We reviewed our experience with 4 cases of chronic dissecting aortic aneurysm (DeBakey IIIb) with the false lumen extending into the abdominal aorta and major branches being perfused from the false lumen. In such cases, resection of the intrathoracic portion of the aneurysm and closing of the distral false lumen may exclude visceral perfusion from the false lumen. In order to ensure continued perfusion of true and false lumens after repair, we performed “double barrel” anastomosis for distal anastomosis in graft replacement of the descending aorta. Follow-up periods ranged from 8 to 21 months, 17 months on average. Postoperatively, neither apparent expansion of the false lumen nor compression of the true lumen was found in these cases. The advantage of this procedure is the effective restoration of visceral perfusion. We emphasize that this procedure is one of the choices of procedures, as a two-staged approach for chronic aortic dissection presenting with visceral perfusion from the false lumen and without an enlarged abdominal aorta, though more patients and longer follow-up are required to fully evaluate this procedure.

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In coronary artery bypass grafting (CABG), a portable suction unit was used in the superior mediastinum to evaluate whether it is effective in decreasing the amount of mediastinal hematoma and the incidence of hematoma-related postoperative complications. Out of 179 consecutive patients who underwent CABG at the Matsuyama Red Cross Hospital, in 97 patients (Group 1), two drainage tubes were placed as usual in the inferior mediastinum, while in 82 patients (Group 2), a small drainage tube of the portable suction unit was additionally placed in the superior mediastinum. The total amount of postoperative drainage in Group 2 was larger than that in Group 1 but there was no statistically significant difference. The postoperative mediastinothoracic ratio expressed in comparison with the preoperative value was 134±22% in Group 1 and 123±15% in Group 2 on the first postoperative day (POD), and 133±20% and 122±14%, respectively on the seventh POD (p<0.001). Regarding postoperative complications, there were two cases of mediastinitis and five cases of late cardiac tamponade in Group 1 but none in Group 2. The difference in the incidence of these complications between the two groups was statistically significant (p<0.02). We conclude that the portable suction unit effectively decreased the amount of mediastinal hematomas and the incidence of mediastinitis and cardiac tamponade following CABG.

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The long-term efficacy of various treatments for intermittent claudication was studied to determine which regimen should be selected. Two hundred and nineteen patients with arteriosclerosis obliterans (ASO) and intermittent claudication of the extremities were divided into two groups based upon the type of treatment: 1) 170 patients who underwent arterial reconstruction and 2) 49 receiving conservative treatment. Fifty-five patients with Buerger's disease (TAO) with intermittent claudication were divided into three groups: 1) 17 patients who underwent arterial reconstruction, 2) 15 with lumbar sympathectomy, and 3) 23 receiving conservative treatment. The background factors of both disease groups were analyzed, and the changes in claudication, the quality of life, and the survival rate were followed up. Among ASO patients, the improvement of intermittent claudication was significantly better in the arterial reconstruction group (p<0.001) than in the conservative treatment group. The quality of life and 5-year surival rate were also superior in the arterial reconstruction group (p<0.01), and they were closely related to the improvement of intermittent claudication. On the other hand, there was no significant difference in any of these parameters between the three groups of TAO patients. This discrepancy in outcome was concluded to be due to differences in the background factors of the two diseases. Accordingly, the treatment for intermittent claudication should be discussed making a clear distinction between ASO and TAO. In conclusion, the treatment of choice for intermittent claudication is arterial reconstruction in ASO patients, whereas surgical treatment should only be considered for TAO patients when conservative therapy is ineffective.

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Among 232 patients undergoing repair for abdominal aortic aneurysms (AAA) during a 10-year period, 5 (2.2%) patients had evidence of inflammatory abdominal aortic aneurysms (IAAA). We examined their clinical course, laboratory, operative and histopathological findings, and considered possible correlations between their diagnosis and surgical treatment. Among these cases of IAAA, 2 patients complained of severe abdominal or back pain. The differential diagnosis from rupture of AAA was difficult in these cases. They also showed inflammatory signs in laboratory, operative and histopathological findings. Ultrasonography, computed tomography and magnetic resonance imaging appear to offer reliable means for diagnosing IAAA; In particular we could recognize the“Inflammatory mantle”in 3 cases, which indicated IAAA. In the surgical treatment, the presence of IAAA necessitates certain modifications in the surgical approach, in order to avoid injuring the retroperitoneal and abdominal structures. We could observe post-operative change in the thickness of the aortic wall, which decreases with time without anti-inflammatory agents.

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Topical cardiac hypothermia has unequivocal preservation effects during ischemia, but it has some disadvantages. Topical cooling, especially with ice slush, can injure the phrenic nerve, disturb the equal distribution of the cardioplegic solution due to coronary artery spasm and damage the epicardium. It is easy to prevent cooling injury without topical hypothermia, but the myocardial oxygen demands are increased. In order to supply the myocardium with oxygen for the increased oxygen demands during ischemia, isolated rat hearts were immersed in perfluorochemicals (PFC) which have excellent transportation of oxygen. The effects of immersion in PFC during mild hypothermic ischemia (at 20°C without cardioplegia and at 30°C cardioplegic arrest) on the cardiac function on reperfusion were evaluated. Under 20°C hypothermic ischemia without cardioplegia, cardiac beating was maintained for 20±4 minutes in the hearts were immersed in PFC, and for 10±2 minutes in the hearts that were not immersed in any solution. In the recovery of cardiac function (LVDP and LV_max dp/dt) after mild hypothermic (30°C) cardioplegic arrest, the hearts immersed in PFC showed better results than hearts that were not immersed.

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From 1976 to 1993, 13 patients with high aortic occlusion were treated surgically. Bypass grafting from infrarenal abdominal aorta to the iliac or femoral arteries was performed in 9 patients, endarterectomy with patch angioplasty in 2, thrombectomy followed by straight graft replacement in 1 and bilateral axillo-femoral artery bypass grafting in 1. In 9 patients, femoro-popliteal run-off was determined by arteriography before or during operation. Occlusion of the femoral artery was detected in two patients, and femoro-popliteal bypass grafting was simultaneously performed with aortic revascularization. Two patients died in the early postoperative period (1: fulminant hepatitis, 1: cerebral infarction), and 4 patients died in the late postoperative period (2: ischemic heart disease, 1: cerebral bleeding, 1: malignant tumor). In one patient the iliac artery occluded 13 years after endarterectomy. All other patients showed patent grafts and satisfactory conditions. In cases of high aortic occlusion, late postoperative results were satisfactory after anatomical revascularization. Ischemic heart disease and cerebral vascular accident were important concerning late complications. Postoperative careful follow-up is necessary.

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CHDF was applied to 8 patients who developed acute renal failure following cardiogenic shock. Four of 8 patients also underwent PCPS (percutaneous cardiopulmonary bypass) and all were weaned from PCPS. Five patients were weaned from CHDF. CHDF was very effective to control the concentration of serum potassium, creatinine, blood urea nitrogen and diuresis.

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Left ventricular wall motion was evaluated after mitral valve replacement (MVR). MVR for mitral regurgitation (MR) was performed with preservation of both anterior and posterior chordae tendineae (Group I, n=12) or posterior chordae tendineae (Group II, n=9). MVR for mitral stenosis was performed with the preservation of the posterior chordae alone (MS Group, n=12). Postoperative regional wall motion was analyzed from the shortening fraction (SF) of the centerline method in 5 of antero-basal (AB), anterolateral (AL), apical (AP), diaphragmatic (DP) and posterobasal (PB) regions. The percentage of post-operative SF for preoperative value (%SF) was compared between Group I and Group II. The value of %SF improved much more in Group I than in Group II at the AL and AP regions. %EF was more significantly increased in Group I than in Group II, although postoperative ESVI and EDVI decreased in both groups. In the MS Group, EF, ESVI and EDVI did not change after surgery. The regional wall motion improved except in the calcified PB region. These results demonstrated that the preservation of both anterior and posterior chordae tendineae for MR was a useful procedure to improve postoperative LV regional wall motion. The preservation of posterior chordae for MS was sufficient to improve the regional wall motion except in the calcified submitral region.

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The effectiveness of recombinant human erythropoietin (rHuEPO) was evaluated in elderly patients who underwent coronary artery bypass grafting. A total of 133 patients were divided into three groups: those who were 70 years of age or older and received rHuEPO (group I; n=32), those who were also 70 years of age or older but did not receive rHuEPO (group II; n=35), and those who were 60 years or younger and received rHuEPO (group III; n=66). In 87.5% of group I, 42.9% of group II, and 98.5% of group III, homologous blood transfusion could be avoided. The percentage of patients without homologous blood transfusion was significantly higher in group I than in group II (p<0.001). The rate of homologous blood transfusion was significantly higher in group I than in group III (p<0.05), but rHuEPO had equal effects in terms of increase in hemoglobin level in the two groups. Furthermore, in patients without anemia, the rate of homologous blood transfusion was almost the same in the two groups. In conclusion, the administration of rHuEPO enables even elderly patients to undergo coronary artery bypass grafting without homologous blood transfusion.

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We reported a rare case of myxoma originating from the anterior leaflet of the mitral valve. A 65-year-old woman was admitted with sympotomes of easily fatigability and palpitation. On auscultation, a grade II/IV systolic murmur was audible at the apex. Echocardiography demonstrated a dense mass arising from the anterior mitral leaflet. The tumor (16×13×10mm in size) was resected from the anterior leaflet of the mitral valve. There was no definite evidence of a tumor stalk on the mitral valve nor valve regurgitation after the operation. Microscopically, polyhedral cells were recognized, indicating myxoma. The postoperative course was uneventful and no recurrence has been noticed during the past 6 years.

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A 67-year-old man receiving treatment for choledocholithiasis was found to have an abdominal aortic aneurysm on CT. The maximum diameter of the aneurysm was 60mm, and the isthmus of a horseshoe kidney was also observed. A total of four renal arteries, two each on the right and left sides, was detected by angiography and helical CT. Two of four arteries bifurcated from the aneurysm. Laparotomy confirmed the presence of a fifth renal artery, which extended from the left common iliac artery to the isthmus. It was not difficult to free the isthmus from the aneurysm. A Y-shaped prosthesis was placed between the normal portion of the aorta and the common iliac arteries without severing the isthmus. The left renal artery arose from the aneurysm and was reconstructed with 6mm knitted Dacron. The right renal artery, which was located below the isthmus, was ligated. The absence of postoperative renal dysfunction confirmed the patency of the reconstructed renal artery. Eleven such cases have been reported in Japan, including the present case. In 5 cases, renal artery reconstruction was performed, and the isthmus was preserved in 8 cases. However, the sites of renal artery bifurcation were correctly detected preoperatively in only 3 of these patients. It appears that accurate preoperative imaging is very important, along with renal artery reconstruction.

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We experienced 2 cases of abdominal aortic aneurysm (AAA) with malignant tumor of urinary organs. Case 1 was a 70-year-old man who was admitted for aortic dissection (De Bakey IIIb) with coexistence of AAA and left renal cancer. After the pseudolumen of the aortic dissection became thrombotic, the abdominal aortic aneurysmectomy and left nephrectomy were performed simultaneously. Case 2 was a 75-year-old man with AAA and prostatic cancer. He was treated by a one-stage operation consisting of aneurysmectomy, prostatectomy and castration. The postoperative courses were uneventful without prosthetic graft infection. Chemohormonal therapy could be induced one month after the operations. Concomitant resection of urinary malignant tumor and abdominal aortic aneurysmectomy may be feasible even in older patients.

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A 62-year-old woman, who received implantation of a prosthetic graft for treatment of a descending aortic aneurysm 15 months previously, was admitted with hemoptysis. An aortogram demonstrated communication from the distal anastomosis to S⁶ of the left lung. After removal of the aorta across the distal anastomosis concomitantly with left lower lobectomy, we replaced a short segment of the graft. Culture of the pus obtained from the anastomotic site was positive for MRSA. Postoperatively, although the left pleural cavity was irrigated continuously with 1% popidone iodine solution, massive bleeding from the distal anastomosis appeared again 2 weeks later. This time, to remove the infected graft as much as possible, two extraanatomical bypasses were created between the right axillary and right femoral arteries, and the ascending and abdominal aorta. The closed prosthetic and aortic stumps were covered by a viable omental flap. Four months later, bleeding occurred again at the site of the proximal anastomosis. The last radical surgery was performed extrapleurally through a trapdoor thoractomy made in the left infraclavicular region. There was a 1.5cm long laceration of the aorta just proximal to the oldest graft-aortic anastomosis. The aorta was divided and closed between the left common carotid and subclavian arteries. The left subclavian artery was ligated at its origin. The pleural cavity was continuously irrigated with popidone iodine to clean up the microorganisms. She was discharged from the hospital on the 258 POD and has been doing well since then.

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We present one case of true aneurysm of the branchial artery which is very rare among peripheral aneurysms. A 52-year-old woman developed a bruise on the right upper arm around June 1993, but did nothing about it because she felt no symptoms. A pulsating mass became palpable at this site around the following month. Digital subtraction angiography revealed an aneurysm formation of 1.5×1.5cm in size in the right brachial artery. Operative findings showed that the wall of the aneurysm joined the normal region and all the vascular layers in the aneurysm were maintained. After resection of the aneurysm, end-to-end anastomosis was carried out. A diagnosis of true aneurysm was confirmed by the pathohistological findings that the vascular three-layer structure was maintained, with few arteriosclerotic changes.

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A 78-year-old man underwent successful removal of a contaminated pacemaker in a case of methicillin-resistant Staphylococcus aureus (MRSA) septicemia. Septicemia was due to a subcutaneous abscess at the site of old cut electrodes. Following debridement of the infected pacemaker pocket, residual leads and the pacemaker system were removed under cardiopulmonary bypass. Bacterial examination of arterial blood and vegetation attached to the leads showed septicemia caused by MRSA. After the operation, antibiotic therapy with vancomycin, arbekacin and minocycline was performed for several weeks. His postoperative course was uneventful without the recurrence of infection. In cases of pacemaker contamination, with septicemia, total removal of the pacemaker system and adequate antibiotic therapy are necessary.

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