Objective : The availability of endovascular aneurysm repair (EVAR) has gradually increased the number of patients undergoing surgical treatment for ruptured abdominal aortic aneurysm (rAAA). The aim of this study was to evaluate our endovascular first-line surgical treatment strategy for rAAA. Methods : We retrospectively reviewed 35 consecutive patients who underwent emergent surgery for rAAA (including ruptured iliac artery aneurysms) between January 2013 and December 2020. The patients were divided according to surgical procedure : Open surgical repair and endovascular repair. Clinicopathological features, including the preoperative state, the choice of surgical procedure and postoperative morbidity and mortality, were compared between the groups. The surgical indication of EVAR was determined according to the same anatomical criteria used for elective operation. Results : About half of 17 patients (48.6%) were assigned to open repair and as many as 14 of them (82.4%) were excluded from the indication of endovascular treatment due to anatomical unsuitability, which included an extremely short proximal neck, severe aortic elongation and access route problems. Logistic regression analysis demonstrated that the patients with open surgery tended to have longer intubation times and higher incidences of post-operative temporal dialysis. There was no in-hospital death among the EVAR patients, while 5 deaths (29.4%) occurred among the open surgery patients (circulatory failure : 2, pneumonia : 1, ischemic enteritis : 1, cardiac failure : 1) [p = 0.013]. Only among the EVAR patients, aortic related death occurred in 1 patient (5.6%), which was acute type A aortic dissection. Conclusion : Endovascular first-line surgical treatment strategy for rAAA is acceptable. However, as the patients with rAAA tended to be unsuitable for EVAR because of anatomical complexity, open abdominal surgery is important even in the endovascular era.

We experienced successful surgical treatment of a pseudoaneurysm of a RV-PA conduit in a 15-month-old female patient whose original diagnosis was pulmonary atresia with ventricular septal defect. Her first operation was a central shunt at the age of 25 days. She underwent a palliative Rastelli procedure (valved conduit of 10 mm e-PTFE graft) when she was 10 months old, but bacterial mediastinitis occurred (Pseudomonas aeruginosa) on the 8th postoperative day, and drainage and negative pressure wound therapy were started combined with administration of antibiotics. It took one month to close the wound when the bacterial culture from the wound became negative. Although she was discharged from hospital on the 49th postoperative day, she was re-hospitalized after 10 days because of high fever. Echocardiography and CT showed no sign of vegetation or breakdown of the conduit and conservative therapy with antibiotics were continued. Two months later, enhanced CT demonstrated a large pseudoaneurysm which originated from the RV-conduit anastomotic site and urgent surgery was performed. Cardiopulmonary bypass was established with the right common carotid artery and internal jugular vein and the infected conduit was replaced with larger-sized one under electrically-induced ventricular fibrillation. Delayed sternal closure with omental filling was performed after 6 days. Fifteen months have passed since conduit replacement and she is now in good condition without recurrence of infection.

We report two cases of penetrating cardiac injuries due to stab wounds, which are rare in Japan. The patients were brought to the emergency room for self-inflicted trauma to the chest with a knife. Case 1 was a 66-year-old female with multiple stab wounds in the chest and abdomen, a JCS score of 300, and shock vitality. CT showed liver injury, left internal thoracic artery injury, and suspected left ventricular anterior wall injury ; thus, an emergency surgery was performed. In the anterior wall of the left ventricle, damage extending to the cardiac cavity was noted, which was repaired by suture closure with felt pledgets and tissue adhesives. The patient was extubated on postoperative day 1 ; no abnormal neurological findings were observed. CT scan on postoperative day 11 showed no coronary artery injury or pseudoaneurysm formation ; the patient was then transferred to a psychiatric hospital on postoperative day 12. Case 2 was an 88-year-old man with a 2-cm-long stab wound in the anterior chest. CT scan showed pericardial effusion with suspected acute hemorrhage, suggesting cardiac injury. However, since there was no contrast agent leakage from the pericardial cavity and the patient was in stable condition with clear consciousness, we concluded that he had only pericardial injury and chose conservative treatment. A CT scan performed about 12 h later showed that the pericardial fluid had already decreased. The patient was transferred to a hospital specializing in psychiatry on postoperative day 18.

An eighty-one-year-old man with non-valvular atrial fibrillation underwent left atrial appendage closure with a percutaneous device. Just after the release of the device, cardiogenic shock and pulseless electrical activity with cardiac tamponade were observed. Drainage of pericardial effusion and establishment of percutaneous cardio-pulmonary support were emergently performed. However, because of uncontrollable bleeding, the conversion to open surgical repair was decided by our heart team. Removal of the device and occlusion of the orifice of the left atrial appendage were performed. This case report emphasizes the importance of taking quick and appropriate surgical conversion for any complication of a percutaneous left atrial appendage closure device.

A 50-year-old man diagnosed with human immunodeficiency virus had been treated with combination antiretroviral therapy. Additionally, he was diagnosed with acute myocardial infarction 9 months earlier and underwent percutaneous coronary intervention. He was allergic to contrast media and had coronary lesions on three branches. Preoperative magnetic resonance imaging revealed severe cerebrovascular injuries. He was admitted to our hospital, and off-pump coronary bypass grafting was performed. The patient was discharged 10 days after the surgery with no progression to cerebrovascular accidents, bacterial infections, or acquired immunodeficiency syndrome.

A 67-year-old woman had aseptic mediastinal abscess during oral steroids treatment for myelodysplastic syndrome (MDS) and Tolosa-Hunt syndrome 15 years ago, and underwent left thoracotomy drainage. The postoperative wound was ulcerated and was diagnosed with pyoderma gangrenosum. She had heart failure symptoms and was diagnosed with severe aortic valve regurgitation (AR) two years ago. Although surgery was indicated at another hospital, they judged that the risk of complications including wound infection and mediastinal abscess was high, and the patient was followed up with medical therapy. However, the symptoms of heart failure gradually worsened, and we planned aortic valve replacement through right anterior mini-thoracotomy. Her postoperative course was unremarkable, and she underwent extubation on the day of the operation and was discharged 12 days postoperatively without complications. We suggest that the right small thoracotomy approach will be useful for patients at high risk of mediastinal abscess and wound infection.

A median full-sternotomy should be avoided in patients with tracheostoma because of the risk of sternal infection and mediastinitis. Recently, there have been some reports on cardiac surgery through a partial sternotomy for combined valvular disease. We present a case in which aortic valve replacement and mitral valve replacement and tricuspid valve annuloplasty were successfully performed through a reverse L shape partial sternotomy. This approach minimizes an incision and secures a distance between the incision and tracheostoma.

A 45-year-old man underwent mitral valve repair for degenerative mitral regurgitation and coronary artery bypass grafting for coronary artery stenosis at the age of 40 years. During this hospitalization, although he had methicillin-resistant Staphylococcus epidermidis (MRSE) sepsis, antibiotic treatment rapidly improved his condition. His improving condition was then reversed as his mitral stenosis gradually worsened. During surgical planning, it was elicited that he had had a stroke 4 years 8 months after his previous operation. Although it could have been cardiogenic cerebral infarction, further work-up did not reveal any other embolic sources. He had two additional stroke episodes 4 months after the first stroke. Follow-up transthoracic echocardiography revealed vegetation-like lesions attached to the mitral annulus. Although there were no signs of inflammation, his blood culture was positive for MRSE, similar to his previous infection. Because these findings were consistent with the diagnosis of chronic infective endocarditis, the patient underwent open-heart surgery. Intraoperatively, the artificial mitral ring surface was not seen, as it was covered by pseudo-intima, excluding the three infected annular sutures. Furthermore, the mitral orifice was stenotic due to pannus formation seen to be continuous with the pseudo-intima. To address these, he underwent mitral valve replacement, tricuspid annuloplasty, and antibiotic therapy. The postoperative course was uneventful. The infection probably originated from the artificial mitral ring infection during the first surgery performed 5 years eariler.

We report a successful troubleshooting strategy for the Stanford type A aortic dissection that occurred in a 77-year-old woman during transcatheter aortic valve implantation (TAVI). She underwent percutaneous coronary intervention on 5 previous occasions ; however, her left anterior descending and left circumflex arteries were obstructed, and the right coronary artery (RCA) served as a feeding artery (although the RCA was also moderately stenosed). She was diagnosed with concomitant heart failure secondary to worsening severe aortic stenosis. In view of the low ejection fraction (31%) and severe ischemic heart disease, we initiated percutaneous cardiopulmonary support (PCPS) to maintain adequate systemic and pulmonary circulation. The femoral artery was atherosclerotic ; therefore, the right subclavian artery was selected for arterial access, and the femoral vein was selected for venous access. Intraoperatively, after stabilizing the PCPS, we started to run the system ; however, arterial flow could not be maintained owing to increased arterial pressure. Transeshophageal echocardiography revealed Stanford type A aortic dissection with the entry point at the brachiocephalic artery. The false lumen extended into the ascending aorta up to the level of the sinotubular junction. Fortunately, no coronary artery compression was detected. Aortic dissection-induced afterload elevation led to ineffective valve opening and consequent left ventricular dysfunction. We performed transapical (TA)-TAVI conversion and entry point closure via the TA route as a troubleshooting strategy. The procedure was performed successfully, and the patient's postoperative course was uneventful.

A 64-year-old man had severe pain and became paralyzed in the right lower limb. He was diagnosed with acute arterial occlusion of his right lower limb and was referred to our hospital. Enhanced computed tomography revealed occlusion of the popliteal artery and lower limb arteries and a filling defect in the proximal descending aorta. Although an electrocardiogram demonstrated atrial fibrillation, blood tests did not reveal any underlying disease that could have led to coagulation abnormalities. To prevent recurrent embolism, an approximately 10 cm long skin incision was made at the fifth intercostal space, and endoscopic-assisted thrombectomy of the proximal descending aorta was performed under femoral-femoral bypass (F-F bypass). Histologically, the mass was a blood clot, and atheromatous degeneration was detected in the resected aortic wall. The postoperative course was good and the patient was discharged after construction of an artificial limb. Direct oral anticoagulant (apixaban) and an antiplatelet medication (aspirin) were prescribed, and no recurrence of thrombosis was observed in over two years.

A 70-year-old man developed sudden chest, back, abdominal, and lower extremity pain, and clinical findings and contrast-enhanced computed tomography (CT) revealed acute type A aortic dissection with visceral, lower leg, and spinal cord ischemia. The false lumen of the ascending aorta was thrombosed, and the entry site was observed in the proximal descending aorta without a re-entry tear. The true lumen of the aorta extended from the descending thoracic aorta to the abdominal aorta and was significantly narrowed. The celiac and superior mesenteric arteries received blood supply from the narrowed true lumen and several intercostal arteries from the partially thrombosed false lumen. Central repair for resection of the entry tear could impair blood flow through the false lumen and the intercostal arteries ; therefore, we performed open aortic fenestration. Postoperative contrast-enhanced CT revealed that the width of the true lumen and blood flow through the false lumen of the descending aorta were adequately improved with resolution of the patient's clinical symptoms. The patient's postoperative course was uneventful, and he was discharged on postoperative day 30. Emergency central repair has been reported as a first-line approach for acute type A aortic dissections ; however, surgical fenestration may be useful for patients who receive conservative treatment for the ascending aorta and present with multiple sites of malperfusion that causes spinal cord ischemia.

A 76-year-old man presented with fever and cough. The salivary PCR test was revealed COVID-19-positive. He was referred to our hospital with oxygen desaturation during following up at home. The plain CT scan showed peripheral infiltrates distributed along the subpleural area and ascending aortic aneurysm. The treatment of COVID-19 was prioritized due to his worsening respiratory condition. He was discharged after 3 weeks. He was readmitted with organized pneumonia and treated with corticosteroids. Though dyspnea on exertion was still present after discharge, the spirometry was within normal limits except for low DLCO. Eight weeks after COVID-19 healing, we performed ascending aortic replacement for an ascending aortic aneurysm. His postoperative course was uneventful. The optimal timing of elective cardiovascular surgery in a patient after COVID-19 is unclear. We report a case of cardiovascular surgery 8 weeks after COVID-19 with no respiratory complications.

The patient was a 41-year-old man with Marfan syndrome. At 36 years of age, he underwent aortic root replacement and arch replacement for acute aortic dissection (DeBakey type I). Five years later, his dissecting aortic aneurysm began to expand, and he was referred to our department for treatment. We performed thoracic endovascular aortic repair to close the entry of the descending aorta. However, sudden back pain appeared 15 days after surgery, and computed tomography (CT) revealed false lumen enlargement. We diagnosed the patient with impending rupture of a descending aortic aneurysm, and we performed urgent thoracoabdominal aortic replacement. The postoperative course was good without paralysis. Subsequent CT revealed enlargement of the aneurysm owing to type II endoleak from the intercostal artery. We performed coil embolization of the intercostal artery and inserted NBCA into the aneurysm, eventually achieving complete aneurysm thrombosis. The ideal treatment for residual dissecting aortic aneurysms after surgery for type A dissection or chronic type B dissection is unclear, and it is necessary to examine the optimal surgical strategy in each case. As in this case, the aneurysm diameter may expand rapidly owing to an increase in blood flow from the residually patent false lumen. This case highlights the need for close follow-up and early secondary operative intervention if the aneurysm enlarges or if residual entries are detected below the stent level.

A 60-year-male patient complained of stomachache, for which he underwent a computed tomography scan. A 35-mm, saccular aneurysm was detected in the left subclavian artery. He was diagnosed with von Recklinghausen's disease (vR disease) from the characteristic physical findings of numerous neurofibromatosis and Café-au-lait spots, as well as intra-sibling onset. A median sternotomy was performed, and the subclavian arterial aneurysm was sacrificed. A bypass connection was established between the ascending aorta and the left axillary artery using the great saphenous vein, and all blood vessels that flowed into the aneurysm were ligated. Although vR disease is known to be associated with vascular lesions, isolated subclavian aneurysms are rare. Due to the low survival rate of ruptured aneurysms and the fragility of blood vessels in vR disease, it is important to make an early diagnosis and perform surgery.