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One hundred and thirty-four patients with vasoocclusive diseases were retrospectively tested for three kinds of antiphospholipid antibody (aPL). The mean age at onset of the disease in 58 patients with aPL was 43 years old. Seventeen, 11, and 9 patients were positive for the aCL IgA, IgM, and IgG isotypes, respectively. The rates of anti-phospholipid syndrome (APS) in patients with arterial (n=94), venous (n= 31), or both arterial and venous (n=9) occlusion were 45%, 29%, and 78%, respectively. The rates of APS in patients with autoimmune disease (n=13), thromboangiitis obliterans (TAO) (n= 36), arteriosclerosis obliterans (ASO) with lower leg involvement (n=8) or aortic arch syndrome (n=5), Raynaud's syndrome (n=15), aortitis syndrome (n= 13), ischemic heart disease (IHD) with young onset (n =12), and bilateral leg deep venous thrombosis (DVT) (n=10) were 77%, 46%, 13%, 80%, 40%, 62%, 33%, and 70%, respectively. The cumulative patency rate for reconstructive surgery in patients (n=13) with aCL was found to be considerably lower than that in those without aCL (n=13). From these results it was concluded that IgA was the most valuable aCL isotype for the diagnosis of APS and that aPL should be examined in patients with double-vessel occlusion, autoimmune disease, bilateral leg DVT, aortic arch syndrome, TAO, Raynaud's syndrome, or IHD with young onset. Furthermore, prophylaxis for graft failure is more strongly recommended for patients with aCL than for those without it.

A totally implantable motor-driven left ventricular assist device (LVAD) has been developed and tested. The performance of this LVAD was tested in a mock circulatory system. This pump provided 8 L/min of output against a mean afterload of 120 mm Hg with a filling pressure of 20 mm Hg when the pump was operated in the fill/empty mode. The right and left pumps were tested in a mock loop. The right pump afterload was kept in the range from 23–32 mm Hg. With increase in the left pump afterload, the pump power output varied from 1.64 to 2.37 W. The instantaneous motor power input varied from 22.6 to 30.6 W with the total system efficiency ranging from 6.7 to 9.4%. To date, 4 in vivo studies have been conducted for up to 12 h. Two animals survived 12 and 10 h, respectively. Termination was due to bleeding in 1 animal, vent tube obstruction in 1, and respiratory failure in 2. All animals died of technical failure. Another experiment is to be undertaken, and a newly designed cannula is now being manufactured.

We experienced four operated cases of so-called inflammatory abdominal aortic aneurysm and one operated case of iliac aneurysm in a recent two years, and the following outcomes were obtained: 1) Although the causative factors are still obscue, remissions in CT (mantle sign), inflammatory findings and clinical symptoms can be observed by administration of steroid. Once the steroid is stopped, however, mantle sign and inflammation recur in some cases, or the same findings as the aneurysm presents are seen in other arteries which disappear after an operation for the primary lesion. So, it is etiologically suggested that these symptoms may be reactions to some exudation from the aneurysm or some autoimmune reactions of atheromatous sclerotic lesiosn. 2) Steroid should be administered first for hydronephrosis with inflammation. 3) Operation should be indicated for even small aneurysms of less than 5cm in diameter.

A 41-year-old man was admitted to the hospital because of double vision. He was short of stature and the hair was white. His voice was high tone and hoarsely. Tylosis like skin lesion and hypospadias were found. There was a previous history of undergoing an operation for cataract. Dysbolism of glucose and fatty liver were confirmed. The patient was diagnosed as Werner's syndrome. Angiography revealed strictures of the bilateral carotid arteries, stricture of the left subclavian artery, and complete occlusion of the left external carotid artery. The coronary artery was normal. A diagnosis of aortic arch syndrome with transient cerebral ischemia was made. This case was determined to be a possible candidate for vascular reconstruction of the cranial portion of external carotid artery. After thromboendarterectomy for the stenosed portion of the left subclavian artery, by using the same portion and greater saphenous vein, a bypass operation was performed at the left internal carotid artery. Postoperative course was uneventful. Some characteristic findings were obtained by cultivation of the abdominal skin. This is the first case of vascular reconstruction of the cranial portion of external carotid artery for this syndrome in this country. Since the disease presents a rapid progress of arteriosclerosis due to its peculiarity, strict observation of the clinical course would be mandatory.

1991年12月までの過去18年間に教室で10例の大動脈弓分枝動脈瘤に対して外科的治療を行った. 年齢は17～82歳 (平均55歳) 男性8例, 女性2例であった. 成因は, 動脈硬化5例, 胸郭出口症候群2例, 炎症性 (ベーチェット病) 1例, 外傷1例, 医原性1例と多彩であった. 主訴は, 頸部や鎖骨上窩の腫瘤が大部分で, その他には胸部異常陰影や胸痛なども認めた. 破裂2例 (1例は腕頭動脈瘤, 1例は鎖骨下動脈瘤), 上肢急性動脈閉塞症1例も認めた. 病変部位は, 鎖骨下動脈5例, 内頸動脈2例, 総頸動脈1例, 外頸動脈1例, 腕頭動脈1例であった. 術式は, 瘤切除+血行再建術を原則として行い, 現在までのところ, 腕頭動脈瘤破裂の出血死と炎症性内頸動脈瘤のグラフト閉塞以外の経過は良好である. 本症はかなり頻度の少ない疾患ではあるが, 破裂や血栓閉塞・塞栓などを合併することもあり可及的すみやかに手術することが望ましい.

Double chambered right ventricle (DCRV) is common in children, and rarely occurs in adults. Three operated cases of DCRV in a 46-, 46-, and 62-year-old patients are described. The peak systolic pressure gradient in the right ventricle was 110 mmHg in case 1, 80 mmHg in case 2, and 150 mmHg in case 3. A right ventriculotomy in a low pressure chamber was performed in cases 1 and 3, and a longituidinal right ventriculotomy from a low to high pressure chamber was used in case 2 associating with VSD. After surgery, the pressure gradient in the right ventricle disappeared but end-diastolic high pressure was recognized in all patients. It was suggested that deterioration of right ventricular diastolic compliance remains after surgery in adult patients with DCRV.

To evaluate the relationship between maximum venous outflow (MVO) of the leg and development of deep vein thrombosis (DVT), venous occlusion plethysmography (VOP) using a Mercury strain gauge was carried out in 56 unilateral DVT patients. The data from these patients were compared with those obtained from several control groups. Then, the relationship between plethysmographic and 9 clinical variables was statistically analysed in the normal legs of these patients. The mean MVO of the normal legs of these patients was significantly higher than that of the affected legs, but it was significantly lower than those of normal controls and patients with mild congestive heart disease. However, it was similar to those in patients with lymphedema and obese men. A decrease in the MVO of the normal legs of these patients was noted in older females with femoral vein obstruction of the left leg, with a shorter number of days from the onset of symptoms or with higher values for the obesity index and calf circumference. Significant correlations between the MVO and the obesity index (r=-0.59), venous capacitance (VC, r=0.49) and the number of days from the onset of symptoms (r=0.40) were found in the normal right legs of these patients (n=40). In the normal left legs (n=16), on the other hand, significant correlations were found between the MVO and the VC (r=0.65) and the MVO and age (r=-0.65). The MVO of the normal legs of these patients was predicted from clinical variables by multivariate analysis, and a multiple correlation coefficient of 0.64 was achieved using 4 variables (F-value>2); i.e. the obesity index, the side of venous obstruction, the number of days from the onset of symptoms and calf circumference. From these results, we concluded that in the normal right legs of these patients, the MVO was more closely related to the obesity index than to the VC or the number of days from the onset of symptoms. In the normal left legs, however, the MVO was influenced by another factor; i.e. the iliac compression syndrome, which might become more apparent with age. Finally, it was concluded that a decrease in the MVO of the normal legs could increase the occurrence of DVT.

The graft patency of bypass surgery to or distal to the popliteal artery for 29 lower extremities with thromboangiitis obliterans (TAO) and for 67 lower ex tremities with arteriosclerosis obliterans (ASO) and six factors influencing graft patency were studied and a new method of scoring distal runoff determined from angiographic findings was employed. Early graft occlusion (EGO, < one month) was found only in lower extremi ties with distal runoff of 5 or less and more frequently in patients with TAO than in those with ASO, although distal runoff in TAO patients (n=29) was signifi cantly less than that in ASO. Among TAO patients with distal runoff of 5 or less, EGO (n = 7) was found only in those without concomitant lumbar sympathectomy (CLS), but the dif ference in distal runoff between patients with EGO and those without it was not significant. From these results, it was concluded that: (1) EGO in patients with TAO is probably due to poor distal runoff with high constrictivity and (2) CLS for such patients could improve EGO, which, in turn, would result in a better cumula tive patency rate.

Most cases of acute suppurative mediastinitis are secondary to esophageal perforation. Nontraumatic mediastinitis is uncommon because of the development of antibiotic therapy. Acute suppurative mediastinitis in a 53-year-old man is presented. The patient primarily infected with pharyngitis, which was extended into each origin of the submandibular, masticator and parapharyngeal space. Tracheostomy performed under this condition brought about severe suppurative mediastinitis, because the focal infection was extended to the mediastinum via peritracheal space. Emergency mediastinal drainage wtih thoracotomy was successful in this case. In deep neck infections, there are no clear border between the compartment of muscle fascia and mediastinum. Extension of infection into the mediastinum may associate with severe complications such as empyema and endocarditis. In a case having focal infection in the peritracheal space, an indication of tracheotomy should be carefully considered.

A case of Takayasu's aortitis with severe bilateral coronary ostial stenosis is reported. A transaortic coronary endarterectomy was performed and sufficient patency was confirmed angiographically 9 years after the operation. This is the first report of late coronary angiography after a transaortic coronary ostial endarterectomy in Takayasu's aortitis. The efficacy of this procedure for coronary ostial stenosis in Takayasu's aortitis is emphasized.

In twelve adult patients with pure aortic stenosis (AS) and pure aortic regurgitation (AR), we measured blood velocity waveforms in the left anterior descending coronary artery (LAD) before cardiopulmonary bypass and after aortic valve replacement. The coronary artery blood velocity waveform in AS was characterized by: (1) a decreased systolic velocity component (frequently reversed) and (2) a slowly increasing rate of diastolic inflow. On the other hand, the characteristics of the velocity waveform in AR were: (1) a relatively large systolic velocity component and (2) a rapidly decreasing diastolic flow wave. After valve replacement both for AS and AR, the velocity waveform returned to an almost normal pattern, indicating that the valve replacement induces beneficial effects on the myocardial inflow.

The patency of the aorta-coronary bypass grafting may closely relate to the velocity profile and flow disturbance in the graft as well as the volume flow rate. In this study, we investigated the blood velocity in two different types of graft, i.e., sequential saphenous vein graft (SSVG) and internal mammary artery graft (IMAG). The SSVG was anastomosed to the major diagonal branch (DIAG) by side-to-side (SSA) anastomosis and to the left anterior descending coronary artery (LAD) by end-to-side anastomosis (EDA in 13 patients who had 75–100% and 75–90% stenoses in the LAD and major diagonal branch, respectively. The IMAG anastomoses were performed to the LAD in 10 patients with 75–100% stenoses of the artery. The blood velocity measurements were performed by 10 MHz 80 channel pulsed Doppler method during surgery. In six patients in the SSVG group, we investigated the configuration of the velocity profile at the region just proximal to the SSA and at the bridge portion between the SSA and EDA. In the other seven patients, we measured the blood flow velocity at several centimeters proximal to the SSA and compared it with that in the IMAG. At the region just proximal to the SSA, the velocity profile skewed toward the anastomosis side wall in all patients, and the flow velocity near the wall opposite to the SSA was reversed in five of six patients. In the bridge portion, directional changes in skewing of the velocity profile were recognized, that is, a skewed pattern toward the wall opposite to the anastomosis (four patients) or a symmetric pattern (two patients). The peak diastolic velocity in the region was 25.4±5.8 cm/sec, significantly lower than that (46.6±12.3 cm/sec) just proximal to the SSA. The velocity profile across the IMAG several centimeters proximal to the graft-coronary anastomosis showed a parabolic configuration with a narrow spectrum. The peak diastolic velocity in the IMAG (26.6±2.0 cm/sec) was almost the same as that in the SSVG (26.6±5.5 cm/sec), but the estimated graft diameter of the IMAG (2.3±0.2mm) was significantly smaller than that of the SSVG (3.4±0.5 mm). These findings may provide insight into the underlying mechanism of graft viability because the patterns of blood flow seem to be a contributory factor in determining the fate of the graft.

Twelve operative deaths were seen in 169 patients who underwent aortocoronary bypass grafting for ischemic heart disease from 1975 to July, 1985. The clinical, angiographic and intraoperative characteristics were evaluated to understand the factors predictive of operative mortality. Clinical factors affecting operative mortality were age and unstable angina pectoris. Angiographic factors were coronary artery lesions including left main coronary trunk stenosis and 3-vessel disease. Intraoperative factors were incomplete revascularization and myocardial preservation. There were no significant differences between operative mortality rates for patients with and without a history of prior myocardial infarction, diabetes mellitus and left ventricular dysfunction. The number of grafts did not affect operative mortality. There was a strong association of operative mortality with incomplete revascularization in patients with severe coronary artery disease.

In 6 patients with pure aortic regurgitation, the velocity waveform in the left anterior descending coronary artery (LAD) was measured using an 80-channel 20-MHz-pulse Doppler velocimeter before and immediately after aortic valve replacement. All patients showed normal coronary angiograms. Flow velocity was analyzed by both zero-cross and fast Fourier transform methods in real time. The LAD flow in severe aortic regurgitation was characterized by an increase in the systolic flow component, a small and rapidly decreased diastolic flow, an irregular velocity profile across the vessel, and a wider velocity spectrum. After aortic valve replacement, systolic flow decreased by 36.3 +/- 21.7% (p less than 0.01), whereas diastolic flow increased by 81.4 +/- 51.8% (p less than 0.05). The ratio of diastolic flow to total LAD flow increased from 63 +/- 13% to 82 +/- 7% (p less than 0.05). The velocity profile became more parabolic and had a narrow spectrum. These results suggest that operation for aortic regurgitation induces beneficial effects on the myocardial inflow immediately after valve replacement.

Ticlpidine, a new inhibitor of platelet aggregation, has been administered to 80 patients with ischemic ulcer due to chronic arterial occlusion, at daily dosis of 300mg or 500mg orally for 6 weeks. Overall judgement on its usefullness revealed that daily 500mg of the drug is superior to 300mg daily dose in the treatment of ulcer. Administration with 500mg daily dose of ticlopidine were judged as useful for the treatment of ischemic ulcer. Ticlopidine was also found to be effective in improving severe pain without showing any serious side effects. In this regard, the drug can be characterized as an useful drug for the treatment of severe ischemic ulcer due to chronic arterial occlusion.Based on the pharmacological property of ticlopidine, inhibition on platelet adhesion and aggregation, it is speculated that enhanced platelet function may be closely correlated to the aggravation of these occlusive diseases.

In 6 patients with pure aortic stenosis, the flow velocity waveforms in the left anterior descending coronary artery were studied using an 80-channel 20-MHz pulsed Doppler velocimeter before and immediately after aortic valve replacement. All patients showed normal coronary arteriograms. The left anterior descending coronary artery flow velocity waveform in aortic stenosis was characterized by a reverse flow in the first half of systole and a slowly increasing diastolic inflow. After aortic valve replacement, the reverse flow in the first half of systole disappeared in all patients, but an end-systolic reverse flow was discerned in 5 of 6 patients. The increasing rate of the diastolic inflow was augmented in all patients. After aortic valve replacement, the time from onset of diastole to the diastolic peak velocity was shortened from 176.8 +/- 28.8 to 90.5 +/- 18.8 ms (p less than 0.01), and the diastolic peak velocity increased from 90.5 +/- 28.0 to 122.5 +/- 17.2 cm/s (p less than 0.05). Blood pressure and heart rate, however, did not change significantly before and after valve replacement. These changes in the left coronary artery velocity waveforms after valve replacement suggest the beneficial effects of removal of aortic stenosis on human coronary artery inflow.

In 13 patients with old myocardial infarction diagnosed with use of the electrocardiogram, coronary angiogram and left ventriculogram and in 11 patients without infarction, thallium-201 imaging with a color display computer system was carried out. In the group without infarction the average ratio of activities in two regions of interest within the myocardial wall, excluding the apex, was 1.14 (1.08 to 1.23). In the group with infarction the average ratio of noninfarcted to infarcted areas was 1.44 (1.23 to 1.78). Objective detection of infarction was possible in 12 patients (92 percent) in the group with infarction. In two patients, the earlier electrocardiographic pattern of infarction had resolved by the time of imaging. These results suggest that the sensitivity of thallium-201 imaging in the diagnosis of old myocardial infarction may be greatly enhanced by objective and quantitative analysis using a color display computer system.

A case of a 31-year-old man who had chronic constrictive pericarditis and underwent long-term hemodialysis for chronic renal failure is reported. Chest and limb roentgenograms showed severe metastatic calcification in the heart and peripheral arteries, and a high serum PTH level and fibrous osteitis indicated secondary hyperparathyroidism. Pericardiectomy, removal of calcified epicardium and subsequently total parathyroidectomy were successfully performed. Histologically, all parathyroid glands showed diffuse hyperplasia. It is considered that the main cause of this case was metastatic calcification involving the pericardium and myocardium associated with secondary hyperparathyroidism.

Characteristics of blood-flow velocities were investigated at different sites in two types of coronary artery bypass grafts, sequential saphenous vein grafts (SSVG) and internal mammary artery grafts (IMAG). The latter appear to have the longest life span. The patency rate of the side-to-side anastomosis of the SSVG is better than that of the end-to-side anastomosis. The SSVG was anastomosed to the major diagonal branch by side-to-side anastomosis and to the left anterior descending coronary artery (LAD) by end-to-side anastomosis in 13 patients who had 75-100% and 75-90% stenoses in the LAD and major diagonal branch, respectively. IMAG anastomoses were performed to the LAD in 10 patients with 75-100% stenoses of the artery. The blood-flow velocities were measured by the 20-MHz, eighty-channel ultrasound pulsed Doppler method during surgery. In six patients in the SSVG group, we investigated the configuration of velocity profiles at the region just proximal to the side-to-side anastomosis and at the bridge portion between the side-to-side and end-to-side anastomosis. In the other seven patients, we measured the blood-flow velocity at several centimeters proximal to the side-to-side anastomosis and compared it with that in the IMAG. At the region just proximal to the side-to-side anastomosis, the velocity profile skewed toward the anastomosis side wall in all patients, and the flow velocity near the wall opposite to the side-to-side anastomosis was reversed in five of six patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients with combined coronary and carotid artery stenosis have a significantly higher mortality or morbidity after the separate or staged operation. A 60-year-old man with severe stenosis in the origin of left common carotid artery, subclavian artery and three-vessel coronary artery disease was admitted for unstable angina pectoris. He had a history of cerebral infarction and occasional amaurosis fugax. Simultaneous brachiocephalic to left common carotid artery bypass grafting using PTFE graft and 3-aortocoronary saphenous vein bypass grafting were performed successfully under deep hypothermic cardiopulmonary bypass. Concomitant cerebral and coronary revascularization under hypothermic cardiopulmonary bypass appeared to be a logical approach, allowing dual protection of the brain and the myocardium.

Claudication is very nuisance to the patient who has a ischemic limb. Claudication itself does not mean immediate amputation of the limb, since the inconvenience of the patient depends more or less on the activity. Things are different in patient who has a severely ischemic limb.It often causes peripheral ulcers, gangrene and amputation. These are life threatening potentially, especially in the elderly; after amputation of a lower extremity, unexpected falls may cause severe injury and stressfull life of post-amputation rehabilitation can possibly lead to cardiopulmonary distress.The advantages of living limb over the artificial is so great that it is reasonable to try more active forms of arterial reconstruction for severely ischemic limb than would be suitable for claudication alone in the broad sense of preventive rehabilitation.We have a demonstrable case of a 30-year-old man who has successfully been recovered with arterial re-reconstruction from severely ischemic leg, suffering from Thromboangiitis Obliterans over the period of 3 years.He had his right lower extremity bypassed previously with a Wesolowski-Weavenit, 6mm in internal diameter, over the segmental stenosis of right popliteal artery for claudica tion, and right lumbar sympathetic ganglionectomy simultaneously.Claudication and ulcers with severe ischemic pain developed in right foot following short period of success.We successfully saved his right foot by arterial reconstruction of autovein bypass over occluded arterial tree, supplying enough blood to improve claudication and also to cure longstanding-ischemic ulcers, though he eagerly wanted his leg amputated because of severe pain.We strongly emphasize the role of arterial reconstruction surgery to get rid of ischemic conditions in the field of rehabilitation for ischemic limb.It does work on salvaging living limb, even in a short period of success.

The clinical efficacy of ticlopidine, a platelet aggregation inhibitor, was evaluated in a double-blind placebo-controlled study on 193 patients with ischemic ulcers due to chronic arterial occlusion. In the group treated with ticlopidine, significantly better efficacy was noted over the placebo group in terms of judgment on overall improvement by doctors in charge as well as by the committee assessing with color slide films. The drug was particularly effective for the treatment of patients with occlusion in the arteries on the distal side and for the ischemic ulcer with relatively small size. In the group with ticlopidine, granulation was significantly improved compared to the placebo group. Those patients who had pain due to arterial occlusion on the distal side were significantly improved by this agent. The mean diameters of ulcers were clearly reduced. Therefore, this agent could possibly be claimed as an effective remedy against the main symptoms of chronic arterial occlu sion. The frequencies of side effects and abnormalities in laboratory tests were comparable in the group treated with ticlopidine to those of the group with placebo. It was, therefore, concluded that this agent has an outstanding clinical value as a conservative treatment in chronic arterial occlusion.

Recently, the concept of pulseless disease (Takayasu's arteritis) has definitely changed 1-6 and there has been a tendency for it to be categorized as the "aortitis syndrome" in Japan, 7 for the clinical manifestations are so variable, depending on the site of the main lesions. Little attention has been given to the surgical treatment of this entity until recently, although some of these lesions are surgically amenable. The purpose of this paper is to report our experiences with the surgical treatment in 12 cases of this syndrome and to discuss some of the technically important problems. Clinical Cases Sixty-three cases of the aortitis syndrome have been encountered at the Second Surgical Division of the Okayama University Medical School during the last 8% years. They are divided into three groups according to the site of the main lesion: (1) classic type, in which the branches of the aortic arch are mainly

Previous Studies The difficulty in maintaining patency of anastomoses of arteries less than 3 mm in outside diameter was shown by Shumacker in 1948.15Seidenberg,14in 1958, presented a method which gave a higher percentage of patency in such arteries. Since that time, further study of the techniques of anastomosis of arteries of 1-2 mm in size has given increasingly good results. Various methods of anastomosis have been tried, and the results may be grouped as follows: Suture Methods. —Chase, Schwartz, and Rob2,3have reported their good results in vessels of 1-2 mm by the use of 7-0 silk suture or fine wire in a classical end-to-end suture method, using a four-power binocular loupe. Jacobson and Suarez10reported consistent patency in such vessels using a binocular microscope with magnifications up to 40 diameters. Variations of the classical suture technique have included the use of an electrically