural hematoma of the aorta

OBJECTIVE

Most previous reports on intramural hematoma of the aorta have focused on the initial episode. The purpose of this study was to clarify the long-term outcome of intramural hematoma of the aorta.

METHODS

Ninety-four cases of intramural hematoma of the aorta (41 type A and 53 type B) were reviewed. There were 69 male and 25 female patients, and their mean age was 66.7 +/- 8.7 years (range, 46-88 years).

RESULTS

Eleven (27%) of the patients with type A hematoma and 1 (2%) of the patients with type B hematoma underwent early surgical intervention. Others were treated medically, and the overall hospital mortality was 7% for patients with type versus 2% for patients with type B intramural hematomas of the aorta (P =.315). Twenty-three patients, 9 (22%) with type A and 14 (26%) with type B intramural hematomas of the aorta, underwent late surgical intervention during the follow-up period, and there were no hospital deaths. A total of 23 patients died during the follow-up period, including 6 of intramural hematoma of the aorta-related deaths (3 in the type A group and 3 in the type B group). The estimated freedom from intramural hematoma of the aorta-related events at 1 and 5 years was 70% +/- 8% and 54% +/- 11% for the type A group versus 73% +/- 6% and 58% +/- 8% for the type B group, respectively (P =.972). After excluding the nonintramural hematoma of the aorta-related deaths, the survival rates at 5 and 10 years were 80% +/- 9% and 80% +/- 9% for the type A group and 91% +/- 8% and 81% +/- 11% for the type B group (P =.211).

CONCLUSIONS

Intramural hematoma of the aorta-related events occur equally in both types of intramural hematoma of the aorta. We recommend close follow-up for at least 5 years because most intramural hematoma of the aorta-related events occur during this period.

Safety and efficacy of epidural cooling for regional spinal cord hypothermia during thoracoabdominal aneurysm repair⋆

Twenty-four consecutive patients underwent epidural cooling as an adjunct to elective thoracoabdominal aortic repair under moderate systemic hypothermia. One patient suffered from postoperative paraplegia (4%), and another died from subarachnoidal hemorrhage (4%). Details of the technique, the associated care, and the pitfalls will be discussed.

Intramural hematoma and dissection involving ascending aorta: the clinical features and prognosis

OBJECTIVE

The clinical features and remedies of acute aortic intramural hemorrhage (IMH) are well discussed. This study prospectively analyzes the features compared with those of Type A aortic dissection, and evaluate the treatment modalities and the prognosis with Type A IMH managed by our original program, Eighty-six consecutive patients consisted of acute type A IMH (n = 36) and dissection (n = 50) were diagnosed between January 1994 and March 2002. Patients with IMH were older (mean 67 and 60, P = 0.0017), more hypertensive (P = 0.0015), not hyperlipidemic (P = 0.0042) than those with dissection. The incidences of preoperative pericardial effusion and aortic regurgitation were significantly lower in patients with intramural hematoma than with dissection, respectively (8:28 versus 22:28, P = 0.0366, 4:32 versus 22:28, P = 0.0011).

METHODS

Urgent operation was performed for the patients of IMH with cardiac tamponade or rupture and all dissections. Uncomplicated patients of the patients with IMH were treated medically. Late surgical conversion was applied for the medical treated case on any condition with persistent pain, progression to type A dissection, ruptured aneurysm, or aneurysmal enlargement (>60 mm). Operative mortality, late cardiovascular event, and long-term survival were evaluated statistically.

RESULTS

Ten urgent surgical repairs were performed with type A IMH patients and one patient died postoperatively. The rest 26 patients were treated medically. The mean follow up period was 39 +/- 28 months. Among the 26 patients, seven were converted surgical intervention. Cardiovascular event free curve on the 26 patients (Kaplan-Meier, CI: 95%) was 65.6% (45.9-85.3), 59.1% (37.5-80.6) at 2, 4 years. There were six dissection and six IMH patients death during follow up. Two of IMH patients died from cardiovascular event. The actuarial survival rate (Kaplan-Meier, CI: 95%) was 87.5% (76.0-99.1):87.9% (66.2-97.1), 81.7% (66.2-97.1):87.9% (78.8-97.0) at 2, 4 years (P = 0.8393).

CONCLUSIONS

Type A IMH tends to occur in older, more hypertensive and not hyperlipidemic patients, showed lower incidences of preoperative aortic valve regurgitation and pericardial effusion than dissection. Medical treatment alone was not enough to manage all type A IMH patients, and 47.2% (17/36) of the patients needed surgical intervention. Urgent surgical repair was not necessary for all type A IMH patients to achieve favorable surgical outcome with careful follow-up using imaging modality.

Management of patients with intramural hematoma involving the ascending aorta

OBJECTIVE

Although intramural hematoma of the aorta is considered a unique pathologic entity, the management of intramural hematoma involving the ascending aorta (type A) has not been well established. The purpose of this study was to establish the optimal mode of management of type A intramural hematoma.

METHODS

We treated patients with type A intramural hematoma as follows. Early operation was carried out only for patients with cardiac tamponade, impending rupture, or rupture. Other patients were treated medically, but patients with progression of intramural hematoma during medical follow-up had their treatment converted to surgery. From February 1992 to March 2001, a total of 33 patients with type A intramural hematoma were treated as described here. Patients were divided according to initial treatment into an early surgery group (n = 9) and a medical treatment group (n = 24). Clinical profiles and in-hospital and long-term survival rates were compared between the groups.

RESULTS

Compared with the early surgery group, the medical treatment group was younger (64.2 +/- 7.0 years vs 71.7 +/- 8.5 years, P =.0319) and had a greater number of involved segments (3.6 +/- 0.6 vs 3.0 +/- 0.9, P =.0395). Eight patients in the medical treatment group were switched to surgery during follow-up because of progression of intramural hematoma. In-hospital mortality rates in the early surgery and medical groups were 11% and 5% (P =.477), respectively. Cumulative 1- and 2-year survivals were 89% and 89%, respectively, in the early surgery group, and 92% and 81%, respectively, in the medical group (P =.49).

CONCLUSION

We concluded that about 70% of type A intramural hematomas could be managed expectantly, and more than 50% could be treated medically alone.

Spontaneous rupture of coronary artery

We report a case of spontaneous coronary artery rupture (SCAR) 3 months after descending aortic replacement. Cardiac tamponade was confirmed at first by using echocardiography following emergency pericardial centesis. The patient was denied aortic dissection by computed tomography, thereafter diagnosed as SCAR with selective angiography, which revealed a leakage from the left circumflex branch. The patient underwent successful rupture site isolation by bilateral ligation and distal revascularization with aortocoronary bypass with saphenous vein graft.

Epidural cooling for regional spinal cord hypothermia during most or all of descending thoracic or thoracoabdominal aneurysm repair

PURPOSE

Hypothermia has some protective effect against ischemia of the spinal cord in thoracoabdominal aneurysm repair. Its method is divided into systemic or regional cooling. Several experimental studies of the regional cooling of the spinal cord have been performed, however, clinical reports are few. The purpose of this study is to evaluate the effect and safety of perfusion cooling of the epidural space during thoracic or thoracoabdominal aortic replacement.

METHODS

Between January 1998 to June 2001 37 patients (True aneurysm: 18 patients, type B aortic dissection: 19 patients) underwent thoracic or thoracoabdominal aortic replacement with an aid of epidural perfusion cooling. The age ranged from 23 to 78 years old with a mean age of 61 years old. Separate perfusion of upper and lower body was used in all cases. Temperature was lowered to around a 31 degrees C or 32 degrees C. In cases where proximal cross-clamping was danger, deep hypothermic circulatory arrest was used.

RESULTS

Ten patients underwent most or all of descending thoracic aneurysm repair with no spinal cord injury and hospital death. Number of patients of the Crawford type I, type II, and type III were 14, 8 and 5 patients, respectively. One Crawford type II patients was complicated with postoperative spinal cord injury (2.7%). There was one hospital death (2.7%) in Crawford type III. The mean epidural cooling time was 150 minutes, and mean infusion volume of cold saline was 981 cc. The mean lowest cerebrospinal fluid (CSF) temperature was 24.3 degrees C, and mean temperature differences between nasopharynx and CSF was 6.3 degrees C.

CONCLUSION

Perfusion cooling of the epidural space during most or all of the descending thoracic or thoracoabdominal aneurysm repair was effective in reducing postoperative spinal cord injury and a safe method in clinical situations.

Ascending aortic replacement through right thoracotomy

A 62-year-old woman with a history of esophageal resection and colon interposition with anterosternal subcutaneous tunnel required replacement of the ascending aorta due to dissecting aortic aneurysm. Preoperative three-dimensional computed tomography enabled us to reveal that right thoracotomy could offer an ascending aortic operation. The patient underwent successful operation under hypothermic circulatory arrest and the right anterolateral thoracotomy provided safe exposure of the diseased ascending aorta even when the suprasternal tunnel precluded conventional median sternotomy.

Establishment of a local cooling model against spinal cord ischemia representing prolonged induction of heat shock protein

OBJECTIVES

Paraplegia is one of the serious complications of thoracoabdominal aortic operations. Regional hypothermia protects against spinal cord ischemia although the protective mechanism remains unknown. We attempted to create a simple model of local cooling under transient spinal cord ischemia and evaluated the effect using functional and histologic findings.

METHODS

Male domesticated rabbits were divided into 3 groups: control, normothermic group (group N), and local hypothermic group (group H). A balloon catheter was used for spinal cord ischemia by abdominal aortic clamping. A cold pack attached to the lumbar region could lower the regional cord temperature initially. Neurologic function was evaluated by the Johnson score. Cell damage was analyzed by observing motor neurons with the use of hematoxylin and eosin staining, terminal deoxynucleotidyl transferase-mediated deoxy-uracil triphosphate biotin in situ nick end labeling (TUNEL), and immunoreactivity of heat shock protein.

RESULTS

Physiologic estimation showed that local hypothermia improved the functional deficits (group N, 1.3 +/- 0.9; group H, 4.9 +/- 0.3; P =.0020). Seven days after reperfusion, there was a significant difference in the motor neuron numbers between groups N and H (group N, 7.2 +/- 1.9; group H, 20.4 +/- 3.2; P =.0090). The number of TUNEL-positive motor neurons was reduced significantly (group N, 7.2 +/- 2.4; group H, 1.0 +/- 0.7; P =.0082). Heat shock protein immunoreactivity was prolonged up to 2 days after reperfusion in the hypothermic group.

CONCLUSIONS

These results suggest that local hypothermia extended the production of heat shock protein in spinal cord motor neurons after reperfusion and inhibited their apoptotic change.

Cleft on tricuspid anterior leaflet

We report a case of isolated congenital tricuspid regurgitation caused by a cleft in the anterior tricuspid leaflet associated with a patent foramen ovale. Preoperative echocardiography revealed severe tricuspid regurgitation resulting from anterior tricuspid leaflet prolapse. The patient underwent successful tricuspid valve repair with simple cleft suture and annuloplasty and direct closure of the patent foramen ovale.