Ischemic heart disease (IHD) poses some serious problems in the surgical treatment of arteriosclerosis obliterans of the lower extremities (ASO) and aortic aneurysm (AA). The surgical management of these vascular diseases in patients with IHD was evaluated. Thirty-five patients had ASO and 31 had AA. All patients underwent coronary arteriogram. IHD was detected in 24 patients (69%) with ASO and in 12 (39%) with AA. The severity of coronary artery disease was graded by the coronary score (CS) proposed by Leaman et al., and the scores were compared with the mode of surgical treatment. In patients with ASO, both the revascularization of coronary arteries (CABG) and of peripheral arteries were performed in one stage in 3 patients with a CS of 16-22. Only arterial revascularization of the lower extremities was performed in 19 patients with a CS of below 5.5. In AA, surgical treatment was performed with consideration of the severity of the coronary artery disease and the surgical approach. Both CABG and aortic reconstruction were performed in one stage in 3 patients with abdominal aortic aneurysm (CS: 9.5-13.5) and in 2 patients with aortic arch aneurysm (CS: 3.5, 8) with a coronary lesion in the left anterior descending branch (LAD). Only aortic repair was performed in 5 patients with a CS below 8 (without LAD lesion). The patients with ASO (CS≤5.5), and those with AA (CS≤8, no LAD lesion) underwent reconstruction only in the arteries of the lower extremities and aortic aneurysms, respectively, without any complications from the associated IHD.

The arm ergometer exercise test (Arm E) was performed in 24 patients with arteriosclerosis obliterans of the lower extremities (ASO) to detect ischemic heart disease (IHD). All patients underwent coronary arteriography. IHD was detected in 16 patients (67%) with ASO. Sensitivity for diagnosis of IHD was 94%, specificity was 75% and accuracy was 88%. The severity of coronary artery disease was graded by the coronary score (CS) proposed by Leaman, et al. and the scores were compared with the mode of surgical treatment. In 3 patients with a CS between 16 and 22, the revascularization of both coronary arteries (CABG) and of peripheral arteries were performed in one stage. In 12 patients with CS below 5.5, only arterial revascularization of the lower extremities was performed without complications from the associated IHD. These results suggest that Arm E is a useful screening test to detect IHD in patients with ASO for surgery.

Transesophageal pacing (TEP) was performed in 54 patients with atheroscrelotic vascular disease to detect ischemic heart disease (IHD). Thirty patients had arteriosclerosis obliterans of the lower extremities (ASO) and 24 patients aortic aneurysm (AA). All patients underwent coronary arteriography. Sensitivity for the diagnosis of IHD was 90% and the specificity 67%, accuracy 83% in ASO and sensitivity 80%, specificity 93%, accuracy 88% in AA. In both vascular diseases the sensitivity was 87%, the specificity was 83%, and the accuracy was 85%. These results suggest that TEP is a useful screening test to detect IHD in patients with atheroscrelotic vascular disease who are candidates for surgery.

A 61-year-old woman with paresthesia and coldness of the right forearm came to our institute. Her right arm was strangulated and tracted by a vinyl string tied at her right brachium. No pulsation of her right radial artery was detected, and her forearm had swollen with subcutaneous hematoma. Her arteriography showed occlusion of the distal site of the right brachial artery, and just proximal to the brachial arterial bifurcation was enhanced by collaterals. She underwent emergency revascularization 6h after injury. There was a thrombus in the artery at the strangulated site, and the arterial intima was circumferentially dissected. The injured site of the artery was completely resected and interposed with basilic vein. Although 8h had passed from injury to reperfusion, myonephropathic metabolic syndrome did not occur after the operation. Her brachial arterial pulsation is now well palpable. The arterial occlusion was probably caused by the circumferential tear of the intima due to not only direct strangulation but also strong traction of the arm. It is necessary to resect a sufficient length of injured artery.

Lipoprotein(a) [Lp(a)] has been considered as an independent risk factor for arteriosclerotic diseases. With an anticipation that Lp(a) would also serve as a risk factor for abdominal aortic aneurysms (AAA), we analyzed serum and tissue Lp(a) levels of patients with AAA in relation to those in healthy individuals. Serum Lp(a) levels were significantly higher in the AAA group (53.2±60.8mg/dl) than in the healthy controls (14.6±13.6mg/d) (p<0.001). The Lp(a) level in the aneurysmal wall of patients with AAA was 49.8±38.2ng/mg. There was a significant correlation between serum and aneurysmal wall Lp(a) levels in AAA patients (r²=0.79, p<0.01). Immunohistochemical examination revealed Lp(a) in the extracellular matrix of the middle layer of the tunica intima, but not in the tunica media or externa.

In 13 patients who underwent left ventriculography both before and after operation, we investigated regional wall motion of the left ventricle (LV) with the centerline method in LV aneurysmectomy. There were no significant differences between preoperative predicted and postoperative ejection fraction. No significant differences were observed between preoperative predicted and postoperative regional wall motion of all segments in all cases and cases without significant stenosis who did not undergo revascularization of the right coronary artery. Postoperative regional wall motion of the inferior wall was significantly better than the preoperative predicted one in cases who underwent revascularization of the right coronary artery with significant stenosis. It is considered that revascularization of the right coronary artery with significant stenosis in LV aneurysmectomy was effective for the improvement of regional wall motion of the inferior wall.

We reviewed our experience with 4 cases of chronic dissecting aortic aneurysm (DeBakey IIIb) with the false lumen extending into the abdominal aorta and major branches being perfused from the false lumen. In such cases, resection of the intrathoracic portion of the aneurysm and closing of the distral false lumen may exclude visceral perfusion from the false lumen. In order to ensure continued perfusion of true and false lumens after repair, we performed “double barrel” anastomosis for distal anastomosis in graft replacement of the descending aorta. Follow-up periods ranged from 8 to 21 months, 17 months on average. Postoperatively, neither apparent expansion of the false lumen nor compression of the true lumen was found in these cases. The advantage of this procedure is the effective restoration of visceral perfusion. We emphasize that this procedure is one of the choices of procedures, as a two-staged approach for chronic aortic dissection presenting with visceral perfusion from the false lumen and without an enlarged abdominal aorta, though more patients and longer follow-up are required to fully evaluate this procedure.

There are various problems associated with the surgical management of concomitant abdominal aortic aneurysm (AAA) and gastrointestinal malignancy. Our surgical strategy for the treatment of concomitant AAA and gastrointestinal malignant diseases, with the exception of colorectal diseases is basically a one-stage operation. This report reviews 6 cases involving concomitant AAA and gastrointestinal malignancy (colon cancer in 3 cases, gastric cancer in 2 and hepatoma in one). In 2 cases involving gastric cancer, we selected a one-stage operation for the coexistent AAA and gastrointestinal malignancy. The postoperative courses were uneventful. In a 69-yearold man with concomitant AAA, hepatoma and ischemic heart disease, a hepatectomy and coronary revascularization preceded AAA repair because the AAA diameter was too small. AAA repair was performed after 4 months when its diameter had been enlarged. In one of the 3 cases involving concomitant AAA and colon cancer, the malignancy was resected first and the patient died of recurrence 7 months after the operation and prior to the operation for AAA. In the second case of colon cancer, AAA repair preceded the resection of the malignancy. A right hemicolectomy was performed 53 days after the AAA operation. The third case had a one-stage operation for coexistent AAA and colon cancer. His postoperative course was uneventful. In this case, we took particular care to avoid graft infection. The 5 cases that underwent both operations have survived without major complications or evidence of recurrence during a follow-up period ranging from 2 months to 4 years.

Human marrow mesenchymal stem cells were cultured in a medium containing glycerophosphate, ascorbic acid, and dexamethasone (Dex) on alumina ceramic discs and on tissue culture polystyrene (TCPS) dishes. Cell proliferation followed by osteogenic differentiation was observed to be equal on both culture substrata. The differentiation resulted in the appearance of bone-forming osteoblasts, which fabricated mineralized matrices on these substrata. Stem cells kept at 4degrees Cfor 24 h outside a CO2 incubator maintained a viability level of more than 90%. The regenerative cultured bone outside the incubator also maintained high alkaline phosphatase activity for several hours. These results verified that cultured bone fabricated at a cell processing center can be transported to distant hospitals for use in hard tissue repair. To date, the tissue engineered cultured bone formed on alumina ceramics in this environment have already been used in clinical situations, such as total ceramic ankle replacements.
Adult ; Aged ; Aluminum Oxide ; Bone Marrow Cells/*cytology ; Cell Differentiation ; Cell Division ; Ceramics ; Humans ; Mesenchymal Stem Cells/*cytology ; Middle Aged ; *Osteogenesis ; Research Support, Non-U.S. Gov't ; *Tissue Engineering