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難治性腹水, 肝硬変症を合併した慢性腎不全患者において血液透析と腹水透析の併用療法の効果を検討した. 症例は77歳, 女性. 10年前よりC型肝炎による肝硬変症を指摘された. 1年前より腎不全を指摘され内科的治療を続けていたが, 貧血, 尿毒症状, 腹水貯留が進行し, 透析導入を目的として当院に入院した. 左内シャント造設と同時に腹腔内に腹腔ポート (SMAP-27, Nipro) を植え込んだ. 血液透析中に, このポートに針を穿刺して腹水を抜き, 血液濾過および透析を施行して濃縮した. 濃縮した腹水を血液回路の動脈チャンバー側から点滴し, 30分から1時間ほど血液透析を続けた. 入院当初, 低蛋白血症 (TP 4.6g/dL) を認めたが, 蛋白濃度も6.0g/dLに上昇し, 腹部膨満も改善したので食事摂取も可能となった. 透析中の血行動態は安定し, 日常生活における活動性が向上した.腹水透析は, 腹水除去および体重管理を容易にし, 血液透析と併用することで全身管理が容易となった. 同時に加療できる時間的な利点とともに, 膨満感や尿毒症による症状から開放され肉体的, 精神的にQOLを是正したと考えられた. また, 腹腔ポートの使用によって腹水穿刺が容易となり, 腹水透析には有用なデバイスと考えられた.

心房細動の80歳の女性に脳梗塞が再発し, 経食道心エコーにより, 左心耳内に2×3cmの可動性血栓像を認めた. 体外循環心停止下に左心耳内部に付着した血栓を除去後, 左心耳入口部を縫合閉鎖した. 血栓は大部分は白色血栓化していた. 術後経過良好であり, 合併症もなく元気に退院した. 左房内血栓の診断には経食道心エコーが有効であり, 高齢者であっても塞栓症を繰り返す症例では検査を行い, 全身状態が良好であれば除去すべきと思われた. 本邦では非弁膜症性心房細動に伴う左房内血栓の除去術はこれまでに6例報告され, 80歳以上は本例が2例目であった.

We present herein the case of a 65-year-old man who suddenly developed fresh perigraft bleeding into the space between a knitted Dacron bifurcated graft and the aneurysmal sac, 12 years after undergoing graft replacement. Intraoperative findings did not show Dacron fiber degeneration at the nonanastomotic sites or a pseudoaneurysm at the anastomotic site. Widened Dacron fiber interstices resulting from graft dilation without sufficient graft healing was thought to have caused delayed hemorrhage through the macroscopically intact graft material, followed by massive clot retention between the graft and the aneurysmal sac. This case report serves to demonstrate that careful long-term follow-up is essential for patients who have undergone vascular graft replacement.

Revascularization of the hypogastric artery often tends to be neglected in aortoiliac reconstructive surgery; however, its incomplete revascularization can result in unfavorable complications such as buttock claudication or necrosis, vascular impotence, and colonic ischemia. Multiple vascular lesions in the abdominal aorta and bilateral iliac arteries were reconstructed using a newly designed double bifurcated graft in five male patients. All five patients demonstrated excellent graft limb patency and postoperative improvement of the ankle-brachial pressure index without any clinical signs of ischemia in regions of the hypogastric artery. Thus, we conclude that an aggressive approach toward hypogastric circulation maintenance is essential in aortoiliac reconstructive surgery. By using this double bifurcated graft, rapid and safe revascularization of the bilateral hypogastric arteries concomitant with the external iliac or femoral arteries can be performed.

Cardiopulmonary bypass (CPB) was established via a sutured collagen sealed knitted Dacron graft in two patients who had undergone extraanatomic bypasses for lower limb ischemia, whose ascending aorta was not suitable for cannulation. One patient, with a history of femorofemoral bypass, underwent surgery for a ruptured aortic arch aneurysm (AAA) and the other patient, with a history of axillobifemoral bypass for chronic dissection involving the aortic arch and descending aorta, had unstable angina and underwent coronary artery bypass grafting. This technique of perfusion was found to be safe and effective for patients with an impaired ascending aorta who have undergone an extraanatomic bypass for the lower limb.

Graft replacement of the descending thoracic or thoracoabdominal aorta was successfully performed in 3 patients using percutaneous cardiopulmonary bypass. Femoral inflow and outflow cannulas were inserted percutaneously after induction of anesthesia with the patient in supine position, and low flow normothermic bypass was established before thoracotomy. Next the patient was placed in a right lateral position to create an operating field. With this body position and even an almost prone position, which was sometimes necessary for easy dissection of adhesion of lung to the aneurysmal wall, the bypass flow was easily maintained adequately. The bypass circuit was coated with heparin, and the activated clotting time (ACT) was controlled to be between 150 and 200 s during the entire operating period. Percutaneous insertion of the cannulas avoided local bleeding in the groin, and the low ACT made control of hemorrhage in the operating field easy. For descending aortic surgery, heparin-coated percutaneous cardiopulmonary bypass proved to be a useful adjunctive measure.

The dual-stage venous cannula is widely used but can obstruct the surgeon's view and interfere with operative procedures in the aortic root. We designed a new stainless steel sheath for a dual-stage venous cannula that enables the cannula to bend and maintain the appropriate angle for the surgical procedures. We suggest that operative procedures in the aortic root can be performed faster during safety cardiopulmonary bypass by use of a dual-stage venous cannula bent by application of this new sheath.