From May 1981 through April 1996, 19 patients with ruptured abdominal aortic aneurysm were admitted to our department. There were 18 men and 1 woman with a mean age of 69 years. Fifteen cases were in shock with a systolic blood pressure<80mmHg and 4 cases required chest compression for hypotension. One patient died of cardiac arrest on the operating table, 3 died of multiple organ failure or respiratory failure in hospital. The overall mortality rate was 21%. The mortality rate of patients under the age of 70 years was 10%, whereas that for those over 70 years of age was 33%. We believe that the use of intraoperative ileal tubing and postoperative continuous hemofiltration would improve the mortality rate in cases of ruptured abdominal aortic aneurysms.

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The correlation between perioperative factors including preoperative complications, treatment, ischemic duration, degree of ischemica as well as the embolized artery and limb salvage and mortality was retrospectively reviewed based on clinical charts and the recurrence rates of emboli and survival rates were followed up. No limb was amputated, but four cases died within 30 days after admission. The causes of death were cerebral embolism in two and SMA embolism and acute renal failure in one each. There was no significant difference in mortality according to any perioperative factor. The recurrence rates of emboli were 23%, 49% and 90% at 1, 2 and 4 years, respectively, and the duration of anticoagulant therapy after discharge did not affect the recurrence rate significantly. The survival rates were 94%, 52%, 29% and 11% at 1, 2, 4 and 5 years respectively. The causes of late death were heart attack in six, cerebral embolism in five, and SMA embolism and cancer in one each. Age and ischemic heart disease were risk factors reducing the long-term survival rate. Although acute arterial embolism of the upper limb does not lead to loss of limbs or life directly, recurrence of embolism was frequently encountered despite anticoagulant therapy and both early and late prognoses were poor.

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Effects of amrinone and dibutyryl cyclic AMP (DBcAMP) on hemodynamics and myocardial metabolism were studied in 16 patients in the early postoperative period following open-heart surgery. Amrinone was administered continously at 10μg/kg/min for 5 hours and DBcAMP at 12μg/kg/min was infused concomitantly for the last 1 hour. Amrinone increased SVI, and decreased HR, PCWP, arterial systolic blood pressure, double product and central temperature difference significantly. Following concomitant administration of DBcAMP for 1 hour, further increase of CI, O₂ delivery, blood sugar and insulin were observed. Significant decrease of excess lactate from 9.31±3.27 to -1.31±1.83mg/dl (p<0.05) showed that anaerobic metabolism improved in the myocardium after amrinone administration, and the effect improved further to -3.64±1.8mg/dl following concomitant administration of DBcAMP. These data demonstrate that amrinone has beneficial effects on hemodynamics and myocardial metabolism, and following supplementary administration of DBcAMP, further improvement in hemodynamics was observed.

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In order to assess the prevalence of carotid artery disease in patients with arteriosclerosis obliterans (ASO) or aortic aneurysm, 142 patients underwent screening for the presence of carotid atherosclerosis (plaque) with B-mode ultrasonography. Seventy-four (87.1%) of the 85 patients with ASO and 37 (64.9%) of the 57 patients with aortic aneurysm had carotid artery lesions. Of these patients, about half had bilateral lesions. The differences in the prevalence of carotid lesions were not significantly related to age or sex. Prevalence did not differ in relation to the severity or location of the primary lesions. The majority of the carotid lesions were located in the internal carotid arteries. The prevalence of carotid lesions was higher among patients with cerebral infarction than in those without any lesions on computed tomography. These results showing high prevalence of carotid lesions in ASO and aortic aneurysm suggest the usefulness of routine carotid ultrasonographic screening and also that it is important in order to determine the correct treatment for these cases.

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Long-term results of surgery for abdominal aortic aneurysms in the over-80 age group were studied. Among nine survivors we found four of them to have had a late death. Their survivals ranged from 17 to 96 months. The ratio of life expectancy was poor (29-51%) in men but good (159%) in women. Long-term survival was not significantly influenced by any preoperative complication but by unexpected disease, such as pancreatic cancer and pneumonia. In postoperative general care, it is important to pay attention not only to preoperative complication but also to the unexpected disease in other organs for octogenarians to achieve a goal of normal Japanese postoperatial survival.

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Ten patients, aged 3 to 43 years, with the tetralogy of Fallot underwent in situ pulmonary valve replacement (PVR) 13 times. The implanted valves were a St. Jude Medical prosthesis (3 times) and a bioprosthetic valve (10 times). In 5 patients PVR was performed at the time of radical repair and in the remaining 5 patients PVR was performed after radical repair. Three patients underwent re-PVR at 6 to 13 years after the first PVR. There was one operative death in re-PVR 14 years after the first PVR and one patient died from congestive heart failure 4 years after PVR. In the patients with the tetralogy of Fallot, the rate of PVR in those who had undergone open Brock's operation were significantly higher than that of the patients without open Brock's operation (p<0.05). Actuarial survival rates at 5 years and 10 years were 88.9% and 88.9%, respectively. Rates of freedom from reoperation at 5 years and 10 years were 88.9% and 59.3%, respectively. Although the early operative results are satisfactory, re-PVR is mandatory in the future. Thus the indications of PVR should be considered carefully.

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We report a case of successful graft replacement of the total aortic arch using selective cerebral perfusion for recurrent distal aortic arch aneurysm (DAAA). A 72-year-old man who had a history of patch aortoplasty for saccular DAAA was admitted to our hospital. Computed tomography and digital subtraction angiography showed recurrent saccular DAAA and coronary angiography revealed 90% stenosis of the first diagonal branch, resulting in a diagnosis of recurrent DAAA with coronary artery stenosis. A graft replacement of the total aortic arch with the aid of selective cerebral perfusion and coronary artery bypass grafting to the first diagonal branch was carried out. Postoperatively, he had no cerebral complications. One year after the operation, he had an operation for an abdominal aortic aneurysm. The patient is now leading a normal life.

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A 66-year-old man suddenly fell into a state of shock on his way back to his room after emergency coronary angiography and intracoronary thrombolysis for acute myocardial infarction. Both echocardiography and pericardiocentesis suggeted a diagnosis of cardiac rupture. The patient was transferred to an operating room with a percutaneous cardiopulmonary support system (PCPS) and intraaortic balloon pumping. Following thoracotomy and release of cardiac tamponade, blow out rupture of the left ventricular free wall was detected. The rupture was repaired using triple mattress sutures by reinforcing with felt pledgets. An infarctectomy was not added and cardiopulmonary bypass was not used. Postoperative recovery of cardiac function was satisfactory and the left ventricular ejection fraction after 2 months was 35%. PCPS and consecutive surgical therapy are effective for the treatment of blow out rupture of the left ventricular free wall.

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A 73-year-old man complained of sudden severe back pain and was admitted to a community hospital on February 2, 1994. DeBakey IIIb aortic dissection was diagnosed and he was treated conservatively. He noted a pulsating mass in his abdomen on June 7, 1995 and was referred to our hospital. Because of a decrease in platelet and fibrinogen and increase in FDP, local disseminated intravascular coagulation was diagnosed. Since abdominal pain continued, impending rupture was suspected. Computed tomogram showed abdominal aortic dissection and multiple iliac aneurysms. As coagulopathy did not improved by medical treatment, we performed prosthetic graft replacement of the aortio-iliac system on September 4, 1995. Before operation, the effectiveness of heparin was confirmed. After the operation local disseminated intravascular coagulation improved without drug therapy.

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A 52-year-old man was referred to our institution because of a solitary aneurysm of the left common iliac artery. The presence of the aneurysm was demonstrated by CT and angiography. The aneurysm had a diameter of about 30mm. The walls of the bilateral external iliac arteries were irregular, like a string of beads. The aneurysm was resected and replaced with a vascular prosthesis. Histological examination of the aneurysm and a part of the left external iliac artery indicated a diagnosis compatible with fibromuscular dysplasia (FMD: medial fibroplasia). A solitary iliac aneurysm is rare, and is usually due to atherosclerosis. However, the aneurysm in this case was related to FMD. To the best of our knowledge, only one other case of a solitary common iliac aneurysm caused by FMD has so far been described.

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In situ saphenous vein graft bypass surgery is a standard procedure for infrainguinal arterial reconstruction. Since revascularization is commonly applied in below the knee region, the application of in situ saphenous vein graft bypass is becoming increasingly. We, however, recently experienced the complication of phlebitis due to unligated branches of the saphenous vein in this procedure. We here report the case and the efficacy of intraoperative angiography and postoperative ultrasound scanning to avoid such a complication.

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A patient with mutiple aneurysms of the thoracic aorta in Behçet's disease was treated with transluminally placed endovascular stent grafts. Stent graft devices composed of several units of self-expandable Z stents covered with ultra-thin woven Dacron were inserted through 18 Fr sheaths via the femoral arteries. The stent grafts were deployed successfully and blood flow into the aneurysms was reduced immediately and no blood endoleak was found on aortography. However minor endoleak due to migrations of the stent grafts was recognized in two distal descending aortic aneurysms twenty days after the operation. Extra stent grafts were inserted to interrupt the endoleak and finally all aneurysms were thrombosed without any endoleak. Former surgical replacement of the aorta due to aneurysms associated with vasculo-Behçet's disease often causes anastomotic leakage and pseudoaneurysms. The endoluminal stent graft treatment is a minimally invasive operation in comparison with former surgical operations, and is useful for aortic aeurysms especially for inflammatory aneurysms in Behçet's disease because it requires no anastomotis. However, improvement of the stent graft devices, including components of the delivery system such as the dilator, sheath and pushing rod, and the development of better devices, is required to reduce delivery failure and to make stent graft treatment more reliable.

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A 74-year-old woman was admitted to our hospital with a diagnosis of a pseudoaneurysm 5 months after graft replacement of the ascending aorta, and underwent re-replacement employing left ventricle venting through a left anterior thoracotomy. Culture of the thrombi in the pseudoaneurysm revealed Psuedomonas infection. On the 11th postoerative day, a single-stage procedure of irrigation, debridment, and immediate closure with omental transposition was performed. Although the chest CT scan 1 month after the omental transposition revealed a residual abcess, it was completely obliterated after 2 months without further operation.

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Isolated tricuspid regurgitation is extremely rare, and in most of the previously reported cases, both tricuspid leaflets and subvalvar tissue have been absent, hypoplastic or fused. For this reason, tricuspid valvoplasty was difficult and valve replacement was adopted in many cases. In the present case, a 52-year-old man, however, the tricuspid valve showed no abnormalities other than a severely dilated tricuspid annulus. Ring annuloplasty was performed, and this resulted in a subsequent satisfactory course.

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We report an 85-year-old woman with rupture of aneurysm of the descending thoracic aorta into the left lung. She was admitted with sudden onset back pain and hemoptysis. Emergency operation was performed to replace the ruptured descending thoracic aorta, and lower lobectomy of left lung. The left lobectomy ensured that hematoma was not left in lung, although it decreased respiratory function after operation. In addition, it decreased bleeding and operating time compared to segmental resection. She was discharged without contracting an infection in the lung or graft, although she needed tracheotomy for a time. We suggest that the lower lobectomy of lung was an important factor in saving this elderly patient with rupture of an aneurysm into the left lung.

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