Arteriovenous fistulae are known to be one of the causes of intractable leg skin ulcers. Because they raise peripheral venous pressure, decrease arterial blood flow to peripheral tissue, and cause venous blood congestion, symptoms of skin coldness, edema, pain, dermatitis and skin ulcers may appear in the legs. We observed a 32 year-old woman with multiple intractable bilateral leg skin ulcers due to arteriovenous fistulae successfully treated with Kampo medicines. In 1999, skin ulcers, edema, and pain presented in both her legs. She was diagnosed has having arteriovenous fistulae with various examinations in 2003. She had subsequently been treated with topical preparations on her legs, analgesics and other palliative treatments, but as symptoms had not improved, she first visited our outpatient clinic in August 2006. After an initial oral administration of tokishakuyakusan extract for 6 weeks, her pain improved. Afterwards, ogikenchuto was added for symptoms of qi deficiency. Moreover, bushi powder was added for the treatment of pain exacerbated in cold conditions. After 6 months, the size of her skin ulcers was fairly reduced, and she had no need of analgesic drugs. In past reports, Kampo medicines have not been used for the treatment of intractable skin ulcers due to arteriovenous fistulae. This case suggests that Kampo medicines are a treatment option in this condition.

Although sequential bypass with in situ arterial conduits (the left and right internal thoracic arteries; LITA and RITA, the right gastroepiploic artery; GEA) in coronary artery bypass grafting (CABG) is technically demanding, it is one of the most important procedures using a limited number of in situ arterial conduits to revascularize a wide area. In this report, we retrospectively investigated the clinical outcome of CABG with 4 or more distal anastomoses using only in situ arterial conduits. From December 1990 to May 1999, 62 patients underwent CABG with in situ arterial conduits, with at least one sequential bypass. There were 59 men and 3 women patients with mean age of 59.6 years (41 to 82 years). Mean postoperative follow-up period was 32 months (1 to 101 months). The total number of distal anastomoses was 4 (1 sequential bypass) in 54 patients, 4 (2 sequential bypasses) in 6 patients, 5 (1 sequential bypass) in 1 patient and 6 (3 sequential bypasses) in 1 patient. There were 5 emergency operations (8%), 37 patients (60%) had a history of myocardial infarction, 30 patients (48%) had diabetes mellitus and 6 patients (10%) had chronic renal failure and were on hemodialysis. Left ventricular ejection fraction was 40% or less in 15 patients (24%). There were no early deaths. Angiographic patency was satisfactory for each graft (sequential: individual, LITA 96.7%: 100%, RITA 100%: 100%, GEA 89.5%: 97.4%). Patency of a distal anastomoses of GEA was rather poorer than that of proximal (p=0.03). Three patients died during the follow-up period (all of them due to malignancy). The 5-year actuarial survival and cardiac event-free rate was 94.6% and 87.2%, respectively. In conclusion, although an indication of GEA sequential grafting needs further study, in situ arterial grafting with at least one sequential arterial conduit was associated with excellent results and achieved more complete revascularization with exclusive use of in situ arterial conduits in patients with diffuse coronary artery disease.

A 62-year-old man was admitted to our hospital because of acute aortic dissection (DeBakey type III b). Inflammatory findings were detected and methicillin-resistant staphylococcus aureus (MRSA) was detected by blood culture. Appropriate antibiotic therapy was begun but was ineffective. Repeated CT scans revealed dilation of the false lumen with thrombus and perianeurysmal inflammatory change in the lung. A diagnosis of infected aortic dissection was made. The patient was treated by resection of the descending aorta and placement of an in situ Dacron graft covered with a pedicled omental flap. An infected thrombus in the false lumen was confirmed by a positive MRSA culture. Computed tomography was found to be more sensitive in the diagnosis of infected aortic dissection. When the infection is not controlled with antibiotics, prompt surgical treatment should be performed.

We report a 65-year-old man with a mobile thrombus in the distal aortic arch with no previous history of thromboembolic events. There was no evidence of either aneurysmal changes or aortic dissection. Transesophageal echocardiography revealed the presence of a mobile tumor in the distal arch. The patient underwent elective resection. The mobile tumor was attached to the aortic wall, approximately 3cm distal to the left subclavian artery. Histological examination revealed an old thrombus containing calcification. He was discharged on the 22nd postoperative day with no thromboembolic complications. This is the first report of a case of mobile thrombus in the distal aortic arch in Japan.

A 41-year-old woman liked farm chemical-free (pesticid-free) vegetables. She was admitted for severe upper abdominal pain. Biliary ascariasis was suspected upon abdominal ultrasonographic examination. ERC (Endoscopic Retrograde Cholangiography) was performed and a linear filling defect was shown in the bile duct. We diagnosed her case as biliary ascariasis. And then, we removed a worm from the bile duct using stone extracer basket forceps. After this, she was given pyrantel pamoate.Abdominal ultrasonographic examination was helpful in diagnostic screening for biliary ascariasis. ERC and basket forceps were useful in removing the parasite.
Biliary ; Ascariasis ; success ; Manufactured aid ; Endoscopic retrograde cholangiography

We treated 261 arteriosclerosis obliterans cases with critical leg ischemia since 1976. Those patients aged 75 years and older were designated as the elderly group and were compared with those under 75 years of age. Among the elderly patients with critical leg ischemia, the percentages of women and Fontaine scale IV cases were higher. The condition of those who had to undergo an initial major amputation was often complicated by cerebrovascular diseases, resulting in a higher early death rate after operation. Therefore, the necessity of early diagnosis and immediate treatment must be emphasized. There were no differences in patency and limb salvage rates between the two groups. In cases of arterial reconstruction however, graft occlusion in the elderly group immediately after operation was frequently observed. It is important to include drug therapy in follow-up to prevent occlusion of the graft following surgery in elderly patients.

A 27-year-old man had received Bentall's operation for annuloaortic ectasia with Marfan's syndrome 4 years previously. He was admitted to our hospital because of sudden abdominal pain and lumbago. The abdominal pulsatile mass with tenderness was palpated and dilatation of abdominal aorta was revealed by abdominal ultrasonography. An emergency operation was performed under a diagnosis of ruptured abdominal aortic aneurysm. At operation, the infrarenal abdominal aorta formed a fusiform aneurysm of which maximum diameter was 6cm. The aneurysm had a thin wall, and ruptured opening about 2cm in diameter at the posterior wall, but no thrombus inside. Graft replacement was done from the infrarenal abdominal aorta to the bilateral common iliac artery using knitted Dacron vascular prosthesis, and reconstruction of inferior mesenteric artery with wrapping of the proximal anastomosis were performed. Histopathological examination of the aneurysmal wall revealed medial necrosis and degeneration, by which Marfan's syndrome was diagnosed. Although abdominal aortic aneurysm is rarely associated with Marfan's syndrome, it often shows rapid development and has a high risk of rupture. Therefore, we suggest that strict observation and early operation are important for abdominal aortic aneurysm associated with Marfan's syndrome.

During 23 years, 224 cases underwent graft replacement of thoracic aortic aneurysms at our institution. Of these, 14 cases suffered postoperative vascular graft infection. Out of the 14 cases, 13 cases had sternal or mediastinal infections, and one case showed sepsis without these deep wound infections. Six cases were positive by blood culture. We thought that sternal or mediastinal infections had a high possibility of contamination of vascular grafts and that cases with these deep wound infections should be treated as cases of graft infection. Reoperation was done urgently soon after the diagnosis of infection was made. When the wound was not so deep, only debridement was performed. In addition to debridement, continuous irrigation through a chest tube and, recently, pedicled omental flap placement were done, when the wound was deep. Except for the one case without deep wound infection, 13 cases were reoperated. There were 4 hospital deaths; 3 operated cases and the nonoperated case, due to lack of control of their infection. Blood culture were positive in all these four cases. The other 10 cases were discharged from hospital without infection. Infection of vascular grafts after operation for thoracic aortic aneurysms is a serious complication and urgent reoperation should be done. However it should be noted that the mortality rate of cases with positive blood culture is high.

Twenty-two patients who underwent vascular reconstruction for carotid occlusive disease by April 1998 were examined in terms of long-term results. The cause of disease was atherosclerosis in 16, and aortitis in 6. The operation method included CEA in 11 and bypass in 5 cases in the atherosclerosis cases, and CEA in 2 and bypass in 6 cases in aortitis. Cases of occlusive disease included 1 early occlusion (atherosclerosis) and 4 late occlusion (atherosclerosis 2, aortitis 2). The cause of early occlusion was considered to be due to technical factors, but late occlusion was thought to be related to progression of disease, anastomotic intimal thickening, and recurrence of inflammation. It is important to enforce strict operative indications, accurate intraoperative monitoring, and perioperative drug control.

A 26-year-old man was suffered a tendon injury in the left knee when playing American football 3 years previously and was treated consevatively. He was admitted to our hospital because of coldness and paresthesia in the left leg since 2 months previously. Femoral angiogram revealed severe stenosis of left popliteal artery and occlusion of the anterior and posterior tibial artery. CT and MRI examination revealed a tumor which protruded into the lumen of the left popliteal artery or dissection of left popliteal artery. Operation was performed by a posterior approach. The left popliteal artery was not compressed from the lateral side and there was a white thrombus in the popliteal artery. Thromboendartherectomy and autologus venous patch plasty was done. Histopathological findings of the stenotic lesion revealed an organizing thrombus, chiefly consisting of fibrin, and intima both of which were infiltrated by granuration tissue. It was suggested that the stenotic lesion was caused by arterial wall hyperplasia or thrombus formation during the healing process after blunt arterial injury. The post-operative course was uneventful.