We performed endovascular stent grafting of a perforated descending aorta, caused by empyema after surgery for lung cancer, in a 75-year-old man. After diagnosing hemorrhage from a perforation of the proximal descending aorta, caused by left empyema, the perforation was repaired with a saphenous vein patch and a pectoralis major muscle flap. However, re-hemorrhage from the same lesion occurred 2 months postoperatively. Temporary hemostasis was achieved with gauze packing and he was transferred to our hospital for endovascular stent grafting. The infection did not resolve after fenestration, so the descending aorta was cropped out to the fenestration lesion. Therefore, endovascular stent grafting was performed on the same day. Postoperatively the bleeding stopped completely without any signs of graft infection, and he was transferred to another hospital on postoperative day 9. No re-hemorrhage or graft infection of the aortic perforative lesion occurred in the early postoperative period. However, the patient died of massive bleeding from the aorta wall of the proximal stump of the stent graft, caused by recurrence of the infection 2 months after the 2nd operation. In this situation, endovascular scent grafting provides the only chance of saving the patient's life. If endovascular stent grafting is performed as a lifesaving procedure, meticulous operative technique is imperative.

It is known that the prognosis of preductal type coarctation of the aorta is poor because cardiac malformation is frequent in these cases. There have been very few reports on adult cases of the coarctation. We have recently carried out aneurysmectomy and reconstructed the descending aorta by a 30mm Veri-Soft tube graft for one adult case of descending aortic aneurysm associated with coarctation of the aorta. The patient was 49-year-old female. Segmental stenosis 5cm in length was demonstrated in the thoracic descending aorta immediately below the bifurcation of the left subclavian artery. The poststenotic dilatation was shown at the distal portion of the segmental stenosis. The postoperative clinical course was uneventful.

During the period between January 1975 and April 1991, 37 patients with acute arterial occulusion of the extremities were admitted to our department and were classified into 2 groups according to their causative factors, including thrombosis and embolism. Among 16 thrombosis patients with involvement of 17 limbs, 4 patients died and 6 limbs were amputated at the time of discharge. On the contrary, among 21 embolism patients with involvement of 25 limbs, 2 patients died and only one limb was amputated. Sixteen of 17 limbs with thrombosis were operated on. Arterial reconstruction was carried out initially on 5 limbs, resulting in successful limb salvage; 3 of 6 limbs which had undergone thrombectomy initially were occluded again soon after the procedure. In the end, 1 limb had to be amputated. On the other hand, 22 of 25 limbs were operated on. Three arterial reconstructions, 18 embolectomies and 1 amputation were carried out initially. All arterial reconstructions and embolectomies were successful. From these results, it was concluded that arterial reconstruction must be done initially for thrombosis patients. For the embolism patients, embolectomy is preferable.

Changes of hemodynamics and chemical mediators before and after aortic clamping were investigated in 12 patients who underwent infrarenal abdominal aortic aneurysmectomy. Patients were divided into two groups; one with an aortic clamping time greater than 1 hour (the long group) and the other with aortic clamping time less than 1 hour (the short group). Cardiac output, mean pulmonary arterial pressure (MPAP), extravascular thermal volume (ETV), polymorphonuclear elastase (PMN-E), α₁ trypsin inhibitor (α₁-TI) superoxide dismutase (SOD), urine N-acetyl-β-D-glucosaminidase (NAG), were measured before and immediately after aortic clamping, immediately after, 1 and 4 hours after aortic declamping. In addition, serum GOT, GPT, creatinine and BUN were measured before and 1, 3 and 7 day after operation. These levels were expressed as ratios of the level before aortic clamping and operation. The MPAP ratio immediately after aortic clamping was 0.83±0.06 in the long group and 0.99±0.08 in the short group. There was statistical significant difference in the MPAP between both groups (p<0.01). In contrast, there was no significant difference in the cardiac output or ETV between the two groups. The PMN-E ratio immediately after aortic declamping was 2.24±0.81 in the long group and 1.19±0.45 in the short group. These ratios increased at 1 and 4 hours after aortic declamping. The PMN-E ratio following aortic clamping in the long group was greater than those in the short group (p<0.05). The SOD at 1 hour after aortic declamping was 0.78±0.13 in the long group and 1.01±0.11 in the short group (p<0.05). The NAG ratio immediately and at 1 hour after aortic declamping was significantly higher in the long group when compared with the short group (p<0.01, 0.1). Serum GOT, GPT, creatinine and BUN ratios showed no change through out this study. There was an increase in protease and a decrease of free radical scavengers in the long group. These findings are commonly known to be linked with organ damage. Through the findings of this study, we suggest that clamping time should be minimized; thus reducing the possible chance of postoperative organ damage.

We investigated the quality of life (QOL) after thoracic or thoraco-abdominal aneurysmectomy in patients who had undergone the procedure within the past 15 years. We compared preoperative to postoperative performance status (PS). Defining PS in the following manner: one increase in that PS grade indicated mild worsening while an increase is by 2 or more indicated severe worsening. Maintenance was indicated by no change of PS after surgery. The QOL maintenance rate was calculated based on the following formula.
QOL maintenance(%)=No. of no change case/No. of operated cases-No. of death×100
There were a total of 74 cases in whom follow-ups could be carried out after surgery. Among them, there were ascending and aortic arch aneurysms in 19 cases, descending aortic aneurysms in 20 cases, dissecting aneurysms in 27 cases and thoraco-abdominal aortic aneurysms in 8 cases. The QOL maintenance rate in the type B dissecting aneurysms was comparatively high (85.7%). There were cases of severe worsening of PS in the ascending and aortic arch aneurysms and type A dissecting aneurysms and the QOL maintenance rate was 50% in each other. We should obtain high operative results due to improve the QOL maintenance rate, and devise the operative procedure without functional disorders of the organs after surgery.

Morphology, location, timing of operation, and complications of multiple aortic aneurysms were investigated in 14 patients (10 men and 4 women with a mean age of 66 years). The locations of the aneurysms were as follows: aortic arch and thoracoabdominal aorta in 1, aortic arch and infrarenal abdominal aorta in 6, descending thoracic aorta and suprarenal abdominal aorta in 1, descending thoracic aorta and infrarenal abdominal aorta in 5, and thoracoabdominal aorta and infrarenal abdominal aorta in 1. Thoracic aortic aneurysms had a mean diameter of 63±13mm. The mean diameter of the abdominal aortic aneurysms was 54±13mm. In 1 patient, thoracoabdominal and infrarenal abdominal aortic aneurysms were operated on simultaneously. Eight patients, 5 with aneurysms of the aortic arch and infrarenal abdominal aorta, 2 with aneurysms of the descending aorta and infrarenal abdominal aorta, and 1 with aneurysms of the aortic arch and thoracoabdominal aorta, underwent two-staged operation. Aortic arch aneurysm was operated first in 3 patients, and abdominal aortic aneurysm in 5. Postoperative complications included spinal cord injury in 1 patient, bowel necrosis in 1, renal impairment in 2, respiratory impairment in 2, and hepatic impairment in 1. There was no perioperative death. Three late deaths occurred. Two staged operation is better for multiple aortic aneurysms. The first operation should be performed for the larger aneurysm.

Medical students at Kurume University begin practical training in clinical skills in their fourth year. At that time, students use the skills laboratory to improve their clinical skills. Medical education resources in the skills laboratory include simulators for emergency resuscitation and heart diseases, wireless stethoscopes, and videotapes. All students use the skills laboratory for 2 months, and its usefulness was evaluated with questionnaires after practical training. More than 50 % of students approved of their practice in the skills laboratory. However, some students were unsatisfied because they were unable to make effective use of the simulators. In the future, an improved skills laboratory will be necessary to improve practical training in the clinical skills for medical students.