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The aim of this study was to evaluate the operative techniques of total arch replacement, the clinical results and the survival curves of patients following this procedure.Since December 2001, 92 patients have undergone surgical treatment for aortic dissection and aneurysm. The total aortic arch replacement was performed in 24 of these patients. There were 16 men and 8 women, and the age range was 42 to 81 years with a mean age of 59.4 years. As the operative technique for total arch replacement, we used the 4-branched prosthetic graft, selective cerebral perfusion (SCP), continuous cold blood cardioplegia (CCBC), and open distal anastomosis under circulatory arrest. The combined operations were coronary bypass grafting in 4 patients, aortic valve suspension in 1 patient and a Bentairs procedure in 1 patient. Eleven (73.3%) patients with acute dissection required emergency operation.The hospital mortality rate was 25% (6 of the 24 patients). The causes of death were multiple organ failure (MOF) due to renal and mesenteric ischemia in 3 patients, cerebral infarction in 2 patients, myonephropathic metabolic syndrome (MNMS) in 1 patient, respectively. The data concerning extracorporeal circulation was 204+/-53 min in total pump time, 136+/-43 min in aortic cross clamp time, 83+/-14 min in SCP time and 48+/-10 min in circulatory arrest time, respectively. The long-term result in actuarial survival rate was 76% for 5 years.We consider the technique of total arch replacement using 4-branched prosthetic graft, SCP, CCBC, and open distal anastomosis is a useful operative method in patients with aortic aneurysm.

A 36-year-old man was admitted to our hospital because of impalement injury due to a downwards fall upon some reinforced steel rods. An emergency operation was performed using percutaneous cardiopulmonary support (PCPS). The steel rods were taken out in the operating room. The heart, great vessels, vertebrae, and spinal cord were not involved in the impalement wounds. We performed a bronchoplasty of the torn and separated right main bronchus, and repaired the impaled left lung without any pulmonary resection. He recuperated without sequelae.

Recently life expectancy has become longer and longer. The purpose of this study was to analyse whether arterial surgery for patients over 80 years of age is advisable.During the last 14 years, 527 patients, 50 of whom were over 80 and 477 of whom were under 80 years of age, received graft replacement or bypass surgery. They suffered from ruptured abdominal aortic aneurysm (R-AAA, n=21), non-ruptured abdominal aortic aneurysm (N-R AAA, n=133) or arteriosclerosis obliterans (ASO, n=373). Complications such as cerebrovascular disease, ischemic heart disease, respiratory and kidney dysfunction, and risk factors for ASO were also checked.All of the patients over 80 with R-AAA (n=3/3) and 50% of the patients under 80 with R-AAA (n=9/18) died during their stay in the hospital. However, none of the N-R AAA patients over 80 (n=0/7) and only one of the 126 N-R AAA patients (0.8%) under 80 died. For the patients over 80 with ASO, the graft patency rate was better than the patients survival rate. There were no age-specific factors that should condemn arterial surgery for patients over 80 years of age.Arterial surgery should not be ruled out on the basis of age alone.

We used fibrin adhesive for the treatment of pulmonary air leak after pneumonectomy to sealing effect of fibrin adhesive which was classified by application and obtained the following results. 98 patients with pulmonary air leak were randomly allocated to the double layer group and spray group. The following were investigated between the double layer group and spray group. 1) size and dose of fibrin adhesive, 2) airway pressure where pulmonary air leak was observed before and after application, 3) duration of postoperative pulmonary air leak, 4) degree of postoperative pulmonary air leak, and 5) postoperative complication. The dose of fibrin adhesives was significantly smaller, the mean duration of postoperative pulmonary air leak was significantly shorter and the degree of postoperative pulmonary air leak was significantly more slight in the spray group than in the double layer group. In addition, the sutured part was examined before and after application of fibrin adhesives with a scanning electron microscope. Fibrin nets were formed more uniformly by the spray method than by the double layer method. From these investigations it is concluded that since the appliance for the spray method is improved and easily used and fibrin nets are formed uniformly by this method, the spray method is useful for the prophylaxis of pulmonary air leak.

The metabolism of toborinone, (+/-)-6-[3-(3,4-dimethoxybenzylamino)-2-hydroxypropoxy]-2(1H)-quin - olinone, a novel inotropic agent, was studied in rats and dogs after intravenous administration. Chemical structures of the 13 metabolites were characterized by direct-probe FAB/MS and field desorption/MS, LC/FAB/MS, and various NMR measurements. After intravenous dosing of 10 mg/kg [14C]toborinone, fecal and urinary recoveries of the 14C dose were approximately 70% and 26-30%, respectively, in both rats and dogs. The predominant component of radioactivity was the unchanged toborinone in every biological specimen in rats and dogs. Although unchanged toborinone was predominantly observed, toborinone underwent extensive conjugations with glucuronic acid, sulfate, and glutathione, either directly or following phase I reaction. Metabolites resulting from oxidative N-C cleavage were minor both in number and in quantity in every biological specimen in rats and dogs. In rats, toborinone underwent O-demethylation to form M-7 and successive phase it reaction to yield the glucuronide M-1 and the sulfoconjugate M-2, and deconjugation to yield M-7, which was a primary metabolite accounted for 35.67% of the radioactivity excreted in the feces by 48 hr. Conjugates M-1 and M-2 were the major metabolites in rat plasma. In dogs, toborinone was metabolized via mercapturic acid pathway to yield the primary metabolites, cysteine conjugates M-10 and M-11 that accounted for 19.10% and 6.70% of the radioactivity excreted in the feces by 48 hr and that were detected species specifically in dogs. The glutathione conjugate M-13, which was isolated from in vitro incubations using dog liver, led us to consider a possible mercapturic acid pathway from the parent compound to M-10. Metabolites in dog plasma and those in urine in both rats and dogs were minor in quantity. The metabolic pathways of toborinone in rats and dogs are proposed herein.

An 81-year-old man was admitted to our hospital with a complaint of dysuria. He had had a right hypogastric aneurysm repaired three years earlier. Physical examination showed a distended soft abdomen and tender mass about the size of a child's head but no murmur was heard over the mass. An excretory urogram (DIP) showed left hydronephrosis and no excretion from the right kidney. Computerized tomography (CT) showed urinary bladder compressed by the mass on the upper right back side. Cystography showed that the large mass occupied the pelvic region with calcification and communicated with the bladder. After a few days, an operation for the aneurysm was undertaken by the surgical department. Although bilateral ureterolysis was possible, a resection of the aneurysm could not be done. The aneurysm was injected with fibrin adhesive and a bilateral nephrostomy was performed. The renal function has been stable and the size of the aneurysm has remained unchanged for 9 months after the surgery.

As of the end of September 1989, 52 EXS Dacron grafts had been implanted for femoropopliteal bypass operations. The distal ends of 27 grafts were anastomosed to above-knee popliteal arteries and those of 25 grafts to below-knee popliteal arteries. The cumulative patency rate of above-knee grafts was 71.3% at 54 months, and that of below-knee grafts was 78.8% at 48 months (n.s.). Kinking and stenosis of the arteriosclerotic proximal and/or mid popliteal artery when the knee was bent were angiographically remarkable. These changes may explain why some femoropopliteal grafts occlude with time and why the late results of above-knee grafts are not much better than those of below-knee grafts.

Out of 216 patients with Buerger's disease, 14 showed the involvement of the iliac artery in addition to the occlusive lesion in the leg arteries. It occurred within 2 to 8 years after the onset of symptom. The obliterative lesion of the iliac artery might owe its cause to a direct proximal progression of thromboangitis obliterans of the femoral artery or to a skip progression of the disease. The skip lesion of the iliac artery might be due to an ascending progress of the thromboangiitic lesion in the branch arteries of the iliac artery. The indication for arterial reconstruction in the case with the involvement of the iliac artery depends on run-off in the deep femoral artery. Out of the 14 cases, 2 underwent thromboendarterectomy with autogenous vein patch grafting of the external iliac artery and 6 underwent bypass grafting, but their long-term follow-up result was poor.

Murine antibody against Mycoplasma pulmonis (Mp) was detected sensitively and specifically in experimentally and naturally infected animals by an enzyme-linked immunosorbent assay (ELISA), using urease conjugated antimurine immunoglobulin. More than 98% of the experimentally infected mice and rats exhibited positive reaction in the ELISA two or more weeks after infection, and the titer remained for a prolonged period (up to one year) after infection. However, we failed to detect antibody in the sera of one-week-postinfected animals. Mice and rats from breeding colonies were tested with the ELISA and compared with isolation of Mp from the respiratory organs. Positive reactions were shown in the ELISA using the sera from 91% of the mice and 98% of the rats from which the organisms were isolated. Conversely, 97% of the mice and 78% of the rats among Mp-free animals showed negative results in the ELISA. The sensitivity and specificity of the complement fixation test, which has been used widely for serodiagnosis of Mp-infection, were apparently lower compared to those of the ELISA. From these results, the ELISA was found to be available for the serodiagnosis of Mp-infection in mice and rats.

Revascularization syndrome is one of the dangerous postoperative complications which results sometimes in loss of a limb, renal shutdown and death due to myoglobin-nephrosis and hyperkalemia. During the past 3 years, 2 cases of revascularization syndrome were experienced in 16 cases of thrombo-embolectomies for acute peripheral arterial occlusion. One patient died from hyperkalemia 100 minutes after revascularization. Another patient suffered from a renal shutdown, and was treated with hemodialysis and thigh amputation. It is sometimes very difficult to predict whether the revascularization syndrome will occur or not. When revascularization is performed within 12 hours after an onset of acute occlusion and when the amount of ischemic muscle is not large, the syndrome may not occur. When the time-interval between the onset of ischemia and revascularization is longer than 24 hours and when the mass of ischemic muscle is large, the syndrome will occur. Preoperative serum creatinine and urea nitrogen level are important parameters predicting the prognosis.

In the last 6 years we have treated 132 patients with varices of the lower extremities and operated on 65 of them. We came to the following conclusions: 1. Stripping of the saphenous vein with subfascial ligature of the incompetent venae communicantes is essential for the complete treatment of primary varicosity with or without ulcer. 2. Pelvic phlebography is necessary to exclude secondary varicosities in both bilateral and unilateral varices. 3. The removal of secondary varices has a definitely negative result if recanalisation is incomplete; i.e. they ought not to be extirpated if the outflow from the great saphenous vein is directed centrally on walking.

During the past thirteen and a half years, 222 cases of iliofemoral venous occlusion were treated. Diagnosis was based mainly on clinical symptoms and phlebography. Surgery, injury, malignancy and heavy muscular exercise were the chief etiologic factors of this disease. As therapeutic maneuvres: (1) thrombectomy, (2) Palma's operation, (3) conservative procedures, (4) extirpation of a tumor, and (5) removal of secondary varicose veins were performed. Long-term results of treatment were reviewed. Thrombectomy and Palma's operation obtained good results in 59% and in 42% of cases respectively, while conservative procedures showed a favorable outcome in 36% of cases where followed. Results of thrombectomy were statistically better than those of conservative procedures (p less than 0.05).

Forty of 266 patients with Buerger's disease underwent 47 vascular reconstructions: bypass in 38, thromboendarterectomy in 7 and replacement in 2. Indications for arterial reconstruction were ulceration or gangrene in 60%, claudication in 33.3% and rest pain in 6.7%. In a follow-up from 6 months to 8 years and 7 months, the overall patency rate was 24% in bypass, 0% in thromboendarterectomy and 100% in replacement. One hundred nine of the 266 patients underwent sympathetic denervation: lumbar in 92 (bilateral in 19) and thoracic in 17. In the course of 11 years follow-up study, 23 cases required amputation of the extremity. A good initial result gradually gave way to recurrence unless the patients discontinued smoking. The most important factor which decides natural history of Buerger's disease is smoking.

Ninety-six limbs of 89 patients with acute deep vein thrombosis of the lower extremity were followed for 1 to 18 years. In the thrombectomy group (43 limbs), the cumulative incidence of pigmentation at the 15th year was 15%, but no stasis ulcers occurred throughout the follow-up period. In the conservative treatment group (53 limbs), the cumulative incidence of pigmentation at the 15th year was 41%, and that of stasis ulceration was 27%. Fogarty thrombectomy restricted below the pelvic vein spur and removal of thrombi in the leg veins by manual milking is sufficient to relieve early morbidity, preserve venous valve function, and promote intrapelvic collateral circulation. Preservation of venous valves in the femoropopliteal region is a key to the prevention of postthrombotic syndrome. Thrombectomy within 5 days of the onset of symptoms is recommended for patients with iliofemoropopliteal venous thrombosis.

During the last 8 years, arterial reconstructive operations such as bypass grafting, thrombendarterectomy and percutaneous transluminal angioplasty were performed on 282 lower extremities with chronic arterial occlusion. Operative indications were intermittent claudication in 57.1% and limb salvage in 42.9%. Early and late failure rate following operations was 31.2%: for claudication group 24.0% and for limb salvage group 40.7%. In 30.6% of claudication group and in 45.7% of limb salvage group, ischemia of limbs, compared to their preoperative status, worsened following occlusion. These limb worsening-rates were high and not negligible. Main causes of failures were poor run off and poor graft. Because chronic arterial occlusion is not a malignant disease, it is not forgivable to worsen limb status by surgery. Therefore, the operative indication for claudicant should be the need of patients in their daily life. For femoro-popliteal bypass grafting in claudicant, not artificial graft but auto vein graft should be used. When no suitable vein is available, conservative therapy is the choice of treatment. In case of limb salvage, artificial graft may be used.

During the past 7 years 116 patients with acute and chronic iliofemoral venous thrombosis were treated surgically and medically. Exploration was undertaken mainly by clinical assessment and routine venography for follow-up was not considered as a requisite. Thrombectomy was performed 18 times in 17 patients with excellent or good results in 66.6%. Palma's operation was carried out 17 times in 17 patients with satisfactory results in 82.3%. These were contrasted with 34.2% satisfactory results among the medical patients. These lead to the following conclusion: 1. Venous thrombectomy within 14 days after the onset is effective. 2. The usefulness of delayed thrombectomy is uncertain. 3. Palma's operation offers satisfactory results for chronic iliofemoral venous thrombosis. 4. In Japan, in contrast with America and Europe, pulmonary thromboembolism is exceedingly rare and ligation or interruption of the inferior vena cava or the femoral vein is not performed routinely.