佐藤 俊充

Infective abdominal aortic aneurysm (IAAA) is relatively rare, but a case which is caused by Haemophilus influenzae type B is very rare. We experienced one IAAA case due to H. influenzae type B. The patient was 69-year-old man presenting with severe abdominal and back pain and elevated C-reactive protein (CRP), as inflammatory marker. The patient was found to have saccular aneurysm infrarenal aorta on computed tomography scanning. First, we started to treat him with antibiotic agent and second, we operated him at day 8 after admission with expanded polytetrafluoroethylene graft. Revascularization was made in situ reconstruction. As the result of culture with aneurysm wall, we found that the cause of this aneurysm was the infection of H. influenzae type B. As far as we know, this bacterium is scarcely reported as the cause of infective aortic aneurysms. We reported this IAAA case with the review of the English literature. Copyright © 2012 by Thieme Medical Publishers, Inc.

症例1は68歳男性で、糖尿病の既往があった。心房細動で植込み型除細動器(ICD)挿入のためワルファリン休薬中で、ICD挿入4日目に突然両下肢脱力、冷感を認め、大腿動脈以下の拍動を触知せず、CTで腹部大動脈終末部に多量の血栓を認め、発症3時間後に血栓除去術を行った。術後2週目に再度両下肢の虚血症状が出現し、CT上両下肢動脈塞栓の診断で再度血栓除去術を行った。その後、左鼠径部の創感染をきたし、糖尿病のため感染コントロールは困難で、左総大腿動脈が破綻して出血し、手術的止血も効果なく、全身状態の悪化とARDS発症で人工呼吸管理を行うも、初回手術後54日目に呼吸不全で死亡した。なお、創感染部と血管壁からCitrobacter Koseriが検出された。症例2は71歳女性で、突然の両下肢脱力で受診した。大腿動脈以下の拍動を触知せず、CTで腹部大動脈終末部に多量の血栓を認め、発症8時間後に血栓除去術を行った。術後経過は良好で術後14日目に独歩退院した。

Background: The architecture of the arterial wall affected with Buerger's disease has been known to be preserved in all three layers, while the one affected by arteriosclerosis obliterans (ASO) is degenerated and destroyed. We analyzed affected arteries with immunohistochemical methods to clarify the differences between Buerger's disease and ASO. Materials and methods: Crural arteries obtained from 13 patients with Buerger's disease and 6 patients with ASO at our institute were studied. In addition, we examined seven specimens from six patients who were thought to be normal (without Buerger's disease or ASO) as negative control. Immunohistochemical studies were performed on paraffin-embedded tissues. The primary antibodies were urokinase-type plasminogen activator (uPA) and matrix metalloproteinase-3 (MMP-3). Both are known to play an important role of extracellular proteolysis and to activate each other. Additionally, plasminogen activator inhibitor-1(PAI-1) was also examined. Results: In Buerger's disease, PAI-1 was well expressed along the internal elastic lamina. Urokinase-type plasminogen activator and MMP-3 were slightly positive in intima and media. In ASO, a slight amount of PAI-1 was recognized on vessel walls, and both uPA and MMP-3 were strongly positive in media. In addition, in the control group, PAI-1, uPA, and MMP-3 were well expressed in media. Conclusion: In Buerger's disease, PAI-1 was strongly expressed around the internal elastic lamina, while both uPA and MMP-3 were slightly recognized on vessel walls. These findings could be one of the reasons the general architecture of vessel walls in Buerger's disease is preserved. (C) 2011 Elsevier Inc. All rights reserved.

【背景】胃十二指腸動脈瘤は内臓動脈瘤の中でもかなり稀であるが，いったん破裂に至ると，致命的になることが多い．今回は未破裂胃十二指腸動脈瘤の 1 症例を経験した．【症例】76歳，男性．既往は高血圧のみであった．近医の超音波検査で偶然に発見された右上腹部拍動性腫瘤の精査目的に当科紹介となった．CT検査および血管造影検査で，最大径 5cmの胃十二指腸動脈瘤と診断したが，瘤のproximal neckが短く，血管内治療は断念し，手術的治療の方針とした．【結果】全身麻酔下に開腹し，総肝動脈，左右肝動脈，胃十二指腸動脈（末梢側）をテーピング，遮断可能とした．瘤壁を切開し，1 カ所の胃十二指腸動脈の開口部を瘤の内腔から縫合閉鎖した．肝への血流は総肝動脈と固有肝動脈の端端吻合にて施行した．術後肝への血流は問題なく維持されていた．【結論】稀な未破裂の胃十二指腸動脈瘤に対して手術的治療を行い，経過良好であったので報告する．

【背景】腹部大動脈瘤（AAA）と上腸間膜動脈（SMA）または腹壁との間で十二指腸が壁外性に圧迫され，閉塞に至る症例は比較的稀であるが，このような症例を 2 例経験したので報告する．【症例】症例 1：81歳，男性．2005年11月下旬頃から，頻回の嘔吐を認め，近医受診．2005年12月上旬当科を紹介受診．CTにて右上方に突出するAAA（最大径75mm）とSMAにより十二指腸水平部が壁外性に圧迫され閉塞していることを確認した．症例 2：71歳，男性．2006年 7 月中旬から食後の嘔吐が頻回となり，近医を受診．上腹部に拍動性腫瘤をふれたため，2006年 7 月下旬当科を紹介受診．腹部単純写真ではガス像から胃および十二指腸の拡張を認めるのみであった．CTで右上方に突出するAAA（最大径65mm）と腹壁により十二指腸水平部が壁外性に圧迫され閉塞していることを確認した．【結果】2 症例とも最終的に人工血管置換術を施行することで軽快した．【結論】AAAを有する高齢者の上腹部イレウスの 2 例を経験し，適切な治療により治癒することができた．