A 77-year-old man with an abdominal aortic aneurysm, detected by abdominal ultrasonography, was referred to our hospital. Multi-detector computed tomography (MDCT) revealed an intrathoracic left subclavian artery aneurysm 30 mm in diameter and a small distal arch aortic aneurysm as well as an abdominal aortic aneurysm 40 mm in diameter. Surgery was indicated for the subclavian artery aneurysm considering the risks of rupture and distal embolism. Our choice for treatment was endovascular repair ; thoracic endovascular aortic repair (TEVAR) and coil embolism. The operation was performed successfully. Orifices of the left subclavian artery and the distal arch aneurysm were covered with a stent graft and the left subclavian artery was occluded with coils distal to the aneurysm. The operation time was 1 h and 44 min. He was extubated in the operation theater. A follow-up CT scan performed at 1 week showed the correct position of the TEVAR device, patency of the common trunk of the brachiocephalic and right common carotid arteries, and complete exclusion of the aneurysms. He was discharged on the 12th postoperative day without complication. Subclavian artery aneurysms, in particular in the intrathoracic location, are rare. Conventional surgery for this entity tends to require arch replacement to be unreasonably invasive as a therapy for peripheral artery disease. We believe this endovascular therapy can be a useful, less-invasive alternative to conventional open surgery.

To reduce surgical invasion, we recently used a limited incision through a retroperitoneal approach in the abdominal aortic surgery. Between May 2001 and March 2002, 18 patients who had infrarenal aortic aneurysm, iliac aneurysm, or aortoiliac occlusive disease were surgically treated using a new approach at Dokkyo University Koshigaya Hospital. Although 1 patient with a short aortic neck had to be converted to conventional surgical incision, the remaining 17 patients were successfully treated with the limited incision (range, 6-10cm). Operative time and intraoperative blood loss were 275.2±62.9min and 968.5±473.8ml, respectively. None of these patients required homologous blood transfusion in the perioperative period. All patients were extubated in the operation room. Oral feeding and mobilization started on day 1.6±0.5 and 1.4±0.9, respectively. Furthermore, all patients were discharged home without serious complications such as postoperative ileus and perioperative death. These results show that the limited incision through a retroperitoneal approach is safe and effective in the abdominal aortic surgery. This technique maintains quality outcome while reducing surgical invasion.

A 24-year-old woman with an abdominal aortic aneurysm (AAA) caused by mucoid medial degeneration of the aortic wall in the absence of Marfan syndrome is reported. She required a Y-shaped graft replacement of the abdominal aorta through a minimal incision and recovered successfully.

We encountered a case of ascending aorta pseudoaneurysm due to a Freestyle-valve free-wall fistula after a modified Bentall procedure with the button technique. A 60-year-old man with Marfan's syndrome who contracted annuloaortic ectasia presented with the onset of Stanford A type acute aortic dissection 3 years ago. The patient underwent aortic root replacement with a Freestyle-valve and ascending and hemi-arch aortic replacement. Thirty-seven months after this operation the patient was re-operated because of pseudo-ascending aorta aneurysm. The cause of the pseudo-aneurysm was a fistula of the Freestyle-valve free-wall and the left coronary artety (LCA) ostial reconstruction component. The fistula was repaired by direct closure with pledgets. The patient was discharged from the hospital 24 days after the operation.

We report a case of massive endobronchial hemorrhage after cardiopulmonary bypass, and its successful treatment utilizing a bronchial blocker tube without circulatory support. An 85-year-old woman underwent mitral and tricuspid valves repair for mitral stenosis and regurgitation, and tricuspid regurgitation. The repairs were performed uneventfully. The patient was weaned from cardiopulmonary bypass. After protamine infusion, massive endobronchial hemorrhage occurred through the tracheal tube. On fiberoptic bronchoscopy, prompt identification and selective occlusion of the hemorrhage source was performed by a Coopdech endobronchial blocker tube (Daiken Medical Co., Ltd, Osaka, Japan). Postoperative contrast-enhanced computed tomography revealed thrombogenic pseudoaneurysm of the right middle lobe pulmonary artery. We speculated that Swan-Ganz catheters induced endobronchial hemorrhage. The patient did not experience any further hemorrhage. She was discharged from our hospital on the 25th postoperative day in good condition.

A conventional reoperation via full sternotomy approach is associated with a higher risk of heart injury compared with first time operations. We employ a minimally invasive cardiac surgery (MICS) for valve reoperations in order to minimize dissection of sternal adhesions. We evaluated MICS for mitral reoperation in this report. We retrospectively analyzed 20 patients (group P) who underwent mitral reoperation via partial lower hemisternotomy (PLH) from July 1997 through March 2002, and 13 patients (group F) who underwent mitral reoperation via full sternotomy from April 1990 through June 1997. All patients received mitral valve replacement in both groups. Concomitant Maze procedures were significantly more frequent in group P (group P: n=8, group F: n=1). Aortic cross clamp times were significantly longer in group P (group P: 110±5min, group F:87±11min). The blood loss during operations was significantly less in group P (group P: 666±100ml, group F: 2, 405±947ml). Postoperative ventilation time and the length of intensive care unit stay were significantly shorter in group P. In group P and F the occurrence of a heart injury associated with sternotomy was 0/20 (0%), 2/13 (15%) respectively. Hospital mortality was 0/20 (0%), 2/13 (15%) respectively. There were neither any hospital deaths nor any postoperative major complications in group P. We conclude that PLH for mitral reoperations could be performed safely and is an alternative approach for mitral reoperations.

Between February 1999 and November 1999, 33 patients (age 67.0±7.6 years old) underwent off-pump CABG using coronary shunt tubes. The number of graft anastomoses per patient was 2.8±0.8. The operative mortality was 0%. There was no incidence of on-pump conversion, low cardiac output syndrome, IABP insertion, mediastinitis or stroke. The maximum CPK-MB during the perioperative period was 25.9±18.8IU/l. One patient had perioperative myocardial infarction probably due to native coronary artery spasm. In patients with off-pump CABG, the intubation time, the ICU stay and the hospital stay were shorter. The number of patients who were extubated in the operating room was higher and the cost was lower than those with on-pump CABG. An early phase study revealed patency ratios of 85% (the previous term) and 97% (the latter term). Off-pump CABG is a safe and effective means of revascularization with no mortality, minimal morbidity and good short-term patency.