Endovascular treatment with a hand-made stent graft was performed successfully for a ruptured infected descending thoracic aortic aneurysm in the patient under chronic hemodialysis. The patient was a 77-year-old man and hemodialysis was continued with a double lumen catheter because of internal shunt occlusion since November 2005. He developed MRSA sepsis around January 2006 and was treated with antibiotics. Left pleural effusion was drained on March 1st, 2006. Initially left effusion from the left side was fluently bloody, however it became bloody the next day. Enhanced CT revealed the descending thoracic aortic aneurysm and left hemo-thorax. He was referred to our service, and was transportedly via ambulance. Home made stent graft was deployed under local anesthesia 2h after the arrival. His hemodynamic status became stable and left pleural hematoma was removed by video assisted thoracic surgery 2 days after endovascular treatment. His postoperative course was uneventful and antibiotics were continued 4 weeks. He is doing well without any recurrence of infection 23 month after the surgery. Careful follow up is mandatory, and endovascular treatment would be useful for the ruptured infected aortic aneurysm.

Aortic emergencies are surgically challenging and the mortality rate remains high. Since December 2003, we have performed endovascular treatment with a stent graft (EVT) in 15 cases of aortic emergency, including 8 cases of aortic rupture or traumatic aortic disruption, 1 case of traumatic iliac artery disruption, 3 cases of aortobronchial fistula (ABF), and 3 cases of aortoenteric fistula (AEF). In 9 cases of aortic rupture and traumatic aortic or iliac disruption, 1 patient died due to traumatic cerebral hemorrhage, but the remaining 8 patients were discharged without complications. While hemoptysis was resolved in all 3 patients with ABF, 1 patient with primary ABF died due to pneumonia, and 1 patient with secondary ABF died due to multiple organ failure. Furthermore, 1 patient with primary AEF progressed well without any evidence of postprocedural stent graft infection. In 2 patients with secondary AEF, both required secondary surgical graft excision, and 1 of these died due to the recurrence of infection. EVT has shown good results in hemostasis for aortic emergency. However, if a source of infection persists, secondary surgical intervention is required in some cases. Commercially available endovascular stent graft make it possible to treat tortuous segments of the thoracic aorta and the abdominal aorta, therefore we expect there to be more patients with aortic emergencies who require EVT.

Cardiac surgery associated with idiopathic thrombocytopenic purpura (ITP) is rare, and only 10 cases have been reported in the literature. In this report, we described the successful surgical management of a patient with ITP, diabetes mellitus and malfunction of mitral bioprosthetic valve. A 62-year-old male, who underwent mitral valve replacement (MVR) by means of a Carpentier-Edwards valve prosthesis and CABG ten years ago, developed malfunction of mitral prosthetic valve. The preoperative platelet count was 52, 000/mm³ and PA-IgG elevated markedly. The diagnosis of ITP was based on findings of bone marrow examinations. Thrombocytopenia was treated by steroids for 4 weeks and large dose γ-globulin (20g/day) for 5 days preoperatively, but platelet count did not increase. Platelet rich plasma (PRP) was transfused prior to cardiopulmonary bypass (CPB) and fresh blood was added to the priming material of CPB. Re-MVR was performed by means of mechanical valve prosthesis. After operation, large doses of γ-globulin and transfusion of PRP were performed for 3 days, and the postoperative course was uneventful. Other reports in addition to this study reveal that cases of cardiac surgery associated with ITP should be initially controlled preoperatively with steroids or high-dose γ-globulin, and if these treatments are harmful or ineffective, splenectomy should be considered.