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.

Methods: This study prospectively examined nine T-OPLL patients who underwent posterior thoracic decompression with kyphosis correction and instrumented fusion at Hamamatsu University School of Medicine between 2017 and 2019. All underwent preoperative selective angiography to detect and evaluate the Adamkiewicz artery and ASA. Intraoperative neuromonitoring and Doppler ultrasonography were performed to analyze neurological complications and spinal cord blood flow. Results: All nine patients showed ASA stenosis in the area of T-OPLL. In all patients, the Adamkiewicz artery was located between T7 and L2 and the area of ASA stenosis corresponded to the level of T-OPLL and greatest spinal cord compression; intraoperative Doppler ultrasonography confirmed the ASA defect at the same spinal level. The number of spinal levels from the Adamkiewicz artery to the most compressive OPLL lesion was greater in the two patients who developed postoperative neurological deficit compared to those who did not (5.5 vs. 2.3, p=0.014). Conclusions This is the first study to report detection of ASA stenosis in patients with T-OPLL. Maintaining spinal cord blood flow is important in these patients to avoid neurological deterioration.

Methods: As part of a 2016 health screening, 320 female volunteers underwent whole-spine radiographs. Age-matched healthy women were grouped according to the number of vaginal deliveries (0, 1–2, or ≥3). Demographic variables and spinopelvic parameters were compared among the three groups. Results: Of the 320 volunteers, 213 were enrolled (mean age, 71.1±7.2 years). The mean number of vaginal deliveries was 2.2. The average pelvic incidence (PI) was 55.6°±11.1° and was significantly higher in the 90 women with three or more vaginal deliveries than in the other two groups (p<0.001). The average sacral slope was 33.4°±11.1° and was significantly higher in the women with three or more vaginal deliveries than in the 18 who did not deliver vaginally (p<0.001). The 105 women with one or two vaginal deliveries had significantly higher PIs and sacral slopes than did those who did not deliver vaginally (p<0.001). Conclusions This is the first study documenting an association between vaginal delivery and pelvic parameters. Bony birth canal realignment during vaginal delivery can affect postnatal PI. Our study helps in understanding the PI changes over a woman’s life span.

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.

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.

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.

Combination of retrospective and prospective study.

Combination of retrospective and prospective study.

Methods: Volunteers over 50 years of age underwent radiographic analysis. Radiographic parameters including pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), thoracic kyphosis, and sagittal vertical axis (SVA) were measured. The the three Scoliosis Research Society-Schwab sagittal modifiers (PT, SVA, PI–LL) were categorized and the KL grade was assessed. Differences in spinopelvic parameters and Oswestry Disability Index (ODI) scores among KL grades were evaluated. Results: A total of 396 volunteers (160 men, 236 women; mean age, 74.4 years) were analyzed. PI–LL and PT in KL4 were significantly higher compared to that in the other KL grades. However, there were no significant group differences in SVA. In women, but not in men, higher frequencies of the worst modifier grade (++) were observed for PI–LL and PT in the KL3 and KL4 groups compared to those for the other KL grades. In women, the ODI score in KL4 was worse compared to that in the other KL grades. Conclusions Individuals over 50 years of age with severe knee osteoarthritis had poor lumbo-pelvic sagittal alignment. Moreover, the progression severity of knee osteoarthritis had more impact onstronger relationship with lumbo-pelvic malalignment and disability-related low back pain in women than in men.

Methods: The subjects were 473 volunteers. They were divided into two groups (activity and non-activity) according to participation or non-participation in sporting activities using a self-filled questionnaire. The evaluation items were height, weight, grip strength, bone density, Hospital Anxiety and Depression Scale (HADS) score, standing radiographic parameters, PRO (evaluated by EuroQol-5 dimension [EQ-5D], Oswestry Disability Index [ODI]), and NDI. Results: There were 101 males in the non-activity group and 69 in the activity group and 178 females in the non-activity group and 125 in the activity group. For the males, the evaluation items with significant influence were cervical lordosis (non-activity group:activity group, 17°:22°) and T1 slope minus cervical lordosis (10°:6°, p <0.05). For the females, the evaluation items with significant influence were sagittal vertical axis (28:14 mm), HADS (10.4:8.4), EQ-5D (0.79:0.86), ODI (17:12), and NDI (12:9, p <0.01). HADS and PRO in the females were significantly correlated with the EQ-5D (−0.40), ODI (0.43), and NDI (0.55). Conclusions Males who participated in sporting activities had better cervical spine alignment but no effect on PRO. Females with sporting activities had better spinal global alignment and less mental stress. It is suggested that sporting activity in females might be associated with PRO because HADS highly correlates with PRO.