Midterm results for endovascular stent grafts via median sternotomy for distal aortic arch aneurysm

Dislocation or perigraft leakage is a major problem during the follow-up period for endovascular stent graft (EVG) implantation via median sternotomy for distal aortic arch aneurysm. Anchoring sutures have been applied for the prevention of these complications. Here, we evaluate the midterm results and the efficacy of anchoring sutures. There were 21 male and 2 female patients enrolled in the study with an average age of 70 years (59–83). Aneurysm types were 21 true aneurysms (13 fusiform, 8 saccular), 1 chronic dissection, and 1 penetrating aortic ulcer. Total arch replacement was performed in two patients and aortocoronary bypass grafting was combined in four patients. Anchoring sutures to fix the EVG via median sternotomy were applied for 11 recent patients. The average follow-up period was 44 (22–79) months. There were no operative mortalities, but one case of paraplegia, one of stroke, and two of temporary spinal cord dysfunction. Complications related to EVG via median sternotomy occurred in five patients who had not received anchoring sutures, but the 11 patients with anchoring sutures showed no EVG-related complications. A chronic type B dissection revealed impending rupture due to false lumen infection 1 year after operation and repeat surgery was performed. Stent dislocation occurred in four patients, two of whom required repeat surgery via left thoracotomy due to endoleakage 3 and 4 years after surgery. One died from aneurismal rupture 5 years after surgery. One required emergency graft replacement because of graft perforation 5 years after surgery. The proportion of patients free from EVG-related events at 5 years after surgery was 75%. Anchoring sutures (P = 0.0155) and a large aneurysm of more than 80 mm (P = 0.0190) were predictors of late EVG-related complications. There were five late deaths: two were from stroke, one from rupture, one from cancer, and one from multiple organ failure after repeat surgery. EVG shortens postoperative recovery with relatively lower mortality, but spinal cord injury is a complication occurring with a relatively high rate. Patients with large aneurysms are not good candidates for EVG implantation via median sternotomy Anchoring sutures to fix the EVG to the aortic wall should help prevent EVG-related events and improve the durability of EVG.     

A case of pulmonary embolism after abdominal surgery]

A 67-yr-old man who suffered from pulmonary embolism following abdominal surgery was reported. The patient received left hemicolectomy and cholecystectomy for cancer of descending colon and cholecystolithiasis, respectively. Anesthesia was maintained with enflurane 0.6-1.0% and pancuronium combined with epidural analgesia. The anesthetic course was uneventful. But after leaving operating room the patient showed severe hypoxemia without abnormal shadow on chest X-P and other abnormal laboratory values. The cause of hypoxemia was unclear, but on the fourth postoperative day pulmonary scintigrams revealed pulmonary embolism. Then 12000 units.day-1 of heparin infusion was started. After 10 days of anticoagulant therapy, the hypoxemia improved and he was discharged on 28th postoperative day. Although pulmonary embolism is a rare disorder, we have to take it into consideration as one of the causes of postoperative hypoxemia.     

Visualization of the female breast in bone scintigraphy]

Breast cancer incidence rates in Japan have more than doubled in the decade between 1975 and 1985 due to a well-established and affluent Western life-style. One hundred patients having breast cancer, 107 patients having mastectomies, and 243 patients having no breast cancer were reviewed for whole body and spot views of bone scintigraphy with 99mTc-MDP. The frequency of positive breast uptake in patients with no breast cancer showed a maximum in those patients between the ages of 30 and 40, with a progressive rise and fall before and after the peak, respectively. Patients between the ages of 50 and 60 with breast cancer showed a maximum uptake of 83%, while those patients between the ages of 70 and 80 with breast cancer showed an uptake higher than 50%. There was a markedly higher breast uptake ratio in the breast cancer group compared to the breast cancer free group. Although this scanning agent was of no value in recognition of tumor localization from breast uptake, we have to suspect a high incidence of cancer existence whenever there was unilateral increased breast activity. Even though the mechanism of 99mTc-MDP uptake by breast tissue is unknown, breast concentration of 99mTc-MDP appears to be influenced by hormones, especially estrogen.     

Molecular Weight-Dependent Lymphatic Transfer of Exogenous Macromolecules from Large Intestine of Renal Insufficiency Rats

To study the lymphatic delivery of exogenous macromolecules via the enteral route in renal insufficiency, we determined the transfer selectivity to the systemic blood and lymph of fluorescein isothiocyanate-labeled dextrans of different average molecular weight (10, 18, 39, and 69kD). The compounds were administered into the large intestinal lumen of rats with occluded renal circulation, with the aid of lipid-surfactant mixed micelles as an absorption prometer. Whereas concentrations of the smaller dextrans (molecular weight under 18 kD) in the lymph of the thoracic duct and in the peripheral plasma were similar, levels of dextrans over 39 kD were significantly higher in the lymph than in the plasma. Further, dextran plasma concentrations decreased in inverse proportion to increasing molecular weight. The molecular weight threshold for a high lymph-to-blood level ratio (18-39 kD) was higher than that previously found in rats with normal renal function (10-18 kD). This difference was accounted for by reduced renal clearance of the low molecular weight dextrans in renal failure. These results are useful in the design of lymphotropic drug delivery in disease states.     

Purification and characterization of abelesculin,a novel ribosome-inactivating protein from the mature seeds of <Emphasis Type="Italic">Abelmoschus esculentus</Emphasis>

A novel, type-1 ribosome-inactivating protein (RIP), abelesculin, from the mature seeds of Abelmoschus esculentus was successively purified to homogeneity using ammonium sulfate precipitation, ion-exchange chromatography and size-exclusion chromatography. Abelesculin was found to have a molecular mass of 30 kDa and a pI of more than 10.1. The protein depurinates 28S rRNA in the ribosomes of rat liver with an EC₅₀ (concentration causing 50% cleavage) of 62.8 pM. Study of the sequence of the 26 N-terminal amino acids of the protein revealed a close relationship with other RIPs. This study reports for the first time that RIPs exist in Malvaceae plants.     

Uncoupling of blood flow and oxygen metabolism in the cerebellum in type 3 Gaucher disease

Cerebral blood flow and oxygen metabolism were measured in a fourteen-year-old girl with type 3 Gaucher disease by using positron emission tomography (PET). Cranial CT and MRI showed only mild brain atrophy. PET demonstrated uncoupling of cerebral blood flow and oxygen metabolism, that is, a mild increase of cerebral blood flow and a reduction of oxygen extraction fraction and cerebral metabolic rate of oxygen only in the cerebellum. Although the mechanism is unknown, the above finding may reflect the underlying pathogenesis of the disorder. PET seems to be more sensitive than CT and MRI in detecting some functional abnormalities in the affected structures. However, further investigations must be done before concluding that this finding is unique to type 3 Gaucher disease.     

An autoantibody cross-reactive to hepatitis C virus core and a host nuclear antigen.

GOR, an epitope borne by the amino acid sequence, GRRGQKAKSNPNRPL, is recognized by anti-GOR antibodies specifically found in patients with non-A, non-B hepatitis (NANBH). The epitope is not coded for by the hepatitis C virus (HCV), the presumed causative agent for NANBH, but by a single copy gene of the host. Anti-GOR antibodies, distinct from anti-HCV (c100-3) antibodies, were revealed to have dual specificities; they target both the presumed core gene product of HCV and a host component. This cross recognition is probably derived from homologous regions between the GOR epitope and a viral epitope on the core protein in HCV. It is therefore suggested that anti-GOR is an autoantibody induced by HCV infection. This may explain the autoimmune disease like aspect of NANBH pathogenesis.     

Diagnosis of portal vein tumor thrombus by pulsed Doppler ultrasonography.

The blood flow of portal vein thrombus was studied by pulsed Doppler ultrasonography in 21 patients with tumor thrombus and 14 with blood clot thrombus. Pulsatile waves were observed in 19 of the 21 with tumor thrombus, with backward continuous waves in 3, and forward/backward continuous waves in 2. In contrast, forward continuous waves were observed in 2 of the 14 with blood clot thrombus. By color imaging, the blood flow could be observed in 9 of 14 with tumor thrombus, but in 1 of 7 with blood clot thrombus. Pulsatile and backward continuous waves were characteristic of tumor thrombus.