During a period of 5 years from January 1991 to December 1995, one-stage operation was performed on 10 cases with ischemic heart and occlusive peripheral vascular disease, excluding cases combined with AAA (abdominal aortic aneurysm). They were composed of 7 men and 3 women whose mean age at time of surgery was 65.8 years. The mean number of coronary artery bypass grafts made was 2.2. The procedures employed for occlusive peripheral vascular disease were TEA (thromboendarterectomy) of the internal carotid artery in 2 cases, aorta-subclavian bypass in 2 cases, aorta-bilateral common iliac artery bypass in 1 case, interposition of the common iliac artery in 1 case, aorta-external iliac artery bypass in 1 case, F-P (femolo-popliteal) bypass in 3 cases (4 bypasses), and F-T (femolo-tibial) bypass in 1 case. Mean operation time was 428 minutes, mean extracorporeal circulation time was 121 minutes, and mean aortic cross-clamp time was 61 minutes. Blood transfusion was not made in 4 cases. There was one operative death in a case of MNMS (myonephropatic metabolic syndrome) with emergency IABP (intraaortic balloon pumping) insertion following complication of PMI (perioperative myocardial infarction). A comparative study was made with 183 non-emergency cases of CABG (coronary artery bypass graft) conducted during the same period. Operation time was longer in cases of one-stage operation, but no significant difference was observed in operative mortality rate, rate of cases not requiring blood transfusion, days of intubation, and postoperative hospitalization duration. The surgical procedure was relatively safe.

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This clinical study was peformed to clarify the postoperative cardiac functions after coronary artery bypass graft surgery in the cases associated with decreased left ventricular ejection fraction (EF) or increased end-diastolic volume index (EDVI). The patients were divided into two groups by preoperative EF. The EF of Group I ranged from 31 to 39% in 42 cases, and the EF of Group II was below 30% in 27 cases. Several parameters of cardiac function such as EF, peak ejection rate (PER), peak filling rate (PFR) or early diastolic peak filling rate were evaluated with radionuclide ventriculography. Postoperative mean values of these parameters significantly improved in both Group I and Group II compared to preoperative values. Although these parameters and left ventricular wall motion did not improve in the 7 cases with an EDVI over 140ml/m² in Group II, the clinical results of these 7 cases were good during the follow-up period except one case which preoperatively had frequent ventricular arrythmia. The clinical condition improved remarkably in the 3 patients who had preoperative angina pectoris among these 7 cases. Surgical indications must be carefully determined in cases with increased EDVI and frequent ventricular arrythmia.

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Eight patients with multiple aortic aneurysms of both the thoracic and abdominal aortae treated surgically from 1991 to 1995 were evaluated clinically. The patients consisted of six men and two women, with an average age of 65.6 years ranging from 50 to 73. The incidence of multiple aortic aneurysms was about 10% of all cases of aortic aneurysms. The entire aorta should be examined in all patients with aortic aneurysms. Among the five patients who underwent a two-staged operation, the thoracic operation preceded the abdominal one in one case, and the abdominal operation preceded the other in four cases. No aneurysm rupture occurred in the two-staged cases. In conclusion we should first replace the aneurysm with the higher risk of rupture. However, when such a judgement is difficult, it is improtant to consider the possibility of a rupture of the second aneurysm or a brain infarction caused by a thrombosis moving from the abdominal aneurysm. The order of operation should be decided according to the location and the size of the thoracic aneurysm.

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A follow-up study of 98 patients undergoing abdominal aortic aneurysm (AAA) repair for 44 months, ranging 2 to 113 months, revealed no difference in 5-year actuarial survival between patients aged 75 or older and patients aged less than 75. The 5-year actuarial survival of ruptured and nonruptured AAA cases was 469% and 71.2%, respectively (p<0.01). Late deaths after the repair of ruptured AAA were all due to atherosclerotic diseases. During a follow-up period after AAA repair, 9 patients were diagnosed as having malignant diseases with a fatal outcome in 6. Careful attention to atherosclerotic and malignant diseases is indispensable for follow-up management after AAA repair.

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It has been reported that the left internal thoracic artery (LITA) should be used for CABG when its free flow is more than 40-80ml/min. In the past 6 years, 120 cases of CABG have been performed in our institution. In 71 of these 120 cases, LITA was anastomosed to the left anterior descending coronary artery (LAD). These 71 cases can be divided into the following two groups: Group L consists of 14 cases, in which LITA-FF was less than 20ml/min. Group H consists of 57 cases, in which LITA-FF was 21ml/min or more. In all cases, LITA was dissected by electrocauterization. Papaverine administration and balloon dilation of LITA were not employed. We performed a comparison study between the groups based on post operative coronary angiographic findings. In group H, LITA graft occlusion was identified in 3 cases, and “string sign” in 7 cases. In group L, “string sign” was identified in only 1 case, and there was no LITA graft occlusion. There was no significant difference between the two groups. Satisfactory results of early graft patency were achieved as follows: 94.7% in group H, 100% in group L. These results suggest that LITA can be used for CABG, even when the free flow is less than 20ml/min.

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There are various problems associated with the surgical management of concomitant abdominal aortic aneurysm (AAA) and gastrointestinal malignancy. Our surgical strategy for the treatment of concomitant AAA and gastrointestinal malignant diseases, with the exception of colorectal diseases is basically a one-stage operation. This report reviews 6 cases involving concomitant AAA and gastrointestinal malignancy (colon cancer in 3 cases, gastric cancer in 2 and hepatoma in one). In 2 cases involving gastric cancer, we selected a one-stage operation for the coexistent AAA and gastrointestinal malignancy. The postoperative courses were uneventful. In a 69-yearold man with concomitant AAA, hepatoma and ischemic heart disease, a hepatectomy and coronary revascularization preceded AAA repair because the AAA diameter was too small. AAA repair was performed after 4 months when its diameter had been enlarged. In one of the 3 cases involving concomitant AAA and colon cancer, the malignancy was resected first and the patient died of recurrence 7 months after the operation and prior to the operation for AAA. In the second case of colon cancer, AAA repair preceded the resection of the malignancy. A right hemicolectomy was performed 53 days after the AAA operation. The third case had a one-stage operation for coexistent AAA and colon cancer. His postoperative course was uneventful. In this case, we took particular care to avoid graft infection. The 5 cases that underwent both operations have survived without major complications or evidence of recurrence during a follow-up period ranging from 2 months to 4 years.

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A comparison was made of the three-dimensional CT angiography (3D-CTA) images of four grafts (IMPRA, Bionit, GELSOFT, and saphenous vein). All patent grafts were visualized by 3D-CTA, and opacification of the graft interior was noted in all cases on transverse sections of CT. Occluded GELSOFT and saphenous vein grafts could not be visualized by 3D-CTA. In spite of occlusion, IMPRA and Bionit were visualized by 3D-CTA. However, opacification of the graft interior could not be noted on transverse sections of CT. Confirmation should be made of the following: 1. distal portion of native artery shown on 3D-CTA, 2. recognition of opacification (high density) of graft interior on transverse sections of CT. When the CT threshold changed, occluded IMPRA and Bionit showed spotty images. This phenomenon should facilitate accurate diagnosis.

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To avoid homologous blood transfusion, the effectiveness of autologous blood predonation was evaluated in patients with elective abdominal aortic aneurysm (AAA) repair. From January 1993 to July 1996, 53 patients underwent Y graft replacement by using autologous rapid transfusion device AT1000^® (Electromedics. Inc, Englewood, CO). The patients were devided in to 3 groups. Thirty one patients had no blood donation (Group A). Twelve patients had 400ml blood donation with administration of an iron preparation (Group B). Ten patients donated the same amount of blood as those in Group B, with administration of both an iron preparation and recombinant human erythropoietin (rHuEPO) (Group C). There were no significant differences in terms of age, gender, operating time, intraoperative bleeding, and total amount of homologous and autologous blood transfusion in the 3 groups. In Group A, the mean volume of homologous blood transfusion was 250±370ml and in both Groups B and C, no homologous blood was required and 400ml autologous blood was used. Homologous blood transfusion was avoided in 58.9 (18/31) of patients in Group A and all of the patients in Groups B and C. Due to the blood predonation prior to surgery, a hemoglobin level decreased significantly at the time of operation in Group B (without rHuEPO), but in Group C (with rHuEPO) the hemoglobin level was kept constant. During the first postoperative week, the minimum hemoglobin level in Group C was significantly higher than in the other groups. In conclusion, by donating 400ml autologous blood before surgery and using an intraoperative autotransfusion system, homologous blood transfusion could be avoided in elective AAA repair. With rHuEPO, the hemoglobin level could be maintained, despite predonation and intraoperative blood loss.

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Morphology, location, timing of operation, and complications of multiple aortic aneurysms were investigated in 14 patients (10 men and 4 women with a mean age of 66 years). The locations of the aneurysms were as follows: aortic arch and thoracoabdominal aorta in 1, aortic arch and infrarenal abdominal aorta in 6, descending thoracic aorta and suprarenal abdominal aorta in 1, descending thoracic aorta and infrarenal abdominal aorta in 5, and thoracoabdominal aorta and infrarenal abdominal aorta in 1. Thoracic aortic aneurysms had a mean diameter of 63±13mm. The mean diameter of the abdominal aortic aneurysms was 54±13mm. In 1 patient, thoracoabdominal and infrarenal abdominal aortic aneurysms were operated on simultaneously. Eight patients, 5 with aneurysms of the aortic arch and infrarenal abdominal aorta, 2 with aneurysms of the descending aorta and infrarenal abdominal aorta, and 1 with aneurysms of the aortic arch and thoracoabdominal aorta, underwent two-staged operation. Aortic arch aneurysm was operated first in 3 patients, and abdominal aortic aneurysm in 5. Postoperative complications included spinal cord injury in 1 patient, bowel necrosis in 1, renal impairment in 2, respiratory impairment in 2, and hepatic impairment in 1. There was no perioperative death. Three late deaths occurred. Two staged operation is better for multiple aortic aneurysms. The first operation should be performed for the larger aneurysm.

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An 81-year-old woman with severe chest pain was admitted to our hospital. Computed tomography showed aortic dilation and a non-enhanced crescentic area in the ascending aortic wall, indicating a DeBakey type-II aortic dissection with thrombus. The ascending aorta was replaced with an impregnated knitted Dacron graft. Fresh clotted hematoma was found in the dissected ascending aortic wall, and the intimal surface was involved with a local atherosclerotic ulcer penetrating the media. Operative findings were compatible with intramural hematoma due to penetrating atherosclerotic ulcer described by Stanson et al. In the literature most penetrating atherosclerotic ulcers are located in the descending aorta, thus this case is rare.

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A 9-year-old boy was first noted to have a heart murmur on the 7th postnatal day. Cardiac catheterization at the age of 4 months showed combined valvular and supravalvular aortic stenosis, bicuspid aortic valve and hypoplastic aortic annulus. Emergency open aortic valvotomy was performed. At the age of 6 years, he had infectious endocarditis which was treated medically. Echo-cardiography at this time showed a 90mmHg pressure gradient across the aortic valve. In August 1992 and in March 1993, ballon valvuloplasties were done but without a significant reduction in the pressure gradient. In July 1993, when the patient was 7 years old, repeated surgical valvotomy and Doty's aortoplasty were performed. Two years later the boy had exertional dyspnea, and a cardiac catheterization showed pulmonary artery pressure of 60/27mmHg, and a 110mmHg pressure gradient across the aortic value. In July 1995, he underwent aortic valve replacement with Konno's aortoventriculoplasty, and a SJM 19mm AHP valve was implanted. One year after surgery, he is without any symptoms. Although the end result was acceptable, earlier AVR with Konno procedure may have spared the child from one extra surgical procedure. Strategic options in the surgical therapy of this condition are discussed.

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We encountered a recurrent suprarenal abdominal aortic aneurysm (AAA) patient with coronary artery disease and hyperlipidemia after repair of infrareanal AAA. A 72-year-old woman complaining of an abdominal throbbing mass was admitted. Computed tomography (CT) and aortography revealed infrarenal AAA which was totally removed and Dacron graft was replaced. The patient was followed as an outpatient. At the time of initial graft replacement there was no remarkable aneurysmal change in suprarenal abdominal aorta. Five years after the initial operation, a suprarenal AAA 5cm in diameter was detected by ultra sonographic examination. CT scan and aortography confirmed suprarenal AAA involving the celiac trunk of the supramesenteric artery and renal artery. Redo AAA operation with reconstruction of these branches was performed under V-A bypass support in a thoracoabdominal approach. Slight renal and liver dysfunction occurred postoperatively. However, serum creatine GOT and GPT values normalized by the ninth postoperative day. Postoperative aortography revealed patency of all branches.

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Total aortic arch repair was performed simultaneously with the aortic root replacement using Cabrol's method in a 61-year-old man with recurrent aortic dissection. Two months prior to admission the patient had undergone a separate replacement of the aortic valve and ascending aorta for acute type A dissection with aortic regurgitation due to a bicuspid valve. He developed a suture line disruption caused by recurrent dissection in the aortic root which had been reinforced with GRF glue on the first operation. During the second operative procedure the dilated aortic arch with the remnant false lumen was found to be extensively injured. Therefore total arch replacement was required in addition to aortic root reconstruction preserving the previously placed mechanical valve.

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A 62-year-old woman was admitted suffering from chest tightness and palpitations. Coronary angiography revealed slight stenosis of the coronary artery requiring medical treatment. At that time right renal artery aneurysm was found accidentally. In addition abdominal echogram showed gallbladder stone. She underwent aneurysmectomy with reconstruction of the right renal artery and cholecystectomy. Postoperative course was uneventful and renal arteriography one month after operation depicted the patent right renal artery. Surgical indications for renal artery aneurysm should be carefully considered.

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We present a rare case of acute type A dissection which developed compression of the true lumen after starting cardiopulmonary bypass (CPB) with femoral arterial return. In this case, the entry was located in the proximal descending thoracic aorta, and the dissection expanded up to the ascending aorta in a retrograde direction. After starting CPB, the false lumen suddenly enlarged and the true lumen was compressed. We observed those changes by intraoperative transesophageal echocardiography, so the perfusion was stopped immediately. A long arterial cannula (Wessex) was inserted from the left ventricular apex with the tip of the cannula remaining in the true lumen of the ascending aorta, and antegrade perfusion was restarted. After that we could maintain adequate extracorporeal perfusion and the replacement of the total aortic arch was completed uneventfully.

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