Inflammatory aneurysms of the thoracic aorta are extremely uncommon. We present a 58 year-old man with an inflammatory aneurysm of the aortic arch. He was admitted because of chest pain. Coronary angiographies showed severe stenosis of the left anterior descending artery and computed tomography revealed an aneurysm of the distal aortic arch. We conducted combined graft replacement of the aortic arch and coronary artery bypass grafting. During the operation, the patient was noted to have extensive peri-aneurysmal fibrosis and inflammation with a thick aneurysmal wall. To avoid excessive hemorrhage, distal anastomosis was performed using the graft inclusion technique. He was discharged 35 days after operation without any major complication. Pathological evaluation of the aneurysmal wall revealed destruction of the mural structure and inflammatory cell infiltration in the adventitia.

Off-pump coronary artery bypass (OPCAB) has recently increased in popularity, but the longterm results are still unknown. We evaluated the mid-term results of OPCAB surgery using multi-slice computed tomography (MSCT), which is a non-invasive postoperative evaluation method. Thirty-one consecutive patients who underwent OPCAB surgery at least 2 years prior to the study were selected. The age was 50 to 79 years (66.9±6.5) and the ratio of men to women was 26: 5. Coronary angiography was performed in all patients at 2 weeks postoperatively. The follow-up was complete, and mean follow-up was 30.9 months. There were no hospital deaths and 1 non-cardiac late death. The graft patency rate in coronary angiography was left internal thoracic artery (LITA) 30/30 (100%), right internal thoracic artery (RITA) 2/2 (100%), radial artery (RA) 14/15 (93%), saphenous vein graft (SVG) 15/17 (88%). No graft became occluded on MSCT study and all patients have been angina-free during the follow-up period. We suggest that OPCAB is feasible in most patients with good patency and low mortality. MSCT is an effective follow up method for the morphological findings and noninvasive quantitative evaluation of the bypass grafts.

Floating masses in the descending aorta are an uncommon source of embolism. We report a 43-year-old woman, with no previous history of thrombotic events, who was admitted to our hospital for renal and splenic infarction. Transesophageal echocardiography and computed tomography showed a floating mass in the descending aorta. We started anticoagulant therapy immediately and performed surgical removal of the mass that had caused multiple embolic episodes. The postoperative course was uneventful. In cases of a free floating thrombus in the aorta, it is important to prevent catastrophic complications by removing it surgically after anticoagulant therapy.

Neointimal hyperplasia is the principal mechanism of graft failure in coronary artery bypass surgery. Systemic administration of cilostazol has been reported to suppress neointimal hyperplasia in some vascular injury models. We sought to deliver cilostazol locally in an attempt to augment its beneficial effect to inhibit neointimal hyperplasia at an anastomotic site. We examined whether the external application of a novel cilostazol-eluting film can inhibit neointimal hyperplasia in a vascular anastomosis model. Canine femoral artery graft interposition was performed in 20 beagle dogs, assigned to 4 groups of 5 dogs each : a graft interposition without copolymer of L-lactide and ε-caprolactone (P (LA/CL) ) film (control group) and groups with P (LA/CL) film containing cilostazol of either 10 mg, 40 mg, or 80 mg doses. All the cilostazol-eluting film with 10 mg, 40 mg, and 80 mg dose groups had a reduced intima/media ratio compared to the control group (0.15±0.03, 0.11±0.03, and 0.12±0.03, vs. 0.31±0.03, p<0.05). Immunohistochemical analyses for proliferating cell nuclear antigens revealed reduced cellular proliferating activity associated with decreased α-actin positive cells in the cilostazol-eluting film groups compared to the control group. External application of cilostazol-eluting film can inhibit neointimal hyperplasia, at least in part, by inhibiting smooth muscle cell proliferation in the intima.

Both aortic dissection and aortic aneurysm are complicated with disseminated intravascular coagulation (DIC) at the rate of four percent. DIC is said to be caused by the imbalance between coagulation and fibrinolysis and is classified into three types : suppressed fibrinolysis, balanced fibrinolysis, and enhanced fibrinolysis. Tranexamic acid has effects on suppressing the fibrinolytic system by inhibiting the mechanism by which plasmin decomposes fibrin. It is generally considered that the use of tranexamic acid for DIC is contraindicated. However, some reports show its effectiveness for non-infective chronic DIC. We illustrate two cases of DIC with enhanced fibrinolysis which are complicated with aortic dissection or aortic aneurysm that were successfully treated with tranexamic acid.

A 57-year-old man was admitted with high fever and chest discomfort associated with aortic valve infective endocarditis. An echocardiogram showed severe aortic valve regurgitation. An emergent operation was performed. The aortic valve was destroyed and an annulus abscess was observed. Aortic valve replacement was performed. There was a large amount of pleural effusion in both chest cavities. Bilateral chest drainage was performed. Cardiopulmonary bypass weaning was performed uneventfully. The operation was finished without any mechanical support required. However, respiratory failure was observed to progress rapidly immediately after the operation. A postoperative X-ray showed bilateral pulmonary edema. Re-expansion pulmonary edema was diagnosed. Because oxygenation was not improved in ventilator settings, venovenous extracorporeal membrane oxygenation (V-V ECMO) was installed. Respiratory support with V-V ECMO was needed for 17 days postoperatively. It took 36 days before the patient was removed from the ventilator. V-V ECMO successfully managed bilateral re-expansion pulmonary edema.

A 57-year-old man presented with a one-month history of dyspnea. Computed tomography revealed a pulmonary embolism, and echocardiography revealed multiple linear floating thrombi in the right atrium. An urgent surgical thrombectomy was performed, and most of the thrombi in the right atrium and bilateral pulmonary arteries were removed under cardiopulmonary bypass. The thrombi in the right atrium adhered to the linear Chiari networks. The patient was treated with rivaroxaban uneventfully and subsequently discharged on postoperative day 26. Herein, we report a case of right atrial thrombi and pulmonary embolism likely augmented by the Chiari network, which was successfully treated with surgical thrombectomy.