Reconstruction of the hepatic artery using the gastroduodenal artery

Although injury of the hepatic artery is not common during the performance of biliary and pancreatic resections, the hepatic artery if involved by tumor extension can be injured during its dissection.Several methods for reconstruction of the hepatic artery have been described and although each technique is applicable in a specific situation, autologous tissue conduits are preferable in contaminated operative fields. We report here another transposition technique to reconstruct the proper hepatic artery using the gastroduodenal artery, which may provide a local autologous artery for repair of hepatic artery damage during pancreaticoduodenectomy.     

Systemic-to-pulmonary artery shunt using the internal mammary artery

Systemic-to-pulmonary artery shunts may be useful for palliation of cyanotic congenital heart disease. We report the case of a 5-year-old boy in whom the internal mammary artery was used to create a systemic-to-pulmonary artery shunt after failure of a previous Blalock-Taussig shunt. This technique may have distinct advantages in selected cases and should be considered as an alternative during investigation of the older child who requires a systemic-to-pulmonary artery shunt.     

胃十二指肠－右肾动脉旁路转流术治疗肾动脉狭窄

作者采用自体大隐静脉间置移植，作胃十二指肠动脉旁路转流术，治疗肾动脉狭窄、肾血管性高血压１例。术后随访１年，取得良好控制高血压疗效。作者认为，间置自体大隐静脉的内径不应小于０．４ｃｍ，吻合后移植大隐静脉段无张力。防止受压、成角、扭曲以及缩短缺血时间，是保护肾脏功能和使手术取得成功的关键。     

Anomalous origin of the right coronary artery from the pulmonary artery

A case of anomalous origin of the right coronary artery from the pulmonary artery in a 73-year-old man is presented. The patient had been suffering from chronic heart failure with mitral and tricuspid regurgitation and atrial fibrillation for two years. Surgical repair was performed successfully, including ligation of the right coronary artery and coronary arterial bypass with a radial artery graft.     

Sequential coronary artery bypass utilizing the internal mammary artery

Fifty consecutive patients underwent sequential bypass grafting of diseased coronary arteries using the left internal mammary artery (IMA) as a sequential bypass graft. There were no perioperative myocardial infarctions, and follow-up from 3 to 5 years revealed that all 50 patients are living and are free of angina. Technical aspects for use of the internal mammary artery as a sequential graft to two or more coronary arteries is technically a feasible procedure when certain guidelines are followed. We advise its use primarily for left anterior descending/diagonal connections and avoid its use when there is a wide angle between the latter vessels to avoid kinking. The distal end-to-side IMA anastomosis is always performed first to the most important coronary artery. With this approach if there is a problem with length or lie of the IMA graft, the sequential anastomosis to the lesser important coronary artery may be aborted. The side-to-side technique is used most often. Postoperative angiograms in 11 patients have revealed no evidence of stenosis, occlusion, or late ill effects.     

Agenesis of the left internal carotid artery with an ophthalmic artery arising from the posterior communicating artery

A case of agenesis of left internal carotid artery is reported. The patient is a forty one-year-old house-wife with sudden episode of headache when she had a fever. CT scan of the head showed a small high density area in the right frontotemporal subcortical region. Four vessel cerebral angiography demonstrated negative lesion except for complete absence of the left internal carotid artery. The blood supply to the left cerebral hemisphere was provided both through the tortuous anterior communicating artery and through the enlarged left posterior communicating artery. Left ophthalmic artery arose from the left posterior communicating artery. The embryological developmental process of this kind of vascular anomaly as well as the relationship between intravascular hemodynamic stress and the induction of cerebral aneurysm were discussed in detail.     

Gastro-duodenal artery arising from the superior mesenteric artery]

These exceptional anomalies of the gastro-duodenal (G.D.) arteries provide a better understanding of certain very odd vessels found on coeliac or superior mesenteric arteries selective arteriography. In our series of 400 dissected bodies, a typical origin of the G.D. artery from the superior mesenteric artery is noted in 4 cases : the aberrant vessel is identified as a G.D. artery because of a) its course, b) and its two usual terminal divisions : superior pancreatico-duodenal and right gastro-epiploic arteries. On the other hand, we have 10 cases of G.D. artery arising from both coeliac hepatic and superior mesenteric arteries with:--a dominant hepatic branch in 6,--a dominant mesenteric branch in 3,--and a balanced origin in 1. A G.D. artery looping around the common bile duct to reach the anterior surface of the pancreas (Michels) was never seen in this series.     

Coronary artery bypass grafting with the right gastroepiploic artery

The excellent results of coronary artery bypass with the internal mammary artery and the increasing numbers of patients who need coronary reoperations, but for whom conventional bypass conduits are not available, have prompted us to evaluate alternative arterial bypass conduits. The right gastroepiploic artery has been used as a coronary bypass graft in 36 patients (32 men), whose ages ranged from 29 to 71 years. Twenty-two patients had had previous coronary bypass grafting and six of these were undergoing their third bypass operation. The right gastroepiploic artery was used as an in situ graft to the right coronary artery or circumflex branches for 17 patients and as an aorta-coronary ("free") graft in 19 patients, six to the left anterior descending or diagonal, six to the circumflex, and seven to the right coronary artery. In conjunction with right gastroepiploic artery grafting, 16 patients received bilateral internal mammary artery grafts and 17 received one internal mammary artery graft. Histologically, right gastroepiploic artery segments from 18 patients could not be distinguished from internal mammary artery segments, and no evidence of atherosclerosis was found. Two patients died in the hospital, one intraoperatively and one 3 months after the operation, of a perioperative stroke. Perioperative morbidity included wound complication in three and reexploration for bleeding in two. At late follow-up 1 to 38 months after operation, two late deaths had occurred and 21 patients were free of symptoms. Postoperative angiography (postoperative interval 1 week to 13 months) was performed in nine grafts, three in situ grafts to the right coronary artery and six free grafts that included two to the left anterior descending, three to the circumflex, and one to the right coronary artery. All right gastroepiploic artery grafts were patient. The right gastroepiploic artery is an arterial conduit that can be used as an in situ graft to posterior coronary vessels and as a free graft to any coronary arterial system. Early graft patency has been excellent, and the histologic similarity between the right gastroepiploic artery and the internal mammary artery suggest that the long-term results will be favorable.     

Anomalous origin of the pulmonary artery from the right coronary artery

A 5-year-old boy who had an anomalous origin of a stenotic pulmonary artery from the right coronary artery with ventricular septal defect and pulmonary atresia is reported. The diagnosis was made at operation. Successful repair was achieved for the complex anomaly by using a pulmonary artery homograft as a conduit and closing the ventricular septal defect.     

Anomalous origin of the ophthalmic artery from the anterior cerebral artery

A 39-year-old woman presented with left visual disturbance and diplopia. Magnetic resonance imaging revealed a well-enhanced tumor in the left tentorium, cavernous sinus, and suprasellar region. Angiography demonstrated an abnormal origin of the ophthalmic artery from the anterior cerebral artery. The tumor was partially removed by left frontotemporal craniotomy with orbitozygomatic osteotomy. Intraoperatively, the anomalous origin of the ophthalmic artery was confirmed. This anatomical variation is extremely rare.     

Internal mammary artery grafting to the circumflex coronary artery

The in-situ left internal mammary artery (LIMA) was anastomosed to the circumflex coronary artery (Cx) in 20 patients. The right internal mammary artery, the saphenous vein and the right gastroepiploic artery were also utilized to bypass the other coronary arteries. Sequential LIMA grafting to the diagonal branch and CX was performed in 2 patients. The sites of LIMA anastomosis were 15 obtuse marginal branches and 5 posterior lateral branches. All LIMA-Cx anastomoses were performed with single 8-0 polypropylene continuous suture technique. Mean number of distal anastomosis was 3.1 ranged from 2 to 4. Mean aortic cross clamp time was 68.5 minutes ranged from 42 to 87 minutes, and mean cardiopulmonary bypass time was 116.6 minutes ranged from 73 to 167 minutes. One patient died of renal failure at 22nd postoperative day, and the other patients were alive with relief of angina. New Q wave was noted in 1 patient. Postoperative angiogram at mean 2.0 months showed 100% patency of LIMA in restudied 12 patients. We concluded that the in-situ LIMA grafting to Cx system can be done with acceptably low mortality and excellent patency rate, and its utilization is particularly desirable in younger patients.     

Anomalous origin of the stenosed circumflex artery from the right coronary artery

During recent years, anatomic variations of coronary arteries have been described with the aid of elective coronary arteriography. We report a case of anomalous origin of the stenosed circumflex artery from the right coronary artery. The patient was operated upon successfully, and the right internal mammary artery was placed on the circumflex artery.