胸部外科

Adequate preoperative planning may facilitate successful procedures in cardiovascular surgery. We have developed a system named the Vesalius 3D suite, combining three-dimensional （3D） image-processing software with an optic-tracking spatial navigation, allowing quick, accessible 3D image interpretation for virtual reality （VR） exploration and measurement from one or more of a range of imaging modalities. We present a novel method of virtual imaging analysis for preoperative planning and simulation in cardiovascular surgery using this 3D-VR system. Based on unimodal or multimodal medical imaging data, digital imaging and communication in medicine （DICOM） data sets can be reconstructed for 3D visualization. Virtually reconstructed images can be viewed on flat-screen or stereoscopic display, revealing each patient’s specific anatomy and the internal structures in exquisite detail. Highly accessible 3D interpretation promptly permits precise measurements of repair-relevant anatomical parameters including geometrically complex shapes. This technology may promote understanding of form and function in the cardiovascular system, and facilitate operative procedures in more challenging cases, and it seems especially valuable for any surgeon to gain experience in practicing for rarely-performed procedures or uncommon patient-specific preoperative surgical rehearsal.

A 52-year-old man developed Stanford type A acute aortic dissection and suffered severe pain in the back and the chest, and numbness of the left lower limb. Contrast-enhanced computed tomography （CT） revealed occlusion of the left iliac artery due to dissection. The celiac artery was also obstructed and the superior mesenteric artery was severely narrowed, but there was no clear sign of organ ischemia. Endovascular treatment in the iliac artery was performed, but the patient complained of right upper abdominal pain 6 hours after the procedure. Serum liver enzyme levels were significantly elevated. Repeat contrast-enhanced CT revealed liver infarction, ischemic cholecystitis, and duodenal ischemia due to decreased collateral flow. We immediately carried out cholecystectomy and revasculariza-tion of the celiac and superior mesenteric arteries using a saphenous vein. The patient underwent central repair for aortic dissection several days after recovery of liver function, and was discharged uneventfully 24 days later.

A 85-year old male with hoarseness due to distal aortic arch aneurysm underwent zone 1 thoracic endovascular aortic repair（ TEVAR） with two-debranching at our hospital. Five years after the TEVAR （90 years old）, computed tomography（ CT） revealed typeⅠa endoleak due to migration of proximal end of the graft. Anatomically, additional TEVAR was impossible. To minimize the invasiveness, a two-stage surgery was planned. First, under deep hypothermic circulatory arrest, the ascending aorta was replaced with the brachiocephalic artery reconstruction and insertion of a stented vascular prosthesis distally through partial sternotomy to preserve the debranching bypass. Six days after the surgery, a transcatheter stent graft was placed from the stented vascular prosthesis to the native descending aorta. Postoperative course was uneventful, and CT scan showed no endoleak.

A 35-years-old pregnant woman with Marfan’s syndrome visited the emergent department. She had sudden severe back pain. She was at the 20th week of gestation. An emergent chest computed tomo-graphy scan showed Stanford type B acute aortic dissection. After admission, strict blood pressure control was started. According to aortic valve insufficiency and fluid retention with pregnancy, acute heart and respiratory failure was getting worse. It seemed risky for both mother and the fetus to continue pregnancy. After sincere and detailed discussion between the patient and our multidisciplinary medical team, the patient decided to continue pregnancy. An urgent Bentall operation was performed. A careful attention was paid for the fetus during and after the surgery. Strict blood pressure control was also continued. The mother and the 30-week-gestation newborn recovered uneventfully. During four years of follow-up, thoracic and thoraco-abdominal aortic replacement was performed. The patient survived all of these procedures without any complication.

Stanford type A acute aortic dissection after off-pump coronary artery bypass grafting（ OPCAB） is a rare but potentially fatal complication. A 61-year-old man with subacute Stanford type B aortic dissection underwent a triple OPCAB using an automated proximal anastomotic device. On postoperative day 4, he had a sudden syncope. An enhanced computed tomography （CT） scan revealed Stanford type A acute aortic dissection. He underwent emergent total aortic arch replacement along with an open stent graft deployment. The entry of the dissection was located at the proximal anastomosis site of the vein graft. This case demonstrates that this device should be used carefully in patients with a history of Stanford type B aortic dissection.

Congenital pulmonary airway malformation diagnosed in adulthood is very rare. A 54-year-old woman was admitted to our hospital with complaints of abnormal chest shadow. Computed tomography（ CT） demonstrated multiple cysts, mass lesions, and consolidation in left lower lobe. Bronchofiber scopy could not establish the diagnose. Left lower lobectomy was performed for diagnosis and treatment. Pathologically the lesion was diagnosed as congenital pulmonary airway malformation.

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We herein report a case of 71-year-old man who was diagnosed as right lung cancer associated with atrial septal aneurysm （ASA）. ASA was incidentally detected on transthoracic echocardiography as a routine preoperative examination. Although upper lobectomy was performed without any postoperative event in this case, generally care must be taken for important comorbidity of cerebral infarction as a potential source of systemic thromboembolism both in pre- and post-surgery.