Leg edema following the harvest of great saphenous vein (SV) is sometimes recognized after coronary artery bypass surgery (CABG). Maximum venous outflow (MVO) is one of the parameters of leg venous function which is measured by straingauge plethysmography. To clarify the mechanism of the development of leg edema after CABG, we measured the perioperative MVO. Six patients had leg edema afer CABG (group I), 4 patients had no edema after CABG (group II). Six patients without edema after cardiac surgery, apart from CABG, were selected as controls (group III). The MVO of both legs was measured before and after the operation. In group I, venous echo or venography of the leg, or both, were performed after the operation. The MVO of legs from which SV had been harvested in group I decreased from 35.0±13.6 (ml/min/ 100ml tissue) to 23.9±7.6 (p=0.04) after the operation, but did not differ from the MVO of the contralateral leg. The preoperative MVO of legs from which SV had been harvested in group I was slightly higher than the legs of other groups. There was no significant change of MVO in group II or III after surgery. No deep vein thrombosis was shown in group I by venous echo and venography. Left ventricular ejection fraction, blood cell count and serum chemistry indicated no changes in any of the three groups after the operation except for the hemoglobin level in group I. These results suggested that the leg which had edema had a relatively high MVO before the operation. This MVO significantly decreased to the level of leg from which SV had not been harvested after the operation, and the edema appeared. In conclusion, postoperative edema in the leg from which SV was harvested was the result of a decrease in venous function due to removal of the SV. SV which causes leg edema might play the greater part of the venous return than others and the total function of the venous return was higher than normal at the point of preoperation.

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The results and surgical techniques were studied in 59 patients who had atherosclerotic lesions in the ascending aorta. Arterial grafting (AG) and sequential grafting for coronary artery bypass grafting (CABG) was used in as many as possible cases and the number of distal anastomoses with AG was 1.3/patient (internal thoracic artery (ITA), 56 anastomoses for 50 patients; gastroepiploic artery (GEA), 17; and inferior epigastric artery, 3). Calcification in the ascending aorta was noted in 26 patients and arterial cannulation was performed via the right axillary artery in 4 patients. Saphenous vein grafts were used for 51 patients and 30 of them required aortic reconstruction for proximal anastomosis. There were 2 hospital deaths (non-cardiac) and no neurological complications. It is difficult to perform CABG in the presence of atherosclerosis in the ascending aorta. However, the right axillary artery cannulation as the site of arterial cannulation and the use of sequential grafting, using ITA and GEA as the pedicled arterial conduits are useful to accomplish CABG in such patients. Neurological complication seems to be manufactured at a minimal level by cautious operative techniques.

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Postoperative hypoxia in 53 consecutively treat patients who underwent coronary artery bypass grafting (CABG) and who were weaned from mechanical ventilation were studied. The 29 patients who required high concentration oxygen (more than 70% H-group) were compared with the 24 patients who required lower concentration oxygen (less than 70% L-group). The preoperative body mass index (BMI) was significantly higher in the H-group (25.6±3.5) than the L-group (23.3±2.8). (p=0.012). Respiratory index (RI) decreased after extracorporeal circulation in all patients. The RI of the H-group during a stay in intensive care unit was significantly lower than that in the L-group. The RI in obese patients (BMI≥26.5) showed a significant reduction. Late deaths were seen in 3 obese patients in the H-group. These data suggested that careful postoperative respiratory managements is necessary in obese patients.

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Thrombomodulin is an endothelial cell membrane protein that is released into the blood in soluble forms in response to endothelial damage. We evaluated thrombomodulin in blood samples taken from the femoral vein before, during and after elective surgery for abdominal aortic aneurysm in 9 patients. Thrombomodulin was measured using an ETA assay. Thrombomodulin decreased significantly just before aortic declamp from before surgery (p<0.001), and remained unchanged just after and 1 hour after aortic declamp. Three hours after aortic declamp, thrombomodulin increased significantly from 1 hour after aortic declamp (p<0.01), peaked at 6 hours after aortic declamp and then decreased. These data suggest that thrombomodulin did not increase significantly during surgery for abdominal aortic aneurysm.

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Continuous warm blood cardioplegia (CWBC) was compared with cold crystalloid cardioplegia (CCC) with regard to postoperative cardiac function. 36 adult patients underwent CABG divided into two groups. The CWBC group (n=21) received continuous warm blood cardioplegia while the CCC group (n=15) received 4°C St. Thomas' Hospital cardioplegic solution. Some parameters or cardiac function, CK and CK-MB levels were measured at admission to ICU, and on the first and second postoperative day (POD) in both groups. The amount of dopamine and dobutamine were measured at admission to ICU and 6, 12, 18, 24 hours after admission to ICU in both groups. Cardiopulmonary bypass (CPB) time, aortic-cross clamp time and incidence of postoperative low output syndrome were similar in the two groups. The spontaneous return to sinus rhythm after aortic declamping was significantly higher in the CWBC group. The cardiac index measued at admission to ICU, 1 POD and 2 POD was significantly larger in the CWBC group. Pulmonary capillary wedge pressure and right atrial pressure measured at 1 POD and 2 POD were significantly lower in the CWBC group. Systemic vascular resistance measured at admission to ICU, at 1 POD and 2 POD were significantly lower in the CWBC group. Left ventricle stroke work index and left ventricle work index measured at admission to ICU were significantly larger in the CWBC group. Right ventricle stroke work index and right ventricle work index were similar in the two groups. The amount of dopamine at admission to ICU and at 6 and 12 hours after admission to ICU were significantly lower in the CWBC group. The amounts of dobutamine at admission to ICU and at 6, 12, 18 and 24 hours after admission to ICU were significantly lower in the CWBC group. CK levels measured at admission to ICU and at 1 POD were significantly lower in the CWBC group. CK-MB levels measured at admission to ICU, 1 POD and 2 POD were significantly lower in the CWBC group.

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The surgical results of 9 patients (group II) who were treated for thoracoabdominal aneurysm using left heart bypass combined with oxygenation were compared to those of 16 patients (group I) using left heart bypass without oxygenation. The left heart bypass time in group II was longer than that in group I, and the operations performed in group II were more extensive with more intercostal and lumbar arteries being reconstructed than those in group I. Nevertheless, bleeding associated with transfusion was less in group II than in group I. Intraoperatively, hypothermia and hypoxemia developed in 44% and 31%, respectively of group I, whereas neither of these conditions occurred in group II. There were three operative deaths in group I, compared with one in group II. Paraplegia was encountered in one patient of group I, but in none of the patients in group II. There were a few patients with respiratory failure or other organ failures in both groups. Our results showed that left heart bypass combined with oxygenation offered more stable and effective respiratory as well as circulatory support for a long duration compared to conventional left heart bypass without oxygenation in the surgical treatment of thoracoabdominal aortic aneurysm.

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The author encountered two cases of iliac arteriosclerotic occlusive disease with the clinical symptoms due to plaque rupture. Lower leg pain was noted at the subacute onset. Stenosis and niche-like opacification of a common iliac artery were indicated by angiography. The stenotic portions were resected and replaced by prosthesis. Leg pain subsequently disappeared. Macroscopic findings showed plaque rupture at the inflow surface of the iliac artery and blood entered the plaque. Acute arterial thrombosis may possibly occur by the same mechanism.

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We perform color Doppler scanning for all patients with leg varix as a preoperative examination. We discovered a case of leg varix with inverse placement of femoral artery and vein by color Doppler scanning and comfirmed it by operation. A 69-year-old female was admitted with a 30-year history of bilateral leg varix and with leg skin ulcer and dermatitis. Color Doppler scanning showed that the femoral vein was lateral to the femoral artery and that the great saphenous vein crossed over the femoral artery from medial side. This was confirmed on operation. This is the first report of this anomaly in Japan.

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Cystic adventitial disease of the popliteal artery is a rare cause of lower extremity occlusive disease. We report 2 cases of this disease. Two male patients aged 27 and 59 year old complaining of intermittent claudication visited our vascular service. Angiography showed a smooth sharp defect of the popliteal artery. Postcontrast computed tomography (CT) scanning and magnetic resonance image (MRI) showed a cystic lesion around the popliteal artery. One patient underwent resection of the cyst, which in the other patient endscopic surgery was performed with the aid of intravascular ultrasonograpy and intravascular endscope. Fifty three cases of this disease have been reported in Japan so far. These patients included 45 men and 8 women with a mean age of 47.7, ranging from 19 to 76 years old. Chief complaints were commonly intermittent claudication and sensory disturbance. In all cases, angiography revealed a smooth sharp defect. Recently 3D-CT scan, ultrasonography and magnetic resonance angiography (MRA) also are accurate for cystic lesions around the popliteal artery and these new technologies easily distinguish such cases from arteriosclerosis obliterans, Buerger disease and popliteal entrapment syndrome. Treatment consist resection of the cyst, in 27 cases reconstruction of the popliteal artery using a saphenous vein graft or artificial graft in 19 cases, percutaneus aspiration under the guide of CT and endscopy in 2 cases and 1 with spontaneous resolution, was seen in 1 case. In conclusion, we encountered 2 cases of cystic adventitial disease of the popliteal artery. 3D-CT scan, ultrasonography and MRA were useful for preoperative diagnosis and evaluation of postoperative condition.

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A case of successful surgical treatment for a ruptured infected aneurysm of the abdominal aorta is presented. A 63-year-old man was admitted with a history of persistent fever of unknown cause and lumbago. During medical treatment, a new abdominal pulsatile mass was revealed on physical examination. Leucocytosis and elevation of C-reactive protein were demonstrated. Abdominal echogram and CT scan showed a ruptured aneurysm of the abdominal aorta. Ruptured infected aneurysm of abdominal aorta was diagnosed, and an emergency operation was performed. We found a tight inflammatory adhesion around the aneurysm, but there was no abcess formation. The aneurysm had the mural thrombi and necrotic tissue. As usual infected tissue was removed as possible with aneurysmectomy, and an artificial graft was replaced. The culture of the aneurysmal wall tissue was negative, but the infiltration of the inflammatory cells, mainly neutrophilic segmented leukocytes, were found on pathological examination. He is doing well without recurrent infection at 8 months after operation. Twenty five cases of infected abdominal aortic aneurysm (AAA) were reported in Japan, and 21 cases of them received surgical treatment. Management of infected AAA is discussed.

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A Case of abdominal aortic occlusion caused by acute aortic dissection (DeBakey's type III b) is reported. A 59-year-old woman was admitted with sudden onset back pain and sensory disturbance of bilateral lower extremities. The pulsations of bilateral femoral arteries were absent. CT and aortogram revealed dissection of the thoracic descending aorta and infrarenal aortic occlusion. Since ischemic change had progressed, bilateral axillofemoral bypass was performed for limb salvage, and the symptoms improved rapidly. Axillofemoral bypass is an easy and safe procedure even in the acute phase of aortic dissection. It provides fast reperfusion, and so is considered to be useful to preventing myonephrotic metabolic syndrome MNMS.

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A case of pseudoaneurysm of the external iliac artery after a total hip arthroplasty is reported. A 48-year-old man had undergone a total left hip arthroplasty 5 years previously. Acute arterial occlusion (AAO) of the left lower extremity occurred 3 times. AAO was due to pseudoaneurysm of the external iliac artery, which was detected by rotating digital subtraction angiography (DAS). Aneurysmectomy and reconstruction were carried out. Rotating DSA was useful for the diagnosis of this unusual case of pseudoaneurysm of the external iliac artery after a total hip arthroplasty is unusual.

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A 63-year-old woman underwent coronary artery bypass grafting and mitral annuloplasty 4 years previously. She was readmitted owing to heart failure. Cardiac catheterization revealed worsened mitral regurgitation, although the internal thoracic artery (ITA) graft had good patency. Reoperation was performed by median resternotomy and continuous retrograde cardioplegia without clamping the ITA graft. The mitral valve had a perforation in the anterior leaflet, and was replaced by a 29mm Carbo-Medicus valve. The patient was discharged with transient myocardial ischemia. Although median resternotomy and continuous retrograde cardioplegia at reoperation provided on excellent view and myocardial protection, myocardial ischemia in the region perfused by the ITA graft may occur when the ITA graft cannot be clamped during continuous retrograde cardioplegia.

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A 59-year-old man was hit by a car in the back of the knees. He had a cold sensation and pulselessness in the right leg. He did not have bone fractures, but had dirty skin injuries in the back of bilateral knees. DSA revealed complete obstruction of the right popliteal artery and good collateral flow to the peripheral arteries in the right lower leg. We did not perform emergency operation because of the good collateral flow and dirty skin injuries. After the healing of the skin injuries, we performed popliteal artery reconstruction with autologous saphenous vein graft. The postoperative course was uneventful with successful patency of the graft.

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The patient was an 83-year-old man. He had pyloric stenosis due to Borrmann type III gastric cancer. He also had an abdominal aortic aneurysm 7cm in length. We performed gastrectomy and Y graft replacement simultaneously. His postoperative course was good. We discussed the operative indications and operative method, especially with regard to simultaneous operation.

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