Objective: Deep femoral artery (DFA) aneurysms are extremely rare cases of aneurysms that are difficult to diagnose. The objective of this report was to discuss the timing and method of surgery for this disease.Patient: We encountered an asymptomatic left DFA aneurysm that was discovered along with a symptomatic aneurysm of the right superficial femoral artery (SFA). Both sides of the aneurysm were resected with Dacron knitted artificial vascular grafts (Gelsoft™ Plus, Vasctek, UK) simultaneously.Result: After the operation, the right SFA had good blood flow, but the graft of the left DFA was occluded. The occlusion was considered to be caused by insufficient blood flow in the graft. The patient was discharged without any complications.Conclusion: The coexistence of DFA aneurysms should be examined if other aneurysms are found. DFA aneurysms are at a high risk of rupture. Careful follow-up is required, and intervention is recommended when the diameter exceeds 35 mm.

Objective: Isolated abdominal aortic dissection (IAAD) co-occurring with an abdominal aortic aneurysm (AAA) is rather rare. The objective of this report was to discuss the adequate timing and method of surgery for this condition.Patients: We encountered two operative cases, for which we carefully considered the timing and method of surgery. One patient underwent open repair 1 month after the onset, and the other patient underwent endovascular aneurysm repair (EVAR) 3 years after the onset.Results: Both patients had a good postoperative recovery and are doing well 8 months after the surgery.Conclusion: The presence of symptoms or an increase in the diameter of an AAA is important in determining the timing of intervention.

Cystic adventitial disease (CAD), a rare arterial disorder, can cause localized arterial stenosis or obstruction. A 55-year-old man presented with a 2-month history of left lower leg pain and paleness when bending the left knee. The patient was diagnosed with CAD of the left popliteal artery based on imaging examinations. Surgery was performed with the patient placed in the prone position using an S-shaped skin incision, and the left popliteal artery was exposed. A simple incision of the cyst wall was made. There was no sign of recurrence at 1 year postoperatively.

Background: Older pacemaker systems, which are magnetic resonance imaging (MRI) incompatible, require replacement with compatible systems when patients are in need of MRI. Replacement involves extraction of the pacing lead, which is usually done with a laser sheath under general anesthesia.Case presentation: We report two cases of complete pacing system replacements allowing patient access to MRI. Both replacements were made under local anesthesia and without the use of special devices over 6 years after the initial surgery. Both replacements used retractable screw-in leads with a cut-down of cephalic or external jugular veins performed during the initial surgeries. Case 1 involved a 79-year-old man with cerebral ischemia, and case 2 involved a 70-year-old man with spinal canal stenosis.Conclusion: With careful management, it is possible to replace an entire pacing system under local anesthesia without additional devices.

PURPOSE: Recent reports have posed doubts about the effect of preradiosurgical embolization in brain arteriovenous malformation (AVM) because it makes the planning of stereotactic radiosurgery (SRS) difficult and has the risk of recanalization out of the target. We investigated whether the performance and quality of embolization may influence the success of SRS based on a retrospective case cohort study. MATERIALS AND METHODS: Seventy-three patients who underwent embolization followed by SRS between 2003 and 2012 in eight institutes with neurointerventionists were considered. They were divided into the following two groups at 3 years of follow up after the final SRS: “successful occlusion group” (S group), with radiologically complete occlusion of AVM; and “non-successful occlusion group” (N group) with persistent remnant nidus or abnormal vascular networks. Patient background, AVM profile, embolization performance grade and complications were compared in each group. The quality of embolization was evaluated with the new grading system: embolization performance grade (E grade), specializing the achievement of nidus embolization. E grade A was defined as sufficient nidus embolization with more than half of the total number of feeders achieving nidus penetration. E grade B was defined as less than half achievement of nidus embolization, and E grade C was defines as failure to perform nidus embolization. RESULTS: Forty-three patients were included in the S group, and 29 patients were included in the N group. The size and Spetzler-Martin grade of AVM and the rate of diffuse type was higher in the N group without statistical significance. The embolization performance level according to E grade indicated a significantly higher rate of successful embolization with more than 50% of nidus penetration in the S group (P<0.001). This difference was also confirmed in the subanalysis for limited cases, excluding smaller AVMs with complete occlusion with SRS alone (P=0.001). CONCLUSION: The cause of the unsuccessful result of post-embolization SRS might be the large, diffuse angioarchitecture, but proper embolization with a high rate of nidus penetration to avoid recanalization is more important. Effective embolization is essential to contribute to and promote the effect of radiosurgery.
Academies and Institutes ; Arteriovenous Malformations* ; Asian Continental Ancestry Group* ; Brain ; Cohort Studies ; Follow-Up Studies ; Humans ; Radiosurgery ; Retrospective Studies*

1)In the 2008 academic year, we developed a new narrative-based medicine (NBM) curriculum at Sapporo Medical University.
2) The program includes lectures on the concept of NBM, the clinical practice of NBM, and the illness narratives of patients' families, and exercises in narrative competence (significant event analysis, parallel chart, and life story).
3) Although some students had negative attitudes about the program, most students evaluated the course positively. We need to continuously improve the curriculum to develop narrative competence in medical students.

A 22-year-old man was hospitalized due to severe back pain having being diagnosed as Stanford type A aortic dissection, AAE, mitral regurgitation and pectus excavatum associated with Marfan's syndrome. A single staged operation including ascending aortic replacement, mitral valve replacement and sternal turnover with a rectus muscle pedicle was carried out in order to keep the blood supply to the plastron to reduce the risk of infection during such a long operation. By this approach, it was found that the operative field was excellent and postoperative hemodynamics were stable. However, frail plastron occurred because of difficulties in keeping the patient stabilized because of severe pain thus re-fixation was required. The necessity of strong pain control after such an operation was also recognized.

The incidence of ventricular subepicardial aneurysm following myocardial infarction is quite low. We report a case of subepicardial aneurysm that was diagnosed on postoperative pathohistologic examination. A 69-year-old man was admitted to our hospital because of left ventricular aneurysm following myocardial infarction. The patient had left main trunk disease, triple-vessel coronary artery desease and low output syndrome. Under cardiopulmonary bypass with the heart arrested, the aneurysm was resected and the defect was closed. The suture line was reinforced using Teflon felt and GRF glue. A saphenous vein graft was anastmosed to the left anterior descending artery. On pathohistologic examination, the wall of the aneurysm was found to be composed of fibrotic tissue, myocardial fibers, medium-sized pericardial arteries, epicardium and fibrin thrombi. We diagnosed this as subepicardial aneurysm.

Seven patients with congenital heart defects suffered from multiple major hemorrhages from the lung after surgery and 5 of them died at 8 to 54 postoperative days because of respiratory insufficiency. In a patient with tetralogy of Fallot associated with pulmonary atresia, bleeding occured after the second shunt operation, presumably from rupture of bronchial collateral vessels. The clinical diagnoses of the other 6 patients were coarctation of the aorta (CoA) with common atrioventricular canal (CAVC) in 1, triple shunt in 1, persistent truncus arteriosus in 2, total anomalous pulmonary venous connection in 1 and CAVC in 1. Subclavian flap aortoplasty was performed without pulmonary artery banding in the patient with CoA and CAVC, whereas complete repair was performed in the other 5 patients. As these patients were associated with severe pulmonary hypertension preoperatively and 4 of them encountered pulmonary hypertensive crisis, the hemorrhage from the lung may be related to pre and postoperative high pressure of the pulmonary artery. Dilatation and rupture of the pulmonary capillary net was demonstrated in the patient with CoA and CAVC. These findings suggest the hypothesis that bleeding occurred due to rupture of the capillary net as a result of transmission of high pressure. Major bleeding from the lung is a rare but catastrophic complication after repair of congenital heart defects. As the treatment is difficult, early surgical intervention and treatment of postoperative pulmonary hypertension are important in complex lesions with severe pulmonary hypertension.

We performed surgical treatment for 21 patients of airway obstructions associated with congenital heart disease from December 1986 to March 1993. In all patients perioperative bronchoscopy demonstrated the cause and site of airway obstructions. Seven patients with corrective cardiac surgery (7/7), 7 with palliative cardiac surgery (7/10) and 2 with surgery for airway diseases (2/4) could be weaned from respirators following surgical treatment. Five patients died postoperatively. A respirator was required in 16 patients (76%) preoperatively. The suspension of pulmonary artery with intraoperative bronchoscopy was carried out in 6 patients. Five (5/6) were successfully extubated earlier postoperative day (mean 8.4 days), whereas only five in 10 patients without that procedure could be weaned from the respirator at a mean of 2 months. Identification of potential airway obstruction and early extubation is needed to reduce the mortality and morbidity caused by airway obstruction associated with congenital heart disease. Preoperative bronchoscopy is useful for diagnosis of airway obstructions and essential for decision making concerning surgical treatment. To early extubation in patients with marked airway obstructions, we recommend appropriate choice of the surgical procedure combined the suspension of pulmonary artery.