To evaluate the efficacy of the retroperitoneal approach (RP) when compared with the transperitoneal approach (TP) in elective aortoiliac reconstruction, 41 cases were reviewed. From February 1987 through October 1991, 16 patients underwent aortoiliac reconstruction through the TP approach and 25 patients underwent operation through the RP approach for abdominal aortic aneurysms (AAA). The TP approach was associated with larger intraoperative blood loss (648.6±416.5ml) when compared with the RP approach (357.7±208.9ml) (p<0.01). The TP approach was associated with greater intraoperative blood transfusion (2093.8±1179.0ml) when compared with the RP approach (1010.4±905.3ml) (p<0.01). Both groups had similar operative times. Postoperative initiation of oral water intake was prolonged in the TP group (50.2±27.4hr) when compared with the RP group (22.3±8.9hr) (p<0.01). Postoperative initiation of walking training was prolonged in the TP group (88.7±37.1hr) when compared with the RP group (60.1±23.2) (p<0.01). This experience demonstrates that the RP approach is a preferable alternative to the TP approach in elective aortoiliac reconstruction.

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From March 1981 to March 1990, 61 patients with Stanford type B acute aortic dissection were initially treated by conservative therapy. Among these 61 patients, the dissected lumen became occluded due to thrombosis early after diagnosis in 25 patients (Group T) and remained patent in 36 patients (Group P). Twentythree patients in Group T (92%) and 22 patients in Group P (61%) were discharged without major complications related to acute aortic dissection. However, 2 patients in Group T (8%) and 14 patients in Group P (39%) required additional surgical therapy or died during hospitalization. The mean aortic diameter at the time of admission in Group T was smaller than that of Group P (38±3mm vs 43±7mm, p<0.05). During the observation period, there was a tendency for the diameter of the dissected aorta in Group T to decrease, but to increase in Group P. Long-term survival appeared to be better in Group T than in Group P, but there was no significant difference in the overall survival curve. Large aortic diameter at the time of admission and the presence of a true thoracic aortic aneurysm were major contributing factors influencing the prognosis. A long-term follow-up study showed that the dissected lumen reduced or disappeared in 14 of 23 patients in Group T (61%) but only 2 of 16 patients in Group P (12.5%). We concluded that the patients with small dissected aortas and thrombosed dissected lumens (Group T) can recuperate only with conservative therapy. However, patients with large dissected aortas and patent dissected lumen (Group P) may require surgical therapy even in Stanford type B aortic dissection.

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From November 1976 to December 1991, we performed extra anatomic bypass procedures (EAB) in 100 cases with aortoiliac occlusive disease. The operative procedures included 26 axillo-femoral bypasses (Ax-F), 27 femoro-femoral bypasses (F-F) and 47 aorto-femoro-femoral bypasses (Ao-F-F). The average age was 75.8 years in Ax-F and 73.8 years in F-F. These were significantly higher than that of Ao-F-F (70.8 years). In addition, the rate of limb salvage in Ax-F was 85%, and this group had more critical cases than the other two groups. The cumulative primary patency rate and survival rate at 5 years were 64.4%, 20.8% (Ax-F), 65.9%, 51.1% (F-F) and 96.5%, 70.4% (Ao-F-F) respectively. The late results of Ao-F-F were comparable to direct aorto-femoral bypass procedures performed in our institution during the same period. On the contrary, the results of Ax-F and F-F were discouraging. We suggest that EAB should be selected for high risk, limb salvage cases and in particular, Ax-F and F-F should be limited to patients with nonphysical acting. We are opposed to appealing for an extended indications of EAB and it should not be regarded simply as a low-risk substitute for aorto-femoral bypass.

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Five patients with isolated stenosis of the left main coronary artery or stenotic ostial lesions underwent direct coronary artery surgery. These surgical approaches included vein patch angioplasty in 2 cases, punch out endarterectomy in 1 case, and resection of the thickened aortic wall and transaortic endarterectomy in 2 cases. Early results were satisfactory, except for one case who died due to severe LOS and MOF. In the late postoperative period, one case of vein patch angioplasty died due to cerebral bleeding, and in the other case, stenosis existed in position of distal patch anastomosis. Since direct coronary artery surgery was successful in both early and late postoperative fidings, it is believed to be useful and safe technique if the candidates are selected properly.

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Arterial reconstructions for iliac artery obstruction (IAO) were performed in 81 patients (70 males and 11 females) with arteriosclerosis obliterans (80) and thromboangiitis obliterans (1) from January 1979 to January 1991. Ages ranged from 36 to 79 with a median age of 63.4. Aortofemoral bypass (AF-B) was performed in 46 cases (including 21 Y graft patients), thromboendarterectomy (TEA) in 11, femoro-femoral cross-over bypass (FF-B) in 26 and axillo-femoral bypass (AXF-B) in 2. No patients in the AF-B, TEA or AXF-B group showed postoperative early occlusion, while two in the FF-B group had early occlusion. The bypass flow measured intra-operatively using an electro-magnetic flowmeter was 50-1, 100 (average 382) ml/min in the AF-B, 190-500 (331) ml/min in the TEA, 90-650 (219) ml/min in the FF-B, and 200ml/min in the AXF-B group. Two patients died; one from ischemic colitis and the other from myonephropathic metabolic syndrome. The long-term cumulative patency rates at 1, 2 and 5 years were 100, 96, and 96% in the AF-B, 100, 100, and 100% in the TEA, and 90, 84, 63% in the FF-B group, respectively. The two AXF-B cases had good patency one year and three years postoperatively. AF-B should be recommended for aorto-iliac obstruction even in high risk patients as long as severe heart disease is absent, because of the long-term patency rate. An additional bypass to the popliteal region should be performed, if bypass flow to the distal region is low.

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Fifty-one cases which underwent surgery for arteriosclerosis obliterans in the aorta and iliac artery at the First Department of Surgery, Hiroshima University School of Medicine were divided into two groups. The EAB group (18 cases) underwent extra-anatomic bypass operation, and the AB group (33 cases) underwent anatomic bypass operation. A comparative study showed the mean age of the EAB group to be 10 years higher than that of the AB group, and the former group exhibited severer symptoms. Renal and pulmonary function declined in the EAB group, and the occurrence rate of complications such as cerebral infarction was also higher At operation, the following approaches were employed; long-term administration of PGE-1 before and after operation, operation with a better visual field under light general anesthesia, simultaneous reconstructive operation in peripheral lesions, artificial vessels of externally supported velour knitted Dacron. There was no case of obstruction in the past 5 years. Extra-anatomic bypass operation therefore provides as good postoperative patency as anatomic operation.

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During the period between January 1975 and April 1991, 37 patients with acute arterial occulusion of the extremities were admitted to our department and were classified into 2 groups according to their causative factors, including thrombosis and embolism. Among 16 thrombosis patients with involvement of 17 limbs, 4 patients died and 6 limbs were amputated at the time of discharge. On the contrary, among 21 embolism patients with involvement of 25 limbs, 2 patients died and only one limb was amputated. Sixteen of 17 limbs with thrombosis were operated on. Arterial reconstruction was carried out initially on 5 limbs, resulting in successful limb salvage; 3 of 6 limbs which had undergone thrombectomy initially were occluded again soon after the procedure. In the end, 1 limb had to be amputated. On the other hand, 22 of 25 limbs were operated on. Three arterial reconstructions, 18 embolectomies and 1 amputation were carried out initially. All arterial reconstructions and embolectomies were successful. From these results, it was concluded that arterial reconstruction must be done initially for thrombosis patients. For the embolism patients, embolectomy is preferable.

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A 74-year-old man presented with swelling in both lower limbs and fatigue. Venography indicated nozzle-like stenosis of the inferior vena cava that appeared during the inspiratory phase but disappeared during the expiratory phase. A large pressure gradient between the upper and lower portion of the stenosis was observed during the expiratory phase. Stenosis during the inspiratory phase was relieved by percutaneous transluminal angioplasty, and symptoms and signs disappeared. Although stenosis occurred only during the inspiratory phase, our patient exhibited symptoms characteristic of Budd-Chiari syndrome. We believe that this patient originally had stenosis of the diaphragmatic portion of the inferior vena cava, and that his symptoms derived from the formation of a parietal thrombus.

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In this study, the author evaluated surgical results in 4 patients over 80 years old (3 males and one female) who were among 24 patients with ruptured abdominal aortic aneurysm (RAAA) who underwent operation at our medical center between November, 1985 and June, 1992. While three patients survived, one, who had preoperative profound shock, died due to mutiple organ failure. The post-operative course of two of the survivors was uneventful, and the other developed non-oliguric renal failure but recovered without hemodialysis. The Fitzgerald classification of the RAAA in the non-survivor was group 4 and that in the 3 survivors was group 2 or 3. The extent of preoperative shock and volume of blood loss were associated with increased operative risk. In conclusion, aggressive resection of RAAA should be performed not only in younger parients but also in elderly patients such as those over eighty years old.

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The authors encountered 22 cases of congenital bicuspid aortic valve, some of which occurred in siblings. In this paper, a 58-year-old brother and a 56-year-old sister cardiac valve disease was diagnosed first at the age of 51 in the brother and at the age of 15 in the sister. Aortic valve replacement using a 21mm Medtronic-Hall prosthesis was done in both cases. Additionally, pacemaker implantation was carried out in the sister. Both cases showed favorable progress after operation. Hereditary factors are involved in congenital bicuspid aortic valve. Therefore if congenital bicuspid aortic valve are found in any patients, thorough investigations including cardiac auscultation, ECG and ultrasound cardiogram should be carried out routinely among immediate family members and relatives to reveal whether any of them is suffering from this congenital anomaly.

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It is known that the prognosis of preductal type coarctation of the aorta is poor because cardiac malformation is frequent in these cases. There have been very few reports on adult cases of the coarctation. We have recently carried out aneurysmectomy and reconstructed the descending aorta by a 30mm Veri-Soft tube graft for one adult case of descending aortic aneurysm associated with coarctation of the aorta. The patient was 49-year-old female. Segmental stenosis 5cm in length was demonstrated in the thoracic descending aorta immediately below the bifurcation of the left subclavian artery. The poststenotic dilatation was shown at the distal portion of the segmental stenosis. The postoperative clinical course was uneventful.

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Aortic valve replacement was carried out for aortic regurgitation in Behçet's disease. A prosthetic valve was fixed using reinforced felt-strip mattress sutures. Difficulty to ensure adequate myocardial protection due to ostial stenosis in the right coronary artery resulted in the occurrence of intraoperative myocardial infarction. Right ventricular assist with the help of a centrifugal pump was employed to obtain successful recovery from right cardiac failure. It was noted that at operation attention should have been paid to the aortic valve and also to abnormalities of the coronary artery and that control of the inflammatory reaction by steroids was essential before and after the operation.

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Cardiac surgery associated with idiopathic thrombocytopenic purpura (ITP) is rare, and only 10 cases have been reported in the literature. In this report, we described the successful surgical management of a patient with ITP, diabetes mellitus and malfunction of mitral bioprosthetic valve. A 62-year-old male, who underwent mitral valve replacement (MVR) by means of a Carpentier-Edwards valve prosthesis and CABG ten years ago, developed malfunction of mitral prosthetic valve. The preoperative platelet count was 52, 000/mm³ and PA-IgG elevated markedly. The diagnosis of ITP was based on findings of bone marrow examinations. Thrombocytopenia was treated by steroids for 4 weeks and large dose γ-globulin (20g/day) for 5 days preoperatively, but platelet count did not increase. Platelet rich plasma (PRP) was transfused prior to cardiopulmonary bypass (CPB) and fresh blood was added to the priming material of CPB. Re-MVR was performed by means of mechanical valve prosthesis. After operation, large doses of γ-globulin and transfusion of PRP were performed for 3 days, and the postoperative course was uneventful. Other reports in addition to this study reveal that cases of cardiac surgery associated with ITP should be initially controlled preoperatively with steroids or high-dose γ-globulin, and if these treatments are harmful or ineffective, splenectomy should be considered.

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Two cases that were surgically treated with atherosclerotic aortic aneurysm, followed by innominate artery aneurysm are reported. The causes of these aneurysms were determined to be arteriosclerosis and idiopathic inflammation. Blood flow reconstruction surgery using grafts was performed on these two patients. In one case, we also employed an internal shunt technique to prevent brain ischemia. It was speculated that this type of aneurysm develops not only in cases of inflammation, but also in multifocal arteriosclerotic vascular diseases. This type of aneurysm will probably increase in the future.

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A 55-year-old female with silent myocardial ischemia was admitted to our hospital for CABG. Her postoperative course was uneventful. However, after the initiation of oral nutrient intake on the first postoperative day, drainage from the anterior mediastinum increased to 600ml/day. The character of the fluid was milky and biochemical examination revealed that it had a high triglyceride content (925mg/dl). The patient was placed on a medium-chain triglyceride diet and intravenous hyperalimentation without success. On the sixth postoperative day, the mediastinum of the patient was re-explored. The fistula was located in the left side of the anterior mediastinum where the thymic tissue is located. The fistula was ligated and the chylorrhea ceased. The incidence of chylothorax after cardiac procedures through median sternotomy is rare. We recommend early surgical ligation of the fistula if the postoperative hemodynamic state of the patient is stable.

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