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Acute aortic occlusion is a rare but catastrophic pathology with high mortality even after revascularization. We describe four patients who underwent thrombectomy or bypass surgery for acute aortic occlusion with concomitant internal iliac artery occlusion. Two patients (82- and 75-year-old men), who had insufficient reperfusion of bilateral internal iliac arteries after treatment (thrombectomy alone and axillobifemoral bypass, respectively), died on postoperative day three of uncontrollable hyperkalemia and multiple organ failure, respectively (mortality: 50%). The third patient (74-year-old man), in whom the left internal iliac artery was reperfused after an axillobifemoral bypass, underwent right lower limb amputation but survived. The fourth patient (63-year-old man) with sufficient internal iliac artery reperfusion bilaterally after aortobifemoral and right internal iliac artery reconstruction, had an uneventful postoperative course. Elevated creatine phosphokinase and myoglobinuria levels were observed in all four patients but were notably higher in the two patients with no reperfusion in either of the internal iliac arteries. Our results suggest that reperfusion of one or more internal iliac arteries may be a crucial factor in reducing mortality in revascularization treatment of acute aortic occlusion with concomitant internal iliac artery occlusion.

62歳，女性．24歳時にファロー四徴症と診断された．今回，発熱，呼吸困難を訴え来院した．NYHA IV度であり，心臓超音波検査でファロー四徴症，三尖弁閉鎖不全症を認め手術適応と判断した．心臓カテーテル検査で主要大動脈肺動脈側副動脈（MAPCAs）を認めた．術中の心腔内還流血や修復術後の左室容量負荷残存を考慮し，MAPCAsコイル塞栓術を先行した後，心内修復術（Medtronic FreeStyle Valve，Transannular patchを用いた右室流出路再建＋心室中隔欠損閉鎖＋三尖弁輪縫縮）を行った．術後第2病日に人工呼吸器を離脱し，第37病日に退院となった．退院時はNYHA I度で術後10年を経過した現在も外来通院中である．高齢者のファロー四徴症であっても肺動脈弁逆流，三尖弁逆流を残存させない術式の選択やMAPCAsコイル塞栓術を先行することにより安全に心内修復術を施行し得た．

The existing literature indicates a crucial role of p38 MAP (mitogen-activated protein) kinase (p38MAPK) and its downstream target MAPKAP kinase 2 (MK2) in ischemic preconditioning (IPC). Accordingly, deletion of MK2 gene should abolish the cardioprotective ability of IPC. Interestingly, we were able to partially precondition the hearts from MK2(-/-) knockout mice suggesting the existence of an as yet unknown alternative downstream target of p38MAPK. A recent study from our laboratory also determined a crucial role of CREB (cyclic AMP response element binding protein) in IPC. Since CREB is a downstream target of MSK-1 (mitogen- and stress-activated protein kinase-1) situated at the crossroad of ERK (extracellular receptor kinase) and p38MAPK signaling pathways, we reasoned that MSK-1 could be a downstream molecular target for p38MAPK and ERK signaling in the IPC hearts. To test this hypothesis, the rat hearts were subjected to IPC by four cyclic episodes of 5 min ischemia and 10 min reperfusion. As expected, IPC induced the activation of ERK1/2, p38MAPK, MK2 and HSP (heat shock protein) 27 as evidenced by their increased phosphorylation; and the inhibition of p38MAPK with SB203580 almost completely, and the inhibition of ERK1/2 with PD098059 partially, abolished cardioprotective effects of IPC. Inhibition of MSK-1 with short hairpin RNA (shRNA) also abolished the IPC-induced cardioprotection. SB203580 partially blocked the effects of MSK-1 suggesting that MSK-1 sits downstream of p38MAPK. shRNA-MSK-1 blocked the contribution of both p38MAPK and ERK1/2 as it is uniquely situated at the downstream crossroad of both of these MAP kinases. Although MSK-1 sits downstream of both ERK1/2 and p38MAPK, ERK1/2 activation appears to play less significant role compared to p38MAPK, since its inhibition blocked MSK activation only partially. Consistent with these results, shRNA-MSK-1 blocked the partial PC in MK2(-/-) hearts, and in combination with SB203580, completely abolished the PC effects in the wild-type hearts. The IPC-induced survival signaling was almost completely inhibited with SB203580, and only partially with PD 098059 as evidenced from the inhibition patterns of IPC induced activation of CREB, Akt and Bcl-2. Again SB203580 alone or in combination with shRNA-MSK-1 inhibited IPC induced survival signal comparatively, suggesting that MSK-1 exists downstream of p38MAPK. Taken together, these results indicate for the first time MSK-1 as an alternative (other than MK2) downstream target for p38MAPK, which also transmits survival signal through the activation of CREB.

A 63-year-old man presented to a nearby doctor with fever and lumbago. Enhanced computed tomography showed a thoracoabdominal aortic aneurysm and enhancement of soft tissue around the aneurysm. He was diagnosed with an infected thoracoabdominal aortic aneurysm and given antibiotics. After 2 weeks, the infection was controlled and he underwent in situ replacement with a bovine pericardial roll graft. A week after the operation, the inflammatory reaction was increased, but the bovine pericardial roll graft was not infected. This suggests that a bovine pericardial roll graft is a suitable material for use in patients with bacterial infections.

The patient, a 55-year-old female Jehovah's Witness who had suffered type B aortic dissection since the age of 53 years, presented with enlargement of the false lumen in the distal aortic arch and was subsequently admitted to our hospital. While hospitalized, her enlarged false lumen ruptured and she underwent replacement of the distal aortic arch and descending thoracic aorta without blood transfusion. Blood conservation strategies for this patient included the following: 1) meticulous hemostasis when incising muscle or soft tissue, 2) minimal use of gauze and discard suckers, 3) exclusive use of a cell salvage device "from skin to skin," 4) low-prime cardiopulmonary bypass, 5) minimal laboratory blood sampling, and 6) preoperative and postoperative erythropoietin treatment. Hemoglobin (Hb) values were 12.5, 15.5, 10.0, and 9.7 g/dL on admission, before rupture, after rupture, and just after the operation, respectively. The patient had an uneventful postoperative course, except for prolonged rehabilitation. The postoperative lowest Hb value was 5.2 g/dL on postoperative day 5, and the Hb value at hospital discharge (postoperative day 55) was 11.0 g/dL. Our experience with blood conservation surgery on this Jehovah's Witness patient suggests that ruptured chronic type B aortic dissection can be safely repaired on bypass through a left thoracotomy with no blood transfusion if the preoperative Hb value is >10.0 g/dL.

Persistent sciatic artery (PSA) is a rare congenital vascular malformation. In this article, we have described the case of a 66-year-old woman presenting with a pulsatile mass in the left buttock and bilateral lower limb ischemia, who underwent surgical therapy. Preoperative computed tomography scanning showed a left thrombosed PSA aneurysm (PSAA) with concomitant occlusion of bilateral iliac, bilateral common femoral, and left popliteal arteries. After recanalization of the left common femoral artery occlusion with a systemic heparin treatment, the patient underwent bypass surgery (left femoropopliteal bypass, right iliofemoral bypass) and PSAA exclusion. Postoperative computed tomography scanning 20 months after surgery revealed that the excluded PSAA was thrombosed with no refilling collateral flow, and that the bypass grafts were patent in both legs. In addition to this case report, a literature review of PubMed articles published between 1965 and 2009 that included the treatment and intermediate/long-term management of symptomatic PSAs was conducted. We found 45 articles (67 limbs), of which 24 (29 limbs) described the intermediate/long-term outcomes in patients treated for symptomatic PSA. Regardless of the method of arterial reconstruction or PSAA repair, intermediate/long-term outcomes of different treatments for lower limb ischemia and PSAAs were satisfactory, and the patients were asymptomatic during the follow-up period which ranged from 2 months to 10 years.

A 56-year-old man with a painful, progressively enlarging pulsatile mass in the bilateral popliteal fossae was diagnosed with a bilateral popliteal artery aneurysm (PAA) and referred to our hospital to undergo surgical therapy. Computed tomographic scanning demonstrated a large, middle-type PAA with a rich mural thrombus in the bilateral popliteal arteries. Following aneurysm exclusion posteriorly, the patient underwent bypass surgery using a ringed polytetrafluoroethylene graft bilaterally. This procedure was chosen to prevent nerve injury caused by mobilization of the adherent nerves and aneurysmal resection. The patient had a satisfactory postoperative course. This procedure may be recommended for large, middle-type PAAs because (1) the adherent tibial nerve trunk and its branch nerves can be protected by aneurysm exclusion with arterial branch ligation and (2) frequently occurring postexclusion expansion of the aneurysm caused by insufficient branch ligation using the medial approach can be avoided.

This study attempts to address an important clinical issue by identifying potential candidates of VEGF signaling through Flt-1 receptor that trigger angiogenic signal under ischemic stress. To determine the significance of VEGF-Flt-1 (VEGFR1) signaling in ischemic preconditioned (PC) myocardium, we used heterozygous Flt-1 knockout (KO) mice to dissect the pathway and identify candidate genes involved in VEGF signaling. DNA microarrays were employed to detect, characterize and distinguish altered myocardial gene expression by comparing between wild type (WT) CD-1 and heterozygous Flt-1 KO mice when exposed to ischemia (30 min) and reperfusion (2 h). Moreover, KO mice demonstrated reduced beneficial effects of PC when compared to the WT with PC. In the KO and WT mice, the % recovery of the left ventricular developed pressure and the maximum first derivative of the developed pressure after ischemia/reperfusion without PC were similar. However, when animals were subjected to PC, the left ventricular functional recovery throughout the reperfusion period was significantly lower in KO mice than in WT mice. These results indicate for the first time that in the heterozygous Flt-1 KO mice, PC is not as effective as that found in WT. This observation may be due to downregulation of several important genes such as growth-regulated oncogene 1 (Gro1), heat shock proteins (HSP), I kappa B kinase β (IKKβ), colony-stimulating factor-1 (CSF-1) and annexin A7, suggesting the importance of VEGF-Flt-1 receptor signaling during PC.

Stress-induced mitogen-activated protein (MAP) kinases have been implicated in various forms of cardiovascular diseases. Ischemia/reperfusion potentiates activation of p38 MAP kinase (p38MAPK) leading to the activation of its downstream target MAPKAP kinase 2 (MK2). While p38MAPK has been shown to induce pro-apoptotic signal, whether MK2 also generates death signal is not known. To determine if MK2 triggers death signal, the hearts of MK2–/– knockout mice and genetically matched wild-type mice were subjected to 30 min ischemia followed by 2 h of reperfusion via Langendorff mode. The results indicated that the hearts of MK2–/– mice were resistant to myocardial ischemic reperfusion injury as evidenced by enhance recovery of post-ischemic ventricular performance, reduced myocardial infarct size and diminished number of apoptotic cardiomyocytes. We conclude that MK2, similar to p38MAPK, is involved in transmitting the death signal to the ischemic myocardium.

L'artere sciatique persistante (PSA) est une malformation vasculaire congenitale rare. Dans cet article, nous decrivons le cas d'une femme de 66 ans se presentant avec une masse pulsatile de la fesse gauche et une ischemie bilaterale des membres inferieurs, traitee chirurgicalement. Le scanner preoperatoire montrait un anevrysme thrombose de la PSA gauche (PSAA) avec occlusion iliaque et femorale commune bilaterale et occlusion de l’artere poplitee gauche. Apres recanalisation de l'occlusion de l'artere femorale commune gauche avec un traitement systemique par l'heparine, la patiente a eu une revascularisation (femoropoplitee gauche et ilio-femorale droite) avec exclusion du PSAA. Le scanner postoperatoire 20 mois apres chirurgie montrait que le PSAA exclu etait thrombose sans reflux collateral, et que les pontages etaient permeables. En plus de ce cas, une revue de la litterature PubMed publiee entre 1965 et 2009 qui incluait le traitement et le suivi intermediaires/a long terme des PSA symptomatiques a ete faite. Nous avons trouve 45 articles (67 membres), dont 24 (29 membres) decrivaient les resultats intermediaires/a long terme chez les patients traites pour PSA symptomatique. Independamment de la methode de reconstruction arterielle ou de reparation du PSAA, les resultats intermediaires/a long terme des differents traitements pour ischemie des membres inferieurs avec PSAAs etaient satisfaisants, et les patients etaient asymptomatiques au cours de la periode de suivi allant de 2 mois a 10 ans.

Nous decrivons un malade presentant une occlusion aortique due a l’expansion du faux chenal apres la reparation d’une rupture aortique abdominale au cours d’une dissection aortique aigue de type B. Un homme de 70 ans se presentait a un hopital voisin avec des douleurs lombo-sacrees importantes, et nous etait adresse avec le diagnostic de rupture aortique abdominale. La tomodensitometrie a l’admission montrait une dissection aortique de type B avec rupture concomitante du faux chenal au niveau d’un anevrysme de l’aorte abdominale sous-renal preexistant. Le malade avait un remplacement aortique abdominal avec reconstruction de la vraie lumiere avec une prothese tricotee bifurquee en Dacron. Au 2eme jour postoperatoire, le malade developpait une ischemie severe de l’hemicorps inferieur. La tomodensitometrie montrait l’occlusion complete de la vraie lumiere au niveau de l’artere renale en raison de l’expansion du faux chenal. Le malade eut une fenestration ouverte en ouvrant le lambeau saillant avec un distal prothetotomie transversale en aval de l’anastomose proximale. Apres fenestration, le patient developpa des complications metaboliques graves (syndrome myo-nephropathique metabolique) et est mort un jour plus tard d’arret cardiaque par l’hyperkaliemie. Le remplacement aortique abdominal avec reconstruction de la vraie lumiere chez les malades ayant une rupture aortique abdominale dans les dissections aortiques aigues de type B peut egalement mener a l’occlusion aortique aigue due a une re-dissection ou a l’alteration de la vraie lumiere accompagnant une propagation retrograde de la thrombose du faux chenal. Cette complication mortelle apres reconstruction de la vraie lumiere pourrait etre empechee par un procede adjuvant tel que la fenestration concomitante.

We describe a patient with aortic occlusion due to false-lumen expansion after repair of abdominal aortic rupture in acute type B aortic dissection. A 70-year-old man presented to a nearby hospital with severe lower back pain, and was subsequently referred to our hospital with a diagnosis of abdominal aortic rupture. Computed tomography scanning on admission revealed type B aortic dissection with concomitant false-lumen rupture at the level of pre-existing infrarenal abdominal aortic aneurysm. The patient underwent abdominal aortic replacement with the true lumen reconstructed using a bifurcated knitted Dacron graft. On postoperative day 2, the patient developed severe lower body ischemia. Computed tomography scanning revealed complete true-lumen occlusion at the renal artery level because of false-lumen expansion. The patient underwent open fenestration by opening the bulging flap with a transverse graftotomy distal to the proximal graft anastomosis. After fenestration, the patient developed severe metabolic complications (i.e., myonephropathic-metabolic syndrome) and died a day later of cardiac arrest resulting from hyperkalemia. Abdominal aortic replacement with true-lumen reconstruction in patients with abdominal aortic rupture in type B acute aortic dissection could also lead to acute aortic occlusion due to re-dissection or true-lumen compromise accompanying retrograde propagation of false-lumen thrombosis. This lethal sequela after true-lumen reconstruction might be prevented by an adjuvant procedure such as concomitant fenestration.

We describe a rare case of an arteriosclerotic aneurysm in the right-sided descending thoracic aorta with a left-sided aortic arch and concomitant aberrant right subclavian artery. A 76-year-old woman, who was found to have an aneurysm of the right-sided descending thoracic aorta, was referred to our hospital for surgical treatment. Contrast computed tomography scan revealed a left-sided aortic arch with an aberrant right subclavian artery, a descending thoracic aorta passing downward behind the esophagus, and an aneurysm of the right-sided and distal (level between the 8th and 10th vertebral bodies) descending thoracic aorta. With a right posterolateral thoracotomy, the patient underwent descending thoracic aorta replacement using an 18-mm woven Dacron prosthesis. The patient had an uneventful postoperative course and was discharged 24 days after surgery. Histological microscopic examination of the resected aneurysmal wall revealed an arteriosclerotic aneurysm. The postoperative computed tomography scan 18 days after surgery revealed no anastomotic aneurysm or abnormal fluid collection.

Nous decrivons un rare cas d’anevrisme atheromateux d’une aorte thoracique descendante droite avec une crosse aortique gauche et une artere sous-claviere droite anormale concomitante. Une femme de 76 ans, qui avait un anevrisme d'uneaorte thoracique descendante droite, etait adressee a notre hopital pour le traitement chirurgical. Le scanner de contraste montrait une crosse aortique gauche avec une artere sous-claviere droite anormale, une aorte thoracique descendante passant derriere l’oesophage, et un anevrisme (situe entre les 8eme et 10eme corps vertebraux) de l’aorte thoracique descendante droite distale. Par thoracotomie postero-laterale droite, la patiente a eu le remplacement de l’aorte thoracique descendante avec une prothese en Dacron tisse de 18 mm. La patiente a eu des suites postoperatoires simples et est sortie 24 jours apres la chirurgie. L’examen histologique de la paroi anevrismale resequee montrait un anevrisme arteriosclereux. Le scanner 18 jours apres la chirurgie ne montrait ni anevrisme anastomotique ni collection liquidienne anormale.

Une femme de 78 ans, qui avait un antecedent de resection abdomino-perineale avec stomie gauche pour cancer du rectum, avait un anevrysme de l’aorte abdominale sous-renale interessant les arteres iliaques commune et interne droites. Elle etait traitee par remplacement prothetique in situ (Dacron bifurque) avec un abord retroperitoneal droit en raison d’un acces limite a l’aorte et aux arteres iliaques lie a la stomie gauche. Les anastomoses distales de la prothese bifurquee etaient faites sur l’artere iliaque externe droite et l’artere femorale gauche, et l’artere iliaque commune gauche etait exclue en ligaturant les collaterales. Le patient a eu des suites simples, et le scanner 13 mois apres la chirurgie montrait l’occlusion de l’anevrysme iliaque commun gauche exclu. En conclusion, un abord retroperitoneal droit peut etre une option pour les patients ayant un anevrysme de l’aorte abdominale qui ont des antecedents de chirurgie abdominale transperitoneale et une stomie gauche.

A 78-year-old woman, who had a history of abdominoperineal resection with the associated left-side stoma for rectal cancer, was diagnosed with an infrarenal abdominal aortic aneurysm involving both common and right internal iliac arteries. She underwent in situ graft (bifurcated Dacron) replacement through a right retroperitoneal approach because of limited accessibility to the aorta and iliac arteries due to the left-side stoma. The distal anastomosis of the bifurcated graft was placed to the right external iliac artery and left femoral artery, and the left common iliac artery was excluded by ligating the branching arteries. The patient had an uneventful postoperative course, and the computed tomography scanning at 13 months after surgery revealed thrombosed occlusion of the excluded left common iliac aneurysm. In conclusion, a right retroperitoneal approach may be an option for abdominal aortic aneurysm patients who had a history of transperitoneal abdominal surgery and an associated left-side stoma.

Un diagnostique d’anevrysme poplite (AP) bilateral a ete etabli chez un homme de 56 ans devant la presence de masses pulsatiles evolutives et douloureuses au niveau des deux creux poplites. Le patient a ete adresse dans notre institution pour prise en charge chirurgicale. Un angioscanner a confirme la presence de deux larges AP avec thrombus mural. Apres exclusion des deux AP par voie posterieure, deux pontages prothetiques en polytetrafluoroethylene annele ont ete realises de chaque cote. Cette technique a ete choisie pour eviter la survenue de blessures nerveuses consecutivement a la mobilisation des nerfs tibiaux durant la dissection de l’anevrysme. Les suites operatoires ont ete simples. Cette procedure peut etre envisagee pour les AP larges en raison (1) d’une diminution du risque de blessure du nerf tibial et de ses branches, du fait d’une simple exclusion de l’anevrysme avec ligature des branches, et (2) de la possibilite d’eviter la croissance anevrysmale postoperatoire par ligature insuffisante des branches collaterales naissant de la zone anevrysmale lorsque l’abord est realise par voie mediale.