A 55-year-old female with silent myocardial ischemia was admitted to our hospital for CABG. Her postoperative course was uneventful. However, after the initiation of oral nutrient intake on the first postoperative day, drainage from the anterior mediastinum increased to 600ml/day. The character of the fluid was milky and biochemical examination revealed that it had a high triglyceride content (925mg/dl). The patient was placed on a medium-chain triglyceride diet and intravenous hyperalimentation without success. On the sixth postoperative day, the mediastinum of the patient was re-explored. The fistula was located in the left side of the anterior mediastinum where the thymic tissue is located. The fistula was ligated and the chylorrhea ceased. The incidence of chylothorax after cardiac procedures through median sternotomy is rare. We recommend early surgical ligation of the fistula if the postoperative hemodynamic state of the patient is stable.

A 75-year old woman in whom a left ventricular tumor had been detected by echocardiography 2 years before referral to our hospital, presented with blurry vison for one month. Acute cerebral infarction was diagnosed. We suspected that the infarction was occurred by an embolus from the intraventricular tumor, and resected it through left atrial incision. The resected tumor was 10 mm in size and it resembled a sea anemone. The tumor was pathologically diagnosed as papillary fibroelastoma. The postoperative course was good, with no recurrence for the last 18 months.

A 42-year-old female was admitted complaining of a pulsating mass of her left upper arm for two years. As she had played volleyball, she hit a ball with her upper arm accidentally for many times. The arteriogram showed a 30×35mm sized brachial artery aneurysm. Replacement of brachial aneurysm with saphanous vein graft was performed. Histologically, the aneurysmal wall consisted of three layers of arterial wall and had multiple breaks in continuity of the elastic layer. We diagnosed it was a true traumatic aneurysm caused by repetitive blunt injury. The causes and etiology of the brachial artery aneurysms were discussed.

A 65-year-old man was referred to our service complaining of intermittent claudication of his left leg. During preoperative examinations, he was found to have bilateral isolated internal iliac artery aneurysms. As it was strongly suspected that ischemic colitis or gluteal ischemia would be caused if his bilateral internal iliac arteries were ligated during aneurysm surgery, his right internal iliac artery was reconstructed using a prosthetic graft. His postoperative course was uneventful. As aneurysm of the internal iliac artery is rare, there are few reports about reconstruction of the internal iliac artery. Technical details and pitfalls of internal iliac artery aneurysm surgery were discussed.

A case of aortic valve replacement in a 92-year-old woman is reported. Severe aortic valve stenosis was pointed out when she suffered from congestive heart failure (CHF). After medical treatment for CHF, she complained of leg edema even with only mild exercise. Aortic valve replacement was performed, because her general condition and her left ventricular contraction on UCG were good. Her postoperative course was good except for a transient rapid atrial fibrillation. We think that surgery should not be withheld on the basis of age alone.

A 68-year-old woman with distal arch aortic aneurysm was admitted. Preoperative magnetic resonance angiography revealed occlusion of the right middle cerebral artery. Single photon emission computed tomography showed decreased cerebral blood flow at rest and decreased reactivity to acetazolamide in the right temporal lobe. At first, a superficial temporal artery to middle cerebral artery anastomosis was made by neurosurgeons. Improvement of both the cerebral blood flow and the reactivity to acetazolamide was confirmed by single photon emission computed tomography 18 days after the operation. Twenty-two days after the operation, a total arch replacement was performed. The postoperative course was uneventful without any neurological complication.

Left ventricular (LV) thrombus is an uncommon primary disease, but following acute myocardial infarction (AMI) it is a common complication associated with a risk of systemic embolism. Especially if the thrombus is ball-shaped, there is a higher risk of systemic embolism. We reviewed 4 cases of thrombectomy including 1 with the acute phase of AMI and another with Takotsubo disease. Between January 2000 and August 2005, 4 consecutive patients underwent thrombectomy for ball-like thrombus in the left ventricle (all men, mean age 53.5 years). We performed thrombectomy through left ventriculotomy. In 3 patients ventriculotomy was repaired with direct closure with double PTFE felt reinforcement, and in the other large acute AMI with the infarction exclusion technique (Komeda-David) because the LV wall was remarkably fragile. All thrombi were ball-like and fresh (mean size 15.8mm). Concomitant coronary artery bypass grafting was performed in 3 cases, the Maze procedure in 2, and mitral annuloplasty (MAP) in 1. All patients survived and have been doing well without any major complications. Surgical thrombectomy is safe and can improve prognosis without systemic embolism. In the acute phase of AMI, the infarction exclusion technique is excellent to prevent bleeding and postoperative remodeling of the left ventricular wall.

Between January and December 2006, 3 patients with aortic abdominal aneurysm (AAA) receiving home oxygen therapy (HOT) and 20 patients without HOT were studied. The 3 patients with HOT were all men, the mean age was 72 years (range, 69-74), and they had been treated with HOT for 37.3 months (1-102) due to chronic obstructive pulmonary disease (COPD) with a mean %VC of 96.9% and FEV1.0% of 42.8%. Only the FEV1.0% value in the preoperative data was significantly lower than in patients without HOT. In the 3 patients with HOT, extubation was performed immediately after operation, and minitracheotomy tubes (Mini-trach^®) to control sputum were inserted in the operation room. The minitracheotomy tubes were removed 5 or 6 days after operation. Postoperatively, no one with HOT had any major complications, while in those without HOT one patient had ileus and another had prolonged intubation. There were no significant differences between the 2 groups in operative time, blood loss, blood transfusion, or hospital stay. In conclusion, based on detached preoperative close estimation and careful postoperative supervision, patients receiving HOT can undergo AAA operations as safely as those not receiving HOT.

The optimal strategy for shaggy aorta syndrome has not been established, however, several case reports are published with the increase of the aged population. We report two men with shaggy aorta syndrome. The one was 75 years old with acute limb ischemia at the left popliteal artery due to the macroembolism from infrarenal Shaggy Aorta. The other was 76 years old with kidney dialysis, who had suffered from blue toe syndrome due to microembolism from the mobile plaque adhering to the infrarenal aortic wall. We successfully performed graft replacement of the abdominal aorta in order to prevent the recurrence of atheromatous embolization from the Shaggy Aorta. They have been free from any embolic event for the last 1 year. The ultrasonogram was useful for preoperative diagnosis and intraoperative management.

A 36-year-old man was transported to our hospital with severe anterior chest and abdominal pain of sudden onset which was diagnosed as Stanford type B acute aortic dissection with visceral ischemia. Aortogram revealed occlusion of celiac, superior mesenteric and inferior mesenteric arteries with aortic dissection. At first, fenestration of the abdominal aorta above the inferior mesenteric artery was immediately carried out, but the abdominal pain continued. Therefore, bypass grafting for the superior mesenteric artery with saphenous vein was performed the next day. The patient's postoperative course was complicated with acute renal failure and paralytic ileus, which were treated medically and he was discharged in good condition.