Summary:It is difficult to treat lung complications caused by chronic graft-versus-host disease (GVHD) after allogeneic stem cell transplantation (allo-SCT). We retrospectively analyzed the characteristics of five patients with mediastinal emphysema (ME) and bilateral pneumothoraces (BP) caused by chronic lung GVHD after allo-SCT. Four of these patients had undergone unrelated SCT, and three had had HLA-identical unrelated donors. All patients received total body irradiation (TBI) during conditioning. Immunosuppressive agents were administered as GHVD prophylaxis, but two patients developed acute GVHD and all the five developed chronic GVHD. The onset of lung complications was 99-1915 days (median, 202 days) after SCT. The onset of ME and BP was 6-48 days (median, 23 days) after the onset of lung complications. Immunosuppressive agents were initially beneficial on the lung complications, but the patients later showed no response to therapy, and all died from respiratory failure 7-195 days (median, 28 days) after the development of ME and BP. The results suggest that these complications progress rapidly, are resistant to treatment, and have a poor prognosis. It is therefore important to start prophylaxis and treatment as early as possible.
Pancreaticoduodenal artery aneurysm can occur from occlusion or stenosis of the celiac artery due to arteriosclerosis or median arcuate ligament compression. The risk of rupture of the aneurysm is independent of the aneurysmal diameter. A 78-year-old woman presented with multiple large aneurysms of the anterior superior pancreaticoduodenal artery. To preserve arterial flow to the liver, bypass grafting from the supra-celiac aorta to the common hepatic artery was performed at first. Coil embolization was successfully performed 10 days later with a dual approach through both the superior mesenteric artery and bypass. It was considered that the combination of the aorto-hepatic bypass and coil embolization was effective for the pancreaticoduodenal artery aneurysms due to celiac artery occlusion.
We report a rare case of severe aortic regurgitation after mitral valve replacement MVR and tricuspid annuloplasty TAP. An 83-year-old woman underwent MVR and TAP for mitral regurgitation and secondary tricuspid regurgitation. The early postoperative course was not eventful until 6 days after surgery. However, 7 days after surgery, she suffered from acute heart failure and transthoracic echocardiography showed severe aortic regurgitation. We performed a second operation 13 days after the first surgery. Intraoperatively, we found the annulus suture of the TAP just under the NCC-RCC commissure of the aortic valve. We speculated that the suture pulled the aortic valve annulus, resulting in severe aortic regurgitation. We removed the suture and replaced the aortic valve with bioprosthetic artificial valve. Postoperative recovery was uneventful, and she was discharged 22 days after the second surgical procedure.
We report a rare case of paraplegia after emergency total arch replacement for type A acute aortic dissection. A 52-year-old man was referred to our hospital for acute aortic dissection. Contrast-enhanced computed tomography showed a type A aortic dissection extending from the aortic root into the right iliac arteries. The true lumen of the descending and abdominal aorta was collapsed and blood flow to the right lower limb had decreased. Large entry and re-entry tears were revealed in the ascending and distal arch aorta, respectively. His preoperative consciousness was clear, hemodynamics were stable, and there was no evidence of paraplegia or paraparesis. Extracorporeal circulation was established by femoral artery and right atrium cannulation. Total arch replacement was performed under moderate hypothermic circulatory arrest lowest bladder temperature : 21.9. The postoperative course was uneventful and he was extubated 6 h postoperatively. Postoperative hemodynamic parameters were stable, the mean blood pressure was maintained at around 70 mmHg, and limb movements were confirmed at that time. Although there was no abnormality of lower limb movement until the following morning, paraplegia occurred about 17 h after surgery. While maintaining a mean blood pressure of over 90 mmHg, urgent cerebrospinal drainage was immediately performed and combined with steroid treatment and a continuous infusion of naloxone. The neurological defect was resolved immediately after cerebrospinal drainage, and neurological function steadily improved through rehabilitation. He was discharged 20 days after surgery with no neurological defects. Late paraplegia after total replacement for type A acute aortic dissection is a rare complication. From our experience, it is suggested that early diagnosis and treatment are important for improving paraplegia.
Infective endocarditis of the aortic valve tends to cause structural damage such as aortic root abscess, and aortic valve replacement is the standard treatment. However, there have been several reports on aortic valve repair for the treatment of infective endocarditis, and it has subsequently emerged as a feasible alternative to aortic valve replacement in selected patients. We report a case of aortic valve repair for infective endocarditis of the aortic valve caused by α-hemolytic Streptococcus. A 50-year-old man was admitted to our hospital with a two-month history of fever of unidentified origin. Transthoracic echocardiography revealed infective endocarditis of the aortic valve. Transesophageal echocardiography confirmed vegetation in the right coronary and non-coronary cusps, and mild aortic regurgitation. Although infection was controlled by approximately one month of antibiotic treatment, there was markedly more severe aortic regurgitation compared to the previous examination. These findings were confirmed on transesophageal echocardiography, and residual vegetation on the right coronary cusp as well as a perforation in the non-coronary cusp were confirmed. Intraoperative findings revealed a perforation in the non-coronary cusp and dehiscence, with vegetation on the right coronary cusp. The vegetation was carefully removed, the non-coronary cusp perforation was repaired with a pericardium patch, and the defect on the right coronary cusp was directly sutured with 6 0 polypropylene. Intraoperative transesophageal echocardiography revealed trivial aortic regurgitation. The postoperative course was uneventful and the patient was discharged 7 days after surgery without any complications. Antibiotics were prescribed for 3 months, and transthoracic echocardiography was performed 5 days, 1 month, and 3 months after surgery. No evidence of recurrence of aortic regurgitation or infection of the aortic valve was observed.
Keywords: arteriovenous fistula, vascular access, endovascular therapy, ultrasonography, peripheral nerve block 〈Abstract〉 [Objectives] This study aimed to investigate the feasibility, efficacy, and long term patency rate of endovascular declotting of thrombosed native arteriovenous fistulas under duplex imaging. [Methods] In 2019 and 2020, 141 cases of acutely occluded native arteriovenous fistulas were treated with endovascular declotting by one surgeon at Nagoya Vascular Surgery Clinic. Most cases were treated with thromboaspiration via a 4 8 Fr sheath followed by percutaneous transluminal angioplasty (PTA). All procedures were carried out under selective cutaneous nerve blocks, with duplex ultrasonography used as the sole imaging modality. The technical success rate and patency rate were assessed. Assisted primary patency was defined as the period between treatment and any surgical intervention. [Results] The technical success rate was 96.5%. The median operation time was 64 minutes. PTA was performed in 121 (85.8%) cases, thrombolysis with urokinase was performed in 15 (11%) cases, and endovascular forceps were used in 29 (20.6%) cases. There were 9 complications, of which two resulted in procedure failure and immediate conversion to open surgery. The median duration of the follow up period was 17.3 months. The primary patency rate was 41.8% at 6 months and 28.6% at 1 year. The assisted primary patency rate was 87.0% at 1 year and 85.6% at 2 years. [Conclusions] Although the primary patency rate was low, the good results regarding the technical success rate and assisted primary patency rate encourage the aggressive application of endovascular treatment for acutely occluded native arteriovenous fistulas.
A 68-year-old man presented with dyspnea and pulsation. He had a history of esophagectomy and presternal gastric tube reconstruction for esophageal cancer 1 year earlier. Electrocardiography revealed atrial fibrillation, and an echocardiogram showed severe mitral valve regurgitation and moderate tricuspid valve regurgitation. He underwent mitral valve repair, tricuspid valve annuloplasty, and isolation of bilateral pulmonary veins via a standard median sternotomy. The mitral and tricuspid valves were evaluated by epicardial echocardiography, and both valves were successfully repaired. The postoperative course was uneventful. The patient was discharged without any complications 6 days after the operation.
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