At our institution, we prioritize the cephalic vein cut down method for dual chamber pacemaker implantation as the first choice due to the concern about complications. If the cephalic vein is not suitable, we switch to the subclavian puncture method intraoperatively. We retrospectively compared perioperative complications between the group in which the patients undergone cut down method (group C, 139 cases) and the group in which whom undergone primary or switched to puncture method intraoperatively (group P, 121 cases). A completion rate of 81% (139/172) was observed for the cut down method. No hemothorax occurred in either group. Pneumothorax occurred in 0 and 2 patients in groups C and P, respectively. Hematoma incidence was significantly higher in group P than that in group C (9.9% vs. 2.8%, p=0.02). The cut down method resulted in fewer complications than the puncture method. Therefore, the cut down method appears to be the first procedure of choice.

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  Background Noncardiac surgery for adult congenital heart disease patients with Fontan circulation is increasing. Special care must be taken to maintain pulmonary circulation. Pneumonectomy is a particularly challenging procedure for pulmonary circulation because of the intraoperative one-lung ventilation (OLV) and lung resection. In this report, we describe the successful management of a partial pulmonary resection under general anesthesia with remimazolam. Case presentation A 39-year-old woman presented with a right ventricular single ventricle Fontan circulation. A laparoscopic partial pulmonary resection was planned. Remimazolam was used for general anesthesia, stable circulation was obtained with dobutamine and noradrenaline, and postoperative spontaneous respiration was quickly obtained with antagonism by flumazenil and managed with stable respiratory and circulatory dynamics. Conclusion General anesthesia with remimazolam could be one of the options for noncardiac surgery in the Fontan circulation because of its lower circulatory depression and rapid recovery of spontaneous breathing by antagonist.

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Background
  Various cases of hypotension are associated with the use of general anesthesia. Here,we report a case of refractory hypotension during general anesthesia that was thought to be affected by preoperative medication.
Case Report
  A 70-year-old patient underwent brain tumor resection with the assistance of photodynamic diagnosis using 5-aminolevulinic acid (5-ALA). The patient had been taking angiotensin receptor blockers (ARB) and calcium channel blockers for hypertension. During general anesthesia induction using fentanyl (100 μg), propofol (2 μg/mL), rocuronium (40 mg), and remifentanil (0.2 μg/kg/min), hypotension occurred. Refractory hypotension persisted despite rapid dose reduction of propofol and remifentanil, repeated doses of phenylephrine (total 0.8 mg), and infusion loading. Since only adrenaline was effective against hypotension, an anaphylactic reaction was suspected, and surgery was canceled. The drug-induced lymphocyte stimulation and basophil activation tests for drug-induced anaphylactic reaction (allergy testing) yielded negative results. Therefore, an overreaction to propofol and remifentanil due to 5-ALA and/or the residual effects of ARBs was suspected. The patient was scheduled to undergo surgery without 5-ALA administration. Moreover, ARB was discontinued 72-h before surgery. Surgery was completed without hypotension.
Conclusion
  We encountered a case of refractory hypotension caused by 5-ALA and the residual effects of ARBs.

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  Middle colic artery aneurysm is a rare aneurysm of visceral arteries. Most cases of middle colic artery aneurysms are treated with endovascular coil embolization or open ligation. However, a colectomy may sometimes be required because of intestinal ischemia. We report a case in which a surgical reconstruction for a middle colic artery aneurysm using a saphenous vein graft was successfully performed in a patient after thoracic endovascular aortic repair and Y-grafting for thoracic/abdominal aortic aneurysms. Surgical reconstruction of the middle colic artery may be an alternative to the colectomy in patients with a high probability of intestinal ischemia.

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