Ischemic heart disease (IHD) poses some serious problems in the surgical treatment of arteriosclerosis obliterans of the lower extremities (ASO) and aortic aneurysm (AA). The surgical management of these vascular diseases in patients with IHD was evaluated. Thirty-five patients had ASO and 31 had AA. All patients underwent coronary arteriogram. IHD was detected in 24 patients (69%) with ASO and in 12 (39%) with AA. The severity of coronary artery disease was graded by the coronary score (CS) proposed by Leaman et al., and the scores were compared with the mode of surgical treatment. In patients with ASO, both the revascularization of coronary arteries (CABG) and of peripheral arteries were performed in one stage in 3 patients with a CS of 16-22. Only arterial revascularization of the lower extremities was performed in 19 patients with a CS of below 5.5. In AA, surgical treatment was performed with consideration of the severity of the coronary artery disease and the surgical approach. Both CABG and aortic reconstruction were performed in one stage in 3 patients with abdominal aortic aneurysm (CS: 9.5-13.5) and in 2 patients with aortic arch aneurysm (CS: 3.5, 8) with a coronary lesion in the left anterior descending branch (LAD). Only aortic repair was performed in 5 patients with a CS below 8 (without LAD lesion). The patients with ASO (CS≤5.5), and those with AA (CS≤8, no LAD lesion) underwent reconstruction only in the arteries of the lower extremities and aortic aneurysms, respectively, without any complications from the associated IHD.

The arm ergometer exercise test (Arm E) was performed in 24 patients with arteriosclerosis obliterans of the lower extremities (ASO) to detect ischemic heart disease (IHD). All patients underwent coronary arteriography. IHD was detected in 16 patients (67%) with ASO. Sensitivity for diagnosis of IHD was 94%, specificity was 75% and accuracy was 88%. The severity of coronary artery disease was graded by the coronary score (CS) proposed by Leaman, et al. and the scores were compared with the mode of surgical treatment. In 3 patients with a CS between 16 and 22, the revascularization of both coronary arteries (CABG) and of peripheral arteries were performed in one stage. In 12 patients with CS below 5.5, only arterial revascularization of the lower extremities was performed without complications from the associated IHD. These results suggest that Arm E is a useful screening test to detect IHD in patients with ASO for surgery.

Transesophageal pacing (TEP) was performed in 54 patients with atheroscrelotic vascular disease to detect ischemic heart disease (IHD). Thirty patients had arteriosclerosis obliterans of the lower extremities (ASO) and 24 patients aortic aneurysm (AA). All patients underwent coronary arteriography. Sensitivity for the diagnosis of IHD was 90% and the specificity 67%, accuracy 83% in ASO and sensitivity 80%, specificity 93%, accuracy 88% in AA. In both vascular diseases the sensitivity was 87%, the specificity was 83%, and the accuracy was 85%. These results suggest that TEP is a useful screening test to detect IHD in patients with atheroscrelotic vascular disease who are candidates for surgery.

A 66-year-old man presented to a local doctor with a chief complaints of episodes of dizziness lasting several seconds. Electrocardiographic findings were suggestive of arrhythmia and old myocardial infarction, and the patient was therefore referred to our hospital. Left ventriculography showed an aneurysm at the posteroinferior wall of the left ventricle, while coronary angiography showed chronic total occlusion of the left circumflex branch (segment 13) and a coronary-pulmonary artery fistula with a coronary aneurysm. On computed tomography, the orifice of the ventricular aneurysm was small, measuring approximately 10 mm. Magnetic resonance imaging showed wall thinning and mural thrombus in the ventricular aneurysm, with aneurysmal dilatation during systole. Suspecting a ventricular false aneurysm resulting from old myocardial infarction, left ventricular reconstructive surgery and resection of the coronary artery aneurysm were performed. Intraoperatively, myocardial necrosis of the posteroinferior wall accompanied by the ventricular aneurysm was seen. There was no pericardial adhesion to the ventricular aneurysm, and the diameter of the orifice of the aneurysm was approximately 10 mm. The ventricular aneurysm was cut open and then closed using a direct suture combined with patch repair. As for the coronary artery aneurysm, the inflow and outflow arteries were each clipped before the wound was closed. The patient had a favorable postoperative course and was discharged from the hospital on the 15th day after surgery. The pathological examination showed residual cardiomyocytes within the aneurysmal wall, thereby establishing the diagnosis of a pseudo-false aneurysm. Our experience with this rare case is reported.

We reviewed our experience with 4 cases of chronic dissecting aortic aneurysm (DeBakey IIIb) with the false lumen extending into the abdominal aorta and major branches being perfused from the false lumen. In such cases, resection of the intrathoracic portion of the aneurysm and closing of the distral false lumen may exclude visceral perfusion from the false lumen. In order to ensure continued perfusion of true and false lumens after repair, we performed “double barrel” anastomosis for distal anastomosis in graft replacement of the descending aorta. Follow-up periods ranged from 8 to 21 months, 17 months on average. Postoperatively, neither apparent expansion of the false lumen nor compression of the true lumen was found in these cases. The advantage of this procedure is the effective restoration of visceral perfusion. We emphasize that this procedure is one of the choices of procedures, as a two-staged approach for chronic aortic dissection presenting with visceral perfusion from the false lumen and without an enlarged abdominal aorta, though more patients and longer follow-up are required to fully evaluate this procedure.