This study was designed to evaluate the optimal surgical treatment strategy for abdominal aortic aneurysm (AAA) coexisting with coronary artery disease (CAD). Twenty-six patients (21 men and 5 women with a mean age of 72.6±3.7 years old) who required surgical treatment of both conditions were examined. Eleven patients underwent a one-stage operation. Four of them had on-pump CABG and 7, including 3 high-risk-patients, underwent off-pump CABG. There were no operative mortalities, but 3 patients had severe morbidity (respiratory failure, acute renal failure, pneumonia). Fifteen patients underwent a two-stage operation. None of them had rupture of the AAA during the interval between the two operations, but 2 patients with large AAA (more than 6cm in diameter) required emergency operation due to impending rupture of the AAA. There was no operative mortality, but one patient suffered acute renal failure. One-stage operation for low-risk patients seems to be a safe and reasonable strategy. One-stage operation for high-risk patients should be performed cautiously, and off-pump CABG is especially useful in such patients.

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Median sternotomy is commonly used for suture fixation of a myocardial lead. Instead of this conventional technique, we used the technique of resecting the 5th costal cartilage through a small horizontal skin incision at the left 5th sternocostal junction in 33 patients, between 1980 and 2001. Here we describe this procedure, as well as the outcome of patients who underwent this myocardial lead fixation procedure. A skin incision of about 6 to 8cm was made in the left 5th intercostal space. Approximately 5cm of the 5th costal cartilage was resected through the skin incision. Then, a myocardial lead was sutured on to the anterior wall of the right ventricle. The generator was generally placed in the upper subcutaneous space of abdomen. Additional costal cartilages were removed in 7 patients in whom a larger operating field could not be obtained initially. The electrode was sutured to the right ventricular wall in 28 patients, right atrial wall in 6 patients, and the left ventricular wall in 5 patients. The mean operation time was 150min and mean bleeding during operation was 82ml. Long-term results (258 months at the longest, at the time of writing) showed that all the patients did well, except for one adult who suffered cerebral infarction, and one child with pacing failure. Based on these findings, we believe that this procedure is minimally invasive method, and is good for fixation of a myocardial lead.

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Endovascular grafting via the aortic arch, a novel alternative method for aortic aneurysm repair, was performed in 18 patients with aortic arch or distal arch aneurysms. For cerebral protection, selective or retrograde cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy. Selective cerebral perfusion was performed through both cerebral arteries and the left subclavian artery. Throughout this procedure, the aorta was filled with carbon dioxide to prevent the spinal arteries from air embolism. Two patients were lost, one due to myocardial infarction and one due to pneumonia. Endoluminal leakage was found in 2 patients, for which reoperation was required. However, no cerebral or spinal complications were observed in this series. Thus we conclude that endovascular stent grafting via the aortic arch is an acceptable alternative for the aortic arch or distal arch aneurysm repair with little risk of cerebral or spinal complications.

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We report the results of aortic arch replacement in 32 patients (20 males, 12 females) with aortic arch aneurysm, including 9 emergency cases. The etiology of aneurysm was atherosclerotic aneurysm in 18 patients, pseudoaneurysm in 1 patient, and aortic dissection in 13 patients. Selective cerebral perfusion (SCP) and retrograde cerebral perfusion (RCP), which are used for brain protection during aortic arch reconstruction, were both employed in this study according to our institutional policy. RCP was started at the moment of circulatory arrest after which the aneurysm was opened. In the case of 1-branch reconstruction or hemiarch replacement, we only employed RCP. If 2-branch reconstruction or total arch replacement was needed, we switched to SCP. After the distal graft anastomosis was performed, antegrade systemic perfusion was started via the 4th branch of the graft. Subsequently, 3 arch vessels was reconstructed with rewarming to shorten the SCP time, and finally proximal graft anastomosis was performed. Distal graft anastomosis with a new technique was applied in the 10 most recent cases. The “cuff” was made at the distal anastomosis site of the graft beforehand and this “cuff” was sutured to the aortic wall in an elephant-trunk fashion. This technique was a simple approach to repairing the distal lesion and allowed easy addition of stitches in case's of bleeding. The in-hospital mortality rate was 6.3% (2 of 32 patients) and the rate of cerebrovascular accident was 6.3% (2 of 32 patients). This technique for aortic arch repair is a useful method that results in low rates of in-hospital mortality and morbidity.

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After bleeding is controlled with hemostats during surgery, the residual material should be resorbed without adverse effects such as inflammation, infection or scar formation. To evaluate the biocompatibility of hemostats, three kinds of commercially available collagen hemostats, cotton type (Integran^®), microfibrillar type (Avitene^®), and sheet type (TachoComb^®), were examined. A rabbit ear chamber (REC), a system for viewing materials in vivo, was applied to the auricle of male Japanese white rabbits. The REC was designed to leave a 50-μm-thick and 6.4mm-diameter chamber, and 0.5mg of each specimen (Integran; n=8, Avitene; n=6, TachoComb; n=6) was placed in the chamber. Macroscopic and microscopic observations were performed every week up to 5 weeks without anesthetizing or stressing the animal. In the Integran group, capillaries infiltrated between the collagen fibers, and the vasculature in the REC field was complete in 6 out of 8 animals at 5 weeks. Cotton type collagen fibers of Integran became thinner every week without effusion. In the TachoComb group, capillaries were directed toward the effusion at 2 weeks, while in the Avitene group, a similar phenomenon was not observed. The vasculature was incomplete, with either effusion or infection at 5 weeks in the Avitene and TachoComb groups. Material was recognized up to 4 weeks in the TachoComb group, whereas the space occupied by material remained vacant without vasculature in the Avitene group. Our results suggest that cotton type configuration is excellent as a collagen hemostat, with smooth capillary infiltration, rapid resorption of material and promotion of the healing process.

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We performed 6 revascularization procedures in 5 patients after removing aneurysms of the superficialized brachial artery. The patients were 2 men and 3 women with an age range of 52 to 73 years. Their periods of hemodialysis ranged from 1 to 10 years. The aneurysms included 3 unruptured aneurysms, 1 ruptured aneurysm at the anastomosis site of an arteriovenous fistula and 1 ruptured infected aneurysm. Three procedures with interposed techniques for aneurysms and 3 brachial-urnal bypasses through the ulnar side roots of the elbow were performed with saphenous vein grafts (SVG) for revascularization. Two interposed SVGs closed after operation angiographically. In contrast, all brachial-ulnar bypass SVGs remained patent. One patient of the 2 graft occlusion patients had a ruptured infected aneurysm, and the other patient had exercised his elbow joint actively after operation. In conclusion, brachial-ulnar bypass through the ulnar side roots in the elbow is an effective revascularization technique for patients who exercise the elbow joint after operation or who have infected aneurysms.

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Ten patients with distal aortic arch aneurysm underwent prosthetic graft replacement using moderately hypothermic cardiopulmonary bypass and selective cerebral perfusion via antero-axillary thoracotomy. Central cannulation was performed in the ascending aorta and venous drainage from the right femoral vein. The mean patient age was 74 years and the mean surgical duration was 5h and 12min. One patient died of multiple cerebral embolisms. Nine patients survived without major complications. Anastomosis between the vascular graft and the distal aorta can be easily achieved via left thoracotomy. Moderate hypothermia provides less coagulopathy and is less invasive. The rate of cerebral complications was acceptable. This technique is preferable for surgical treatment of the distal aortic arch.

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The approach for the heart and proximal aorta in a patient with a tracheostomy poses difficult problems such as mediastinitis and inadequate operative exposure. We report a case of successful surgical treatment for type A aortic dissection in a patient with tracheostomy using a Y shaped skin incision and median full-sternotomy. A 63-year-old woman with a tracheostomy was referred to our hospital because of type A thrombosed aortic dissection and cardiac tamponade. At first we treated the patient conseservatively, but follow-up CT taken on the 20th day after onset revealed that false lumen of the ascending aorta was patent and the size of ascending aorta had increased to 6cm in diameter. We therefore performed hemiarch replacement (24mm Hemashield gold graft) through a Y shaped skin incision and median full-sternotomy. The postoperative course was uneventful and she was discharged on the 19th postoperative day.

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A 62-year-old man was admitted to our hospital because of acute aortic dissection (DeBakey type III b). Inflammatory findings were detected and methicillin-resistant staphylococcus aureus (MRSA) was detected by blood culture. Appropriate antibiotic therapy was begun but was ineffective. Repeated CT scans revealed dilation of the false lumen with thrombus and perianeurysmal inflammatory change in the lung. A diagnosis of infected aortic dissection was made. The patient was treated by resection of the descending aorta and placement of an in situ Dacron graft covered with a pedicled omental flap. An infected thrombus in the false lumen was confirmed by a positive MRSA culture. Computed tomography was found to be more sensitive in the diagnosis of infected aortic dissection. When the infection is not controlled with antibiotics, prompt surgical treatment should be performed.

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A descending thoracoaortic aneurysm excluded by stent-grafting had expanded during a period of one and a half years. There was no endoleakage but there was shortening of the stent-landing on both proximal and distal sides. Aneurysm seemed to be pressed by blood pressure through the graft in TEE. The aneurysm was replaced by an artificial graft through a left heart bypass. Because ESP diminished during the operation, VIth intercostal arteries were reconstructed immediately, and CSF drainage was performed. Following this procedure there was no paraplegia.

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We report a case of Marfan's syndrome in a patient who, 20 months after undergoing Cabrol's operation, underwent beating coronary artery bypass grafting without the aid of cardiopulmonary bypass for ostial stenosis of the left main coronary artery after acute myocardial infarction was diagnosed. The patient was a 31-year-old woman who had undergone Cabrol's operation for annulo-aortic ectasia at 29 years of age, and whose course thereafter was uneventful. On May 26, 2000, she complained of chest pain, and was admitted to our hospital with a diagnosis of acute myocardial infarction. On June 17 of the same year, a 90% ostial stenosis of the left main coronary artery was detected by coronary angiography. She subsequently underwent beating coronary artery bypass grafting without the aid of cardiopulmonary bypass, using left internal thoracic artery (LITA) anastomosis to the left anterior descending artery (LAD) via median sternotomy. The LAD was so much displaced laterally and pericardial adhesion was so dense on the apical aspect that good visualization of the LAD could not be obtained by the conventional percardiotomy. Therefore, the pericardium over the contemplated LAD anastomosis was resected circularly, and the LITA was anastomosed to the LAD through the pericardial opening. Postoperative angiography showed a widely patent LITA, although the stenotic lesion of the left main coronary ostium was totally occluded.

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A 74-year-old man with pain and swelling of the left thigh was transferred from another hospital for further investigation. On admission, a diagnosis of a left femoral vein thrombosis was made and he continued on anticoagulant therapy. However, three and a half hours after admission he suddenly developed hypotensive shock and became unconscious. Rupture of a peripheral aneurysm was suspected in view of a rapid fall in the hematocrit and the images of vascular echography. Rupture of a left popliteal aneurysm was specifically diagnosed following intraarterial digital subtraction angiography. An emergency aneurysmectomy and vascular reconstruction using the great saphenous vein was performed. Interestingly, Klebsiella pneumoniae was cultured from both the wall of the left popliteal artery and the wound. Antibiotic therapy was therefore changed to flomoxef (FMOX) on the 5th postoperative day (POD 5) and treatment continued for a total of 6 weeks in accordance with the therapy of infectious endocarditis. He returned to the previous hospital on POD 61.

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A 46-year-old woman was admitted to Yoichi Hospital for a midshaft fracture of the left femur following a ski injury. Four days after the injury osteosynthesis with intramedullary nails was performed. On the 18th postoperative day, a painful and pulsatile tumor was observed in the medial aspect of the left thigh. A left femoral arteriogram showed a 6cm large aneurysm of the superficial femoral artery. The aneurysm was excised with a short segment of the vessel and the arterial continuity was restored by an end-to-end anastomosis. The postoperative course was uneventful and she has no symptom of left lower limb ischemia for 3 years. False aneurysm which has been recognized as a late complication of fracture of the femur usually occurs in the deep femoral artery. There are few reports concerning the combination of midshaft fracture of the femur and false aneurysm of the superficial femoral aretry. We describe this case and discuss this rare complication which should be kept in mind when displacement of bone fragment is large enough and close to the artery.

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We report the successful repair of impending rupture of a pseudoaneurysm of the brachiocephalic artery (BCA) in a 70-year-old man. He had undergone a mediastinal tumor resection through a median sternotomy in 1995. Pathological examination revealed non-Hodgkin's lymphoma. Two years later, he underwent radiation therapy of 65 Gray for metastasis to the supraclavicular lymph nodes. On January 18, 2000, plastic surgeons planned to perform a pectoralis major musculocutaneous flap to repair a radiation skin ulcer. During the operation, the BCA was lacerated, possibly in an area of radiation tissue damage. We performed a prosthetic graft (10-mm Gelseal^TM) replacement of the BCA. The right subclavian artery had to be ligated. Postoperative digital subtraction angiography (DSA) showed excellent reconstruction of the artery. Magnetic resonance angiography of the brain showed a deficit in the anterior communicating artery and stenosis of the posterior communicating artery, which indicated that the reconstruction procedure was reasonable. Seven months later, on August 18, 2000, the patient was transferred to our hospital because of swelling of the right neck and oozing from the previous cutaneous wound. CT scan and DSA demonstrated the presence of a pseudoaneurysm of the proximal anastomosis site, which required emergency surgery. Before this third sternotomy, a saphenous vein graft was interposed between both external carotid arteries. Removal of the prosthetic graft and resection of the pseudoaneurysm were performed under mild hypothermia and cardiopulmonary bypass with left common carotid arterial perfusion. Then, the wound was closed completely using a left pectoralis major musculocutaneous flap. The postoperative course was uneventful and DSA showed good patency of the graft and intracranial arteries. The patient was discharged without neurological complications. We conclude that prior reconstruction of the carotid artery is a safe and effective procedure for patients with aneurysmal changes in the BCA, especially in the case of re-operation.

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A 70-year-old man was admitted to our hospital because of cough and dyspnea. On the 7th hospital day, he suddenly suffered by severe pulmonary congestion and bilateral pleural effusion with a prominent heart murmur. After improvement of the symptoms, 3-D CT scan and cardiac catheterization confirmed patent ductal aneurysm of about 10.5cm in diameter. Because of pulmonary hemorrhage, an emergency operation was performed using a left thoracotomy approach. A large aneurysmal mass of about 12cm in diameter was transected and the pulmonary end and aortic end of the ductus arteriosus were closed using a patch under partial cardiopulmonary bypass. His postoperative course was uneventful and he was discharged on the 27th day after operation.

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