Endovascular aortic aneurysm repair using stent graft (SG) for both thoracic and abdominal aortic aneurysms (SG therapy) rapidly became widespread in Japan because of its relatively low invasiveness. Pre- and postoperative contrast enhanced CT are mandatory in SG therapy and angiography is required during SG therapy. Therefore contrast induced nephropathy (CIN) might occur after SG therapy. In our hospital, a renal protection protocol (oral N-acetylcysteine, perioperative normal saline infusion and bicarbonate infusion during SG therapy) was introduced in June 2010. In this report, the effect of the renal protection protocol on renal function after SG therapy was evaluated. During May 2008 and March 2012, 229 patients underwent SG therapy in our hospital. Serum creatinine (CRTN) was higher than 1.5 mg/dl and estimated glomerular filtration rate (eGFR) was less than 50 ml/min/1.73 m² in 26 patients. In these 26 patients, the renal protection protocol was applied in 15 patients (group P) and group P was compared with the 11 patients without renal protection protocol (group N). Also the relationship between CIN occurrence and preoperative renal function was evaluated in 192 patients who did not receive the renal protection protocol. CIN was defined as more than 25% or 0.5 mg/dl increase of CRTN based on the European Guidelines. As renal protection protocol, N-acetylcysteine (600 mg) was given 4 times every 12 h. Normal saline infusion was started on the evening of the day before surgery at the rate of 50 ml/h and was continued until 1h before surgery. Sodium bicarbonate solution (151 mEq/l) was started 1 h before surgery at the rate of 180 ml/h and the infusion rate was decreased to 60 ml/h during surgery. After surgery, 1,000 ml of normal saline was given at a rate of 60 ml/h. In group N, CRTN increased 1 and 3 days after SG therapy and returned to baseline level 6 days after SG therapy. On the other hand, CRTN was lower than baseline after SG therapy in group P. At 3 days after SG therapy, the percent change of CRTN component with baseline level was significantly lower in group P (14.5±19.1% in group N, -3.7±15.8% in group P, p=0.014). CIN occurrence tended to be more in group N (45% in group N, 7% in group P, p=0.054). Among the 192 patients without the renal protection protocol, CIN occurred in 16 patients (29.1%) out of 55 patients with preoperative CRTN≥1.0 mg/dl and eGFR≤50 ml/min/1.73 m², however CIN occurred in only 1 patient (0.7%) among 137 patients with preoperative renal function out of this range (p<0.001). Renal protection protocol seemed to be effective to prevent CIN after SG therapy. Renal protection might be useful for patients with a CRTN≧1.0 mg/dl and eGFR≦50 ml/min/1.73 m².

Endovascular repair for abdominal aortic aneurysm (EVAR) has become widespread in Japan because of its low invasiveness. However adequate proximal neck length is required for EVAR. Unfortunately the surgical mortality of para-renal aortic aneurysm cases has been higher than that of infrarenal aortic aneurysm cases, especially in high-risk patients. A manufacture-modified fenestrated Zenith stent graft system has already been developed, however this new device is not yet available in Japan. Furthermore this device could not be used in an emergency situation because it takes 2-3 weeks for preparation. Therefore we introduced a surgeon-modified fenestrated Zenith stent graft (fenestrated Zenith) system in December 2010 for patients with a proximal neck length of 5-10 mm. The fenestrated Zenith was not indicated if the supra-renal angle and proximal neck angle exceeded 35°. From May 2007 to February 2012, abdominal aortic aneurysms (AAA) with a short neck were repaired with fenestrated Zenith in 11 high-risk patients (group Fene), and AAAs with a proximal neck length of more than 15 mm were repaired with a standard Zenith in 43 patients (group IFU). There were two ruptured AAA in the Fene group. Proximal neck length was significantly shorter in the Fene group (5.5±1.4 mm in the Fene group, 26.4±9.5 mm in the IFU group, p<0.0001) and proximal neck angle was significantly less in the Fene group (20±13° in the Fene group, 36±18° in the IFU group, p=0.008). The Zenith stentgraft system was deployed successfully in all patients. The frequency of type Ia endoleak detected by angiography after stent graft deployment and balloon attachment did not differ significantly (36% in the Fene group 26% in the IFU group, p=0.475) and the frequency of Palmaz stent requirement for type Ia endoleak which persisted after 10 min of additional balloon attachment also did not differ significantly (27% in Fene group, 9% in IFU group). All fenestrated renal arteries were shown to be patent by angiography. There was no hospital death despite 2 cases of ruptured AAA, nor were these major complications in either group. Serum creatinine levels at 1, 3, 6 and 30 days after EVAR did not differ significantly between the 2 groups. In 9 out of 11 patients, only type II endoleaks were detected and aneurysm shrinkage tended to be more in Fene group (9.9±5.7 mm in Fene group, 5.4±6.1 mm in IFU group, p=0.062) on enhanced CT 6 months after EVAR. Also all fenestrated renal arteries were patent in these 9 patients. The surgeon-modified fenestrated Zenith system seemed to be effective for AAA patients with short proximal necks, but long term follow up is mandatory.

Oren-to extract alone was administered to 28 patients who had pain in the tongue but without organic lesions, and who had either a “hypofunctioning constitution” or a “normal functioning constitution”. The patients were predominantly women in their 50's. Treatment was continued for at least two months. The results were excellent in nine, good in 15, and unchanged in four. No side-effects attributable to Oren-to were observed. When the effect was compared in patients with and without dryness of the mouth, no significant difference was found. Thus it was shown that Oren-to was effective in the treatment of pain in the tongue in patients with either 'hypofunctioning constitution“ or ”normal functioning constitution“, regardless of whether they ”had dryness of the mouth or not. It seems that this preparation is also effective for the treatment of pain in the tongue in patients with psychosomatic disease who have a “hypofunctioning constitution” or “normal functioning constitution”. We discuss our study focusing on this condition.

  When subacute elderly patients are transferred from an acute hospital to a rehabilitation facility, the likelihood is that the environmental change will decrease the patients' ability to perform the basic activities of daily living (ADLs). In this study, we assessed the effects of the ambient changes on ADLs by the use of the Barthel Index, the reliability as well as validity of which is rated high for assessing the patient's fundamental ability. Our subjects consisted of the patients with hemiplegia who had undergone medical treatment of stroke and those who had been operated on for femoral neck fracture (FNF) in Toride Kyodo General Hospital. They were transferred to the convalescent rehabilitation ward (CRW) of Aida Memorial Rehabilitation Hospital, affiliated with our hospital. We compared the BI scores given to the patients by physical, occupational and speech therapists, when discharged from our hospital, and those scores given by nurses within one week after the patients moved to the CRW. Differences between BI scores given at Toride Hospital and those at the rehabilitation hospital averaged -5.9±16.0 points for stroke patients and -7.3±14.1 pointsfor FNF patients. Spearman's rank correlation coefficient of BI scores in the acute hospital and in the CRW for stroke patients was 0.91 (p<0.001) and 0.69 (p<0.001) for FNF. There was no significant difference in changes in BI scores between stroke and FNF. However, there was a tendency for the patients' functional ability in daily living to be assessed lower in the FNF patients than in the stroke patients. This was probably because the former were older than the latter on the average. The average age of the FNF patients was 81.4 years and that of the stroke patients was 68.5 years.

We report a case of thoracic endovascular aortic repair (TEVAR) with a fenestrated stent graft for ulcer-like projection (ULP) of the proximal anastomosis after total arch replacement (TAR) for acute type A aortic dissection (DAA). A 73-year-old woman with a history of surgical resection of a left atrial myxoma in January 2009 underwent TAR for DAA in November 2011. The contrast enhanced CT (CE-CT) 72 days after TAR revealed two ULPs anterior and posterior to the proximal anastomosis. Surgical repair would be difficult because of the history of cardiac and aortic surgery, therefore TEVAR with a fenestrated stent graft was performed. The postoperative course was uneventful and she was discharged on the 8th postoperative day. The CE-CT 3 months after TEVAR showed almost completely thrombosed ULPs. Endovascular repair with fenestrated stent graft for the proximal anastomotic ULP can be a useful and effective treatment.

We applied a new circulatory support system to three patients with descending aortic operation between 1989 and 1990. The new system consisted of a polyvinylchloride tube coated with hydrophilic heparinized polymer and a roller pump. Low doses of heparin (0.5mg/kg) were administered in two patients and none in one patient before aortic bypass. The aortic crossclamping time ranged between 52 and 64 minutes. In two patients, whose inflow cannulae were 18Fr. or 20Fr., successful bypass flow exceeded 2l/min and optimal distal aortic pressure were maintained during aortic cross-clamping. The postoperative courses of these patients were uneventful, free from thromboembolic episodes and subsequently discharged from hospital. Furthermore, postoperative careful examination revealed no thrombus formation occurred in the three devices. In conclusion, our new simple, antithrombogenic circulatory system is extremely useful for descending aortic operations.

A case of 65-year-old man of aorto-caval fistula induced by ruptured abdominal aortic aneurysm is reported. The symptoms were hematuria and chest pain, and an emergent operation was performed. In the operation, Fogarty's balloon occlusion catheter was used to reduce bleeding from inferior vena cava, and to prevent pulmonary embolism. The fistula was 3cm in size, and abdominal aorta was replaced with a low porosity polyester Y-graft. The symptoms of pulmonary congestion and hematuria were improved after operation. The balloon occlusion catheter was effective for reducing bleeding from IVC, and prevention from pulmonary embolism after operation.

A 61-year-old man underwent percutaneous coronary intervention (PCI) for the right coronary artery. However, he had an acute onset of right neck pain and swelling after PCI. Contrast enhanced computed tomography (CT) revealed extravasation into the mediastinum and aberrant right subclavian artery. After transfer to our hospital, we performed emergency endovascular repair for iatrogenic arterial injury. His postoperative course was uneventful.