Magnetic resonance angiography (MRA) is capable of imaging arteries in the half to whole body by a single acquisition without a nephrotoxic contrast medium, and acquired images can be reconstructed into a specific cross-sectional view in an arbitrary directions. MRA is applicable for vessels non-reachable by a catheter approach, and collateral vessels can be fully visualized. Since MRA is minimally-invasive with no exposure to ionized radiation, it can be repeatedly applied for follow-up. However, there are also disadvantages: the temporal and spatial resolutions are inferior to those of X-ray angiography, and, at present, it cannot be used as a guide for intervention. Moreover, gadolinium administrations may cause NSF in patients who have lost renal function, as a new risk. Accordingly, strict consideration is required for an indication of its application. Development of non-contrast MRA and evaluation of the wall itself may draw more attention in the future. Plaque imaging is being routinely performed nowadays, and the measurement of vascular wall shear stress, which has a close association with arteriosclerosis, may become possible by utilizing the time-resolved phase-contrast method capable of measuring the time-resolved velocity vectors of blood flow throughout the body. (*English Translation of J Jpn Coll Angiol, 2009, 49: 503-516.)
Recent technical advancement has allowed simultaneous visualization of the artery of Adamkiewicz and whole aorta by multidetector-row-CT (MDCT). Although we could visualize the artery of Adamkiewicz in a high percentage of patients with thoracoabdominal aortic diseases, CT scanning with an adequate protocol and careful post-processing are necessary for accurate evaluation. Noninvasive evaluation of the artery of Adamkiewicz is useful in planning surgery. Preoperative evaluation of the intercostal arterial level from which the artery of Adamkiewicz originates is reportedly important for preventing postoperative spinal cord ischemia. Although, the usefulness of preoperative information on the artery of Adamkiewicz is still controversial, preoperative identification of the artery of Adamkiewicz by imaging has gradually spread since our first report, and has been included in preoperative evaluation items at many institutions, revealing its contribution to improvement in surgical results. (*English Translation of J Jpn Coll Angiol, 2004, 44: 693-699.)
Objective: We report our current treatment strategy for acute type A aortic dissection with organ ischemia as well as notable findings in our experience. Materials and Methods: Among 101 cases of acute type A aortic dissection, 25 had organ ischemia. Malperfusion was assessed at the aorta, proximal portion of the branch, organ parenchyma, and organ function by means of multiple modalities, including transesophageal echocardiography (TEE), near-infrared spectroscopy, and physical examinations. It was assessed every time the perfusion status was altered. Results: There were three operative deaths and one late hospital death. Uncertainty of symptoms and inadequate preoperative assessment in an emergent situation indicated the necessity of an overall check-up of organ ischemia in the operating room on a routine basis. Multi-modality assessment including TEE was helpful for this purpose. Two cases indicated that recovery of a true lumen could be inadequate despite true lumen perfusion including central cannulation. Thrombus in the false lumen appeared to be responsible. Conclusions: To solve practical problems in treating acute type A dissection with organ ischemia, real-time information on organ perfusion is important for detecting the presence of malperfusion, making an appropriate strategy, and immediately assuring the efficacy of the means taken.
Objective: Late cardiac and aortic reoperation after CABG is indispensable for patients with atherosclerotic disease, but reoperations are still associated with high morbidity rates. Patients and methods: Between January 2002 and December 2010, 459 patients underwent coronary artery bypass grafting. Six patients (males; mean age, 65.0 ± 5.7 years) with previous arterial bypass grafts (mean, 2.8 ± 1.2 per patient) required reoperation for cardiac and aortic disease (3, valvular disease; 3, acute type I aortic dissection) during long-term follow-up. The mean interval between the initial operation and reoperation was 5.4 ± 2.0 years. Grafts visualized by preoperative enhanced computed tomography were harvested as pedicles and clamped for myocardial protection. The total arch or ascending aorta was replaced in three patients. The aortic valve was replaced in two patients, and the aortic and mitral valves were replaced in one. Results: Durations for surgery, total cardiopulmonary bypass, and cardiac ischemia were 611.5 ± 172.6, 223.2 ± 88.4, and 133.4 ± 58.0 minutes, respectively. Perioperative myocardial infarction did not develop, and all patients recovered uneventfully with no neurological deficits. Conclusion: Bypass grafts should be preoperatively visualized and carefully exposed. Cardiac damage must be avoided during reoperation after coronary artery bypass grafting.
Objectives: To evaluate the impact of initial aggressive decongestion (Phase 1) on the maintenance phase of complex physical therapy (CPT). Materials and Methods:We reviewed 27 patients with unilateral and 3 patients with bilateral lower extremity lymphedema who started CPT between April, 2009 and October, 2010. Twelve patients elected to undergo in-hospital Phase 1 (Group I), while the other 18 started CPT on an outpatient-basis without having Phase 1 (Group O). The extremity volume was assessed at the beginning of CPT, and then 3 and 6 months later. Results:A significant reduction in extremity volume was achieved in each group after 6 months of CPT: from 9049 ± 1912 mL at the beginning to 7771 ± 1486 mL (p = 0.0033) in group I; and from 7370 ± 1392 mL to 7036 ± 1241 mL (p = 0.0200) in group O. However, after 6 months, extremity volume reduction (–845 ± 1283 mL in group I vs. –404 ± 370 mL in group O; p = 0.7672) and volume reduction rates (–23.6 ± 22.7% in group I vs. –46.4 ± 52.2% in group O; p = 0.2564) did not differ significantly between the groups. Conclusion:Phase 1 did not have a significant impact on the maintenance phase in terms of control of the extremity volume for at least 6 months after the induction of CPT.
Introduction: In the absence of endovascular aneurysm repair due to financial constraints, Abdominal Aortic Aneurysm (AAA) in Sri Lanka is managed exclusively by open surgery. We report our experience with open AAA repair with emphasis on peri-operative morbidity and mortality. Methods: Seventy nine consecutive open AAA repairs were carried out between April 2004 and March 2010. A multiple regression model was used to identify predictors of significant peri-operative morbidity and mortality. Results: Mean age of the study cohort was 68 years. There were 63 (80%) males and 16 (20%) females. Mean aneurysm diameter was 6.4 (3.5-9.70) cm. Twenty seven (34%) underwent emergency surgical repair (group-1) while 52 (66%) had elective repair (group-2).The peri-operative mortality was 10/27 (37%) in group-1, 4/52 (7.6%) in group-2, (p = 0.0035). Significant post-operative morbidity was seen in 5/17 (29%) in group-1 and 7/48 (15%) in group-2, (p = 0.27). Aneurysm diameter >7 cm (p = 0.001), emergency repair (p = 0.004), history of smoking (p = 0.002), aortic cross-clamp time >60 minutes (p = 0.044), and need for post-operative ventilwation >24 hours (p = 0.024) were found to be independent predictors of peri-operative mortality or significant morbidity. Conclusion: Open aneurysm repair still has a strong place especially in the limited resource setting, with acceptable outcomes.
Objective:Therapeutic angiogenesis by peripheral blood mononuclear cells (PB-MNCs) implantation has been shown to be a safe and effective treating for critical limb ischemia (CLI). We herein report our investigation of the long-term efficacy of implantation of granulocyte-colony stimulating factor (G-CSF)-induced PB-MNCs to treat patients with CLI for which surgical bypass and/or percutaneous transluminal angioplasty are not possible. Methods and Methods: Eleven cases were enrolled in this study. Following an injection of G-CSF (250 ug/day) for 3 days, PB-MNCs (1.1 ± 0.5 × 1010 including 1.5 ± 0.2 × 107 CD34-positive cells) were harvested by apheresis and then injected into 13 ischemic limbs. Results: Resting pain either diminished or improved in 10 cases (91%) at 4 weeks, and ulcer formation was cured in 6 out of 10 limbs (60%) after treatment. The time required to enhance the arteries at the level of foot-joint by angiography which was performed in the abdominal aorta was shortened by 1 month (10 ± 4 seconds) and 6 months (12 ± 1) compared with the pretreatment time (15 ± 5). Three patients died after treatment, and the actuarial survival rate at 3 years was 73%. Freedom from major amputation at 3 years was 92%. Conclusion: The local injection of G-CSF-induced PB-MNCs showed striking early and long-term effects.
A 65-year-old woman, recently diagnosed with diabetes, presented with fever and a warm, pulsatile, tender mass over the medial aspect of her left thigh. She gave a history of diarrhea two weeks earlier. All lower limb pulses were present. CRP was 18.3 mg/l with evidence of neutrophil leukocytosis.Contrast angiography demonstrated a saccular aneurysm in her left superficial femoral artery (SFA). The aneurysm and surrounding infected, necrotic muscle was excised, and the limb was re-vascularized in-situ. Cultures from the aneurysmal wall grew both coliform bacilli and staphylococcus aureus. A mycotic aneurysm of the SFA, following a previous gastroenteritis, harbouring both staphylococcal and coliforms, makes this case unique.
A 76-year-old woman underwent a Bentall procedure for acute aortic dissection. A dissection involving half of the proximal portion of the left main coronary artery trunk was confirmed. The dissected site was resected, and a section of the superficial femoral artery was harvested and used as an interposition graft between conduit and the residual left main trunk. Two years after surgery, the graft remained well patent. If the coronary dissection involves only the left main artery trunk, the superficial femoral artery should be used as an artery graft for the anatomical reconstruction, potentially leading to better early and late outcomes.
We report a case of lower extremity ischemia caused by a persistent sciatic artery aneurysm . The patient was successfully treated with a ringed expanded polytetrafluoroethylene (ePTFE) graft and recovered uneventfully. The graft was patent during the follow-up and no signs of kinking or restenosis.
We describe concomitant Marfan syndrome and Takayasu’s arteritis complicating a pseudoaneurysm of the left ventricular outflow that developed after aortic root reconstruction. A patient was admitted with a high fever four months after initial root reconstruction that included valve sparing (reimplantation) as well as coronary artery reconstruction using a Carrel’s button technique. Computed tomography revealed a pseudoaneurysm at the posterior side of the aortic root. We applied a modified Bentall procedure including coronary artery reconstruction using the Piehler technique. Pathological assessment of a specimen of the aorta revealed no central medial necrosis, but significant lymphocytic infiltration and thick fibrous adventitia indicating Takayasu’s arteritis. This case was unique in terms of having simultaneous Takayasu’s arteritis and cardiovascular manifestations of Marfan syndrome that were surgically treated.
For a 75 year-old man with extensive aortic aneurysm, who had undergone a previous infra-renal abdominal Y-graft, a staged replacement of remaining segments was performed. A hybrid procedure of open-laparotomy debranching of visceral branches and endovascular stentgraft insertion in the thoracoabdominal aorta was performed first, followed by subsequent direct replacement between the proximal ascending and distal arch using cardiopulmonary bypass. Three months thereafter dissection of enlarged proximal descending aorta occurred, for which we performed an emergent endovascular stentgraft deployment which bridged "elephant trunk" of the arch graft and the previous stentgraft. Consequently total aortic replacement was successfully accomplished without any neurological sequela.
Acute type-B aortic dissection with malperfusion is a serious cardiovascular condition associated with high morbidity and mortality. Recent studies have investigated the efficacy of thoracic endovascular aortic repair (TEVAR) as treatment for acute aortic dissection. In this report, we present a case of acute type-B aortic dissection complicated with malperfusion, which was successfully treated with emergent TEVAR for entry closure by a Matsui-Kitamura stent graft (MKSG). MKSG is a flexible custom-made curved stent graft. The main advantages of MKSG for emergent TEVAR include flexibility, shape, and small profile when compressed.
We present a woman with surgically untreatable extended arteriovenous malformations (AVM) and consumptive coagulopathy, which had been controlled by conservative compression and anticoagulation therapies for 17 years. At age 13, she was diagnosed with extended AVM in the entire left leg and pelvis. At age 16, limited surgical resection of the enlarged superficial vein in the left calf was performed for persistent leg pain. One year later, anticoagulation therapy was performed for massive bleeding from hemorrhoids due to AVM and coagulopathy. Despite its intractability, her condition has been favorably controlled with conservative methods, including compression and anticoagulation therapies.
The aim of this paper is to report a rare case of aortic coarctation with type B aortic dissection. A 37 year-old man had sudden, intense back pain. Enhanced computed tomography revealed aortic coarctation (CoA) at the proximal descending aorta and acute type B aortic dissection just distal to the CoA. The dissecting, descending aortic aneurysm had expanded to a maximal diameter of 52 mm. The aortic coarctation was resected and then the descending aorta was replaced with prosthetic grafts in an uneventful procedure. Surgical repair resulted in a good outcome.