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金沢大学医薬保健研究域医学系, From 1973 to 1998, we resected and reconstructed the great vessels in 44 patients with primary lung cancer or mediastinal tumor. Among them, 39 patients (28 with lung cancer and 11 with mediastinal tumor) and 5 patients (all with lung cancer) underwent reconstruction of the superior vena cava (SVC) and aorta, respectively. The SVC was repaired by expanded polytetrafluoroethylene (EPTFE) graft (n = 8), prosthetic patch (n = 5) or direct suture (n = 26). The aorta was repaired with temporary subclavian artery-descending aorta (n = 3), or left atrium-femoral artery bypass (n = 2). No complication or operative death occurred after surgery. The survival rate of the patients with lung cancer who underwent SVC reconstruction at 3 year and 5 year were 26.2% and 11.2%, respectively. Five of 11 (45.5%) patients with mediastinal tumor are alive at 5 years. We concluded that extended resection for primary lung cancer or mediastinal tumor invading the SVC is acceptable operation method for some patients.

1994年12月迄の11年間に, 当科において経験した下大静脈腫瘍血栓を伴う腎細胞癌症例9例に対し, 手術成績を中心に臨床的検討を行った.1985年以前の症例に比し5年生存率で23.4%も改善した.これは早期癌症例の増加だけでなく, 病期IIIの治療成績の改善も寄与していたし, 術後のInterferon投与例が多かった為かもしれない, Out of 173 patients with renal cell carcinoma diagnosed at our department between January 1984 and December 1994, 9 (5.2%) had an inferior vena caval tumor thrombus. They consisted of 6 men and 3 women between 43 and 74 years old with a mean age of 59.8 years. The tumors were on the right and left sides in 5 and 4 patients, respectively. According to the Novick's classification, 2, 1, 4 and 2 patients had level 1 (perirenal), level 2 (infrahepatic), level 3 (intrahepatic) and level 4 (suprahepatic) tumors, respectively. Five patients without distant metastases underwent nephrectomy and removal of the vena caval tumor thrombus. Although renal tumors and vena caval tumor thrombi were completely resected in all of the 5, 4 died of disease within 3 years. Only 1 patient without tumor invasion into the inferior vena caval wall survived over 5 years without disease. Since surgical treatment is the sole radical method for renal cell carcinoma, surgery is recommended for the patients even with a vena caval tumor thrombus unless there are metastases.

We report a case of left renal cell carcinoma extending into the inferior vena cava associated with the acquired cystic disease of the kidney (ACDK). The patient was a 46-year-old man, who had been treated with hemodialysis for 12 years. In November 1992, ACDK was observed on computed tomography (CT) for routine check up, but no tumorous lesions were detected. He noticed bleeding from the urethra in May 1994. CT and magnetic resonance imaging (MRI) revealed left renal tumor with intrahepatic vena caval tumor thrombus. There were no findings of distant metastasis. Left radical nephrectomy and partial removal of vena cava were performed. Histopathologically, renal cell carcinoma, pT3b, pN0, stage III was diagnosed.

金沢大学医薬保健研究域医学系, Ischemic heart disease (IHD) poses a major complicating factor for abdominal aortic aneurysm (AAA) repair. To identify patients with IHD, we evaluated patients scheduled to undergo AAA repair with dipyridamole-thallium scintigraphy (DTS) and coronary angiography (CAG). If indicated, coronary revascularization was performed. Finally, an assessment of the effectiveness of these preventive measures was made. One hundred and ten patients scheduled to undergo AAA repair were identified and treated accordingly over a 20-year period. As the pre-operative evaluation and prophylactic surgical revascularization strategies were instituted in 1983, the patients were divided into 2 groups: 25 patients between 1973-1982 (group A) and 85 patients between 1983-1992 (group B). The mean age of patients in group A was 65.3 years. The male/female ratio within this group was 21:4. One patient in the group had a history of IHD and 9 had hypertention. The mean age of patients in group B was 67.7 years. The male/female ratio within this group was 77:8. Fourteen patients in this group had a history of IHD and 27 had hypertension. Screening and treatment of IHD in group B was as follows. All patients with a history of IHD underwent CAG. Of the 32 patients with cardiac risk factors, including hypertension and hyperlipidemia, or ECG abnormalities who underwent DTS, 8 were referred for CAG. Thirty-nine patients with no risk factors and a normal ECG proceeded to AAA repair without further workup. Perioperative myocardial infarction occurred in 2 patients in grouzp A, leading to death in 1 patient. Coronary revascularization was performed in 5 patients in group B. No perioperative myocardial infarction occurred in this group. Pre-operative identification of high-risk cases with DTS, CAG, and coronary revascularization in patients with IHD may prevent cardiovascular complications in patients undergoing AAA repair., 心筋梗塞は腹部大動脈瘤の術中術後の合併症で最も重篤なものの一つである. ジピリダモール負荷心筋スキャン, 冠状動脈造影により評価を行い, 必要な症例には冠状動脈再建を行う方針を開始した1983年以降と, それ以前の腹部大動脈瘤の待機手術例を比較検討した. 1982年までの前半の10年間の症例は25例で術前併存症としての虚血性心疾患を1例に認めた. 1983年以降の後半の10年間の症例は85例で, 術前併存症としての虚血性心疾患を14例に認め, 全例冠状動脈造影にて評価した. 後半において高血圧や高脂血症などの危険因子もしくは心電図異常を認める32例にジピリグモール負荷心筋スキャン等を施行し, うち8例に冠状動脈造影を施行した. 前半の25例において術後心筋梗塞を2例に認め, うち1例が死亡した. 後半の85例中5例に冠状動脈バイパスを施行した. 後半の85例において術後心筋梗塞は認めなかった. 腹部大動脈瘤手術では積極的な虚血性心疾患対策が必要である.

金沢大学医薬保健研究域医学系, Radical operation for T4 lung cancer is technically difficult. We report here 3 cases of T4N0M0 lung cancer involving aorta or left subclavian artery which was successfully operated on. We could carry out combined aortic resection more safely and speedy under the assistant devices, such as Anthrontube and Biomedicus Centrifugal Pump. Even T4 lung cancer having aortic invasion with N0 disease can be operated on and be expected long-term survival using these assistant devices., 12

金沢大学医薬保健研究域医学系, We analyzed cerebral protection of twenty-five patients, 11 of whom underwent ascending-arch aortic replacement and 14 underwent aortic arch replacement, supported with cardiopulmonary bypass. Twenty of patients underwent selective cerebral perfusion (SCP) with moderate hypothermic circulatory support; 12 of single SCP, 8 of double SCPs. Major arch branch reconstruction were performed with 11 patients; 3 of triple branches, 2 of double branches and 6 of single branch reconstruction. Cerebral impairment was found in 7 patients (25%) with SCP; 3 of them died of low output syndrome and major bleeding during perioperative period. Four of 17 patients, who survived more than one month, showed cerebral infarction in 2 patients and temporary neurological deficit in 2 patients. Our strategies for cerebral protection are (1) careful cerebral four vessels study, (2) SCP with perfusion pressure more than 40 mmHg and flow rate of 7-10 ml/kg/min under moderate hypothermia, (3) bilaterally double branches perfusion minimally for arch replacement, (4) intensive cerebral monitoring from multiple aspect, (5) pharmacological support with barbiturate or aprotinin, (6) gentle maneuver and reliable major branch cannulation to prevent debris embolism.

金沢大学医薬保健研究域医学系, Postoperative brain dysfunction was studied for 18 patients who survived more than 30 days after operations of aortic arch aneurysms. The operative procedures were graft replacement in 12 patients, resection with direct or patch closure in 3, and thromboexclusion in 3. Except for thromboexclusion, adjuncts were used: temporary bypass in 1, partial EPC (extracorporeal circulation) in 2, and selective cerebral perfusion during EPC in 12. As for intra-operative monitoring, the temporal artery blood pressures were more than 50 mmHg in all, but the electroencephalogram changed to flat wave just after clamping the aorta in one patient. Postoperative brain dysfunction occurred in 5 patients, including temporary loss of consciousness in 2, lasting loss of consciousness in 1, and paralysis with loss of consciousness in 2. Postoperative brain dysfunction occurred more often in old aged men with atherosclerotic aneurysms. Patients with temporary brain dysfunction had no remarkable change in CT scan, but patients with lasting brain dysfunction had low density areas. It is recommended to prevent this complication as follows: 1) pre-operative evaluation of cerebral vascular disorders, 2) gentle maneuver of atherosclerotic lesions, 3) bilateral cerebral perfusions and intra-operative monitorings, 4) intensive perioperative care of circulation and respiration., 11

金沢大学医薬保健研究域医学系, 血行再建術の付加手技としてballoon catheterを用いた術中経管的拡張術を13症例に18回施行した.年齢は57～81歳平均72.7歳であり,全例男性であった.血栓内膜摘除術やバイパス術の術中に経管的拡張術をinflowに3例,outflowに3例,腎動脈に1例施行した.EPTFEグラフトの吻合部狭窄に対して血栓摘除術と経管的拡張術を7例に11回施行した.動脈硬化病変に対する本法の成績は1年開存率100%, 3年開存率80%であり,4例が経過観察中に死亡したが全例で拡張部位は開存していた.吻合部狭窄に対する本法の成績は6か月開存率34.6%, 10か月で0%であり,2回の拡張術を施行した4例のうち,1例にグラフト感染をきたした.動脈硬化病変に対する術中経管的拡張術の開存率は良好であった.吻合部狭窄に対する経管的拡張術は侵襲が少なく血栓摘除と同時に簡便に行える利点があるが,開存率が低いことと繰り返し行うことによる感染の危険性があった., Transluminal angioplasty during vascular reconstructive procedures was performed to 18 lesions in 13 patients. Ages ranged from 57 to 81 years with a mean of 72.7 years, and all patients were men. Transluminal angioplasty during the thromboendarterectomy or bypass grafting was performed to 3 patients for inflow dilatation, 3 patients for outflow dilatation and 1 patient for renal artery dilatation. Transluminal angioplasty with thrombectomy for the anastomotic stenoses of EPTFE grafts was performed 11 times for 7 patients. The results of this method for arteriosclerotic lesions were as follows; patency was 100% at 1 year and 80% at 3 year. Four patients died during the follow-up periods and the dilated lesions were all patent at the time of death. The results of this method for anastomotic stenoses were as follows; patency was 34.6% at 6 month and 0% at 10 months. Graft infection occurred in 1 of 4 patients to whom transluminal angioplasty was performed 2 times. The patency of transluminal angioplasty during vascular reconstructive procedures for arteriosclerotic lesions was good. Transluminal angioplasty for anastomotic stenoses was noninvasive and easily performed with the thrombectomy, but the patency was not so good and there was the risk of graft infection by repeated operations.

Out of 173 patients with renal cell carcinoma diagnosed at our department between January 1984 and December 1994, 9 (5.2%) had an inferior vena caval tumor thrombus. They consisted of 6 men and 3 women between 43 and 74 years old with a mean age of 59.8 years. The tumors were on the right and left sides in 5 and 4 patients, respectively. According to the Novick's classification, 2, 1, 4 and 2 patients had level 1 (perirenal), level 2 (infrahepatic), level 3 (intrahepatic) and level 4 (suprahepatic) tumors, respectively. Five patients without distant metastases underwent nephrectomy and removal of the vena caval tumor thrombus. Although renal tumors and vena caval tumor thrombi were completely resected in all of the 5, 4 died of disease within 3 years. Only 1 patient without tumor invasion into the inferior vena caval wall survived over 5 years without disease. Since surgical treatment is the sole radical method for renal cell carcinoma, surgery is recommended for the patients even with a vena caval tumor thrombus unless there are metastases.

We report a case of left renal cell carcinoma extending into the inferior vena cava associated with the acquired cystic disease of the kidney (ACDK). The patient was a 46-year-old man, who had been treated with hemodialysis for 12 years. In November 1992, ACDK was observed on computed tomography (CT) for routine check up, but no tumorous lesions were detected. He noticed bleeding from the urethra in May 1994. CT and magnetic resonance imaging (MRI) revealed left renal tumor with intrahepatic vena caval tumor thrombus. There were no findings of distant metastasis. Left radical nephrectomy and partial removal of vena cava were performed. Histopathologically, renal cell carcinoma, pT3b, pN0, stage III was diagnosed.