Background/Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using a 19-gauge needle is an efficient sampling method for the diagnosis of lymphadenopathy. This study compared 19-gauge conventional and Franseen needles for the diagnosis of lymphadenopathy and classification of malignant lymphoma (ML). Methods: Patient characteristics, number of needle passes, puncture route, sensitivity, specificity, and accuracy of cytology/histology for lymphadenopathy were analyzed in patients diagnosed with lymphadenopathy by EUS-FNA using conventional or Franseen needles. Results: Between 2012 and 2022, 146 patients met the inclusion criteria (conventional [n=70] and Franseen [n=76]). The median number of needle passes was significantly lower in the conventional group than in the Franseen group (3 [1–6] vs. 4 [1–6], p=0.023). There were no significant differences in cytological/histological diagnoses between the two groups. For ML, the immunohistochemical evaluation rate, sensitivity of flow cytometry, and cytogenetic assessment were not significantly different in either group. Bleeding as adverse events (AEs) were observed in three patients in the Franseen group. Conclusions Both the 19-gauge conventional and Franseen needles showed high accuracy in lymphadenopathy and ML classification. Considering sufficient tissue collection and the avoidance of AEs, the use of 19-gauge conventional needles seems to be a good option for the diagnosis of lymphadenopathy.

An 88-year-old man was diagnosed with right renal pelvic carcinoma and underwent laparoscopic right nephroureterectomy. On postoperative day 3, he developed aspiration pneumonia and sepsis and received antibiotic therapy. A central venous catheter (CVC) with an outer diameter of 12 G was inserted via the right internal jugular vein for total parenteral nutrition. On the day after catheterization, pulsatility reverse flow was observed in its lumen, and arterial mispuncture was suspected. Enhanced computed tomography (eCT) revealed that the CVC was inserted at the right internal jugular vein and had penetrated the right subclavian artery, and the CVC tip was positioned at the ascending aorta. Our team discussed the strategy, including direct arterial suture, endovascular therapy, and a percutaneous closure device. Because the patient was too frail to endure direct arterial closure, we chose endovascular therapy. Under general anesthesia, we pulled the CVC. Immediately afterwards, we deployed a GORE® VIABAHN® VBX using the transaxillary approach. On postoperative day 1, eCT showed that the GORE® VIABAHN® VBX was positioned from the right subclavian artery bifurcation, and there were no complications of hemorrhage, endoleak, or migration. His postoperative course was uneventful, and he was transferred to another hospital on postoperative day 16.

A 59-year-old man who was diagnosed with hypertension and a large thoracoabdominal aortic aneurysm was referred to our hospital for surgical treatment. He underwent open surgery and thoracic endovascular aneurysm repair in three stages. He developed paraplegia after the third surgery. Despite acute postoperative treatment and rehabilitation, his lower extremity motor function and bladder and bowel dysfunction did not improve. He was transferred to a recovery hospital 67 days after the third surgery. However, he was readmitted to our hospital about four months later for management of a refractory decubitus ulcer and recurrent urinary tract infections. Computed tomography revealed hematoma and calcification around the femur. Based on the clinical course and imaging findings, we diagnosed neurogenic heterotopic ossification associated with postoperative paraplegia in this patient. He had flap reconstruction for the ulcer. Finally, he was discharged 79 days after readmission. To date, no study has reported neurogenic heterotopic ossification associated with postoperative aortic aneurysm paraplegia. The mechanism underlying this condition is similar to the widely accepted process associated with traumatic spinal cord injury, and conservative treatment comprising pressure ulcer treatment and antibiotics was continued. Although acute rehabilitation is important after highly invasive aortic aneurysm surgery, rehabilitation is limited by the risk of neurogenic heterotopic ossification in patients with postoperative paraplegia, and recovery and maintenance of activities of daily living are challenging. To our knowledge, early diagnosis and prompt treatment for these complications are important considering neurogenic heterotopic ossification.

The peripherally inserted central catheter (PICC) is widely used as a central venous catheter for both pediatric and adult patients. Fewer procedure-related complications have been reported than for conventional methods using the internal jugular, femoral, or subclavian veins for access. On the other hand, thrombosis and phlebitis are more common than in conventional methods, and sometimes the catheter cannot be removed by manual traction. In this study, a 13-year-old girl had received long-term sedation from a PICC due to neurodegenerative disease. The patient was referred to our department because of difficulty in manual drawing for removal of the PICC. A CT scan showed that the PICC was bent at the right axillary vein and there was a high-density area around it. Surgical treatment was chosen after a joint conference between the department of pediatrics and us to discuss the reliability and invasiveness of the several treatments. Under general anesthesia, an incision was made under the right subclavian bone, and her axillary vein was exposed. The lumen of the vein was filled with a white plaster-like compound, and the catheter itself was buried inside it. The compound was removed, and the bent PICC was straightened and removed from the puncture site. There is no other case for difficult removal of PICC in this form without calcification. We believe that surgical removal was effective in this case because of her vascular structure.

We present a successful case of redo-tricuspid valve replacement for tricuspid prosthetic valve endocarditis. A 78-year-old man who underwent tricuspid bioprosthetic valve replacement for severe tricuspid regurgitation thirty-two years earlier was referred to our institution with persistent high fever and back pain. The blood culture was positive for Streptococcus oralis, and echocardiography revealed a mobile vegetation attached to the tricuspid prosthetic valve with moderate tricuspid regurgitation. A clinical diagnosis of prosthetic valve endocarditis was established. Redo-tricuspid bioprosthetic valve replacement was performed following antibiotics therapy. The patient was discharged on postoperative day 49 after 6 weeks of additional antibiotic treatment, and had no recurrence of infection for 6 months after redo-surgery.

In cases of renal cell carcinoma causing embolism in the inferior vena cava, aggressive surgical resection is recommended and expected to improve the prognosis. The patient was a 52-year-old man who had been on hemodialysis since the age of 45 due to diabetic nephropathy. A CT scan for anemia revealed a tumor in the right kidney, and the patient was referred to the urologist at our hospital. A thorough examination revealed a diagnosis of primary right renal carcinoma with tumor embolization in the inferior vena cava (IVC) that extended to the right ventricle. During surgical resection of the tumor, a midline abdominal incision was made. The liver was detached and exposed to the IVC by the gastroenterological surgeon, followed by dissection of the right kidney for removal by the urologist. The wound was then extended to the anterior chest, and a mid-thoracic incision was made. The SVC was snared, and a right atrial incision revealed a tumor. We resected the tumor at the level of the diaphragm while blocking the IVC, and sutured the right atrium. The IVC was then incised centrally from the confluence of the right renal veins to identify the renal tumor that was resected from the lumen along with the venous wall. The missing IVC wall was reconstructed with an expanded polytetrafluoroethylene (ePTFE) patch. In this case, the patient received complete resection of a right renal cell carcinoma, with inferior vena cava embolism and tumor extending into the right ventricle, using extracorporeal circulation. He was discharged on the 29th day after surgery without any major postoperative complications. The use of cardiopulmonary bypass is considered to be an effective means of ensuring surgical safety in cases of complete resection of malignant tumors that have spread from the IVC to the heart.

A 72-year-old female was diagnosed with systemic lupus erythematosus and antiphospholipid syndrome (APS) in 2014 and was followed up. Severe mitral regurgitation coexisted with APS, but the case was nonsymptomatic, and surgery involved high risk. Therefore, the physicians continued their observation. In 2020, the patient experienced rheumatic severe mitral stenosis and shortness of breath on exertion. Paroxysmal atrial fibrillation and coronary stenosis were also detected. Therefore, we planned mitral valve replacement, tricuspid annuloplasty, coronary artery bypass, pulmonary vein isolation and left atrial appendage closure. During extracorporeal circulation (ECC), we performed coagulation management based on blood heparin concentration using HMS PLUS. Because the APS patient showed prolonged activated clotting time (ACT), and coagulation therapy based on ACT is unreliable. She was discharged from our hospital on postoperative day 23. No complications, including bleeding and thrombosis, were observed 2 years after the operation. We experienced a case of APS who underwent cardiac surgery and performed coagulation management by measuring heparin concentration during ECC. We targeted a 3.5 U/ml heparin concentration, and her clinical course was uneventful.