A 76-year-old woman who had undergone 5 surgical procedures and chemotherapy for retro-peritoneal liposarcoma was found to have a right ventricular aneurysm by echocardiography, magnetic resonance imaging (MRI) and right ventricular cineangiogram. We decided that it was a false aneurysm because of communication with the right ventricle through a small orifice. At operation, aneurysm was not strongly adherent, so we closed the small orifice with a purse-string suture, and covered it with part of the wall of the aneurysm. Subepicardial aneurysm of the right ventricle was diagnosed by operative and pathological findings. The postoperative course was uneventful and she was discharged on the 15th postoperative day.

A 58-year-old woman admitted for further examination of the proximal descending thoracic aortic aneurysm (TAA) combined with atypical coarctation and aortic regurgitation (AR). The chest CT and aortography confirmed these diagnoses, and revealed a pressure gradient of 40mmHg at the descending thoracic aorta with a severe calcification of the aortic wall, and severe AR. We scheduled a one-stage operation for this patient. First, we performed aortic valve replacement. Then we made a graft replacement from the aortic arch to the descending aorta using a stent graft via the aortic arch. Finally we did a reconstruction for lower limb perfusion using an aorto-iliac (extra-anatomical) bypass. The patient is now doing well 3 years after the surgery without any endoleak and without any difference of blood pressure between upper and lower limbs.

A-23-year-old man, with intellectual disability and history of self-inflicted injuries, presented with chest pain. A 3mm “picked” wound in the left chest was observed on physical examination. Chest computed tomography revealed a needle in the pericardium. Emergency surgery was performed by median sternotomy. At first we could not find the needle because it was completely buried in the heart, but when the posterior wall of the heart was exposed, the head of the needle appeared protruding from the posterior wall. It was removed and the wound of the posterior wall was closed with direct mattress sutures without cardio-pulmonary bypass. On inspection, the needle was 34mm long.

Distal anastomosis during total arch replacement (TAR) for thoracic aortic aneurysm (TAA) is often difficult to perform because of the limited surgical view. The most common methods available are direct anastomosis of a 4-branched graft to the distal aorta, or stepwise anastomosis with the elephant trunk procedure. However, the stepwise technique requires graft-to-graft anastomosis, which is often associated with bleeding. In the present study, we developed a new approach, which we have termed the “Branched Graft Inversion technique”, which does not require anastomosis between grafts, and facilitates anastomosis with a view equal to that in the stepwise technique. A 65-year-old man with a diagnosis of saccular-type thoracic aortic aneurysm was admitted. Cardiopulmonary bypass was established by cannulating the ascending aorta and femoral artery via a median sternotomy. We performed distal anastomosis under selective cerebral perfusion during hypothermic circulatory arrest (25°C). An inverted branched graft was inserted into the descending aorta and anastomosed using mattress and running sutures together with outer reinforcement with a Teflon felt strip. The distal end of the inverted branched graft was then extracted, and reconstruction of the neck vessels and proximal anastomosis were performed. Our newly developed Branched Graft Inversion technique was useful during TAR for TAA.

We report a case of secondary aortoenteric fistula (SAEF). A 76-year-old man who had undergone bifurcated graft replacement for an abdominal aortic aneurysm 18 years previously was admitted to our hospital on 2008. Since the patient was in hemorrhagic shock and had several comorbidities, he first underwent emergency endovascular aneurysmal repair (EVAR). The patient recovered from shock, and then the duodenal fistula was closed and a temporary tube enterostomy was made on the next day. The patient's recovery was uneventful and he was discharged 34 days after EVAR without any sign of infection. However, the patient was admitted for a recurrent SAEF 16 months after the procedure. Although emergency surgery was performed, he died due to sepsis 11 days after surgery. EVAR could be useful to control bleeding associated with SAEF ; however, it would be necessary for a long-term results to perform additional radical surgery subsequently to ensure the patients' hemodynamic recovery.

We present two cases of thoracic aortic aneurysm combined with aberrant right subclavian artery. Case 1 was a 71-year-old man, and case 2 was a 74-year-old man with an aortic arch aneurysm associated with a diverticulum of Kommerell. In both cases, we performed total aortic arch replacement through median sternotomy using cardiopulmonary bypass, systemic hypothermia and selective cerebral perfusion. We reconstructed all 4 arch branches. The aberrant right subclavian artery arose from the distal portion of the aortic arch, distal to the origin of the left subclavian artery. It crossed the midline between the esophagus and spine. To prevent compression of the trachea and esophagus by the right subclavian artery, we reconstructed it by the anterior side of the trachea. The postoperative course was uneventful.

Two cases of ruptured abdominal aortic aneurysm (AAA) treated with retroperitoneal approach are presented. Case 1 was a 73-year-old man with an infrarenal AAA of 44mm in diameter, and case 2 was a 73-year-old man with a 54mm pseudoaneurysm after graft replacement for AAA. Both patients had a history of previous laparotomy and their aneurysms had ruptured into only the right retroperitoneal space. A left retroperitoneal approach permitted wide and rapid exposure of the aorta with minimal damage to the intestines and respiratory function. Their postoperative courses were uneventful.

We treated a 62-year-old man with aneurysms of the descending thoracic aorta (45mm: proximal, 60mm: distal). We evaluated the intima of the aorta by intraoperative direct echography using a small probe (finger tip size), which detected floating mural thrombi in the proximal descending aorta. Therefore we chose the proximal and distal open technique with retrograde cerebral circulation under deep hypothermia during graft replacement of the descending aorta. There was no complication during or after surgical treatment.

A combined aortic and mitral valve replacement was performed in a 50-year-old man who had undergone living-related renal transplantation one year previously. The oral administration of tacrolimus was continued perioperatively while monitoring blood tacrolimus level. The postoperative administration of human atrial natriuretic peptide (hANP) was effective to maintain urine output was performed in addition to frosemide, mannitol, dopamin and prostaglandin E₁ infusions. He was discharged on the 37th postoperative day without rejection, infection or renal dysfunction. This is the first report in Japan describing successful combined aortic and mitral valve replacement after renal transplantation.

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.