Background: The purpose of this study was to examine the effectiveness of tranexamic acid (TA) in reducing blood loss during thoracic aortic surgery (TAS). Method: We recruited 54 patients (24 men and 30 women; age, 71.1±9.9 years) who underwent TAS (excluding patients who underwent combined surgery) from August 2008 to October 2009. The patients were divided into 2 groups: 19 patients who received TA (T group; 11 men and 8 women; age, 70.8±9.7 years) and 35 patients who did not receive TA (N group; 13 men and 22 women; age, 71.3±10.1 years). The T group received 16 mg kg^-1/hr^-1 of TA intraoperatively. The conditions in the 2 groups were acute aortic dissection (T group, n=10; N group, n=25) and true aneurysm (T group, n=9; N group, n=10). The operative procedures were total arch replacement (T group, n=7; N group, n=12), partial arch replacement (T group, n=5; N group, n=3), and ascending aorta replacement (T group, n=7; N group, n=20). Results: A comparative study of the amount of transfused blood yielded the following findings: red cell concentrate, 1016.8±777.0 ml (T group) vs. 2062.4±1695.1 ml (N group); fresh frozen plasma, 833.7±743.5 ml (T group) vs. 1789.7±1502.3 ml (N group); and platelet concentrate, 263.2±189.2 ml (T group) vs. 537.1±163.2 ml (N group). In all cases, the amount of blood transfused in the T group was significantly less than that in the N group (P<0.05). The presence of thrombotic complications (cerebral infarction, myocardial infarction, etc.) was investigated, but no significant differences were noted between the 2 groups. Conclusion: The use of TA in patients undergoing TAS led to a significant reduction in the amount of blood transfused. Moreover, the use of TA did not increase thrombotic complications.

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Objectives: Multiple injuries may lead to traumatic thoracic aortic rupture (TTAR), which can be fatal. We evaluated the relationship between the clinical findings and outcomes of 26 patients with TTAR who were treated at our institution. Methods: A total of 26 patients (men, 21; women, 5; average age, 45.8±19.6 years) with a diagnosis of TTAR received from 1999 to 2009 were studied. We categorized patients into groups based on outcome (survival or death) and investigated the relationship between outcome and the following factors: injury mechanism, vital signs, other combined injuries, injury severity score (ISS), revised trauma score, and probability of survival (Ps). Results: Of the 26 TTAR patients, 7 underwent emergency operations, 5 underwent delayed operations, 1 received conservative treatment, and 13 suffered cardiopulmonary arrest immediately after consultation and died. Of the 13 patients who died, 11 died within 2 hours after injury because of bleeding. Two of the 7 patients who underwent emergency operations died within 1 day of consultation, whereas all those who underwent delayed operations survived. Patients who underwent TTAR repair had a relatively good outcome. Analysis of the relationship between the clinical data and outcome showed that young age was significantly correlated with survival, and that the Glasgow Coma Scale (GCS), heart rate, respiratory rate, or the occurrence of cardiac shock were not significantly related to outcome. The Abbreviated Injury Scale (AIS) was used to score the severity of multiple injuries, and the ISS was calculated from the AIS score. The ISS was significantly higher in the death group (P=0.007). The ISS did not significantly differ among body parts (P=0.077), but the ISS of the extremities was higher than those of other parts. Pelvic fractures were frequent in the death group. Our strategy, whereby the patient initially underwent pelvic external fixation followed by TTAR repair was found to be very effective. The P values calculated by the Trauma Score and Injury Severity Score method were significantly high in the survival group (both, P=0.007). Conclusion: To treat TTAR, it is important to accurately evaluate the damage due to multiple injuries and to apply an appropriate treatment strategy. Immediate repair of TTAR after bleeding due to combination injury improves outcome.

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Objectives: Treatment strategies for Stanford type A dissection with a thrombosed false lumen remain controversial, and whether surgery or conservative treatment should be performed is a matter of ongoing debate. In this study, we examined the treatment strategies for cases in which treatment was initiated conservatively at the onset. Methods: This study involved 20 patients with Stanford type A acute aortic dissection with a thrombosed false lumen treated between February 2002 and October 2010. We compared cases with indications for surgery at the onset or with conversion to surgery during the course of treatment to those not indicated for surgery until the remote phase. Results: The average diameter of the ascending aorta at the onset was 42.5±5.6 mm (range, 35–48) in the non-operative group and 49.3±4.8 mm (range, 40–60) in the operative group. The diameter was significantly larger in the operative group. There were significantly more cases with a site of entry or ulcer-like projection in the ascending aorta or aortic arch in the operative group. However, no significant difference was observed in the thickness of the false lumen between the 2 groups. Conclusion: Because surgical outcomes for re-dissection are poor, surgery should be aggressively performed in high-risk cases. In particular, semi-emergency surgery is necessary in patients with an ascending aorta diameter of 50 mm or more, or in whom there is an entry into the ascending aorta or aortic arch.

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Objectives: Abdominal compartment syndrome (ACS) is an important factor in the development of multiple organ failure (MOF). With the aim of preventing ACS, we used open management for patients who had undergone critical ruptured abdominal aortic aneurysm (AAA) repair, and investigated the efficacy of open management on MOF and mortality. Methods: We performed a case-control study of patients who required open management (n=10) and compared the results with those of patients who underwent primary closure (n=10) after ruptured AAA repair. Results: Prior to surgery, the patients who required open management had long-term hypotension and needed cardiopulmonary resuscitation more frequently than the patients who underwent primary closure. During surgery, the patients who required open management had more blood loss and more severe acidosis than the patients who underwent primary closure. The mortality rate of the patients who required open management was 10%, whereas that of the patients who underwent primary closure was 0%. If they had an adverse clinical profile, the patients who required open management had more instances of organ failure. Therefore, we gave those patients large intravenous infusions to treat postoperative shock and renal failure. Conclusion: Open management in patients with critical ruptured AAA is effective in treating and preventing ACS.

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Extracranial carotid artery aneurysms are very rare, but serious complications may result from these aneurysms such as emboli, thrombosis, or rupture. Various treatments for such aneurysms have been reported, including open surgery and endovascular surgery. However, large aneurysms which extend to the skull base can be difficult to treat using conventional methods. Case: A 50-year-old woman presented with a pulsatile mass in her right neck. The proximal side of the aneurysm was located near the origin of the internal carotid artery (ICA). Three fusiform aneurysms, measuring a maximum of 3.1 mm in diameter, were observed to be threaded through a narrow channel. The main aneurysm extended to the base of skull. An aneurysmectomy was not indicated because the distal ICA could not be controlled. We considered that an endovascular procedure could be performed because no mural thrombus existed, and the patient was classified as tolerable according to a Matas test. The aneurysm was successfully treated by distal coil embolization, proximal ligation and a partial resection. An aneurysmectomy with reconstruction has been the standard treatment for extracranial ICA aneurysms. However, some cases aneurysmectomy is not indicated, and therefore an alternative treatment option should be selected based on the size, location and type of aneurysm(s), as well as on the presence or absence of infection.

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In terms of prognosis, the evaluation and treatment of arterial disease using iodinated contrast medium is restricted in patients with renal dysfunction or drug allergies. Cases of endovascular therapy (EVT) using carbon dioxide (CO2) angiography have recently been reported. We admitted a 75-year-old man presenting with renal dysfunction and a complaint of left foot pain. Carbon dioxide angiography revealed severe stenosis in both the common iliac and left anterior tibial arteries. We diagnosed arteriosclerosis obliterans (ASO) and performed percutaneous arterial ballooning and stenting. By utilizing CO2 angiography and intravascular ultrasound (IVUS), we successfully treated EVT in a patient with renal insufficiency involving below-knee arterial stenosis.

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We report a case of obturator bypass from the external iliac artery to the below-knee popliteal artery with an autologous vein graft for a patient with MRSA prosthetic graft infection. A 67-year-old man presented with an infected right femoro-above-knee popliteal prosthetic bypass graft. Graft excision and extra-anatomic revascularization were scheduled, because the entire prosthetic graft was involved. Complete graft excision and obturator bypass to the below-knee popliteal artery using a great saphenous vein were performed simultaneously. The postoperative course was uneventful and he was discharged without recurrent infection or intermittent claudication. An obturator bypass to the below-knee popliteal artery using the autologous vein may be one treatment option in cases involving infection involving the whole graft, in cases of femoral artery to above-knee popliteal artery bypass.

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A 30-year-old woman with a 15-year history of systemic lupus erythematosus (SLE) was admitted to our hospital with sudden anterior chest pain. Her condition had been controlled by steroid therapy for 15 years. She initially received a diagnosis of pericarditis because she had a history of 2 episodes of pericarditis. However, her chest pain continued, and enhanced computed tomography was performed 8 days after admission which demonstrated Stanford type A aortic dissection. We performed graft replacement of the ascending and arch aorta as an emergency operation under deep hypothermic selective cerebral perfusion. The patient was discharged uneventfully on the 30th postoperative day. A histological study of the aortic wall demonstrated that inflammatory cells infiltrated the media and obliterative endarteritis of the vasa vasorum, but there was no evidence of arteriosclerosis. These findings were consistent with a diagnosis of vasculitis. There are some reports regarding aortic dissection in SLE patients; however, aortic dissection due to vasculitis is extremely rare.

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We report a case of superior mesenteric artery (SMA) dissection which was treated conservatively without anticoagulation or antiplatelet agents. We also review 33 cases of isolated SMA dissection treated conservatively, reported in Japan from August, 2008 to April, 2011 (including the present case). There were no cases which required surgical revascularization. In the anticoagulation group, there were 5 cases with a persistent false lumen and 2 cases with recurrence of a false lumen. In the antiplatelet group, there were no cases of false lumen recurrence.

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Stanford type A dissection has a poor prognosis. Moreover, when it is associated with branch ischemia, the reported short-term mortality rate is high: 30%–50%. We report a case of unsuccessful emergency treatment of a patient with type A aortic dissection with brachiocephalic artery ischemia in whom cerebral herniation developed after aortic arch replacement. Case: A 63-year-old woman was admitted to our hospital with a diagnosis of cerebral infarction. However, on hospital day 2, she lost consciousness and a left conjugate deviation developed. Aortic dissection was diagnosed on the basis of computed tomographic (CT) images, which revealed a depression of the brachiocephalic artery by a false lumen. Because the patient appeared to recover consciousness, emergency aortic arch replacement was performed. However, although the patient temporarily regained consciousness postoperatively, her consciousness steadily deteriorated again. CT revealed a massive cerebral edema and brain herniation, and the patient died on day 9 postoperatively. In patients with type A aortic dissection associated with widespread cerebral infarction, surgery should be performed if the cerebral edema improves, and if this is not possible, an attempt should be made to perform external decompression, or ligate the common carotid artery.

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We report an extremely rare case of acute arterial obstruction caused by a tumor thrombus with a final diagnosis of esophageal tumor. A 68-year-old man complaining of sudden pain in his bilateral lower extremities was referred to our institute. Since contrast-enhanced computed tomography revealed occlusions of bilateral popliteal arteries he underwent emergency surgery on the day of admission. Bilateral longitudinal incisions from the popliteal arteries to the tibioperoneal trunks were made, and patch angioplasty using autologous saphenous vein graft were performed after the removal of the thrombi of both lesions. On the second post-operative day, as he complained of abdominal pain with a concurrent significant drop in his blood pressure and the rapid progression of anemia, he underwent emergency endoscopy on suspicion of upper gastrointestinal bleeding. Tumor lesions were identified in the thoracic esophagus and the gastroesophageal junction. Spindle cell carcinoma was detected by microscopic examination of biopsy specimens, but these histopathologic findings differed from those of the embolic material at the time of operation. He was subsequently transferred to another hospital for treatment for esophageal cancer and investigation of another primary tumor.

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