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大動脈炎症候群が疑われた腹部大動脈縮窄症に胸部下行大動脈瘤を合併した症例に対し下行大動脈置換と下行-腹部大動脈バイパス術を行い良好な結果を得たので報告する.症例は67歳,女性.左側胸部痛精査のCT,DSAで最大径60mmの下行大動脈瘤と腎動脈分岐後の腹部大動脈縮窄を認めた.さらに上腸間膜動脈から下腸間膜動脈に著しく拡張したmeandering mesenteric arteryを介した側副血行路がみられた.血液検査上炎症所見はなかったが形態学的に大動脈炎症候群が疑われた.手術は左第4肋間開胸と左腹部斜切開でF-Fバイパス下に下行大動脈瘤切除,人工血管置換を行い,下行置換のグラフトに作製した分枝と大動脈分岐上の腹部大動脈との間に後腹膜経路でバイパス術を行った.術後経過は良好で術後42日で軽快退院した.大動脈炎症候群では術後の炎症再燃,吻合部動脈瘤の発生が危惧されるが,術後約1年の経過観察中合併症なく社会復帰している.

The thoracic cage after a lung resection is filled by the remaining lobes, the elevated diaphragm, the diminished thoracic cage, and by mediastinal shifting. The changes in the thorax after a lung resection were quantified using magnetic resonance imaging. The study group consisted of 39 patients who had undergone a lobectomy, four who had undergone a pneumonectomy, and 14 controls. The left ventricular angle, ascending aortic angle, mediastinal shift, longitudinal length of the thoracic cage, the distance between the thoracic apex and the level of the aortic valve, and diaphragmatic elevation were all measured. After a right lower lobectomy, the mediastinum shifted more rightward than after a right upper lobectomy. The diaphragm became more greatly elevated after a right upper lobectomy than after a right lower lobectomy. When a chest wall resection was added to a right upper lobectomy, the mediastinal anatomical changes decreased. After a left upper lobectomy, the degree of mediastinal shifting was greater than after a left lower lobectomy. A left upper lobectomy shifted the mediastinum at the level of the right atrium. This method is easily reproducible and was found to be effective for quantifying the changes in the thorax after a lung resection.

We evaluated our hypothesis that morphological change of the aortic dissection can be predicted by serial measurements of hemostatic molecular markers. Between February 1999 and February 2003, 50 patients with chronic aortic dissection of the descending thoracic aorta were studied at random intervals of 1 to 59 months (mean, 15.4+/-14.3) after onset. Morphologies of the false lumen of the aortic dissection determined by computed tomographic (CT) images were divided into four groups. Twenty-two images had aortic dissection associated with intramural hematoma or a completely thrombosed false lumen without ulcer-like projections (group 1), 14 had a thrombosed false lumen with ulcer-like projections (group 2), 18 had patent, but a partially thrombosed false lumen (group 3), and 15 had a completely patent false lumen (group 4). Blood samples for detection of hemostatic molecular markers were collected on the same day or within 1 month of the CT scan being performed. Thrombin-antithrombin complex (TAT) and D-dimer proved to be significantly higher in group 3 than in group 1. There was no significant correlation between the external diameter and hemostatic molecular markers except for prothrombin fragments 1+2 (PTF1+2). Simultaneous determinations of these hemostatic markers and multiple CT scans were performed more than twice in 19 of the patients. These cases were divided into three groups according to the morphological changes of the false lumen in the interval; morphologically progressive, regressive and no change cases. Five cases showed reduction or disappearance of the false lumen (the regressive cases). Only one case showed that the false lumen progressively enlarged and was partially patent thereafter (the progressive case). Mean plasma levels of TAT and D-dimer were changed correlated with the morphological progressive or regressive changes. The morphology of aortic dissection was correlated with hemostatic molecular markers such as TAT or D-dimer. We concluded that the serial measurement of D-dimer and TAT is useful for predicting morphological changes in chronic aortic dissection, and it can be an alternative way to follow up for patients of aortic dissection.

Atherosclerotic and dysplastic aneurysms of the extracranial internal carotid artery are rare in Japan. We have experienced only four cases since 1982. The patients were two men and two women with a mean age of 67 years (range 51 to 82 years). All four patients had a saccular type aneurysm; sizes ranged from 30 to 75 mm. Aneurysmectomy and end-to-end anastomosis of the internal carotid artery could be performed in two patients. One patient underwent aneurysmorrhaphy followed by primary closure of the internal carotid artery, and the remaining patient underwent aneurysmectomy followed by a prosthetic graft replacement (6 mm-PTFE graft). During aneurysm repair, simple arterial cross-clamping (time 18 to 57 min; mean +/- SD: 31.3 +/- 18.0 min) was used in all patients. During arterial clamping of the carotid artery in two patients, somatosensory evoked potentials and regional cerebral oxygen saturation detected by near-infrared spectroscopy remained within normal ranges. All patients survived without neurologic deficits. These findings indicate that intraluminal shunting may be unnecessary during aneurysm repair if the patient does not have obstructive disease in the contralateral carotid artery and if no somatosensory evoked potentials or regional cerebral oxygen saturation abnormalities occur during proximal arterial clamping. After aneurysmectomy, end-to-end anastomosis of the internal carotid artery is the preferred method of repair if the length of the distal internal carotid artery permits.