A 62-year-old man with a complete type of Behçet's disease suffering from lower abdominal pain was admitted to our hospital. Abdominal CT and angiograms demonstrated a right isolated iliac aneurysm. When his general conditions had become stable, we evaluated the activity of Behçet's disease, especially inflammation and the existence of intestinal lesions, and found no abnormalities. He underwent graft replacement for the iliac aneurysm. The postoperative course was uneventful. Angiograms revealed good opacification of the graft and no abnormality of the anastomotic site. Some reports have emphasized anastomotic complications of vascular surgery associated with Behcet's disease. We should periodically check for inflammatory signs, anastomotic aneurysm and other recurrent aneurysms.

A 28-year-old woman with patent foramen ovale who developed tricuspid valve infective endocarditis with complications of multiple infarctions and abscesses was treated surgically. The patient was transferred to our institution because of fever and joint pain. Echocardiography revealed a large vegetation (25 mm) on the tricuspid valve and a patent foramen ovale. Computed tomography and magnetic resonance imaging showed cerebral infarctions, multiple lung abscesses, and vertebral osteomyelitis. Staphylococcus epidermidis was identified in blood cultures. After treatment with adequate antibiotics for 5 weeks, the patient underwent surgical resection of the vegetation followed by tricuspid valve repair and direct closure of the patent foramen ovale. Antibiotic therapy was continued postoperatively, and the patient was discharged 7 weeks after the operation. No further endocarditis or embolism has occurred. In cases of right-sided endocarditis with systemic embolism and abscesses, the presence of a patent foramen ovale should be considered, and appropriate timing of the operation should be determined to prevent further systemic embolization of the vegetation.

From January 1982 to August 1993, 23 cues of advanced renal cell carcinoma with tumor thrombus in the inferior vena cava (IVC) were treated surgically. In terms of clinical stage, 12 cases were in stage III and 11 cases were in stage IV. The 23 cases were divided into three groups according to the location of the tumor thrombus in the IVC. In two cases, the tumor thrombus extended to near the right atrium or the hepatic vein, and in six cases, the thrombus extended to the hepatic IVC. All these tumor thrombus with invasion to the IVC wall were removed under partial cardiopulmonary bypass. In 15 cases, tumor thrombus were limited to near the junction of the renal vein, which were removed by balloon catheter or finger after clamping of proximal and distal side of IVC and renal vein. Direct suture of the IVC wall in 12, patch repair with EPTFE in 10 and graft replacement with EPTFE graft in 1 were performed. Eight patients who had distant metastasis, regional lymph node metastasis and extracapsular invasion died within one year, but 4 patients were alive more than four years. Survival rate at three years and five years according to the Kaplan-Meier method was 37.5% and 18.8%, respectively. In conclusion 1) partial cardiopulmonary bypass was useful and could control bleeding when tumor thrombus in the IVC extended to the junction of the hepatic vein or right atrium. 2) long term survival cases were recognized in cases with no distant metastasis, no regional lymph node metastasis and no extracapsular tumor invasion. 3) nephrectomy associated with tumor thrombectomy in the IVC was valuable on the basis of long-term prognosis.

Drug refractory atrial flutter (AF) with secundum atrial septal defect (ASD) and pulmonary valvular stenosis was treated by surgical correction and intraoperative radiofrequency (RF) current ablation. Supraventricular arrhythmia, especially AF, is frequently found in aged patients with ASD. Perioperative managements for this arrhythmia were difficult because of drug refractoriness. We performed this ablation combined with intracardiac corrections, and sinus rhythm has been maintained without any drugs for 18 months. This case indicated that RF current ablation during open-heart surgery is useful and safe method of treatment of AF.

A 34-year-old male patient was admitted to our hospital with sudden onset of severe chest pain. A diagnosis of acute aortic dissection (Stanford type A) was made based on the results of examinations such as CT-scan and angiography. An emergency surgical replacemant of the ascending aorta was carried out. Multiple malperfusion phenomena such as cerebral, renal, right upper extremity and visceral Ischemia appeared postoperatively. With strict conservative therapy and laparotomy (descending colectomy), he survived and was rehabilitated. Acute aortic dissection associated with malperfusion phenomena are frequent and potentially extremely poor complication. Therefore, prognosis is determined by accurate and rapid diagnosis and salvage of the ischemic organs. In treatment of the acute aortic dissection, the control of the blood pressure is important, but also close attention should be paid to sufficient perfusion of the major organs.

A 75-year-old man was admitted complaining of sudden bilateral foot coldness and numbness. The patient had undergone endovascular repair for abdominal aortic aneurysm (AAA) 5 years previously. Abdominal X-ray showed a highly kinked endovascular stent-graft, and aortography revealed occlusion of the stent-graft and infrarenal aorta. Emergency axillo-bifemoral bypass was performed to restore the blood flow of the lower extremities, and he recovered uneventfully. Endovascular repair for AAA can be performed with low mortality and morbidity, and is accepted worldwide as a minimally invasive treatment. However, there are several late complications, such as newly developed endoleak, graft migration, graft occlusion, AAA expansion, and AAA rupture. Therefore, great attention should be paid to following patients treated with endovascular procedures for abdominal aortic aneurysm.

A 78-year-old woman complaining of suddenly developed numbness and coldness of the left hand was referred to our hospital on the suspicion of embolism. A 2×1cm mass was revealed in the fossa ovalis of the interatrial septum by echocardiography. She underwent operation under a preoperative diagnosis of thrombus in the left atrium or tumor of the interatrial septum. In the operation, the mass was excised including the interatrial septum and the defect of the interatrial septum was closed with a PTFE patch. A sagittal section of the mass showed that it was a fresh thrombus covered with normal endocardium of the fossa ovalis except for a small protrusion to the left atrial cavity. These findings yielded diagnosis of thrombus trapped in a patent foramen ovale. She was discharged after an uneventful postoperative course, although temporary pacing was needed for transient bradycardia in the early postoperative days. In this case, we hypothesize that an unidentified venous thrombus trapped in a patent foramen ovale had partly passed through the interatrial septum and caused paradoxical embolism in the left hand. Paradoxical embolism is a well-known phenomenon described in a number of reports. There are some reports of a trapped thrombus in a patent foramen ovale detected by echocardiography or in autopsy. We describe a rare case of surgical demonstration of a trapped thrombus in a patent foramen ovale, and recommend that examinations for venous thrombus with a suspicion of paradoxical embolism are necessary for patients of thromboembolism.

A 59-year-old man with a history of hypertension who suddenly developed back pain and apoplexy was transferred to our hospital 20 min after the clinical onset. Physical examination showed right conjugate deviation of the eyes and left paralysis, suggesting disorder of the right cerebral hemisphere. Enhance computed tomography showed an aortic dissection from the ascending aorta to bilateral iliac arteries, and the right common cranial artery was compressed by a false lumen. Acute type A aortic dissection complicated with cerebral malperfusion was diagnosed, and an emergency operation was performed 2.5h after the onset. Cardiopulmonary bypass was established with right femoral artery inflow and bicaval venous drainage. We found the dissection entry at the ascending aorta using the distal open technique, and performed hemiarch graft replacement with selective cerebral perfusion. The postoperative course was uneventful without deterioration of neurological function. Postoperative computed tomography showed no evidence of cerebral bleeding. He was given on ambulatory discharge on the 22nd postoperative day.

We report an unusual case of a 71 year-old man who developed chronic consumption coagulopathy caused by an abdominal aortic aneurysm. He was diagnosed as having the dissecting aortic aneurysm (DeBakey type IIIa) and the abdominal aortic aneurysm in 1989, and had been attending to our hospital as an outpatient since then. He developed macrohematuria in March 1990. The laboratory data showed the decrease in platelet, fibrinogen, plasminogen and α₂ plasmin inhibitor and the increase in FDP. The bleeding tendency was controlled by the administration of gabexate mesilate and heparin, but the laboratory data revealed that consumption coagulopathy continued. The abdominal aortic aneurysm was successfully replaced with a prosthetic vascular graft in June 1992. Postoperative hematological findings revealed the improvement, and he discharged 32nd day and doing well after operation.

A 5-year-old boy with tricuspid atresia who underwent the Björk procedure died due to right atrial thrombus and left pulmonary embolus 37 days after operation. It is suggested that thromboembolism may be a frequent complication after the Björk procedure due to the turbulent blood flow at the right atrio-ventricular anastomosis and also due to congestive blood flow. Anticoagulation therapy seems to be essential for postoperative management.