Immediate surgical intervention is required for Stanford type A aortic dissection. However, the surgical results of emergency surgery are still poor, especially in patients associated with myocardial ischemia. This study was undertaken to evaluate the surgical results of acute type A aortic dissection in association with myocardial ischemia. In the past six years 7 cases of acute type A aortic dissection underwent surgical repair with simultaneous coronary-artery bypass grafting (CABG). There were 5 male and 2 female with a mean age of 47±16 year-old. The causes of myocardial ischemia were proximal progression of dissection into the coronary orifice in 5 and association of atherosclerotic coronary heart disease in 2. Six patients developed cardiogenic shock before surgery. Bentall's type of operation was performed on 4 patients and prosthetic graft replacement of ascending aorta was performed on 2 patients. Single bypass grafting was performed on 5 patients and double bypass grafting was performed on 2 patients. One patient died due to brain damage and acute renal failure on the tenth postoperative day, and another patient required left ventricular assist device for 9 days due to postoperative low cardiac output syndrome. Ultimately 6 patients (86%) survived and were discharged. In conclusion, surgical management is not easy for the emergency patients with type A acute aortic dissection in association with myocardial ischemia, however, reasonable surgical results can be obtained with supplemental CABG and mechanical support of the left ventricle.

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Purpose. To determine the involvement of leukocytes in reperfusion injury following acute arterial occlusion of the lower extremities, the effect of leukocyte removal filters or leukotrien B4 (LTB4) antagonist was investigated using a canine acute arterial occlusion model. Methods. Twenty-eight mongrel dogs, weighing 15 to 20kg, underwent temporal occlusion of the infrarenal aorta and lumbar arteries followed by release of occlusion 12 hours later. Experimental groups consisted of the three following groups: Group I (n=12; control), dogs without any treatment; Group II (n=8), dogs treated with leukocyte removal filters from the onset of reperfusion until one hour after reperfusion; and Group III (n=8), dogs pretreated with LTB4 antagonist immediately before reperfusion. Serum myoglobin, CPK, and GOT were measured and compared among the three groups. Results. Values of serum myoglobin, CPK, and GOT, were significantly elevated after reperfusion in Group I as compared to those before reperfusion. However, increase in these values was significantly elevated after reperfusion in Group I as compared to those before reperfusion. However, increase in these values was significantly attenuated in Group II and Group III as compared to Group I. Conclusions. These data suggested leukocyte depletion injury following acute arterial occlusion of the lower extremities. Leukocytes appear to play a significant role in this type of reperfusion injury.

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Purpose. To investigate deteriorating effects on systemic organs due to actute arterial occlusion of the lower extremities, ultrastructural changes of the heart and lung after temporal occlusion of the abdominal aorta for 24 hours were examined with transmission electron microscopy (TEM). Methods. Fifteen mongrel dogs, weighing 10 to 15kg, underwent temporal occlusion of the infrarenal aorta and lumbar arteries followed by release of occlusion and restoration of circulation 24 hours later. After three-hours' reperfusion, the heart and lungs were excised for pathological evaluation with TEM. Experimental groups were divided into three groups according to the maximum values of CPK (group I, max CPK≤10000; group II, 10000<max CPK≤40000; group III, max CPK>40000 (IU/L)), which had been measured during and after the reperfusion period. Results. TEM examination revealed the following findings in the myocardial tissue: slight cell edema of the myocytes, disruption of the myofibrils, swelling of the mitochondria, interstitial edema, type III bleb formation, cellular edema of endothelial cells and intravascular hemostasis. Pathological findings in the lung tissue included: pulmonary edema, congestive atelectasis, edema of Type I lung epithelial cells and increased neutrophils in the capillary. These findings were significantly remarkable in groups II and III as compared to group I. Conclusions. Elevation of CPK values after the reperfusion period correlated well with the degree of cell damage in the heart and lungs. Free radicals generated during the reperfusion period and their related pathways may play a significant role in the development of cardiac or pulmonary failure after acute arterial occlusion of the lower extremities.

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Preoperative and postoperative evaluation was conducted on 25 patients (33 lesions) with arteriosclerosis obliterans (ASO) by three-dimensional CT angiography (3D-CTA) and intraarterial digital subtraction angiography (IA-DSA). The usefulness and problems of 3D-CTA for diagnosis of ASO were studied. Both methods had equal ability to detect lesions in the area of the iliac artery and the femoral artery. Totally occlusive lesions were accurately diagnosed by 3D-CTA, but diagnosis of stenotic lesions was much less accurate. To confirm blood flow following vascular reconstruction 3D-CTA was useful and IA-DSA was not required. 3D-CTA images can be obtained from desired directions and clearly detect calcification and blood clots with little health risk involved. They are useful for the diagnosis of ASO.

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We treated 261 arteriosclerosis obliterans cases with critical leg ischemia since 1976. Those patients aged 75 years and older were designated as the elderly group and were compared with those under 75 years of age. Among the elderly patients with critical leg ischemia, the percentages of women and Fontaine scale IV cases were higher. The condition of those who had to undergo an initial major amputation was often complicated by cerebrovascular diseases, resulting in a higher early death rate after operation. Therefore, the necessity of early diagnosis and immediate treatment must be emphasized. There were no differences in patency and limb salvage rates between the two groups. In cases of arterial reconstruction however, graft occlusion in the elderly group immediately after operation was frequently observed. It is important to include drug therapy in follow-up to prevent occlusion of the graft following surgery in elderly patients.

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The authors examined the frequency of thromboembolism and bleeding complications in cases of mechanical valve replacement during the past 5 years in the Tokyo area. There were 21 cases of thromboembolism and 15 cases of bleeding complications. Analyzing these cases with regard to anticoagulant therapy, 71% of the thromboembolism cases and 47% of the bleeding complication cases had 10∼25% result on the thrombotest at the time of the event. Consequently, in cases of mechanical valve replacement it is necessary to reevaluate the therapeutic range of the thrombotest results. This was a retrospective study of a TAS (The Tokyo area anticoagulation study for cardiac valve replacement by using PT-INR) trial and we intend to carry out a prospective study on the therapeutic range of the thrombotest and PT-INR.

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A 58-year-old woman, had received a transvenous permanent pacemaker was the subject of this study. Cervical phlegmon, induced by gastroduodenoscopy infected the tract of the transvenous pacemaker lead inserted into the left subclavian vein by the puncture method. Local management was unsuccessful, and consequently, microbial endocarditis developed with tricuspid valve vegetation. Removal of the entire system under cardiopulmonary bypass successfully eliminated the infection. It is neccesary that pacemaker patients undergoing procedures that may be associated with infections receive prophylactic antibiotics before such procedures. Patients with pacemaker infections should undergo aggressive total removal of the pacemaker system at an early stage of infection, particularly in cases with bacteremia.

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A 49-year-old man with impaired left ventricular function successfully underwent a one-stage operation of coronary artery bypass grafting (CABG) and replacement of infrarenal abdominal aortic aneurysm (AAA). Left ventricular ejection fraction, left ventricular end-diastolic and mean pulmonary artery pressures were 24%, 25mmHg and 33mmHg, respectively. The AAA was 6cm in diameter and accompanied by bilateral common iliac artery aneurysm. After completion of CABG, AAA replacement was performed during extracorporeal circulation. There were no hemodynamic changes associated with aortic clamping or declamping under the mechanical cardiac assist during AAA surgery. This procedure appeared to be a feasible one-stage procedure in patients with AAA and coronary artery disease accompanied by impaired left ventricular function.

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Aberrant right subclavian artery is a common congenital anomaly of the aortic arch, with a reported prevalence of approximately 0.5%. However aneurysms of this aberrant vessel are very rare. A 71-year-old man was admitted with cerebral hemorrhage. Chest X-ray revealed an abnormal upper mediastinal shadow. Angiography, computed tomography (CT) scan, and magnetic resonance (MR) imaging revealed an aberrant origin of the right subclavian artery arising as the fourth branch of the aortic arch and crossing the mediastinum from left to right indenting the esophagus posteriorly. The origin of the right subclavian artery was aneurysmal (maximum diameter was 5cm), and this aneurysm did not compress the esophagus. The patient was treated by Dacron patch graft aortoplasty and right subclavian artery reconstruction with the aid of cardiopulmonary bypass and hypothermic selective cerebral perfusion. The postoperative course was uneventful and there were no major complications. The surgical technique is detailed as well as a review of all the cases in the literature.

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Patient 1 was a 62-year-old woman who had been treated for hypertension for three years. Stanford A type acute aortic dissection occurred accompanied by right coronary ischemia. CABG and graft replacement of the ascending aorta were performed 8 hours after the onset of coronary ischemia, but after cardiopulmonary bypass the patient could not be weaned from the RVAD because of right ventricular infarction. On the 8th day after operation, she died due to right heart failure. Patient 2 was a 72-year-old male. Stanford A acute aortic dissection occurred and right coronary ischemia appeared during UCG examination in the ICU. CABG and graft replacement of the ascending aorta and the aortic arch were carried out less than 1 hour from the onset of coronary ischemia. The postoperative course was satisfactory and uncomplicated. If the dissection extends to the aortic root, it is important to monitor the ECG carefully to detect myocardial ischemic changes. In cases with coronary ischemia, early operation and CABG are mandatory.

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A 64-year-old man was admitted with intermittent high fever of 4 months duration and with three episodes of arterial embolism in the previous 2 months. Several investigations revealed evidence that those episodes involving bilateral popliteal arteries and the left external iliac artery originated from mycotic emboli. Severe mitral insufficiency due to infective endocarditis was also recognized. The ischemic symptoms improved after medical treatment. Despite antibiotic therapy for 4 weeks, inflammatory signs did not subside. Since aneurysm formation of the left external iliac artery at the embolized portion was detected on CT, mitral valve replacement and aneurysmectomy with femoro-femoral grafting were done concomitantly. Inflammatory signs disappeared immediately after the operation. Pathological findings indicated organization of the mitral vegetation and evidence of active infection in the aneurysm wall. Though aneurysmal change of a symptomatic embolized site is not common, the preoperative evaluation of possible associated mycotic aneurysm is important to decide on surgical strategy for infective endocarditis complicated by embolism.

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Two patients, a 32-year-old man and a 23-year-old woman, underwent successful reoperations 22 and 18 years after radical repair of the tetralogy of Fallot (TOF). The former patient had a diagnosis of pulmonary stenosis and aortic regurgitation due to infective endocarditis. Patch reconstruction of the right ventricular outflow tract (RVOT) and aortic valve replacement were performed. The latter patient was diagnosed as having pulmonary stenosis and a recanalized ventricular septal defect (VSD), followed by patch reconstruction of the RVOT and direct closure of a residual VSD. Reoperation 15 years or more after radical repair of TOF is rare. Only 15 such cases including the present two have been reported in Japan.

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A 13-year-old girl with asplenia syndrome who previously had undergone left subclavian-to-pulmonary artery shunt after removal of a cavopulmonary shunt with interposition of a short segment of the left superior vena cava was admitted for congestive heart failure. Angiography revealed aneurysmal dilatation of the left superior vena cava. Percutaneous coil embolization of the shunt was successfully performed and the venous aneurysm was diminished. Interposition of a venous component in systemic-to-pulmonary artery shunt should be avoided even after removing a cavopulmonary shunt.

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A 52-year-old male was diagnosed as having aortic stenosis secondary to a bicuspid aortic valve associated with Klippel-Feil syndrome. Aortic valve replacement was successfully performed without any problems in the surgical or anesthesiological management. Only five such cases including ours, who underwent cardiac surgery have been reported. It is possible to perform cardiac surgery for patients with Klippel-Feil syndrome of their cardiac function can be well preserved.

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Isolated left-side inferior vena cava is rare, there being only four cases associated with abdominal aortic aneurysm reported so far in the Japanese literature. A 72-year-old man was admitted to our hospital for the evaluation of an abdominal pulsatile mass. CT scan revealed abdominal aortic aneurysm with isolated left-sided inferior vena cava. Aneurysmectomy and bifurcated graft replacement was performed with retracting inferior vena cava. The postoperative course was uneventful.

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