Three-channeled aortic dissection of the ascending aorta is rare. A 38-year-old man was given a diagnosis of DeBakey type I aortic dissection with three-channel at the ascending aorta on a chest CT scan. Right axillar and left femoral artery and two-stage right atrial cannulas were used to institute cardiopulmonary bypass. Hemiarch replacement was performed. The open proximal anastomosis technique was used under deep hypothermic circulatory arrest and selective cerebral perfusion. This three-channeled aortic dissection was thought to be produced by DeBakey type II dissection first followed by a retrograde dissection of DeBakey type III b. Since obstruction of the brachiocephalic artery due to the expansion of the pseudolumen was found during rewarming, reconstruction of the brachiocephalic artery was necessary. The present case was treated successfully by right axillary artery perfusion and subsequent reconstruction of the brachiocephalic artery.

Subclavian arterial aneurysms are relatively rare compared to aortic aneurysms. The common causes of subclavian arterial aneurysms are arteriosclerosis, non-specific inflammation, thoracic outlet syndrome, and trauma. A case of a subclavian arterial aneurysm is reported. The patient was a 57-year-old woman. She had no previous history of hypertension, infection and trauma. She underwent complete resection of the aneurysm and reconstruction of right subclavian artery. Exploration of the aneurysmal wall revealed circumferential ridge which caused stenosis of the right subclavian artery at the orifice of the aneurysm. It has been suggested that a subclavian arterial aneurysm developed as a result of abnormal development of the embryologic right fourth and distal sixth aortic arches.

It is commonly believed that prosthetic valve implantation in actively infected patients is to be avoided. After normalization of C-reactive protein and white blood cell counts, and sterilization of blood cultures by treatment with antibiotics, we performed valvular surgery. We performed mitral valve repair in cases where the mitral valve lesion did not involve the annulus. From July 1992 to November 1996, 13 patients (mean age, 50 years) were treated surgically for infective endocarditis (IE) at Kansai Medical University. Twelve of the patients had native valve endocarditis (NVE), and 1 had prosthetic valve endocarditis (PVE). In 6 patients, the causative organisms were determined. These included: α-Streptococcus in 4 patients, Enterococcus in 1, and methicillin-resistant Staphylococcus aureus (MRSA) in 1. The affected valves were as follows: aortic valve alone in 4 patients, mitral valve alone in 6, aortic and mitral valves in 2, and a prosthetic aortic valve in 1. The PVE was due to a MRSA infection which occurred 9 months after aortic valve replacement. All patients were treated preoperatively for heart failure and the infection. The surgical procedures performed were: aortic valve replacement in 4 patients, mitral valve replacement in 3, mitral repair in 3, double valve replacement in 2, and re-aortic valve replacement in 1. There were no deaths or recurrences of IE in hospital or during follow-up to date. In all of the mitral valve repair cases, the mitral regurgitation on follow-up echocardiograms was grade I. Our results show that surgical treatment of IE after management of preoperative conditions can be successful. Furthermore, despite the absence of laboratory findings indicative of ongoing inflammation or infection, pathologic examination revealed active inflammatory reactions and organisms in 4 cases. In 1 patient, MRSA was culthued from an annular abscess that was resected intraoperatively. We suggest that cessation of antibiotic therapy be regarded with caution and suggest that the infected site must be resected surgically.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.