A 75-year-oldm an with an aortocaval fistula as a complication of aortoiliac aneurysm visited our hospital. He complained of shortness of breath and melena. Physical examination revealed a pulsating abdominal mass with thrill and continuous murmur. Chest X ray showed cardiomegaly with pulmonary congestion. CT scan showed infrarenal aortoiliac aneurysm and echo Doppler scan revealed aortocaval communication at the inferior caval bifurcation. Aortoiliac bifurcated graft and patch reconstruction of IVC were performed. The postoperative course was uneventful, and his congestive heart failure and hepatorenal dysfunction immediately improved.

An investigation on the efficacy of preoperative autologous blood donation in open-heart surgery was made using frozen red blood cells and MAP red blood cells in cooperation with the Red Cross Blood Center. In 109 cases which received the donation, the rate of cases which received no homologous blood transfusion was 93.6% (35.3% in the cases without donation). Even in the cases of redo operation or aortic surgery, in which extensive blood loss is expected, 75% of those given a donation of 1600-2000ml frozen blood required no homologous blood transfusion. The hemoglobin concentration in the cases which received blood donation for more than 4 weeks did not decrease, indicating that safe donation is feasible. The aforementioned frozen and MAP blood preparations can be preserved for a long period so that blood donation can be started even before deciding on the date of operation. Also, its usefulness is not affected by the postponement of the operation. Furthermore, there was no problem in safety with respect to transfer, treatment, and storage of the autologous blood in cooperation with the Red Cross Blood Center, suggesting that this is useful as a preoperative donation method, especially in small- and middle-scale hospitals, which have no separate blood centers. However, there were 2 cases in which aggravated symptoms were noted after blood collection. Therefore, it is important to carefully select cases for autologous blood donation in open-heart surgery and it is desirable to set up appropriate donation schedules.

A descending thoracoaortic aneurysm excluded by stent-grafting had expanded during a period of one and a half years. There was no endoleakage but there was shortening of the stent-landing on both proximal and distal sides. Aneurysm seemed to be pressed by blood pressure through the graft in TEE. The aneurysm was replaced by an artificial graft through a left heart bypass. Because ESP diminished during the operation, VIth intercostal arteries were reconstructed immediately, and CSF drainage was performed. Following this procedure there was no paraplegia.

Under scheduled anticoagulation therapy, surgery for abdominal aortic aneurysm was performed in 4 patients who had undergone heart valve surgery and implantation of a mechanical prosthesis. Warfarin and antiplatelet agents were prescribed in all cases preoperatively. Antiplatelet agents were discontinued from seven to 10 days before operation. Warfarin was stopped from two to three days before operation and heparin (200IU/kg/day) was administered by continuous intravenous infusion to produce an activated clotting time of around 150 seconds. Bolus intravenous heparin of 3, 000 IU was added before aortic crossclamp. Oral anticoagulants were resumed from the beginning of oral intake, and heparin was stopped when the prothrombin time reached therapeutic levels (% PT=40%). In three patients perioperative courses were uneventful. Intraperitoneal hemorrhage occurred in one patient who simultaneously underwent cholecystectomy and aneurysmectomy with Y-grafting. He required blood transfusion and interruption of anticoagulation. Brain thromboembolism occurred in this patient 26 days after the operation. We believe that scheduled anticoagulation for the operation of abdominal aortic aneurysm is safe and useful in patients with prior prosthetic heart valve surgery. However, the coexistence of coagulopathy requires more intensive anticoagulation therapy.

A 73-year-old woman was admitted to undergo three simultaneous operations: aortic valve replacement (AVR), coronary artery bypass grafting (CABG) and abdominal aortic aneurysm repair. She had previously undergone percutaneous catheter intervention in the left coronary anterior descending artery. Computed tomography revealed an abdominal aortic aneurysm 5cm in diameter. Aortic valve stenosis (AS) was shown with a pressure gradient of 60mmHg, and 90% stenosis of the distal right coronary artery was also shown. CT scan and aortography revealed porcelain ascending aorta. The patient underwent simultaneous operations because of severe AS, coronary artery disease and abdominal aortic aneurysm. An aortic cannula was placed in a position higher in the ascending aorta with no calcification. Cardiopulmonary bypass was started using a two-staged venous cannula through the right atrium. At first, AVR was performed with cardioplegic solution and ice slush. Because it was difficult to inject the cardioplegic solution into the coronary artery selectively due to the calcified orifice of coronary artery, we closed it immediately by removing the calcified intima of the porcelain aorta after completion of AVR. The second cardioplegic solution was injected through the ascending aorta. Next, CABG to RCA was performed using the right gastroepiploic artery without anastomosis to the ascending aorta. Cardiac surgery was first performed, followed by abdominal aortic aneurysm repair after discontinuation of cardiopulmonary bypass. The patient was extubated the next day and stayed for two days in the intensive care unit. She is very well now one year after the operation.