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.