We report a case of a 55-year-old male with type B-chronic aortic dissection. Patient presented with intermittent claudication due to limb malperfusion resulting from expansion of a patent false lumen during walking regardless of normal range ankle-brachial index (ABI) at rest. Preoperative stress vascular ultrasonography was an effective modality for proper diagnosis. We should be concerned of reversible ischemia due to the dissection fl ap in patients with type B aortic dissection. Fenestration of the aorta can be a choice of treatment in such patients. The patient has been doing well with no ischemia for 3.5 years after the operation. Key words: chronic aortic dissection, aortic fenestration, limb malperfusion Case ReportA 55-year-old man with a history of type B aortic dissection suffered 1.5 years ago, presented with intermittent claudication was referred to our hospital. The ABI of this patient at rest in the supine position was within the normal range. Right ankle-brachial index (ABI) was 1.07, left one was 1.05. However, the ABI worsened after walking exercise (Fig. 1a). Right ABI turned down to 0.55, left ABI turned down to 0.57.Intermittent claudication started at distance of approximately 50 meters.Computed tomography revealed that the false lumen was patent and that a dissection fl ap extended to the terminal aorta. The true lumen was compressed by the false lumen and was narrowed.Mobile fl ap was detected near the terminal aorta by vascular ultrasonography, and blood fl ow to the bilateral limb was maintained without decrease in the ABI. However, a stress vascular ultrasonography performed after a 6-min walking exercise revealed that the subtotal occlusion of the true lumen in the terminal aorta caused by the expansion of a patent false lumen (Fig. 2). Furthermore, blood fl ow to the bilateral limb was reduced with simultaneous decrease in bilateral ABI.We performed surgical resection of the fl ap in the terminal aorta under laparotomy. During the procedure, the dissection fl ap was found extended to 15 mm in the proximal position to the terminal aorta bifurcation. The distal edge was blind with a mural thrombus, though a small re-entry was present (Fig. 3). After fenestration, aortotomy was closed with 4-0 Prolene sutures reinforced with a 10-mm-width felt strip.His symptom resolved following the operation. Achievement of functional recovery by this surgical treatment was confi rmed by a stress ABI (Fig.1b) and stress vascular ultrasonography performed after a 6-min walking exercise. Thermography after a walking test showed increased blood fl ow in the lower extremities, compared to the fl ow before the test. Enhanced computed tomography revealed
BACKGROUND AND OBJECTIVE: Turbulent blood flow in patients with aortic valve stenosis (AS) results in morphological and functional changes in platelets and coagulation factors. The aim of this study is to determine how shear stress affects platelets and coagulation factors. METHODS: We retrospectively evaluated data from 78 patients who underwent AVR to treat AS between March 2008 and July 2017 at Kagoshima University Hospital. RESULTS: Platelet (PLT) count obviously decreased at three days after AVR, and increased above preoperative levels at the time of discharge. In contrast, platelet distribution width (PDW), mean platelet volume (MPV), and platelet large cell ratio (P-LCR) increased three days after AVR, then decreased to below preoperative levels. No differences were evident between groups with higher (HPPG > 100 mmHg) and lower (LPPG < 100 mmHg) peak pressure gradients (PPG) before AVR, whereas PLT count, PDW, MPV and P-LCR improved more in the HPPG group. Plateletcrit (PCT), which represents the total volume of platelets, increased after AVR due to decreased shear stress. High increasing rate of PCT was associated with lower PLT count, higher PDW and lower fibrinogen. CONCLUSION: Shear stress affects PLT count, PDW, and fibrinogen in patients with AS.
Purpose: We investigated whether mitral annuloplasty (MAP) should be performed for mild ischemic mitral regurgitation (IMR). Methods: We selected 57 patients with preoperatively mild IMR. Twenty-eight patients who previously had moderate MR or more, underwent MAP (group 1) while 29 patients with persistent mild MR, did not (group 2). We reviewed MR changes and outcomes of these patients. We also investigated other IMR patients with preoperatively moderate or more MR as reference data (group 3). Results: In group 1, MR was none or trace in 25 patients immediately after operation, however, eleven out of these patients (44%) showed postoperative MR up-grade. The trends of MR changes in group 1 were similar to those of patients in group 3. In group 2, MR was graded mild in 79% of patients in mid-term postoperative stage although 28% of patients were up-graded or down-graded during postoperative follow-up. Conclusion: MAP is not necessary for patients with persistently mild IMR. Patients with preoperatively mild IMR with episodes of MR exacerbation had better be treated similarly as those with moderate or more IMR and undergo MAP.
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