We report a case of aortic arch rupture due to blunt chest trauma. The patient was a 66-year-old man who was driving a motorcycle and collided with a parked car. The chest roentogenogram showed mediastinal widening and computed tomography showed hematoma of the mediastinum and intimal tear of the aortic arch. As his hemodynamic state was stable, he underwent aortography which demonstrated pseudoaneurysm of the aortic arch. An emergency operation was performed under cardiopulmonary bypass with selective cerebral perfusion. The intimal and medial tear of the aortic arch and left common carotid artery were replaced with grafts and his postoperative course was uneventful. Traumatic aortic rupture is frequent in the descending aorta but aortic arch injury is rare. Immediate diagnosis and surgical repair are necessary in such cases.

A 61-year-old woman with paresthesia and coldness of the right forearm came to our institute. Her right arm was strangulated and tracted by a vinyl string tied at her right brachium. No pulsation of her right radial artery was detected, and her forearm had swollen with subcutaneous hematoma. Her arteriography showed occlusion of the distal site of the right brachial artery, and just proximal to the brachial arterial bifurcation was enhanced by collaterals. She underwent emergency revascularization 6h after injury. There was a thrombus in the artery at the strangulated site, and the arterial intima was circumferentially dissected. The injured site of the artery was completely resected and interposed with basilic vein. Although 8h had passed from injury to reperfusion, myonephropathic metabolic syndrome did not occur after the operation. Her brachial arterial pulsation is now well palpable. The arterial occlusion was probably caused by the circumferential tear of the intima due to not only direct strangulation but also strong traction of the arm. It is necessary to resect a sufficient length of injured artery.

In 13 patients who underwent left ventriculography both before and after operation, we investigated regional wall motion of the left ventricle (LV) with the centerline method in LV aneurysmectomy. There were no significant differences between preoperative predicted and postoperative ejection fraction. No significant differences were observed between preoperative predicted and postoperative regional wall motion of all segments in all cases and cases without significant stenosis who did not undergo revascularization of the right coronary artery. Postoperative regional wall motion of the inferior wall was significantly better than the preoperative predicted one in cases who underwent revascularization of the right coronary artery with significant stenosis. It is considered that revascularization of the right coronary artery with significant stenosis in LV aneurysmectomy was effective for the improvement of regional wall motion of the inferior wall.

A 95-year-old man suffered repeated episodes of loss of consciousness. Ruptured abdominal aortic aneurysm with giant retroperitoneal hematoma was diagnosed by computed tomography scans, and was referred to our hospital for surgical management. As he was about to be transported cardiopulmonary arrest developed, and emergency operation was started under resuscitation for pulseless electrical activity condition. We found a left common iliac artery aneurysm intraoperatively. We improved his hemodynamics by clamping the infrarenal abdominal aorta, and performed replacement of the left common iliac artery with a tube graft as quickly as possible. We inserted an intestinal drainage tube because of the expected high intraperitoneal pressure which caused by marked edema of the intestinal tract. He was weaned from respiratory support on the 5th postoperative day. He could walk on his own and was successfully discharged on the 28th postoperative day.

Type B intramural hematoma (IMH) is not considered to be a life-threatening condition, and medical treatment is the first treatment choice. We report 2 cases of ruptured type B intramural hematoma. Total arch replacement was performed via median sternotomy, which is not a common surgical strategy for type B dissection. Case 1 : a 77-year-old woman was transferred to our hospital with chest and back pain. CT revealed type B IMH with a large hematoma in the anterior mediastinum. She underwent total arch replacement, but she died of respiratory failure on the 167th postoperative day. Case 2 : a 60-year-old man was transferred to our hospital with chest and back pain. CT revealed a type B IMH with a large hematoma on the anterior side of the arch. He underwent total arch replacement, but died of sepsis on the 13th postoperative day. We had 2 rare cases of ruptured type B IMH. In both cases, postoperative courses were problematic. However, median sternotomy could be an approach for ruptured type B dissection in some cases.

A woman aged 87 underwent root replacement with a mechanical valve and ascending/arch replacement for annuloaortic ectasia with aortic regurgitation and ascending/arch aneurysm 10 years before and thoracic endovascular aortic repair for thoracic descending aneurysm 5 years before. She had been doing well but suffered sudden chest/back pain and bilateral lower-limb paralysis. Contrast-enhanced CT scans revealed filling defects initiating from the distal end of the thoracic stent graft and continuing to the bilateral femoral arteries. Massive thrombosis from the thoracic stent graft to the bilateral femoral arteries was diagnosed. The entire circumference of the thrombus was enhanced, and the thrombus was conceivable not attached to the aortic/arterial inner wall. Although the patient took warfarin orally for the replaced mechanical valve, anticoagulation with heparin was added. Her general condition promptly deteriorated and she died deceased 6 hours after the onset. Thrombosis continuing distally from the thoracic stent graft is extremely rare.

A 77-year-old man suffered sudden chest oppression in driving. The patient had undergone aortic valve replacement with a mechanical valve for unknown valvular heart disease 17 years before. On arrival, the symptom was improved and hemodynamics were stable. Contrast-enhanced CT scans revealed remarkable pear-shaped dilatation of the aortic root (76 mm in maximum diameter), ascending aortic dissection, and extravasation from the posterior wall of the dissecting aorta with mediastinal hematoma compressing the left atrium. Ruptured type A acute aortic dissection with root ectasia (following aortic valve replacement) was diagnosed and urgent root and ascending aortic replacement was performed preserving the replaced mechanical valve. Initially, surgery not under hypothermic circulatory arrest but under normothermic aortic cross clamp was planned. Although sudden massive bleeding from the rupture site (dorsal to the ascending aorta) occurred during exposure of the ascending aorta (just proximal to the origin of the brachiocephalic artery), the procedure could be continued under bleeding control by the surgeon's fingers. The patient underwent re-sternotomy for hemostasis and undertook rehabilitation for discharge on the postoperative day 30. Mortality of ruptured type A acute aortic dissection is extremely high, and no surgical surviving case has been reported in the Japanese language.

A 66-year-old man with a history of pyogenic spondylitis a month before was presented with dyspnea. Severe aortic regurgitation due to infective endocarditis was suspected in transthoracic echocardiogram, and emergency surgery was conducted. The aortic valve with three cusps was markedly destroyed with vegetation. After resecting the cusps, there was a cavity just below the commissure between the left and noncoronary cusp (intervalvular fibrous trigon). In retrospective findings of intraoperative pre-cardiopulmonary bypass transesophageal echocardiogram, a left ventricular diverticulum with paroxysmal movement had been detected at the same place. The diverticulum was left untreated to shorten cardiac arrest time because of low left ventricular function, and aortic valve replacement alone was performed. Cardiopulmonary bypass was weaned with intra-aortic balloon pumping (IABP). Percutaneous cardiopulmonary support (PCPS) was initiated owing to hypotension in the intensive care unit. The PCPS and IABP were discontinued on postoperative day (POD) 5 and 6, respectively. Torsades de pointes and ventricular fibrillation occurred respectively 2 h after weaning the PCPS and on POD9, but recuperated to sinus rhythm within a minute. A 6-week course of antibiotic infusion was planned, and the patient is now undertaking rehabilitation on POD30 for discharge.

There are various problems associated with the surgical management of concomitant abdominal aortic aneurysm (AAA) and gastrointestinal malignancy. Our surgical strategy for the treatment of concomitant AAA and gastrointestinal malignant diseases, with the exception of colorectal diseases is basically a one-stage operation. This report reviews 6 cases involving concomitant AAA and gastrointestinal malignancy (colon cancer in 3 cases, gastric cancer in 2 and hepatoma in one). In 2 cases involving gastric cancer, we selected a one-stage operation for the coexistent AAA and gastrointestinal malignancy. The postoperative courses were uneventful. In a 69-yearold man with concomitant AAA, hepatoma and ischemic heart disease, a hepatectomy and coronary revascularization preceded AAA repair because the AAA diameter was too small. AAA repair was performed after 4 months when its diameter had been enlarged. In one of the 3 cases involving concomitant AAA and colon cancer, the malignancy was resected first and the patient died of recurrence 7 months after the operation and prior to the operation for AAA. In the second case of colon cancer, AAA repair preceded the resection of the malignancy. A right hemicolectomy was performed 53 days after the AAA operation. The third case had a one-stage operation for coexistent AAA and colon cancer. His postoperative course was uneventful. In this case, we took particular care to avoid graft infection. The 5 cases that underwent both operations have survived without major complications or evidence of recurrence during a follow-up period ranging from 2 months to 4 years.

A 67-year-old man suffered sudden chest pain. Computed tomography with contrast medium revealed dissection from the ascending aorta to the bilateral iliac arteries and hematoma around the left external iliac artery. Type A acute aortic dissection complicated with rupture of the left external iliac artery was diagnosed. Urgent endovascular repair (stent-graft implantation) was first performed for the arterial rupture more critical than the aortic dissection. On the next day after satisfactory hemostasis and hemodynamical stabilization, semi-urgent ascending aortic replacement was achieved, and the patient survived. Acute aortic dissection complicated with rupture of the aortic branch was extremely rare, and only 5 cases have been reported in the English literature.