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Objective: The aim of this study was to elucidate the long-term results of crossover bypass (CB) for iliac atherosclerotic lesions in the era of endovascular treatment (EVT). Methods: A retrospective multicenter cohort study was performed. CB was performed in 242 patients between 2003 and 2014 by vascular surgeons at multiple medical centers in Japan. Results: Perioperative mortality was 1.7%. Primary patency rates were 86% at 5 years and 82% at 8 years. Univariate analysis showed that critical limb ischemia (Rutherford class 4-6), vein graft, and superficial femoral artery occlusion were significantly associated with low primary patency. In multivariate analysis, only critical limb ischemia influenced primary patency. The secondary patency rate was 87% at both 5 and 8 years. The limb salvage rate was 98% at both 5 and 8 years. The overall survival rates were 71% at 5 years and 49% at 8 years. Conclusion: The long-term results of CB were good in our study, compared with previous reports. Our results suggest that CB remains an option for the arterial reconstruction in unilateral iliac occlusive disease after EVT failed.

Six patients with acute Type A aortic dissection were medically treated due to advanced age, patient refusal and comorbidity despite surgical indication. Computed tomography after onset revealed a thrombosed false lumen in 3 patients and a patent false lumen with flap in 3 patients. All patients were stable during admission except 1 patient who presented with shock. After admission, treatment including strict control of systolic blood pressure was started according to a predetermined treatment strategy. All patients had no significant complications during hospitalization. All patients survived and returned to their usual activities. Medical treatment for stable elderly patients is a possible therapeutic option for acute Type A aortic dissection.

A 64-year-old woman was referred to our hospital with palpitation and exertional dyspnea. An electrocardiogram showed sinus rhythm, but supraventricular tachycardia was recorded on Holter monitoring. Multidetector computed tomography revealed a small left ventricular outpouching in the apex, with a narrow connection to the ventricle and normal coronary arteries. Surgery for the left ventricular pouch was performed successfully. Histological examination demonstrated that the left ventricular diverticulum consisted of three layers of the ventricular wall, with the myocardial layer mostly replaced by fibrous tissue. The patient has been well after surgery.

A 37-year-old male was transferred to our hospital with a diagnosis of acute myocardial infarction and a mass in the ascending aorta. Echocardiography revealed dyskinesia on the left ventricular apex and a floating mass lesion just above the aortic valve. Acute myocardial infarction was considered to be caused by embolism from the floating mass in the ascending aorta. Emergency surgery was successfully performed and histological examination showed the extirpated mass in the ascending aorta was thrombus. The patient has been well on oral anticoagulant and no recurrence has been seen on echocardiogram 4 years after the operation.

上肢動脈閉塞患者に対し,吻合部カフ付き人工血管にて血行再建術を行い,良好な結果を得たので報告する.症例は74歳男性,右手指の疼痛を自覚,近医で加療するも軽快せず,壊死病変も出現,本院紹介となる.動脈造影にて右上腕中枢より上腕動脈が閉塞,末梢は橈骨,尺骨動脈分岐部から造影された.自家静脈にてバイパス手術施行も, 3週間後に閉塞し,上腕動脈血栓内膜摘除術施行. 4カ月後,再び冷感,疼痛が出現,手指の壊死も進行した.腋窩動脈付近より末梢が完全閉塞しており,人工血管(BARD PERIPHERAL VASCULAR社製Distaflo ® 6 mm)にて再度バイパス手術施行.術後手関節の動脈拍動も良好となり,手指断端も治癒した.上肢の血行再建術では,中枢側動脈では人工血管を用いる場合もあるが,上腕動脈以下の末梢では自家静脈が使用されることが多い.今回の経験を報告して,若干の文献的考察を加える.

症例は92歳の女性で心不全を契機に重症の大動脈弁狭窄症と診断された.心不全に対する内科的治療の後も軽労作にて容易に浮腫を生じるため手術を勧められた.本人,家族の強い希望に加え,心臓超音波検査上の左室収縮能は維持されており,全身状態も良好と判断されたため大動脈弁置換術を施行した.術後-過性のrapid afとなった以外は経過良好で術後25日目に軽快退院した.超高齢者というだけで手術を避けるべきではないと考える.

A 26-year-old man who underwent aortic valve replacement for aortic regurgitation due to Takayasu's arteritis 2 years earlier experienced left amaurosis persisting for some minutes. Computed tomography showed aneurysmal dilation of the ascending aorta to a diameter of 60 mm and occlusion of the left carotid artery. Cardiac echography showed perivalvular leakage. Following administration of a calcium antagonist, the patient's amaurosis subsided and brain bloodstream scintigraphy showed no abnormalities. We resected the aneurysm instead of using Bentall's operation. Following an uncomplicated postoperative course, the patient was discharged 21 days after surgery and echocardiography has shown no perivalvular leakage to date.

両側多発性肺炎症性偽腫瘍の1例を経験したので報告する.症例は49歳, 男性で健康診断にて胸部異常陰影を指摘された.胸部陰影は両側に計7ヵ所認め, 転移性肺腫瘍を疑ったが, 原発巣は不明であり, 左側肺の病巣 (8ヵ所) を摘除した.病理組織像は, 膿瘍中心と炎症性細胞 (リンパ球, 形質細胞, マクロファージ) の浸潤像が主体であった.対側の陰影は術後3ヵ月後に消失していた.炎症性偽腫瘍は多くは孤立性に発生して, 摘出を受けるためその予後は不明であるが, 本症例の経過より自然寛解の可能性が示唆された.

Three patients had severe abdominal pain of sudden onset. Computed tomography showed localized dissection in the superior mesenteric artery in two patients and in the celiac artery in one. With conservative therapy abdominal symptoms were self-remitted. All patients were successfully treated with medication and have been doing well during follow-up.

We present a case report on a 54-year-old woman with extraskeletal osteosarcoma of the left atrium featuring severe congestive heart failure. We resected the tumor, which occupied the left atrium and had widely infiltrated the atrial wall, but the patients died of the tumor 9 months after surgery. This is to our knowledge the 32nd case of cardiac osteosarcoma ever reported.

A 76-year-old female had suffered from distal arch aortic aneurysm and chronic DeBakey IIIB type dissecting aneurysm. The patient underwent thoracic endovascular aortic repair (TEVAR). After TEVAR the patient had a motor and proprioceptive loss on the left side and a pain and body temperature loss on the right side below the level of T7. At diagnosis of Brown-Sequard syndrome, corticosteroid and free radical scavenger were administered soon afterwards. Her neurological deficits gradually improved and the patient was discharged with the aid of a walking stick three months after TEVAR.

A 58-year-old female was referred to our hospital with an abnormal shadow on her chest X-ray. Further examination revealed the left anterior descending coronary artery to pulmonary artery fistula with aneurysms. The patient was successfully repaired with operation and had no residual fistulas and aneurysms.

A 67-year-old female had suffered from fatigue and palpitation. Cardiac examination revealed coronary sinus atrial septal defect, moderate mitral and tricuspid regurgitation, coronary artery disease, and supraventricular tachycardia with paroxysmal atrial fibrillation. Surgical repair of the anomaly, regurgitant valves, and arrhythmia associated with coronary revascularization was successfully performed and the patient has been doing well in normal sinus rhythm.

In total aortic arch replacement, distal aortic anastomosis is often remarkably difficult because of the deep operative field. Once bleeding from the anastomotic area occurs, it is intractable not only because of technical problems but also decreased coagulability due to deep hypothermia and the fragility of the aortic wall. We describe a simple but reliable strategy for distal anastomosis, which is unique with regard to the approach to the anastomotic area and the anastomotic method.

僧帽弁位の Carpentier-Edwards Pericardial Bioprosthesis の使用後に一過性の逆流と溶血を生じた症例を経験したので報告する. 症例は, 69歳女性で手術後より収縮期雑音を認め, 心エコー検査にて生体弁中央からの逆流が認められた. 同時に溶血 (LDHの上昇と貧血の進行) を来し, 再弁置換を考慮したが, 術後12日目に逆流は消失した. 弁縫着時のステントディストーション (stent distortion) によるものと思われるが, 詳細についての報告は少なく, 生体弁置換後の逆流においては鑑別すべき病態と考えられた.

抗薬剤抗体陽性のため他家血輸血が不可能な狭心症例に対し, 自己血輸血を行うことにより冠動脈バイパスを安全に行えたので報告する. 症例は62歳, 女性で, 狭心症のため当院に入院した. 精査の結果3枝病変と診断されたが, 術前の不規則抗体スクリーニングにて抗薬剤抗体および抗P1抗体 (冷式抗体) 陽性となり, 予約血すべてとの交差適合試験で不適合と判定された. 貧血があったため手術を延期し, エリスロポエチンを併用しながら自己血を800ml採血後手術を行った. 手術は左冠動脈前下行枝および回旋枝へ大伏在静脈を用いて2枝バイパスとした. 総出血量は580gであった. 術後ヘモグロビンは7～10g/dlで経過し, 溶血性貧血等の重篤な合併症もなく無輸血で順調に経過した.

Recent studies have reported that apoptosis may be induced by reperfusion injury following ischemia in cardiomyocytes. We present a case with evidence of apoptosis induced by myocardial ischemia without reperfusion. DNA fragmentation was demonstrated in the nuclei of the myocardial cells surrounding the ventricular septal rupture following acute myocardial infarction without reperfusion in the infarct-related left anterior descending coronary artery. This finding suggests that ischemia without reperfusion may induce apoptosis in myocardial cells.

Reports of left atrial ball thrombus without mitral valve disease are few. We experienced a case of free-floating left atrial ball thrombus that developed in a short period in a patient with atrial fibrillation and dilated left atrium but intact mitral valve. Surgical removal of the thrombus was performed. It was presumed that atrial fibrillation and enlarged left atrium were the contributory factors to thrombus development.

A 46-year-old female with alcoholic liver dysfunction was admitted for mitral regurgitation due to infective endocarditis. She underwent mitral valvuloplasty and resection of the vegetation without complication. After removal of the chest tube, late cardiac tamponade occurred and subsequently recurred. On the 64th day after mitral valvuloplasty, we performed redo median sternotomy with small laparotomy trying to reveal and repair injured lymphatic vessels in the pericardial space and successfully cured the leakage of lymph. The post reoperative course was uneventful and the patient was discharged 20 days after reoperation. We review a rare complication of recurrent cardiac tamponade of lymphatic leakage associated with liver dysfunction.

A 74-year old male presented with a dilatation of the thoracic aorta late after an acute aortic dissection. Computed tomography (CT) showed chronic dissecting aortic aneurysms just below the distal aortic arch. The total descending thoracic aorta was surgically replaced. Four weeks later, a massive bloody effusion developed in the right thorax and a subsequent CT scan revealed an extravasation of the contrast material out of the vascular prosthesis. Emergency surgery disclosed bleeding from a small vascular graft rupture and a successful repair was performed.

A 31-year-old man with severe aortic regurgitation due to a defective bicuspid valve underwent surgery using modified Ross procedure. The right ventricular outflow tract (RVOT) was reconstructed with a 25 mm stentless xenograft valve sutured with a rolled equine pericardium. Oozy bleeding from the RVOT was controlled with an autologous pericardial patch and fibrin glue. Postoperative echocardiography showed no aortic regurgitation. No blood transfusion was required.

To investigate whether the use of a stentless porcine aortic xenograft can be an alternative for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure, 9 patients underwent the Ross procedure and RVOT reconstruction with a stentless xenograft since January 2000. After the aortic valve was replaced with a pulmonary autograft, a stentless xenograft with a xeno- pericardial roll was implanted in the RVOT. One patient required subsequent aortic valve replacement because of severe regurgitation of the pulmonary autograft. All patients recovered well from the operation. The right ventricle-pulmonary arterial pressure gradient was 18 ± 7 mm Hg at discharge and was not significantly increased during the 2-year follow-up period. Although 1 patient died of ventricular arrhythmia 5 months after, his cardiac function was normal, and transpulmonary valve pressure was 19 mm Hg in the follow-up. The other 7 patients are currently in New York Heart Association functional Class I. Although long-term follow-up is required to explain the durability, the stentless xenograft with a pericardial roll is considered to be an alternative for reconstruction of the RVOT within 2 years after the Ross procedure.

65歳男性の両側性孤立性内腸骨動脈瘤を経験した. 通常, 内腸骨動脈瘤の手術は内腸骨動脈の血行再建を行わずに内腸骨動脈起始部の血流遮断とか内腸骨動脈瘤縫縮術が行われている. この症例は両側性であり, 両側の動脈結紮により結腸虚血または殿筋虚血を生じる可能性があったため, 一側内腸骨動脈の血行再建を行った. 症例を呈示するとともに内腸骨動脈血行再建術の問題点につき述べる.

A saccular aneurysm in the right-sided aortic arch with aberrant left subclavian artery is an uncommon disease, and surgical treatment is complicated. Three patients with Edwards type III-B right aortic arch and enlargement of the Kommerell's diverticulum underwent operations. Right thoracotomy was the preferred approach for this lesion and partial cardiopulmonary bypass is a safe and simple procedure when the aortic arch has mild atherosclerosis.

A 68-year-old man was hospitalized with the complaints of left back pain and fever. He had a history of using steroids to treat uveitis for about thirty years. Computed tomography on the chest demonstrated an impending rupture in an aortic arch aneurysm, which was consequently surgically excised. Candida albicans was identified in the wall of the aneurysm, so fluconazole and itraconazole were administered. The patient was discharged at 120 days after surgery without recrudescence of the candida. To our knowledge, this is the fifteenth case of a successfully treated aneurysm caused by candida infection.

We report herein the case of a patient with chronic renal failure in whom mitral valve stenosis with extensive mitral anular calcification involving the entire anulus and leaflets was successfully treated surgically. Excision of both leaflets and partial resection of the anular calcification enabled the insertion of a 23-mm St. Jude Medical prosthetic valve. The technical difficulties involved with inserting the appropriate-sized prosthetic valve in a narrowed mitral anulus with heavy calcification are discussed following this case report.