Case report
A 64-year-old man was referred to our hospital 6 months ago for
cryoglobulinemia. He had previously been treated for gangrene of the
right toe 2 years prior during winter; however, since then symptoms of
necrosis and numbness of the lower extremities worsened. CGs were
detected through qualitative analysis (Fig. 1a). However, no additional
abnormalities were detected upon further examination. Hence, he was
diagnosed with active idiopathic cryoglobulinemia. Subsequently,
immunosuppressive therapy with corticosteroids and cyclophosphamide was
initiated. However, he had persistent numbness in the lower limbs, and
CG levels slightly decreased (Fig. 1b) without a negative outcome.
Therefore, he underwent three rounds of plasma exchange (PE) and double
filtration plasmapheresis; subsequently, qualitative analysis of CG was
found to be negative (Fig. 1c). The day after PE, our patient
experienced sudden chest and back pain. Contrast-enhanced computed
tomography revealed Stanford type A acute aortic dissection.
Regarding the use of hypothermia during surgery, since the patient had
undergone PE the day before, we decided to perform the surgery using CPB
under deep hypothermia circulatory arrest. After esophageal temperature
was lowered to 20°C and circulatory arrest was accomplished, selective
cerebral perfusion was initiated. Cardiac arrest was induced using
retrograde blood cardioplegia at 20°C, which was administered every 30
minutes. We finished anastomosing the distal aorta, and then, started
recirculation and rewarming. After anastomosis of the proximal aorta,
antegrade blood cardioplegia was administered at 30°C to 35°C. Weaning
from CPB was smooth and uneventful, with no changes in cardiac function.
Also, no signs of agglutinin reaction and thrombosis in the CPB circuit
were observed. The total CPB time, aortic cross clamp time, and
selective cerebral perfusion time were 255, 153, and 56 minutes,
respectively. The minimal nasopharyngeal temperature during the
procedure was 17.3°C.
One day after surgery, the patient was extubated in the intensive care
unit and had no significant postoperative complications. Six months
after surgery, he received outpatient treatment for cryoglobulinemia.