Aneurysmectomy with bifurcated graft replacement was initially performed on a patient with a ruptured abdominal aortic aneurysm, and an emergency operation was performed successfully on a proximal anastomosis pseudoaneurysm-rectal fistula that was diagnosed by bloody stool a year after operation. On the 10th postoperative month, CT detected a small pseudoaneurysm at the anastomosed prosthetic aortic graft. On the 1st postoperative year the patient first passed a slight amount of bloody stool, after which there was a large amount of bloody stool. Emergency CT and barium enema showed a pseudoaneurysm extending from near the anastomosed prosthetic aortic graft to the upper margin of the rectum and perforation into the upper rectum (Rs). An abscess covered the prosthetic aortic graft in the pseudoaneurysm, extending to the retroperitonerum on the left. We judged the case to be prosthetic aortic graft infection caused by the abscess and performed an emergency operation. The operation consisted of removal of the bifurcated prosthetic aortic graft, right axillo-bifemoral artery bypass, debridement, lavage, and packaging of the gastrocolic omentum. We report a successfully operated case of prosthetic aortic graft infection caused by pseudoaneurysm, rectal perforation and retroperitoneal abscess.

Blow-out type cardiac rupture after acute myocardial infarction (AMI) is usually a fatal complication. We report the case of a 64-year-old man, admitted to our hospital for AMI with cardiac shock. ECG and echocardiography showed a cardiac rupture after anterior AMI. We performed an emergency operation with a percutaneous cardiopulmonary support system (PCPS) and intra-aortic balloon pumping (IABP). The actively bleeding site, located at the anterior wall, was approximated using a large mattress suture with felt strips to close the rupture site, and the site was covered with fibrin glue. The patient was discharged on POD 48. We report a successful surgery for a case of blow-out type cardiac rupture after AMI.

Floating masses in the descending aorta are an uncommon source of embolism. We report a 43-year-old woman, with no previous history of thrombotic events, who was admitted to our hospital for renal and splenic infarction. Transesophageal echocardiography and computed tomography showed a floating mass in the descending aorta. We started anticoagulant therapy immediately and performed surgical removal of the mass that had caused multiple embolic episodes. The postoperative course was uneventful. In cases of a free floating thrombus in the aorta, it is important to prevent catastrophic complications by removing it surgically after anticoagulant therapy.

A 60-year-old man who had undergone aortic arch replacement 9 years prerviously was admitted complaining of motor and sensory disturbance of bilateral lower extremities. Bilateral femoral arteries were not palpable and he showed acute panperitonitis just after admission. Enhanced CT and arteriography revealed that the lower half of the body was severely ischemic due to the compression of the graft by a pseudoaneurysm of the proximal anastomotic portion of the aortic arch, and therefore performed an urgent operation. Recognizing acute bowel necrosis of the inferior mesenteric artery (IMA) area on laparotomy, Hartmann's operation was performed. After that, a right axillo-bifemoral bypass was also made in order to improve the perfusion of the lower half of the body. Though acute renal failure occurred because of DIC and myonephropathic metabolic syndrome (MNMS) postoperatively, the intensive therapy was eventually effective and he recovered.

Aortic valve disease is frequently associated with coronary artery disease and arrythmia. Recently, the mortality of aortic valve replacement has decreased because of more effective myocardial protection, so operations that combine aortic valve replacement and coronary bypass grafting or the Maze procedure for atrial fibrillation have been performed. We treated 25 patients undergoing aortic valve replacement combined with coronary bypass grafting and 2 patients undergoing aortic valve replacement with a modified Maze procedure from 1990 to 1996. Among the patients undergoing aortic valve replacement combined with coronary bypass grafting, there were no perioperative deaths and no development of coronary artery disease, malfunction of mechanical valve, or thrombosis. Two patients undergoing aortic valve replacement with a modified Maze procedure and tricuspid valve annuloplasty have reverted to sinus rhythm from atrial fibrillation with no anti-arrythmic agent. Surgery for combined aortic valve disease and coronary artery disease or arrythmia resulted in an improvement of late survival and quality of life.

A 62-year-old woman was admitted for chest and back pains. She was found to have thrombosed type A aortic dissection by enhanced computed tomography. Since she had no clinical symptoms after her admission, she was discharged. Forty days after the admission, she returned with acute renal failure and ischemia of both lower extremities. Occlusion of the abdominal aorta was diagnosed and emergency axillobifemoral bypass was performed. Her renal function and the ischemia of both lower extremities improved dramatically and she was discharged 30 days after the operation. Axillobifemoral bypass is one of the most effective and least invasive operations in such cases.

The internal mammary artery (IMA) has been widely used in CABG due to the excellent long-term results. However, the extensive use of bilateral IMA grafting has been believed to increase operative morbidity and mortality. This study was designed to determine if bilateral IMA grafting in diabetic patients increased the likelihood of mediastinitis. We analyzed the data of 386 consecutive patients who underwent isolated CABG in 1992 to 1996. The definitions of sternal wound complications are as follows, (1) mediastinal dehiscence and (2) mediastinal wound infection. Subtypes include superficial wound infection and deep wound infection (mediastinitis). Among these patients 97 received unilateral IMA grafts and 289 did bilateral IMA grafts. mediastinitis did not occur in any subjects. The occurrence rate of mediastinal dehiscence and superficial wound infection was 7.2% (7/97) for bilateral IMA grafting, 7.3% (21/289) for unilateral IMA grafting. No patients died of wound complications. The occurrence rate of mediastinal dehiscence and superficial wound infections were 12.0% (4/33) for bilateral IMA grafting in diabetic patients, 12.0% (14/117) for unilateral IMA grafting in diabetic patients. That of this complications was 4.7% (3/64) for bilateral IMA grafting in non-diabetic patients, 4.1% (7/172) for unilateral IMA grafting in diabetic patients, without significant differences in wound complication. Bilateral IMA grafting in diabetic patients carried no great risk of mediastinitis, but diabetes mellitus itself was a great risk for mediastinitis.