A 77-year-old woman underwent percutaneous coronary intervention (PCI) for chronic total occlusion of the left anterior descending artery using a drug-eluting stent (DES). Re-stenosis, stent fracture, and aneurysm were found on follow-up coronary angiography (CAG), and thus implantation of multiple DESs was required. Surgery was indicated because CAG 48 months after first DES implantation revealed enlargement of the aneurysm with other new lesions. She successfully underwent off-pump coronary artery bypass grafting and resection of the aneurysm.

A 62-year-old woman was referred to our hospital for treatment of hemolytic anemia 10 years after total arch replacement for acute aortic dissection. The cause of hemolysis was confirmed to be mechanical damage of red blood cells at the kinked graft. Because aortic valve regurgitation and occlusion of the left subclavian artery were also found, resection of the kinked graft, aortic valve replacement and reconstruction of the left subclavian artery were carried out concomitantly at reoperation. Her postoperative course was uneventful, and hemolysis resolved soon after the operation.

We report a case of aortic arch replacement and extraanatomic bypass from a branched graft to both bifemoral arteries in a patient with aortic dissection complicated by ischemia in the lower extremities. A 61-year-old woman was found to have thrombosed type II aortic dissection by enhanced computed tomography (CT). Because she had no clinical symptoms, we chose conservative pharmacotherapy. A year later, she suddenly felt severe back pain and dyspnea. CT demonstrated type IIIb aortic dissection. She developed lower extremity ischemia because the true lumen in the abdominal aorta was severely compressed by the false lumen. Two weeks after onset, we planned a bilateral axillo-femoral bypass because the right lower limb ischemia had worsened, with severe pain. However, CT showed ascending aortic dissection. Hence, emergency graft replacement of aortic arch was required. A T-shaped graft was anastomosed to the bilateral femoral arteries, and was used as a delivery line during cardiopulmonary bypass. Although distal anastomosis of the arch was constructed only to the true lumen, leg ischemia persisted. Therefore, the T-shaped graft was connected to the branched graft used for antegrade systemic perfusion. We used INVOS as an indicator of intraoperative lower limb ischemia, which was useful for judging whether or not revascularization of lower extremity was achieved. After the operation, the bypass graft was patent, and ischemia in the lower extremities disappeared.