In Japan, doctors inexperienced stent-graft new devices are required to secure agreement on criteria and choice of the device size in endovascular aneurysm repair (EVAR) from experienced doctors. It was hoped that strict patient selection might reduce the learning curve for initial successes in given procedures. In a leading center in Japan, a number of cases which were scheduled for operation at other institutes were evaluated anatomically. We surveyed the initial success of Zenith AAA system implantation in the remaining cases by inexperienced doctors and evaluated the results. This study aimed to verify the validity of strict patient selection in improving the success rate of inexperienced doctors. We enrolled 112 consecutive patients from 19 institutes, who were scheduled for repair between January and October in 2007. All patients were evaluated on the basis of a less-than-3mm reconstructed CT image. Mean patient age was 76±5.7 years. All cases satisfied the Zenith's anatomic prerequisites. Fifteen cases were excluded for various reasons, the major reason being insufficiency of the proximal landing zone (LZ) length, angle and contour. The second reason was difficulty to approach via the iliac artery. Ninety seven cases were included, of which 17 cases were low-risk candidates for EVAR. Medium-risk seventy two cases requiring some advice to avoid problems with device size, technique of implantation and choice of main-body side. Eight cases were high-risk, requiring the presence of an experienced surgeon. Excluded cases had significantly shorter proximal LZ, larger aortic diameters 15mm below the renal artery and tortuous access routes on preliminary measurement by inexperienced doctor. Perioperative mortality was 0%, while the major complications were injury to the iliac artery in one high-risk case and thromboembolism of the superficial femoral artery in another. Perioperative proximal type I endoleak occurred in 5 cases. In 3 of these cases, the endoleak was eliminated by implantation of a Palmatz stent. In the other 2 cases, it disappeared within a month without additional procedures. These cases had a significantly greater angle between the proximal LZ and the suprarenal aorta and significant amount of mural thromboses in the proximal LZ. Perioperative type III endoleak occurred in 3 cases. In all cases the endoleak was eliminated by additional procedure. Perioperative type II endoleak occurred 8 cases. In 3 of these cases, the endoleak disappeared within a month. In the 5 other cases, the endoleak did not disappear. Mid-term results showed iliac leg thromboembolism in one case and new type II endoleaks in 3 cases. Type II endoleak occurred in cases which had significantly greater angles between the proximal LZ and the aneurysm. The results which were evaluated in our center had excellent perioperative and mid-term outcomes. We think this evaluation system is effective for risk assessment and reduces the learning curve in EVAR. In anatomically marginal cases, it is possible for proximal type I endoleak and injury of the iliac artery to occur. It is impossible to exclude these marginal cases if treatment need for EVAR is a priority. In these cases, lessexperienced operators should be trained in troubleshooting techniques in advance.

The expression levels of heat shock proteins after heat stress on rat slow soleus and fast plantaris muscles were examined and compared during a recovery period following 1 h of heat stress. The left hindlimbs of adult male Wistar rats (n=15) were carefully inserted into a stainless steel can and subjected to heat stress for 1 h by raising the air temperature inside the steel can to 54-58t with a flexible heater so as to bring the muscle temperature up to 42°C. The muscles of the contralateral right hindlimb served as the control. The expression levels of HSP 60, HSP 72, and HSC 73 were analyzed by Western blotting after 0, 2, and 4 h of recovery following 1 h of heat stress. In the soleus muscle, all of the HSP levels analyzed were significantly increased during 0-4 h of recovery. On the other hand, heat stress had no effect on the expression levels of HSPs, except HSP 60, in the plantaris muscle during recovery after 1 h of heat stress. These results suggest that the slow soleus muscle has a higher ablility to respond quickly to heat stress than the fast plantaris muscle.

To determine whether fiber type-specific expression of heat shock protein (HSP, or stress protein) occurs in unstressed rat skeletal muscle, the medial gastrocnemius of adult female Sprague-Dawley rats was subjected to immunohistochemical analysis. Antibodies against 5 types of anti-myosin heavy chain (MHC) were used to classify the type of fibers, and 2 types of anti-HSP antibodies were employed to analyze the fiber type-specific expression.
Serial cross-sections of 10 μm thick cut by a cryostat were incubated with primary anti-MHC or anti-HSP 60 and 72 antibodies, followed by biotinylated secondary anti-mouse antibodies, and avidin-biotin complex solution. A peroxidase DAB substrate kit (Vector SK-4100) or BCIP/NBT solution was used to visualize the immunoreaction of each fiber type.
By using the 5 types of anti-MHC antibodies, fibers were classified into 4 types : slow-type I, fasttypes IIA, IIX, and IIB. Anti-HSP 72 antibody reacted with many, but not all, type I and IIA fibers, whereas anti-HSP 60 antibody reacted specifically with type I fibers. Neither type IIX nor IIB fibers showed immunoreactivity with anti-HSP 60 or 72 antibodies. These results suggest that the expression of HSP 60 protein is related to that of type I MHC, and that the expression of HSP 72 protein may be related to that of types I and ha MHC, in unstressed rat skeletal muscle.

A Case of abdominal aortic occlusion caused by acute aortic dissection (DeBakey's type III b) is reported. A 59-year-old woman was admitted with sudden onset back pain and sensory disturbance of bilateral lower extremities. The pulsations of bilateral femoral arteries were absent. CT and aortogram revealed dissection of the thoracic descending aorta and infrarenal aortic occlusion. Since ischemic change had progressed, bilateral axillofemoral bypass was performed for limb salvage, and the symptoms improved rapidly. Axillofemoral bypass is an easy and safe procedure even in the acute phase of aortic dissection. It provides fast reperfusion, and so is considered to be useful to preventing myonephrotic metabolic syndrome MNMS.

We studied the effects of granulocytic elastase (GEL) and fibronectin (FN) on the coagulation and fibrinolytic system when using cardiopulmonary bypass (CPB). Blood sampling was performed before CPB (Pre), just after CPB (Post) the 1st postoperative day (PD1) and the second postoperative day (PD2). Laboratory parameters were GEL, FN, fibrinogen (Fib), prothrombin time (PT), fibrin degradation products (FDP), D dimer (D-D), α2 plasmin inhibitor plasmin complex (PIC) and antithrombin III (AT III). The level of GEL was highest and that of FN was lowest at Post. The levels of Fib, PT and AT III were lowest and that of PIC was highest just after CPB. The levels of FDP and D-D were highest on PD1. The levels of GEL and D-D correlated just after CPB and on PD1 and PD2. The level of GEL correlated with that of PIC on PD1. These results demonstrated that the level of FN decreased with CPB. And it was expected that CPB time affected the level of GEL. The levels of GEL affects D-D and PIC which are fibrinolysic factors particularly related to secondary fibrinolysis.

A Pulmonary arterial flow-directed catheter (Oxymetry 93A-741-7.5F), combining the fiberoptic reflectometric system of continuous measurement of mixed venous blood oxygen saturation (SvO₂) was used for hemodynamic measurements including thermodilution cardiac output estimation and hemoglobin value in 21 cases of open heart surgery. Immediately after open heart surgery there was low correlation between Hb (hemoglobin value) and SvO₂ (r=0.513, p<0.05). However there was no correlation between SvO₂ and cardiac function (pulmonary capillary wedge pressure and cardiac index). With almost normal Hb (10-13g/dl) the average cardiac index (CI) in cases of SvO₂ less than 60% was 2.47l/min/m² which was significantly lower than those with SvO₂ more than 60% (p<0.01). With normal CI (2.5-4.0l/min/m²) the average Hb in cases of SvO₂ less than 60% was 7.40g/dl which was significantly lower than those of more than 60% (p<0.01). This study suggested that there is low cardiac function or severe anemia in the state of SvO₂ less than 60%.

The Chiari network is an embryological remnant. It has rarely clinical importance but may very infrequently cause thrombosis and some other complications. Chest pain and pulmonary thrombosis were developed in a 23-year-old man. Cardiac ultrasonography revealed Chiari network in his right atrium, and no other thrombogenic lesions were found. Although anti-coagulant therapy was performed, pulmonary thrombosis were redeveloped. Chiari network was thought the cause of chest pain and pulmonary thrombosis. Operative removal of Chiari networks performed. The patient was postoperatively free from chest pain and pulmonary thrombosis.

A case of chylorrhea arising after median sternotomy for treatment of atrial septal defect was reported. The patient was a 55-year-old male, who had visited our outpatient clinic with a complaint of edema in the bilateral lower legs in June 1990. Under a diagnosis of atrial septal defect, a patch closure was performed in November. On the 5th postoperative day, a full liquid diet was started. Two hours and a half after the food intake, the drainage from a tube inserted into the anterior mediastinum turned milky white. Chylorrhea was diagnosed. The patient was placed in N.P.O. and maintained by an intravenous hyperalimentation. Drainage of 250-350ml/day milky white fluid persisted until the 14th postoperative day, when a 5cm removal of the mediastinal tube resulted in dramatic decrease in drainage. Thus chylorrhea in this case was cured by conservative treatment.

We report a relatively rare case of syphilitic aortic aneurysm that was treated by reconstruction with interposition of a prosthesis. The patient was a 72-year-old woman who presented with an abnormal shadow on chest radiograph and an abdominal pulsatile tumor. Aortography revealed double aneurysms in the descending thoracic and infrarenal abdominal regions, combined with a left common iliac artery aneurysm. Microscopic examination revealed an inflammatory infiltrate within the adventitia and destruction of the elastic fibers in the media, classical features of syphilitic aortitis. The incidence of double aortic aneurysm is expected to increase in the future, and one of the many problems involved in the management of this disorder is the correct timing for safe surgery. We prefer simultaneous surgery to secondary surgery, since this rules out the possibility of rupture of the remaining aneurysm. In order to perform this operation safely, it is necessary to treat the patient's general condition with regard to the surgical procedure and possible adjevant therapy.

There were 16 patients who developed acute renal failure (ARF) follwing cardiovascular operation using extracorporeal circulation. They were treated by either CPD or CAVH because their ARF were resistant to medical treatment. These patients were divided into three groups according to their treatment; 7 patients treated by CPD (Group A), 5 patients treated both CPD and CAVH (Group B), 4 patients treated by CAVH (Group C). The survival rate was 33% in Group A, 20% in Group B, and 0% in Group C. The prognosis of the each group was poor. CPD and CAVH were effective to control the concentration of serum potasium and water removing. But CPD and CAVH were not very effective to control the concentrations of serum creatinine and blood urea nitrogen. There were three patients who developed low proteinemia which was one of the side effects of CPD. Seven of nine patients treated by CAVH, developed bleeding. The side effects of CAVH were seemed to be more severe than those of CPD.