• Journal of Chest Surgery
• /
• v.36 no.3
• /
• pp.142-149
• /
• 2003

To know the feasibility of the coronary artery bypass graft (CABG) for multivessel coronary artery disease with purely bilateral internal thoracic arteries (ITAs), we analyzed the short-term clinical results and the coronary angiography of the patients. Material and Method: From March 2001 to June 2002, four hundred and five patients underwent CABG. Purely bilateral ITAs were used in 159 patients (39.3%). We analyzed these patients retrospectively The mean age of these patients was $61.2{\pm}8.5$ (range: 30 ~80) years and there were 123 male patients. The preoperative risk factors were as follows: diabetes in 54 patients (34.0%), history of acute myocardiac infarction within 4 weeks in 29 (18.2%), and emergency operation in 6 (3.8%). Off-pump CABG was carried out in 128 patients (80.5%). Associated procedures were mitral valvuloplasty (5), aortic valve replacement (3), Dor procedure (1), and so on. Result: The mean number of distal anastomoses was $3.1{\pm}0.9$ (range: 2~6), the mean duration of hospital stay was $8.4{\pm}4.5$ days. There was one (0.6%) operative death. Except for one early death, no other patients suffered from low cardiac output. The other postoperative complications were occurred as follows: reoperation due to bleeding in 3 patients, perioperative myocardiac infarction in 1, transient cardiac arrest in 2, transient cognitive dysfunction in 7, and transient ischemic attack in 1, and deep sternal wound infection in 1 patient. Recently, early postoperative angiography was performed in 19 patients who had triple vessel disease. The total number of distal anastomosis was 78 (mean $4.1{\pm}0.8$/patient). All distal anastomosis sites were patent, but competition flow was observed at the bypass sites where the native coronary artery stenosis was not significant. Conclusion: The CABG with purely bilateral ITAs for triple vessel disease was performed safely. The early patency rate was relatively good in small number of patients. However the long-term patency rate and the functional study to evaluate the sites where competition flow was observed should be followed.

• Journal of Chest Surgery
• /
• v.29 no.2
• /
• pp.177-184
• /
• 1996

Between 1987 and 1994, 21 patients were treated surgically for aortic aneurysm involving the thoracoabdominal aorta. There were 11 males and 10 females, and their age ranged from 20 to 67 years old and mean age was 41.5 years. Many complained of back pain, chest pain or discomfort, and flank pain, but three patients were asymptomatic. 15 patients had chronic dissection (71.4%) and 6 had nondissecting fusiform or saccular aneurysm(28.5%), and of those 15 patients with chronic dissection, 6(28.5%) had atherosclerosis assniated with hypertension, 5 (23.8%) were Martian syndrome, and 2 (9.5%) were associated with pregnancy. The diameter of an aneurysm ranged from 6cm to 12cm, and their extent was classified as type I in 7(33.3%), type II in 8(38.1%), type III in 3(14.3%), and type IV in 3(14.3%) patients based on Crawford classification for TAA . Diseased aorta was replaced with artificial vascular graft in all but one patient. In whom the aortic tear site due to pseudoaneurysm was closed by primary suture. For the spinal cord protection during the operation, we used partial cardiopulmonary bypass (FV-FA or PA-FA bypass) in 12 patients (57.1%), Biopump (LA-FA bypass) in 4(19.0%), total circulartory arrest and CPB in 2 (9.5%), Gott's heparinized shunt in 1(4.7%), and simple aortic cross clamping in 2 (9.5%). The most common complication after the operation was hoarseness due to unilateral vocal cord palsy which onured in 5 patients (23.8%), and the next common complication was wound infection in 4 patients(19.0%), paraplegia in 2 patients (9.5%), chylothorax in 1 patient(4.7%). The hospital mortality rate was 9.5% (2deaths), and there was no late death. Our experience shows that the graft replacement of TAAA had reasonable rate of mortality, low rate of serious complication, and provided good post operative state of the pati nts, and since the thoracoabdominal aortic operation is not a high risky procedure anymore, we recommend a radical operation for the indicated patients.

• Journal of Chest Surgery
• /
• v.40 no.2 s.271
• /
• pp.83-89
• /
• 2007

Background: The surgical repair of an isolated coarctation of the aorta, without complex cardiac anomalies, has improved, with very good results. However, despite the success of surgical repair, many long-term complications, such as hypertension, re-coarctation and an aortic aneurysm, still exist. Material and Method: Between 1991 and 2006, 50 patients diagnosed with an isolated coarctation of the aorta were reviewed retrospectively. The incidence of re-coarctation and hypertension were compared with respect to age and surgical methods. Result: There were no early & late mortality, or post operative aortic aneurysms. Hypertension developed in 11 patients (22%). A greater number of patients in the child/adult group had hypertension (52.4%) than in the neonate/infant group (0%). With respect to the surgical methods, the patients in the graft interposition group suffered more hypertension (88.9%) than those in the EEEA (extended end to end anastomosis) group (5.3%). Post operative re-coarctation developed in 2 out of the 29 patients (6.9%) in the neonate/infant group and 2 out of the 21 patients (9.5%) in the child/adult group, but without any statistical difference. There were no statistical differences between the operative type-related groups. Conclusion: Even though the surgical outcomes have greatly improved, an isolated coarctation of the aorta still has many long-term problems, such as hypertension and re-coarctation. An isolated coarctation is accepted as a systemic vascular dysfunction, and often progresses to other cardiovascular diseases. Therefore, patients with a coarctation of the aorta have to be carefully followed-up, and aggressive management must be given when required.

• Journal of Chest Surgery
• /
• v.36 no.4
• /
• pp.229-241
• /
• 2003

Background:Autogenous vein is the preferred vascular graft for patients who require coronary artery bypass surgery or peripheral arterial bypass surgery. When an autogenous vein is not available, an allograft saphenous vein can be used as an alternative conduit. Although arterial homograft has been under investigation since the beginning of this century, the viability of endothelial cells and the optimum mode of storage for the venous and arterial allografts is controversial. In addition, with the recently gained knowledge of vascular endothelial functions, such as the production of nitric oxide or thrombomodulin, the viability and antigenicity of endothelial cells are being studied again. The purpose of this study was to evaluate the viability of endothelial cells in the preserved human saphenous veins. Material and Method: The veins were stored in a $4^{\circ}C$ RPMI (Roswell Park Memorial Institute) 1640 solution including 10% fetal calf serum, for one, three, five, seven or fourteen days. After the completion of the storage period, the veins were divided into two groups: Group I: studied immediately at $4^{\circ}C$ (cold) storage (I-1, I-3, I-5, I-7, I-14), and Group II: studied after storage at $-196^{\circ}C$ liquid nitrogen tank (cryopreservation) in an RPMI 1640 solution containing 10% DMSO for two weeks (II-1, II-3, II-5, II-7, II-14). Light microscopy and scanning electron microscopy (SEM), frypan blue exclusion testing, and thrombomodulin immunohistochemistry were performed. Result: In a morphometric study using SEM, there was statistically significant increase in Gundry Score in Groups I-7, I-14, II-5, II-7, and II-14 and showed cellular destruction (p<0.05). In the thrombomodulin immunohistochemistry study, there was reactivity in Groups I-1, I-3, and I-5, but the cryopreserved group revealed decreased reactivity (p<0.05). The trypan blue exclusion testing also showed superior viability in cold storage Group I. Conclusion: Venous allografts preserved in a $4^{\circ}C$ RPMI 1640 solution showed well preserved endothelial cellular integrity and thrombomodulin expression at up to seven days of preservation. Although cryopreservation of venous allografts stored in 10% DMSO -RPMI 1640 solution maintained the endothelial cellular structure on SEM, immunohistochemistry from the thrombomodulin and trypan blue exclusion testing showed decreased viability, It remains to be seen whether the decreased thrombomodulin reactivity could be restored, and what the nature to the relationship is between thrombomodulin and long-term patency of allografts.

• Journal of Chest Surgery
• /
• v.42 no.4
• /
• pp.480-486
• /
• 2009

Background: The Fogarty thromboembolectomy catheter technique was devised to extract distal arterial emboli and it represents a milestone for the treatment of patients with acute arterial occlusion since the 1960s. The major causes of arterial occlusion have changed from emboli of a heart origin to atherosclerosis over the past 30 years. Accordingly, questions have been raised about the effectiveness of simple Fogarty thromboembolectomy. Material and Method: During the period from March 1990 through August 2008, 156 patients who requiring Fogarty thromboembolectomy were analyzed. The patients were divided into two groups: those with simple Fogarty thromboembolectomy (Group 1, 79 patients) and those with additional vascular bypass graft surgery (Group 2, 77 patients). The duration of symptoms, the cause of thrombi, admission via the emergency room, a history of acupuncture or misdiagnosis, combined diseases, the anatomic occlusion site and the cause of death were analyzed using T-tests, cross tab tests, Chi square tests and Kaplan-Meier tests, respectively. Result: The mean age was 64$\pm$10 years in the 2 groups. The duration of symptoms (pain) in Group 1 vs Group 2 was 12$\pm$4 days vs 71$\pm$14 days (p=0.001). 50 (63%) patients in Group 1 were admitted via the emergency room vs 18 (23%) patients in Group 2 (p=0.005). Misdiagnosis and the treatment for herniated intervertebral disc or acupuncture were given to, 20 (25%) patients in Group 1 vs 30 (39%) patients in Group 2. Anticoagulation treatment before admission was performed in 22 (28%) patients in Group 1 vs 11 (14%) patients in Group 2. The causes of thrombi were heart disease in, 24 (30%) patients in Group 1 vs 6 (8%) patients in Group 2 (p=0.001), atherosclerosis in 46 (58%) patients in Group 1 vs 67 (87%) patients in Group 2 (p=0.001) and trauma in 9 (11%) patients in Group 1 vs 6 (8%) patients in Group 2. The combined diseases were cerebrovascular accident, hypertension and diabetes mellitus in 22 $\sim$ 37% of the total patients. The occlusion sites were mainly in the iliac and femoral arteries. Endarterectomy was performed in 7 (9%) patients in Group 1 vs 18 (23%) patients in Group 2 (p=0.012). Treatment was successful in 27 (34%) patients in Group 1 and in 40 (52%) patients in Group 2 (p=0.019). Reocclusion occurred in 37(47%) patients in Group 1 vs 20 (26%) patients in Group 2 (p=0.000), Amputation was done in 4 (5%) patients in Group 1 vs 12 (16%) patients in Group 2 (p=0.012) and death occurred in 10 (13%) patients (Group 1) vs 3(4%) patients (Group 2) (p=0.044). Conclusion: The recent past has shown a decline in the effectiveness of simple Fogarty thromboembolectomy with a changing pattern of acute arterial occlusion from a rheumatic heart origin to atherosclerosis. Additional bypass procedures play a role for the treatment of arterial occlusion instead of always performing simple Fogarty thromboembolectomy.

• Journal of Chest Surgery
• /
• v.31 no.5
• /
• pp.472-480
• /
• 1998

We reviewed the surgical results of intracardiac lateral tunnel Fontan procedure for the repair of functional single ventricles. Between 1990 and 1996, 104 patients underwent total cavopulmonary anastomosis. Patients' age and body weight averaged 35.9(range 10 to 173) months and 12.8(range 6.5 to 37.8) kg. Preoperative diagnoses included 18 tricuspid atresias and 53 double inlet ventricles with univentricular atrioventricular connection and 33 other complex lesions. Previous palliative operations were performed in 50 of these patients, including 37 systemic to pulmonary artery shunts, 13 pulmonary artery bandings, 15 surgical atrial septectomies, 2 arterial switch procedures, 2 resections of subaortic conus, 2 repairs of total anomalous pulmonary venous connection and 1 Damus-Stansel-Kaye procedure. In 19 patients bidirectional cavopulmonary shunt operation was performed before the Fontan procedure and in 1 patient a Kawashima procedure was required. Preoperative hemodynamics revealed a mean pulmonary artery pressure of 14.6(range 5 to 28) mmHg, a mean pulmonary vascular resistance of 2.2(range 0.4 to 6.9) wood-unit, a mean pulmonary to systemic flow ratio of 0.9(range 0.3 to 3.0), a mean ventricular end-diastolic pressure of 9.0 (range 3.0 to 21.0) mmHg, and a mean arterial oxygen saturation of 76.0(range 45.6 to 88.0)%. The operative procedure consisted of a longitudinal right atriotomy 2cm lateral to the terminal crest up to the right atrial auricle, followed by the creation of a lateral tunnel connecting the orifices of either the superior caval vein or the right atrial auricle to the inferior caval vein, using a Gore-Tex vascular graft with or without a fenestration. Concomitant procedures at the time of Fontan procedure included 22 pulmonary artery angioplasties, 21 atrial septectomies, 4 atrioventricular valve replacements or repairs, 4 corrections of anomalous pulmonary venous connection, and 3 permanent pacemaker implantations. In 31, a fenestration was created, and in 1 an adjustable communication was made in the lateral tunnel pathway. One lateral tunnel conversion was performed in a patient with recurrent intractable tachyarrhythmia 4 years after the initial atriopulmonary connection. Post-extubation hemodynamic data revealed a mean pulmonary artery pressure of 12.7(range 8 to 21) mmHg, a mean ventricular end-diastolic pressure of 7.6(range 4 to 12) mmHg, and a mean room-air arterial oxygen saturation of 89.9(range 68 to 100) %. The follow-up duration was, on average, 27(range 1 to 85) months. Post-Fontan complications included 11 prolonged pleural effusions, 8 arrhythmias, 9 chylothoraces, 5 of damage to the central nervous system, 5 infectious complications, and 4 of acute renal failure. Seven early(6.7%) and 5 late(4.8%) deaths occured. These results proved that the lateral tunnel Fontan procedure provided excellent hemodynamic improvements with acceptable mortality and morbidity for hearts with various types of functional single ventricle.

• Journal of Chest Surgery
• /
• v.37 no.9
• /
• pp.787-792
• /
• 2004

Even though there well developments in various treatment techniques for acute limb ischemia, this disease is both life threatening and limb threatening. We investigated early and mid-term results of operation for acute limb ischemia with symptoms, the combined diseases, location of occlusion, complication in our patients. Material and Method: A retrospective review was conducted in 54 patients (43 men, 11 women, mean age 67.2 years) presenting with acute limb ischemia due to arterial thrombosis or embolism between Jan. 1996 and Dec. 2003, initially underwent thromboembolectomy. Result: In 33 patients (61.1%) the timeinterval from the onset of symptom to admission was within 24 hours. Causes of acute limb ischemia were embolic occlusion (27.8%), native arterial thrombosis (66.7%), and bypass graft thrombosis (5.6%). The distribution of arterial occlusion location was at 8 aortoiliac (14.8%) and 43 distal to femoral (79.6%) and brachial (5.6%). Clinical categories were grade I in 64.8%, IIa in 24.1%, IIb in 7.4%, and III in 3.7%, All the patients were received embolectomy. Underlying diseases were heart disease (72.2%), hypertension (33.3%), cerebrovascular accident (16.7%) and diabetes (18.5%). History of smoking was noted in 96,3% of the cases. Mortality rate was 5.6％ and overall amputation rate was 9.3% (5/54). The 1-year limb salvage rate was 93.62%. Postoperative complications were 1 wound infection, 1 G1 bleeding, 3 acute renal failure, and 1 compartment syndromes. The functional outcomes of the salvaged limb according to the recommended scale for gauging changes in clinical status, revised version in 1997 were +3 in 68.5%, +2 in 9.3%, +1 in 7.4%, -1 in 5.6%, -2 in 3.7%, and -3 in 5.6%. Conclusion: This study revealed 5.6% mortality and the amputation rate was 9.3%. We have retrospectively shown good results from early diagnosis & early operation. To improve outcome, early diagnosis and understand the underlying diseases, prompt treatment and operation would be appreciated.

• Journal of Chest Surgery
• /
• v.32 no.5
• /
• pp.413-421
• /
• 1999

Background: Ischemia reperfusion injury is known to contribute to the major causes of the early graft failure in lung transplantation. Triiodothyronine (T3) has been suggested to ameliorate ischemia reperfusion injury from both in vivo and in vitro experiments of various organs. Prospecting its beneficial effect for pulmonary allograft preservation, we made a new solution by adding T3 into the extracellular type dextran solution. Material and Method: Twelve adult mongrel dogs underwent left lung allotransplantation. Six donor dogs were flushed with the new solution(Group 1, n=6), and the remaining six were flushed with Euro-Collins solution to serve as controls(Group 2, n=6). Allografts were stored in each preservation solution for 20 hours at 4$^{\circ}C$. Left single lung transplantations were performed. The right pulmonary artery and the right main bronchus were clamped at 15 minutes after the reperfusion and maintained throughout the experiment to evaluate the transplanted left lung function. Result: Arterial carbon dioxide tension was better in group 1 than in group 2 throughout the experiment period and the difference was statistically significant at 2 hours after reperfusion(28.0${\pm}$3.0 mmHg and 53.1${\pm}$17.4 mmHg, p<0.05). The differences of arterial oxygen partial pressure, peak airway pressure and pulmonary vascular resistance showed no statistical significance. The malondialdehyde(MDA) level, measured from tissue obtained at 120 minutes after reperfusion showed no statistically significant difference. The tissue wet/dry ratio of group 1(649${\pm}$27 %) was significantly lower than that of group 2(686${\pm}$71 %, p<0.05). The microscopic examination revealed varying degrees of injury represented mainly by findings such as perivascular neutrophil infiltration, capillary hemorrhage and interstitial congestion. These findings were less severe in group 1 than those in group 2. Conclusion: The new solution demonstrated superior allograft preservation after 20 hour ischemia compared to Euro-Collins solution in canine single left lung transplantation model, these results suggest that T3 might be a promising agent for pulmonary allograft preservation.

• Journal of Chest Surgery
• /
• v.41 no.5
• /
• pp.541-549
• /
• 2008

Background: Vasoconstrictor-induced reduction in arterial graft diameter can cause significant flow deprivation. The aim of this study was to evaluate the effect of vasodilator pretreatment on vasoconstrictor-induced blood vessel spasm in vitro. Material and Method: Rabbit brachial arteries (BA) and celiac arteries (CA) were cut into rings $(3{\sim}4mm)$ and suspended with a force displacement transducer (TSD $125C^{(R)}$, Biopac Inc. USA) in a tissue bath filled with 5 mL modified Krebs solution bubbled with 5% $CO_2$ and 95% $O_2\;at\;38^{\circ}C$. The rings were contracted with vasoconstrictors, and the developed tension changes were considered control values. The rings were then pre- treated with $30{\mu}M$ nitroglycerin, nicardipine, verapamil, and papaverine, respectively, for 40 minutes and rinsed with the physiologic buffered salt solution three times every 15 min. The vasoconstrictor-induced tension changes after the previous procedure were considered experimental values. Data are expressed as the percentage tension induced by vasoconstrictors before and after pretreatment with vasodilators. Result: Nicardipine depressed vasoconstriction induced by norepinephrine, angiotensin II (All), and U46619 in both the BA and the CA more significantly than did nitroglycerin (p<0.01) and verapamil (p<0.05). Verapamil depressed vasoconstriction induced by 5-hydroxytryptamine (5HT), All, and U46619 in the BA and by 5HT in the CA more significantly than did nitroglycerin (p<0.01). Conclusion: These findings suggest that both nicardipine and verapamil effectively depressed vasoconstrictor action. Nicardipine is thought to be more effective than verapamil for the prevention of vasoconstrictor action.