A Case of Total Arch Replacement for Saccular Aortic Arch Aneurysm With Esophageal Obstruction
症例は87歳の男性．1年前からの嚥下障害を主訴に近医を受診し，CT検査で偶発的に弓部大動脈瘤（TAA：thoracic arch aneurysm）を認めたため，当院に紹介となった．TAAは最大径74.5 mmの小弯縦隔側に突出する嚢状瘤で，食道造影検査で瘤による食道の圧排と通過障害を認めた．術前冠動脈造影検査で左冠動脈前下行枝の有意狭窄が指摘され，Canadian Study of Health and Aging Scaleは4であったが，認知機能や呼吸機能の低下はなく，Japan SCOREは死亡率11.4％（合併症51.8％）であった．治療は全弓部人工血管置換術＋冠動脈バイパス術を施行...
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| Published in | Shinzo Vol. 55; no. 9; pp. 915 - 921 |
|---|---|
| Main Authors | , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
Japan Heart Foundation
15.09.2023
公益財団法人 日本心臓財団 |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0586-4488 2186-3016 |
| DOI | 10.11281/shinzo.55.915 |
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| Abstract | 症例は87歳の男性．1年前からの嚥下障害を主訴に近医を受診し，CT検査で偶発的に弓部大動脈瘤（TAA：thoracic arch aneurysm）を認めたため，当院に紹介となった．TAAは最大径74.5 mmの小弯縦隔側に突出する嚢状瘤で，食道造影検査で瘤による食道の圧排と通過障害を認めた．術前冠動脈造影検査で左冠動脈前下行枝の有意狭窄が指摘され，Canadian Study of Health and Aging Scaleは4であったが，認知機能や呼吸機能の低下はなく，Japan SCOREは死亡率11.4％（合併症51.8％）であった．治療は全弓部人工血管置換術＋冠動脈バイパス術を施行した．術後脳神経学的合併症なく，概ね順調に回復し，食道造影検査でも通過障害は改善され，術後26日目にリハビリテーションのため転院となった．高齢患者に対するTAAの治療では，侵襲度の観点から胸部ステントグラフト内挿術も考慮されるが，瘤切除が必要な症例では開胸による全弓部人工血管置換術が第一選択となる．術後合併症回避のためには，呼吸機能や虚弱などの耐術能評価に基づいた術前からの予防的介入が肝要である． |
|---|---|
| AbstractList | 症例は87歳の男性．1年前からの嚥下障害を主訴に近医を受診し，CT検査で偶発的に弓部大動脈瘤（TAA：thoracic arch aneurysm）を認めたため，当院に紹介となった．TAAは最大径74.5 mmの小弯縦隔側に突出する嚢状瘤で，食道造影検査で瘤による食道の圧排と通過障害を認めた．術前冠動脈造影検査で左冠動脈前下行枝の有意狭窄が指摘され，Canadian Study of Health and Aging Scaleは4であったが，認知機能や呼吸機能の低下はなく，Japan SCOREは死亡率11.4％（合併症51.8％）であった．治療は全弓部人工血管置換術＋冠動脈バイパス術を施行した．術後脳神経学的合併症なく，概ね順調に回復し，食道造影検査でも通過障害は改善され，術後26日目にリハビリテーションのため転院となった．高齢患者に対するTAAの治療では，侵襲度の観点から胸部ステントグラフト内挿術も考慮されるが，瘤切除が必要な症例では開胸による全弓部人工血管置換術が第一選択となる．術後合併症回避のためには，呼吸機能や虚弱などの耐術能評価に基づいた術前からの予防的介入が肝要である． |
| Author | Edo, Naoki Yoshida, Keisuke Mitsuishi, Atsuyuki Matsuo, Tomomi Miura, Yujiro |
| Author_FL | 吉田 圭佑 三石 淳之 三浦 友二郎 松尾 朋峰 江戸 直樹 |
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| Author_xml | – sequence: 1 fullname: Miura, Yujiro organization: Division of Cardiovascular Surgery, Department of Surgery, Kochi University, Kochi Medical School – sequence: 1 fullname: Matsuo, Tomomi organization: Kochi University, Kochi Medical School – sequence: 1 fullname: Mitsuishi, Atsuyuki organization: Division of Cardiovascular Surgery, Department of Surgery, Kochi University, Kochi Medical School – sequence: 1 fullname: Yoshida, Keisuke organization: Division of Cardiovascular Surgery, Department of Surgery, Kochi University, Kochi Medical School – sequence: 1 fullname: Edo, Naoki organization: Division of Cardiovascular Surgery, Department of Surgery, Kochi University, Kochi Medical School |
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| References | 9）Choi HY, Jeon U, Lee SW, et al：A case of dysphagia aortica caused by a large thoracic aortic aneurysm. Soonchunhyang Med Sci 2018；24：216-219 11）Suleman M, Pyuza J, Sadiq A, Lodhia J：Aortic aneurysm：An uncommon cause of dysphagia. SAGE Open Med Case Rep 2022；10：2050313X221135602 1）Ogino H, Ando M, Sasaki H, Minatoya K：Total arch replacement using a stepwise distal anastomosis for arch aneurysms with distal extension. Eur J Cardiothorac Surg 2006；29：255-257 15）Seike Y, Matsuda H, Fukuda T, et al：Total arch replacement versus debranching thoracic endovascular aortic repair for aortic arch aneurysm：what indicates a high-risk patient for arch repair in octogenarians? Gen Thorac Cardiovasc Surg 2018；66：263-269 16）Ikeno Y, Yokawa K, Yamanaka K, et al：Total arch replacement in octogenarians and nonagenarians：a single-center 18-year experience. J Thorac Cardiovasc Surg 2020；160：346-356.e1 2）Grimaldi S, Milito P, Lovece A, et al：Dysphagia aortica. Eur Surg 2022；54：228-239 17）伊藤武久，飯田有輝，関 慎之介，ほか：心臓外科術患者に対する術前教育の有用性について．中部リハ誌 2009；4：11-13 8）Kyaw WA, Lim CY, Khalil MAM, et al：A fatal case of Ortner’s syndrome and dysphagia aortica secondary to rapidly expanding mycotic thoracic aortic aneurysm in a chronic kidney disease patient. SAGE Open Med Case Rep 2018；6：2050313X18799247 3）青木洋介，加藤 収，中西洋一ほか：大動脈瘤による圧迫が成因と考えられたTracheopathia osteochondroplasticaの1例．気管支学 1989；11：604-607 10）Wang ID, Huang HK, Tsai PY, Chang WK：Dysphagia aortica. QJM 2019；112：137-138 14）志水秀行，平原憲道，本村 昇，ほか：本邦における心臓血管外科手術の現状：2017年，2018年の日本心臓血管外科手術データベースからの報告 4．胸部大動脈手術．日心臓血管外会誌 2020；49：169-179 4）Petrov I, Nedevska M, Chilingirova N, et al：Endovascular repair of dissecting thoracic aortic aneurysm in a patient with Turner syndrome. J Endovasc Ther 2006；13：693-696 18）Morimoto Y, Matsuo T, Yano Y, et al：Impact of sarcopenia on the progress of cardiac rehabilitation and discharge destination after cardiovascular surgery. J Phys Ther Sci 2021；33：213-221 7）Godar M, Yuan Q, Zhang P, et al：Multiple thoracic aortic aneurysms and dysphagia aortica. Eur Heart J Cardiovasc Imaging 2013；14：1026 12）Minatoya K, Inoue Y, Sasaki H, et al：Total arch replacement using a 4-branched graft with antegrade cerebral perfusion. J Thorac Cardiovasc Surg 2019；157：1370-1378 19）Rockwood K, Song X, MacKnight C, et al：A global clinical measure of fitness and frailty in elderly people. CMAJ 2005；173：489-495 5）Ebihara T, Yamasaki M, Kubo H, Yamaya M：Dysphagia in a patient with rapidly enlarged thoracic aortic aneurysm. J Am Geriatr Soc 2006；54：1294 6）Siddiqui J, Hughes F：Dysphagia due to thoracic aortic aneurysm, relieved by thoracic endovascular aneurysm repair：a case report and review of the literature. BMJ Case Rep 2011；bcr0920114793 20）Kishimoto Y, Yoshikawa Y, Morimoto K, et al：Impact of frailty on early and mid-term outcomes of hybrid aortic arch repair. Surg Today 2022；52：1194-1201 13）Ikeno Y, Yokawa K, Matsueda T, et al：Long-term outcomes of total arch replacement using a 4-branched graft. J Thorac Cardiovasc Surg 2019；157：75-85.e3 21）本多 祐，向原伸彦，村上博久，ほか：フレイルが心臓手術後の経過や歩行能力に与える影響．日心臓血管外会誌 2022；51：67-72 |
| References_xml | – reference: 18）Morimoto Y, Matsuo T, Yano Y, et al：Impact of sarcopenia on the progress of cardiac rehabilitation and discharge destination after cardiovascular surgery. J Phys Ther Sci 2021；33：213-221 – reference: 6）Siddiqui J, Hughes F：Dysphagia due to thoracic aortic aneurysm, relieved by thoracic endovascular aneurysm repair：a case report and review of the literature. BMJ Case Rep 2011；bcr0920114793 – reference: 3）青木洋介，加藤 収，中西洋一ほか：大動脈瘤による圧迫が成因と考えられたTracheopathia osteochondroplasticaの1例．気管支学 1989；11：604-607 – reference: 17）伊藤武久，飯田有輝，関 慎之介，ほか：心臓外科術患者に対する術前教育の有用性について．中部リハ誌 2009；4：11-13 – reference: 19）Rockwood K, Song X, MacKnight C, et al：A global clinical measure of fitness and frailty in elderly people. CMAJ 2005；173：489-495 – reference: 9）Choi HY, Jeon U, Lee SW, et al：A case of dysphagia aortica caused by a large thoracic aortic aneurysm. Soonchunhyang Med Sci 2018；24：216-219 – reference: 20）Kishimoto Y, Yoshikawa Y, Morimoto K, et al：Impact of frailty on early and mid-term outcomes of hybrid aortic arch repair. Surg Today 2022；52：1194-1201 – reference: 14）志水秀行，平原憲道，本村 昇，ほか：本邦における心臓血管外科手術の現状：2017年，2018年の日本心臓血管外科手術データベースからの報告 4．胸部大動脈手術．日心臓血管外会誌 2020；49：169-179 – reference: 11）Suleman M, Pyuza J, Sadiq A, Lodhia J：Aortic aneurysm：An uncommon cause of dysphagia. SAGE Open Med Case Rep 2022；10：2050313X221135602 – reference: 5）Ebihara T, Yamasaki M, Kubo H, Yamaya M：Dysphagia in a patient with rapidly enlarged thoracic aortic aneurysm. J Am Geriatr Soc 2006；54：1294 – reference: 13）Ikeno Y, Yokawa K, Matsueda T, et al：Long-term outcomes of total arch replacement using a 4-branched graft. J Thorac Cardiovasc Surg 2019；157：75-85.e3 – reference: 15）Seike Y, Matsuda H, Fukuda T, et al：Total arch replacement versus debranching thoracic endovascular aortic repair for aortic arch aneurysm：what indicates a high-risk patient for arch repair in octogenarians? Gen Thorac Cardiovasc Surg 2018；66：263-269 – reference: 12）Minatoya K, Inoue Y, Sasaki H, et al：Total arch replacement using a 4-branched graft with antegrade cerebral perfusion. J Thorac Cardiovasc Surg 2019；157：1370-1378 – reference: 8）Kyaw WA, Lim CY, Khalil MAM, et al：A fatal case of Ortner’s syndrome and dysphagia aortica secondary to rapidly expanding mycotic thoracic aortic aneurysm in a chronic kidney disease patient. SAGE Open Med Case Rep 2018；6：2050313X18799247 – reference: 7）Godar M, Yuan Q, Zhang P, et al：Multiple thoracic aortic aneurysms and dysphagia aortica. Eur Heart J Cardiovasc Imaging 2013；14：1026 – reference: 10）Wang ID, Huang HK, Tsai PY, Chang WK：Dysphagia aortica. QJM 2019；112：137-138 – reference: 4）Petrov I, Nedevska M, Chilingirova N, et al：Endovascular repair of dissecting thoracic aortic aneurysm in a patient with Turner syndrome. J Endovasc Ther 2006；13：693-696 – reference: 1）Ogino H, Ando M, Sasaki H, Minatoya K：Total arch replacement using a stepwise distal anastomosis for arch aneurysms with distal extension. Eur J Cardiothorac Surg 2006；29：255-257 – reference: 21）本多 祐，向原伸彦，村上博久，ほか：フレイルが心臓手術後の経過や歩行能力に与える影響．日心臓血管外会誌 2022；51：67-72 – reference: 16）Ikeno Y, Yokawa K, Yamanaka K, et al：Total arch replacement in octogenarians and nonagenarians：a single-center 18-year experience. J Thorac Cardiovasc Surg 2020；160：346-356.e1 – reference: 2）Grimaldi S, Milito P, Lovece A, et al：Dysphagia aortica. Eur Surg 2022；54：228-239 |
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| Snippet | 症例は87歳の男性．1年前からの嚥下障害を主訴に近医を受診し，CT検査で偶発的に弓部大動脈瘤（TAA：thoracic arch aneurysm）を認めたため，当院に紹介となった．TAAは最... |
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| SubjectTerms | Canadian Study of Health and Aging（CSHA） Scale total arch replacement 弓部大動脈瘤 食道通過障害 |
| Title | A Case of Total Arch Replacement for Saccular Aortic Arch Aneurysm With Esophageal Obstruction |
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