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Background Saphenous vein graft aneurysm (SVGA) is a rare complication after coronary artery bypass grafting; however, it may lead to fatal conditions. A redo sternotomy poses a high risk of injury to the patent graft. Case report A 59-year-old man with chest pain was diagnosed with a giant SVGA (67 mm) anastomosed to the right coronary artery (RCA) and compressing the right atrium. Considering the high risk of injury to a patent graft through the sternum, a surgical procedure was planned without redo sternotomy. Through an upper midline abdominal incision, redo bypass grafting was performed to the distal RCA using the right gastroepiploic artery, followed by resection of the aneurysm using the right anterior lateral thoracotomy approach. The postoperative course was uneventful. Conclusion In patients with an SVGA anastomosed to the right coronary system, our surgical strategy may be a useful alternative to redo sternotomy to avoid injury to the patent graft.

Introduction: Isolated internal iliac artery (IIA) aneurysms (IIIAAs) rarely occur. However, they may enlarge asymptomatically and rupture, causing fatality. Even after successful surgery of ruptured IIIAAs, there might be a potential risk of postoperative spinal cord ischemia (SCI)-related paraplegia, which is extremely rare. However, this paraplegia significantly impacts patients’ activities of daily living. Patient concerns: A 71-year-old man who had no remarkable medical history was referred to our hospital with sudden lower abdominal pain. Diagnosis: Computed tomography (CT) revealed right IIIAA with small volumes of contrast medium extravasation and hematoma. He presented with cyanosis in the bilateral lower limbs. Moreover, blood gas analysis showed lactic acidosis. Therefore, he was diagnosed with ruptured IIIAA complicated by peripheral circulatory failure. Interventions: Considering his pre-shock status, an emergency operation comprising ligation of the proximal neck and suture closure of the distal IIA orifice was successfully performed. Outcomes: Immediately after surgery, motor and sensory dysfunction in the bilateral lower limbs occurred. Magnetic resonance imaging confirmed the presence of SCI. The patient could not stand independently and had neurogenic bladder and rectal disorder. Conclusion: Postoperative SCI is a serious complication with no definitive predictors, preventive methods, or highly efficacious treatments. Therefore, vascular surgeons should preempt its occurrence and focus on preventing hemodynamic instability and maintain collateral extra-segmental arterial blood flow, especially in ruptured cases.

Rational: Bacillus Calmette–Guérin (BCG) intravesical instillation therapy is a widely used treatment for bladder cancer; however, an infectious aneurysm has been reported as a rare complication. Patient concerns: A 76-year-old man who underwent BCG intravesical instillation therapy for bladder cancer presented with prolonged dull back pain for 3 months. Diagnosis: Computed tomography (CT) revealed both thoracic and abdominal aortic aneurysms (AAAs). Follow-up CT at 4 weeks after the initial examination showed rapid enlargement of both aneurysms and typical findings of inflammation. Therefore, he was diagnosed with an impending rupture of infectious aneurysms. Interventions: Although open surgical resection of both aneurysms and vascular reconstruction were ideal, these operations were considered highly invasive for the patient. Therefore, a hybrid operation consisting of simultaneous endovascular repair of the thoracic aneurysm and open surgery of the abdominal lesion was performed. Outcomes: BCG “Tokyo-172” strain was identified in the resected sample from the aneurysmal wall, and he continued to receive oral antituberculosis drugs for 6 months. No sign of recurrent infection was observed 1 year after the operation. Lessons: A hybrid operation might be justified as an alternative to the conventional open surgical procedure, especially for patients with infectious aneurysms caused by weak pathogenic bacteria such as, the BCG mycobacteria.

骨軟骨腫（外骨腫）は最も頻度の高い良性の骨腫瘍であり，若年者の大腿骨遠位部に好発する．骨軟骨腫の血管系の合併症は膝窩動脈領域の報告が散見されるが，仮性動脈瘤形成は比較的稀である．症例は48歳，女性で，右膝窩部の拍動性腫瘤を主訴に紹介された．MD-CTで膝窩動脈の仮性瘤と診断され，疼痛と拡大傾向を認めるため，手術を施行した．仮性瘤内腔に膝窩動脈に通じる約1 mmの交通孔を認め，膝窩動脈に近接して鋭利な骨軟骨種の突起を認めた．交通孔を含む膝窩動脈を部分的に切除した後，端々吻合を行った．仮性瘤の発生機序として，大腿骨の骨軟骨腫が隣接した膝窩動脈に接触し，損傷を受けた結果，出血をきたし，仮性瘤を形成した可能性が示唆された．大腿骨遠位部に骨軟骨腫を指摘されている症例は，膝窩動脈が損傷を受ける可能性ひいては仮性動脈瘤の形成を念頭に置いて経過観察する必要があると考えられた．

SummaryThe quadricuspid aortic valve (QAV) is a rare congenital malformation that usually presents with aortic regurgitation (AR). The first case was reported in 1862. Most cases were diagnosed at the time of surgery or postmortem examination. With advances in imaging techniques, more cases have been diagnosed before surgery. We describe a 59-year-old man whose QAV had not been noted until the current admission. Transthoracic echocardiography revealed dilation of the left ventricle, severe AR, and suspected QAV. The QAV was confirmed by transesophageal echocardiography and 64-slice multidetector computed tomography. This case was a QAV with three equal cusps and one smaller cusp (type B in Hurwitz and Roberts classification). Because the cardiac catheterization and aortography showed severe AR and a QAV, the patient underwent elective surgery. The surgery consisted of replacing the QAV by a mechanical prosthesis. There were no post-operative complications. The patient revealed no symptoms in the post-operative 7 months.

症例は57歳男性, 頚部腫瘤を主訴として受診した.精査にて甲状腺癌を疑われ, 胸部CTを行ったところ, 右S6に肺腫瘍を指摘された.CT下細胞診ではneuroendocrine cell tumorの診断であった.このため原発性肺癌と診断し肺葉切除を予定したが, 術直前の胸部CTにて肺腫瘍が縮小かつ板状に変形していた.このため術前日にCT下ポイントマーカー挿入を施行し, 甲状腺左葉切除及び胸腔鏡下肺部分切除を一期的に行った.迅速病理診断にて甲状腺腫瘍は高分化型乳頭状腺癌であり, 甲状腺左葉切除及び頚部リンパ節郭清が行われた.また肺腫瘍は迅速病理診断で悪性所見を認めなかったため, 胸腔鏡下肺部分切除を行った.術後病理組織診断では肺腫瘍は肺クリプトコッカス症であった.細胞診の結果が臨床所見との不一致をみる場合, 胸腔鏡下肺生検は積極的に行われるべきと考えられる.

We report a successful treatment of massive bleeding due to spontaneous splenic rupture after mitral valve replacement. A 61-year-old man was admitted to our hospital for intermittent high fever. An echocardiogram demonstrated a large vegetation on the posterior cusp of the mitral valve and mitral regurgitation of moderate degree. Staphylococcus epidermidis was cultured from his arterial blood. He underwent a mitral valve replacement after 3 weeks of antimicrobiological therapy with penicillin G crystalline and minocycline hydrochloeide. The patient fell into hemorrhagic shock on postoperative day 11 after complaining dull pain on his left upper abdomen for 3 days. A computed tomography demonstrated a splenic rupture and massive hematoma in the retroperitoneum. A splenic arterial embolization was done before splenectomy. The blood and clot of 2800 g were sucked from peritoneal and retroperitoneal cavities. There were no mycotic aneurysms nor abscess but the torn capsule on the swelled and partially necrotic spleen. The patient discharged uneventfully on postoperative day 43. Infective endocarditis frequently causes splenic infarction but rarely splenic rupture. Anticoagulation therapy after mitral valve replacement might have emphasized the bleeding in the patient.

症例は26歳男性, 咳嗽を主訴として受診した.胸部CTで前縦隔腫瘍を指摘され入院, CT下生検では浸潤型胸腺腫の診断であった. 腫瘍摘出術, 及び右上葉部分切除, 中葉切除, 心膜部分切除施行したが, 前縦隔, 右肺門に腫瘍が残存, 心嚢液中にも腫瘍高腫瘍細胞を認め, 非治癒切除となった. 術後病理では未分化型胸腺癌の診断であった.術後, CDDP+ADR+VCR+CPAによる化学療法を2コース行い, 更に50Gyの放射線療法を行った. 現在, 術後6年を経過しているが無再発生存中である.

Brain tissue carbon dioxide tension, pH, and oxygen tension were measured in dogs undergoing hypothermic circulatory arrest below 20 degrees C with three types of blood gas manipulation. During core cooling, dogs were given pure oxygen (group I, n = 8), 5% carbon dioxide in oxygen (group II, n = 10), or 7% carbon dioxide in oxygen (group III, n = 4). During core cooling, brain tissue carbon dioxide tension decreased significantly in group I. During circulatory arrest, carbon dioxide tension rose by 21.5 mm Hg in group I, 35.3 mm Hg in group II, and 57.0 mm Hg in group III, nearly doubling in each group. From the last 5 minutes of core cooling to the end of rewarming, carbon dioxide tension was significantly higher in groups II and III than in group I. Brain tissue pH fell by 0.33 to 0.35 during 60 minutes of circulatory arrest and did not recover in groups II and III. Brain tissue oxygen tension decreased significantly during the latter two thirds of the circulatory arrest period in all three groups. To reduce progressive tissue hypercapnia and acidosis during and after circulatory arrest, a more hyperventilatory manipulation of blood gases than that achieved by alpha-stat strategy was thought beneficial for core-cooling perfusion.

Cardiac reperfusion injury after heart transplantation or cardiopulmonary bypass has been difficult to control due to the variable degree of myocardial damage with respect to the length of ischemia and the complexity of the surgical procedure. Here, we evaluated the myocardial metabolic and functional recovery of hearts infused with a nicorandil vasodilator-magnesium (Mg) solution just prior to reperfusion (terminal cardioplegia). Donor hearts (20 dogs) were removed and immersed in a 4°C water bath containing 20 mEq/1 KCL-5% glucose for 6 hours, and then were transplanted to recipient dogs. Orthotopically transplanted dog hearts were either reperfused without any further treatment or received a terminal cardioplegic solution containing 8 mg/ 1 nicorandil, 30 mEq/1 Mg, and 50 g/1 glucose, which was infused at a pressure of 75 cm H2O for 2 minutes. During the reperfusion period, myocardial tissue PCO2 (t-PCO2) and calcium ion (t-Ca) were continuously monitored by an ISFET (ion-sensitive field effect transistor) sensor. Myocardial oxygen consumption and lactate flux were calculated/monitored at 5, 10, 20, and 40 minutes of reperfusion. Thereafter, myocardial function was evaluated at 45 minutes of reperfusion using LVSWI. Just after reperfusion, the treatment group (group B, n = 10) had a significantly greater coronary flow than the control group (Group A, n = 10, 35.0 ± 10.1; group B, 47.4 ± 8.5 ml/100 g/min, p < 0.025). Myocardial tissue PCO2 and calcium ion levels in group B were significantly decreased at 5 minutes of reperfusion (A: 110 ± 21 → 88 ± 16; B: 126 ± 24 mmHg → 44 ± 7 mmHg, t-PCO2, p < 0.001; A: 3.5 ± 0.7 → 3.2 ± 0.7; B: 2.7 ± 0.7 mM → 1.7 ± 0.6 mM, t-Ca, p < 0.001). Also, group B had better metabolic recovery, as evaluated by increased myocardial oxygen consumption and increased lactate flux. Thus, terminal nicorandil-Mg cardioplegia improved myocardial blood flow, which in turn markedly improved tissue acidosis, thereby reducing the extent of reperfusion injury.

Spontaneous rupture of the thoracic descending aorta is rare, and uniformly fatal without surgery. We report herein the case of a man in whom such a rupture was successfully treated with emergency surgery. We believe that the rupture in this patient was most likely associated with perforation through an atherosclerotic plaque of the descending aorta and was induced by sudden hypertension.

A total 782 consecutive patients underwent open-heart surgery with CPB between January, 1979 and December, 1988, at the Yamagata University Hospital. We assessed the incidence of postoperative infections in relation to age, the duration of surgery and antibiotic prophylaxis, and examined the causative organisms, after which the types of infecting flora were compared between the 1st period, from 1979 to 1983 and the 2nd period, from 1984 to 1988. Postoperative infection occurred in 104 of the 782 patients (13.3 per cent); in the form of a wound infection in 41 (5.2 per cent), pneumonia in 33 (4.2 per cent), urinary tract infection in 9 (1.2 per cent), prosthetic valve endocarditis in 6 (0.8 per cent), and other infections in 15 (1.9 per cent). Patients aged under 12 months or over 60 years showed a higher incidence of infection, being 17.4 per cent and 19.2 per cent, respectively. Patients who underwent an operation of over 8 hours duration also had a significantly higher incidence compared to those whose operation time was less than 4 hours, being 32.9 per cent and 6.3 per cent, respectively (p

Forty-one patients who underwent cardiac surgery under conditions of systemic hypothermia and intermittent cold crystalloid potassium cardioplegia were studied, in order to elucidate the effects of ventricular fibrillation and reperfusion on the myocardium, by using the intramyocardial pCO2 and temperature sensor. All patients were assigned to 2 groups, namely; group A (21 cases), in which the time between the aorta declamping and defibrillation was under 10 minutes, and group B (20 cases) in which the time was over 10 minutes. In both groups A and B, myocardial pCO2 increased at the rate of 3.58 +/- 1.70 and 2.16 +/- 0.62 mmHg/min (p less than 0.05) after aorta declamping, respectively and the myocardial pCO2 decreased at the rate of 5.59 +/- 0.60 and 4.18 +/- 0.76 mmHg/min (p less than 0.05) after defibrillation, respectively. In group A, the myocardial calcium content, pre-CPB (cardio pulmonary bypass) was 10.98 +/- 1.62 nmol/mg/dry weight and at the time of aorta declamping it was 15.90 +/- 1.81 nmol/mg/dry weight (p less than 0.05). In group B, the myocardial calcium content, pre-CPB, was 14.62 +/- 2.15 nmol/mg/dry weight and at the time of aorta declamping it was 18.23 +/- 4.36 nmol/mg/dry weight (p less than 0.05). At both three and six hours after the operation, the left ventricular work index per minute (LVWI) in group A showed better cardiac pump function than that in group B. We therefore conclude that when reperfusion is encountered, acidosis can be minimized by prompt defibrillation.

Two patients with thoracic aortic aneurysm ruptured to the lung are reported. They had a previous history of a large amount of hemoptysis requiring uregent hospitalization. Surgical treatment was performed in each of the patients after the emergent pre-operative examinations. The first patient was a 71-year-old male with a huge syphilitic fusiform aortic arch aneurysm ruptured to the left lung, who had a large amount of hemoptysis and vertigo. Graft interposition was undertaken employing cardiopulmonary bypass and separate perfusion of brachiocephalic vessels, but weaning from the circulatory supporting unit did not succeed because of uncontrolled bleeding from the dissected damaged lung. The second patient was a 75-year-old male with an egg-shaped saccular descending thoracic aortic aneurysm ruptured to the left lung. He was operated on by aneurysmectomy under partial cardiopulmonary bypass. No complications appeared after the operation. In the technics of ruptured thoracic aortic aneurysm repair, dissection of the damaged lung from the aneurysm must be avoided if possible.

Pulmonary lesions are often observed in patients with progressive systemic sclerosis (PSS). A rare case of bronchial carcinoid that was found at operation for ruptured giant bulla in a patient with PSS is reported. The patient, a 37-year-old female, had been treated for PSS since 1971. She was admitted to our hospital because of dyspnea and chest pain in January 1981. Chest X-ray films revealed left pneumothorax. As continuous left thoracic drainage was ineffective, surgical treatment was undertaken. At operation a solid tumor (3×3cm) was newly recognized in the left S9, together with ruptured giant bulla in the left S8. Therefore, left lower lobectomy was performed. Histological examination revealed that the tumor was argynophilic bronchial carcinoid and the bulla had interstitial pneumonia. Although the postoperative course seemed uneventful, bone metastases (the fourth lumbar vertebral body) appeared 15 months after operation, and she died 17 months after operation.

Twelve patients with heart valve surgery over the age of 65 were investigated postoperatively by the cardiac catheterization method at rest and during the dopamine infusion test. Cardiac lesions were mitral stenosis in five patients and mitral regurgitation and/or aortic regurgitation in seven. The patients ranged from 67 to 73 (average 70.0)years old and the mean follow-up period was 38.9 months.The functional state recovered from 2.9 to 1.6 according to the NYHA classification after the follow-up term, so the left ventricular pump function referred to the cardiac index, stroke volume index and left ventricular stroke work index did not change significantly. However left ventricular systolic function referred to the left ventricular end-systolic pressure to end-systolic volume index ratio, end-systolic wall stress to endo-systolic volume index ratio and tension-volume ejection fraction were markedly increasd in the cases of left ventricular volume overload from valvular regurgitation. After the dopamine infusion test, ejection time was shortened, and forward stroke flow was increased because of the decrease in regurgitant flow, in contrast to the absence of a change in total stroke flow.

Since non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for inhibition of inflammation, an in vivo assay for leukotaxis would be of use in comparing the biological activity effects of the agents. Here, the effects of 4 different NSAIDs on in vivo leukocyte accumulation was determined by quantitating N-formyl-methionyl-leucylphenylalanine induced leukotaxis in the rabbit anterior eye chamber. New Zealand white female rabbits were treated for three days with the following regimens: ibuprofen or aspirin, 0.1, 1.0, 10.0 or 100.0 mg/kg/day, indomethacin or flurbiprofen, 0.01, 0.1, 1.0, or 10.0 mg/kg/day. Indomethacin and flurbiprofen significantly reduced leukotaxis in a dose of 10.0 mg/kg/day. Aspirin was associated with a weak inhibition of leukotaxis. Ibuprofen had biphasic effects, 1.0 mg/kg/day potentiated and 10 mg/kg/day inhibited leukotaxis, whereas leukocyte accumulation was uneffected by a high dose (100.0 mg/kg/day). These results suggest that modulation of leukotaxis by NSAIDs may reflect a differential dose-response sensitivity of lipoxygenase and cycloxygenase pathways.

The purpose of this study was to evaluate the rabbit anterior eye chamber as a quantitative measure of leukotaxis using 51Cr-labeled homologous leukocytes and then to determine the effects of ibuprofen on N-formyl-methionyl-leucyl-phenylalanine (FMLP) -induced leukotaxis. Leukocyte accumulation was assessed at various intervals (0-24 h) after instillation of FMLP (10(-4) M, 40 microliters) and at various doses (FMLP 10(-6)-10(-4) M). New Zealand white rabbits (2.6-3.0 kg) were treated with ibuprofen for three days with the following regimens: 8.0, 17.5, 35.0, 70.0 mg/kg/ day. Leukocyte quantitation was determined using a direct cell count and recovery of 51Cr-labeled leukocytes from anterior eye chamber aspirations 3 h after their injection into the systemic circulation. FMLP induced a dose-dependent accumulation of leukocytes. Leukocyte influx into the anterior eye chamber increased between 2 and 4 h after FMLP instillation, peaking between 4 and 6 h, then resolving after 8 h. Ibuprofen inhibited leukocyte accumulation into the anterior eye chamber in a dose dependent fashion with a maximum (90.0 +/- 1.4%, X +/- SEM) inhibition with 70 mg/kg/day and an ID50 of 8 mg/kg/day. In conclusion, the anterior eye chamber FMLP-stimulated leukotaxis assay is useful to evaluate the role of pharmacologic agents. Here, ibuprofen was found to inhibit leukotaxis in a dose-dependent manner.

The purpose of this study was to investigate the cellular composition of peritoneal fluid during post-surgical re-epithelialization and to determine the metabolism of arachidonic acid by these cells. Rabbits underwent a midline laparotomy followed by abrasion of the broad ligament. The presence of adhesions was graded and the peritoneal exudative cells collected up to 14 days thereafter. Ascitic fluid and cells were separated by centrifugation and the cellular percipitate incubated with [14C]arachidonic acid. The aliquot was separated by silica Gel G thin-layer chromatography and the specific radioactivity of each strip determined. To evaluate the reformation of adhesions 14 days after the first abrasion, rabbits underwent reabrasion of the same area and the pattern of arachidonic acid metabolism by the ascites cells was similarly evaluated. Six hours after the abrasion, PMNs comprised 87.5% of the peritoneal exudative cells (total 0.03 × 107 cells/rabbit). On Day 3, the total cell number increased to 2.92 × 107, 97.6% of which were large mononuclear cells. No significant change in the type or distribution of adhesions was evident from 6 hr through Day 2. After Day 7, the total number of adhesions was minimal; however, those that were present were primarily severe. The second-look evaluation of adhesion formation was not found to be consistent prior to the 7th postoperative day, since many filmy bands present prior to that time were not present later. The in vitro formation of 5-HETE by these cells increased from 6 hr through Day 11. Production of di-HETE increased beginning Day 3 and maintained high steady state levels thereafter. 15-HETE levels increased relatively abruptly from 6 hr to Day 1 and continued to increase thereafter. 6-keto-PGF1a levels rapidly increased over the initial 24 hr and remained at almost the same concentration. Although TxB2 and PGE2 were at relative low concentrations 6 hr after peritoneal injury, production of these metabolites dramatically increased through the later phase of healing. Reabrasion was followed by a lesser number of leukocytes in the peritoneal fluid compared to the initial abrasion. The percentage of macrophages in the peritoneal fluid 24 hr after the reabrasion procedure was higher than after the first abrasion. The incidence of severe adhesions after reabrasion was also higher than after the first abrasion. The formation of TxB2 and 15-HETE by macrophages recovered from the peritoneal fluid 1 day after reabrasion was greater than after the initial abrasion. Since the marked increase in the number of macrophages paralleled the increase in arachidonic acid metabolites, recruitment of an active cellular element into the site of tissue healing (i.e., the activated postsurgical macrophage) accompanied postsurgical repair. These findings lend in vitro support to the clinical observation of repetitious adhesion reformation and suggest that the balance of biochemical mediators involved in initial adhesion formation may not be identical to those involved in adhesion reformation.

We evaluated oxidized regenerated cellulose (ORC) in experimental rabbit and dog models to assess its potential for reducing or preventing adhesion formation and reformation. Evaluation was performed in the following anatomical sites: (1) uterine horn trauma; (2) small bowel resection and anastomosis; (3) parietal peritoneum excision; and (4) adhesion reformation in the uterine horn. Ten to 14 days after ORC treatment, adhesion formation was macroscopically and microscopically evaluated. Results demonstrate that ORC produced graded reduction in adhesion formation and significantly prevented adhesion reformation.

We determined the level of sodium ceftizoxime (CZX) in the right atrium and mitral papillary muscle of 22 adults and 6 children undergoing open-heart surgery, 60 and 120 minutes after intravenous administration of this drug at the dosages of 2 grams for adults and 1 gram for children. The CZX level in the right atrial muscle after 60 minutes was 37.0 micrograms/g in adults and 51.0 micrograms/g in children. The CZX level in the papillary muscle of the mitral valve, determined at 120 minutes was 16.9 micrograms/g. In the present study, we measured the level of the antibiotic CZX in the myocardial tissue during open-heart surgery. The purpose of this was to determine the quantity in which the antibiotic is taken into the myocardial tissue.

Angiogenesis was observed and measured after injection of human follicular fluid into rabbit corneas. Undiluted human follicular fluid stimulated angiogenesis in every case, with new blood vessels visible 3 days after injection and extending 2.0 millimeters from the corneal scleral limbus into the injection site by day 15. Stimulation of angiogenesis was lost by heating or diluting the follicular fluid but was retained after charcoal stripping or dialysis. Human follicular fluid contains an angiogenic factor that may be associated with perifollicular neovascularization during folliculogenesis.