We describe a young adolescent patient with spontaneous abdominal aortic rupture who was treated successfully. A 14-year-old boy was admitted to our hospital with severe abdominal pain and hypovolemic shock, without any episode of trauma. Computed tomography (CT) revealed massive hematoma in the retroperitoneal space and extravasation of copious amounts of contrast medium in front of the terminal aorta. Neither aortic aneurysm nor dissection was observed in this CT. An emergency operation was carried out. At first, left thoracotomy and clamping of the thoracic descending aorta were performed in order to reduce the aortic bleeding. Midline laparotomy revealed an aortic perforation of approximately 8mm at the bifurcation of the abdominal aorta. The aortic wall surrounding the perforation was nearly normal without any aortic aneurysm or dissection. A segment of the terminal aorta (length, 3cm) including the perforated lesion was excised and reconstruction was performed with a woven Dacron tube graft (10mm in diameter). On microscopic examination, the marginal tissue near the perforation showed diminished elastic fibers and minimal dissection of the medial layer of the aortic wall; however, no cystic medial necrosis or inflammation was seen.

A 49-year-old man was admitted to another hospital because of exertional dyspnea. He had run an entire 20-km race 33 days before admission. Echocardiograms, MRI and CT scans, and cineangiograms showed a right ventricular tumor arising from the tricuspid valve, which occupied the area from the right ventricular outflow tract (RVOT) to the pulmonary trunk and extended to the bilateral pulmonary arteries. MRI scans suggested that the tumor had not invaded the normal cardiac structure. The patient was transferred to our hospital for surgery. An operation was performed on the same day, since the tumor could have caused pulmonary embolisms. Under cardiopulmonary bypass, a right atriotomy, pulmonary arteriotomy and incision in the RVOT were made. The tumor had adhered to the chordae of the tricuspid valve, myocardium of the RVOT, and pulmonary valve. It was completely resected macroscopically. The postoperative course was uneventful and the patient was discharged on the 18th postoperative day. The size of the tumor was 2.0×2.0×10.0cm and the histological diagnosis was angiosarcoma. The patient died 4 months after the operation due to brain metastasis and local recurrence. This appeared to be a case of rapidly progressive cardiac angiosarcoma with an unusual noninvasive growth pattern.

The purpose of this study was to measure and analyze peroneus longus reaction time (PRT) as well as ankle movement during ankle sprain simulation. PRT was measured for six control ankles and six unstable ankles with an inversion ankle sprain (1 male and 5 females per group, respectively) using an ankle inverting platform and high speed camera. The unstable group showed a significantly slower PRT (58.8±8.7 ms) than the control group (46.5±8.1 ms). The inversion angular velocity was significantly faster in the unstable group (152.8±62.6 d/s) than the control group (83.2±38.4 d/s). There was no significant difference between the two groups regarding ankle eversion time. Our results indicate that it is important to lead an unstable ankle to reduce inversion angular velocity to prevent recurrent inversion ankle sprain.

A 41-year-old woman with neurofibromatosis (NF) was admitted to our hospital for severe pain and right leg swelling of 5 days duration. Paralysis of the right leg due to compartment syndrome was also recognized. She had been diagnosed as von Recklinghausen's neurofibromatosis, previously. 3 D-computed tomography showed a ruptured anterior tibial artery aneurysm. There was a normal patent posterior tibial artery. Since her complaint of pain was severe, we performed an emergency operation. Under the pneumatic tourniquet technique, the aneurysm was resected, and both the proximal and distal sides of the anterior tibial artery were ligated. A massive hematoma was completely removed. Postoperatively, the dorsalis pedis and posterior tibial pulses remained palpable. The paralysis improved considerably and she was given an ambulatory discharge from our hospital 21 days after the operation. Histological examination revealed proliferating wavy spindle cells infiltrating between the adventitia and mesothelium of the aneurysmal wall and staining positively for S 100 immunoperoxidase.

A case is described of the staged surgical repair of thoracic aortic aneurysm after revascularization of single functioning ischemic kidney of a 68 year old man. A hitological evaluation of renal function was obtained before renal revascularization, which encouraging us to perform the repair of thoracic aortic aneurysm with less risk of post-surgical acute renal failure. In case of single ischemic kidney, renal revascularization should be preceded to other major surgeries in order to prevent renal shut down.

Between 1970 and October, 1992, 120 cases of abdominal aortic aneurysms (AAA) were treated for surgical repair. Thirteen of these cases (11%) were performed with simultaneous repair for coexistent visceral vascular diseases and other intestinal organ diseases. Another 9 patients (7.5%) were treated with coronary revascularization for combined ischemic heart disease. Six of these cases received both operations during the same hospital stay. Our surgical strategy for coexistent AAA and ischemic coronary artery disease is basically a staged operation. Coronary revascularization should precede AAA repair. Operative mortality was 1.1 percent for elective AAA repair. Long-term survival was 78% for elective surgery with a mean follow-up of 51 months, and 52% for emergency surgery with a mean follow-up of 46 months. Major risks for late death were malignant neoplasms and ischemic coronary artery disease. Survival rate of the 9 patients with successful concomitant coronary revascularization and AAA repair was 89% after 51 months of mean follow-up. We conclude that re-evaluation for coexistent ischemic heart disease is the most important point for management before and after AAA repair.

Among the 203 cases of aortic valvular surgery, we experienced 8 cases of acute coronary insufficiency during the early postsurgical period. Five cases suffered from right coronary insufficiency. The other 2 cases had left coronary failure, and the remaining case had both. The main symptom of right coronary failure was right ventricular dysfunction, resulting in inability to wean from cardiopulmonary bypass in 3 cases, and left ventricular dysfunction due to inferior myocardial infarction in 2 cases. On the other hand, the main symptom of left coronary insufficiency was acute left ventricular pump failure with a broad anteroseptal infarction, and cardiac arrest occurred in the other 2. All patients receiving an emergency coronary artery bypass graft survived. Two cases expired due to thromboembolism in the interposed graft to the left coronary ostium in Cabrol's or Piehler's procedures. In the 6 survivors we could not detect any recent coronary lesions by postsurgical coronary cineangiography. We suggest that the pathophysiology of this phenomenon was coronary artery spasm and a lack of coronary reserve capacity in severe left ventricular hypertrophy of aortic valvular disease combined with diastolic dysfunction. Prompt coronary artery bypass grafting and a careful myocardial protection using retrograde cardioplegic solutions might save patients in this critical condition and an appropriate decision on the surgical indications for aortic valvular surgery is necessary before the occurrence of left ventricular diastolic dysfunction and demand ischemia.

An 80-year-old man was transferred to our hospital because of blunt traumatic aortic arch injury caused by a fall. Computed tomography (CT) revealed a pseudoaneurysm and mediastinal hematoma around the aortic arch, right hemothorax, left hemopneumothorax, lung contusion and spine fractures. His hemodynamic condition was stable but he required mechanical ventilation because of severe hypoxemia. Surgery was postponed until twelve days after the injury, when his lung function improved and active bleeding decreased. During surgery we found that the intimal disruption extended to half of the circumference of the aortic arch, and thus performed total arch replacement under deep hypothermic circulatory arrest and selective cerebral perfusion. The patient suffered respiratory failure and pneumonia postoperatively as well as multiple cerebral infarctions. He was referred to a rehabilitation center on postoperative day 130.

We report a case of reoperation for proximal and distal pseudoaneurysmal formations of the ascending aorta with aortic regurgitation (AR) after an ascending aorta replacement for acute type A aortic dissection. The patient was a 69-year-old woman who had undergone ascending aorta replacement for acute type A aortic dissection six years previously. Subsequent development of pseudoaneurysms of the ascending aorta and aortic regurgitation were revealed by computed tomography and echocardiography respectively. We chose debranch Thoracic Endovascular Aortic Repair (TEVAR) with a staged approach. First, aortic valve replacement, patch closure of proximal pseudoaneurysmal formation, coronary artery bypass, and ascending aorta-axillary artery bypass were performed. Two weeks later, debranching and TEVAR were performed. Cardiac reoperation for proximal and distal pseudoaneurysmal formations of the ascending aorta with aortic regurgitation after an ascending aorta replacement is known to be high risk. Nevertheless we performed the operation safely in two-stage surgery.