荒川 衛

OBJECTIVE: The predissection aortic diameter is the best reference for determining the size of the frozen elephant trunk in aortic dissection. We aimed to develop a new prediction method to estimate the predissection diameter of proximal descending aorta. Furthermore, we evaluated the accuracy of the estimated predissection proximal descending aortic diameters calculated using 3 prediction methods. METHODS: A total of 39 patients with acute type A aortic dissection who underwent predissection computed tomography were included in derivation sets. We measured the aortic dimensions at 3 levels of the proximal descending aorta: 5, 10, and 15 cm from zone 2. We developed a new prediction method-postdissection aortic diameter divided by 1.13 (AoDNew factor)-and estimated the predissection aortic diameter using the new and previously proposed methods by Rylski (AoDRylski) and Yamauchi (EquationYamauchi). Furthermore, we validated the new prediction method using a validation dataset with 24 patients. RESULTS: The rate of bias ≤2 mm was significantly greater with EquationYamauchi and AoDNew factor than with AoDRylski in the derivation group at each level of the proximal descending aorta (P < .001). In the validation group, the rate of bias ≤2 mm was significantly greater with EquationYamauchi and AoDNew factor than with AoDRylski at 10 cm and 15 cm from zone 2 (10 cm: P = .014, 15 cm: P < .001). CONCLUSIONS: These results suggest that the new prediction method can be used as a simple and accurate estimation method for the predissection aortic diameter at the proximal descending aorta.

OBJECTIVES: Zone 2 anastomosis with total cervical branch reconstruction for acute type A aortic dissection and aortic arch aneurysms became possible after stent-graft introduction. This may be an easier procedure and reduce the risk of recurrent laryngeal nerve palsy. Therefore, this study aimed to compare the outcomes between Zone 2 and Zone 3 distal anastomoses. METHODS: After evaluating the patient data in our institute between April 2016 and April 2022, the patients in whom distal anastomosis was performed at Zone 2 with a stent-graft were defined as the Zone 2 group (n = 70). The patients in whom distal anastomosis was performed at Zone 3 were defined as the Zone 3 group (n = 24). RESULTS: The incidence of new-onset recurrent nerve palsy was one patient (1.4%) in the Zone 2 group and six patients (25.0%) in the Zone 3 group (p < 0.001). The lower body perfusion arrest time was 44.3 ± 9.1 min in the Zone 2 group and 52.9 ± 12.8 min in the Zone 3 group (p = 0.005). There were no significant differences in in-hospital mortality and morbidities. Multivariable analysis showed that only age was an independent predictor of overall mortality. CONCLUSIONS: Performing distal anastomosis at Zone 2 with a frozen elephant trunk or stent-graft reduced the lower body perfusion arrest time and possibly prevented recurrent nerve palsy.

Malignant cardiac tumor is a rare tumor with extremely poor prognosis, and metastatic cardiac tumor causes superior vena cava( SVC) syndrome. A 52-year-old man visited a clinic with a chief complaint of facial edema. Contrast-enhanced computed tomography( CT) revealed a mass in the right atrium( RA)obstructing the SVC. Echocardiography revealed a mass about to incarcerate the tricuspid valve orifice. The patient was transferred to our institution for emergency surgery. Tumor resection was performed under general anesthesia. A cardiopulmonary bypass was established with cannulate in the ascending aorta, in the RA through the right femoral vein, and in the left ventricle for venting. The RA was incised, and the tumor was resected. The SVC was incised, and the tumor and blood clots were removed. Because adhesion between vessel wall and the mass was tight, complete mass removal and recanalization of the SVC was not attempted. Pathological diagnosis was metastatic squamous cell carcinoma. All imaging studies failed to identify primary lesions. The clinical course was uneventful, and the patient was discharged on postoperative day 17. Four months postoperatively, chemotherapy for squamous cell carcinoma was initiated. The patient is alive at approximately 28 months postoperatively.

A 78-year-old man presented with severe stage 3 (Fontaine IV, Rutherford 5, W1 I3 FI0) right limb ischemia. Although his artery was completely occluded from below the right external iliac to the popliteal artery, collateral circulation from the right lateral femoral circumflex artery was well developed and supplied the lower extremity arteries. We selected an uncommon crossover bypass strategy with the left common femoral artery to the right lateral femoral circumflex artery to improve lower extremity perfusion via indirect revascularization. Bypass using the lateral femoral circumflex artery as an outflow is an option for patients with major lower extremity artery occlusions.