A 60-year-old man underwent open surgery for chronic dissecting abdominal aorta accompanied with a horseshoe kidney. Through open laparotomy, the abdominal aortic aneurysm was exposed without revision of the horseshoe kidney. Cold ringer solution was infused to accessory renal arteries for renal protection. After supra-renal clamping, proximal anastomosis was then performed at the level just below the renal arteries. Abdominal cross clamp time at the level of the supra-renal arteries was 23 min. Median and right accessory arteries were reattached with an ischemic time of 73 and 103 min, respectively. Although serum creatine was elevated a preoperative level of 1.17 mg/dl to 3.63 mg/dl at postoperative day 2, that was gradually decreased to nearly preoperative level of 1.25 mg/dl at discharge. Postoperative enhanced CT demonstrated patency of the reattached accessory arteries. The patient was discharged without major complication on postoperative day 21. One year postoperatively, his follow-up course was uneventful without deterioration of renal function.

Background: A review committee for unapproved and off-label drugs with high medical needs determined that the indication of fibrinogen concentrate for cardiovascular surgery would be publicly acceptable in 2021. However, the Japanese Society of Cardiovascular Surgery is required the conduct of several surveys demonstrating that fibrinogen concentrate can be used properly in medical settings. A questionnaire concerning the use of fibrinogen concentrate in cardiovascular surgery was one such required survey. Methods: A questionnaire concerning the use of fibrinogen concentrate was conducted in December 2021 at 551 certified training facilities of the Japanese Board of Cardiovascular Surgery, and responses were received from 375 facilities (68%). Results: Fibrinogen concentrate was used in 98 centers (26%). Aortic surgery (thoracic/thoracoabdominal) (50%) and cardiac redo surgery (24%) were eligible common surgeries requiring fibrinogen concentrate, and the intraoperative measurement of fibrinogen levels was performed in 77% of centers. The triggers for the use of fibrinogen concentrate were a fibrinogen level <150 mg/dl in 30%, <100 mg/dl in 20% and massive bleeding tendency in 40%. Of note, only 39 facilities (10%) were able to prepare cryoprecipitate in-hospital, and 34 centers (9%) used it for cardiovascular surgery. One hundred and seven centers (29%) planned to apply for facility accreditation for the use of fibrinogen concentrate, and 40 facilities (10%) answered that they would decide based on the situation. The expected number of annual cases in which fibrinogen concentrate would be used for cardiovascular surgery reached 4,860 cases: <10 cases in 52 centers, 10-19 cases in 50 centers, 20-49 cases in 31 centers, 50-99 cases in 12 centers and ≥100 cases in 2 centers. Conclusion: We conducted a questionnaire on the use of fibrinogen concentrate. Intraoperative fibrinogen level measurement was performed at approximately 80% of institutions, and the annual number of cases likely to use fibrinogen concentrate was predicted to reach about 5,000 cases. However, only 10% of centers used cryoprecipitates prepared in-hospital.

[Introduction] Acupuncture has been used in patients with functional digestive symptoms. Acupuncture treatment was used on a patient with upper stomach pain and feeling of fullness accompanied by pain in knee, neck and shoulders. Details of the clinical experience have been written in this brief report and shows improvement in gastric symptoms and increase of normogastria in gastric electrical activities by acupuncture treatment.[Case] A 73 year-old female patient, who was 148 cm tall and 51 kg in weight, complained of some chronic pain at the first medical examination. However, in the 24th treatment, the patient complained of severe stomach pain and feeling of fullness accompanied by 36 points on the gastrointestinal symptom rating scale (GSRS). Therefore, electrogastrograms (EGG) were recorded, as a noninvasive clinical evaluation of gastric function, at 15 minutes before and after the 30th treatment for 10 minutes using the retaining needle technique at bilateral ST36 andST40.[Result] The decrease of GSRS showed improvement of gastric symptoms by acupuncture treatment. After treatment, the percentage of normogastria in EGG increased to 71% from 58%, thus stabilizing theincrease in power spectra.[Discussion] It has been suggested that the increase of nomogastria in EGGs show an improvement of gastric symptoms. Moreover, the patient was told about the positive changes in EGG by an acupuncturist, and explaining that the acupuncture treatment seemed to improve clinical symptoms. Thus, acupuncture treatment contributed to an improvement of symptoms in a patient with stomach pain and feeling of fullness.[Conclusion] Acupuncture treatment induced an increase in percentage of normogastria in EGG power and resulted in an improvement in gastric symptoms of a patient with upper stomach pain and feeling of fullness.

A 53-year-old man was urgently hospitalized with chronic renal failure, congestive heart failure, pulmonary edema, and pneumonia. He received respiratory support and dialysis after hospitalization in the intensive care unit. Coronary arteriography revealed an old myocardial infarction and unstable angina (triple vessel disease). Surgery was planned. However, after dialysis under heparin administration, clot formation was noted in the dialyzer. Serological tests confirmed the presence of antibodies to heparin-platelet factor 4 complex ; accordingly, heparin-induced thrombocytopenia (HIT) was diagnosed. Coronary artery bypass surgery should preferably be performed early in the case of coronary artery disease. However, surgery during the acute phase of HIT when antibodies to heparin-platelet factor 4 complex (HIT antibodies) are present is associated with a very high risk of developing thromboembolism. There is no criterion regarding the optimal timing for surgery when HIT antibodies are present. Therefore, clinicians are often confused about this. In cases where the platelet count, D-dimer level, fibrinogen degradation product (FDP) level, and fibrinogen level improve, thrombin production due to HIT antibodies is thought to decrease. We considered that the improvement in these values suggests that the number of HIT antibodies decreases and thus HIT antibody activity would be reduced. We evaluated the platelet count, D-dimer level, FDP level, and fibrinogen level over time and accordingly determined the optimal timing for surgery. In the present case, argatroban administration was started after HIT developed, and the platelet counts increased gradually ; the D-dimer and FDP levels decreased, whereas there were no significant changes in the fibrinogen levels. Although HIT antibodies were still present, we performed off-pump coronary artery bypass grafting under the administration of argatroban when the platelet count, D-dimer, and FDP values improved. The patency of coronary bypass grafts was confirmed postoperatively ; the patient did not develop thromboembolism during the perioperative period and was discharged without complications. When HIT antibodies are present, an improvement in platelet count, D-dimer, and FDP values is thought to be useful in determining the optimal timing of surgery.

An 83-year-old woman who had an attack of fever, fatigue, and lumbar pain was hospitalized as an emergency. Detailed investigations revealed that she had urinary infection, infectious spondylitis, and bacteremia with Streptococcus pneumonia, for which she received antimicrobial therapy. After 12 days in hospital, enhanced computed tomography showed that the aortic arch had expanded, with fluid collection. Though there had been no imaging findings by computed tomography scan on admission. We thought this was an infected thoracic aortic aneurysm with Streptococcus pneumonia, and continued to administer the antibiotic drugs for infection control. After 14 days in hospital, she developed hoarseness and complained of severe back pain. Emergency computed tomography scan showed that the aortic arch had further expanded to 66 mm in size and that much more fluid had collected. We decided it was an impending rupture of the rapidly-expanding infected thoracic aortic aneurysm, and we then performed an emergency operation. The infected portion of the thoracic aorta was resected. The ascending, arch, and descending portions of the aorta were replaced with rifampicin-bonded synthetic graft, and then omental wrapping was performed. Antimicrobial administration was continued after surgery. The postoperative course was uneventful. The infection was successfully controlled. She was discharged without complications. No signs of recurrent infection have been observed for 1 year and 6 months after operation.

Basically, adverse event report after vaccination is collected by free descriptive comments and sometime it is difficult to evaluate the reliability of diagnosis. Based on these actual situations, in abroad, standardized criteria was implemented for the collection and/or evaluation of spontaneous reports. In this article, we discussed regarding the measures to implement Brighton criteria, which is expanded as global standardized criteria, in Japan.

The saphenopopliteal junction (SPJ) is found at various levels and has various patterns compared with the saphenofemoral junction. Although this can cause difficulty in the surgical treatment of varicose veins and affect the outcome, there have been few reports on preoperative assessment of the small saphenous vein (SSV) regarding this point. This study was undertaken to evaluate three-dimensional CT venography with dual-route injection for the preoperative assessment of a small saphenous-type varicose vein. We examined a total of 15 legs in 15 patients with a small saphenous-type varicose vein, which were preoperatively evaluated by CT venography and then surgically treated. The patients included 4 men and 11 women with ages ranging from 50 to 80 years old (mean age, 66 years). The grading of varicose veins according to the CEAP classification was C2, C3, C4, and C5 in 3, 4, 6 and 2 legs, respectively. The CT imaging was performed with contrast medium diluted ten-fold, which was injected into the great and small saphenous veins simultaneously. CT venography clearly visualized the lower extremity veins. Whereas the popliteal vein coursed deep above the level of the femoral intercondylar groove, it followed a shallow course below the level of the knee joint. In 11 legs (74%), the SPJ was located in the shallow portion, whereas it was in the deep portion in 4 legs (26%). Among the former group, the SSV was connected to the great saphenous vein via the Giacomini vein in 2 cases, and the gastrocnemius vein was connected to the SSV before the SPJ in 3 cases. Among the latter group, a localized large venous aneurysm with thrombus before its termination was found in one case. In another case, the SSV showed branched termination in the deep portion. Our three-dimensional CT venography with dual-route injection provides more accurate information on venous anatomy in the lower extremity. The accuracy of images acquired by CT venography with dual-route injection was verified by intraoperative findings. Although Doppler ultrasound is essential for examining the presence of regurgitation in the veins and locating the course of a varicose vein in the surgical field, all 15 cases had scheduled surgery under local anesthesia based on accurate preoperative diagnosis. This study suggests that CT venography with dual-route injection is beneficial in preventing undesired complications during surgery and avoiding additional procedures for recurrent varicose veins.