Spontaneous formation of aorto-caval fistulae is rare, occurring only in 4% of all ruptured abdominal aneurysms, and spontaneous rupture of the inferior vena cava (IVC) associated with the unruptured abdominal aneurysm has not been previously found in the literature. A 79-year-old woman with abdominal pain and hemorrhagic shock, was found to have a leaking abdominal aortic aneurysm and was transferred to our hospital. Preoperative CT revealed a massive right retroperitoneal hematoma and an infrarenal large abdominal aortic aneurysm. At laparotomy, no leaking site was found in the aneurysm, but a 2-cm laceration in the wall of IVC was found. The injured site was closed with a patch while controlling bleeding with a balloon catheter. The patient recovered uneventfully and was discharged on the 17th postoperative day. The mechanism of spontaneous rupture of the IVC is unknown, but and may occur due to incidental and abrupt increase in venous pressure in a stenotic IVC.

We describe successful resection and anatomical revascularization in 2 men aged 75- and 50 who suffered from prolonged systemic infection. Blood culture was positive in both cases, Klebsiella pneumoniae and Staphylococcus aureus (MSSA), respectively. Case 1 was misdiagnosed as acute appendicitis and underwent laparotomy. Postoperative CT revealed leaking aneurysm. Case 2 was diagnosed correctly on screening CT. Bacterial culture of all surgical specimens proved negative. The postoperative course was fortunately uneventful. The early and accurate diagnosis of infected aneurysm is important to establish surgical strategy. Timing of surgical intervention is still difficult to determine for minimizing the risk of graft infection.

A 76-year-old male was admitted to our hospital because of melena. However, no remarkable findings of rupture were shown by enhanced CT scan and angiography. On the 9th day of admission, he fell into a state of shock because of sudden massive bloody intestinal discharge. Colonofiberscopic findings revealed a primary arterio-enteric fistula. Therefore, an emergency operation was undertaken. Following aneurysmectomy, colostomy was performed in the descending colon. Right axillo-femoral artery bypass was finally performed as an extra-anatomical bypass to secure the right leg blood flow.

A 55-year-old man was admitted with anterior chest pain. He had received aorto-renal bypass for left renal artery stenosis at the age of 24. His coronary angiography with ergotamine malate provocation showed 99% stenosis in the left anterior descending artery and circumflex artery and abdominal aortography revealed an aneurysm with a diameter of 4cm at the proximal site of the graft anastomosis. The patient was surgically treated with aneurysmectomy and PTFE grafting (7mm) between abdominal aorta and the already-implanted graft to the left renal artery. His postoperative course was uneventful and no major complication such as renal failure were observed. Anastomotic aneurysm is a fairly common complication associated with arterial reconstruction which is most common in the common femoral artery. This is the first reported case of anastomotic aneurysm complicated by aorto-renal bypass.

A 54-year-old man consulted our hospital because of nocturnal and mild exertional chest pain. Echocardiography demonstrated a mobile mass in the right atrium. There were no abnormal findings on the coronary angiogram. Because of the large size of the mass, surgical removal was carried out and a yellowish, globular tumor, sized 20×15×13mm, attached to the anterior tricuspid leaflet with a short stalk was excised. Postoperative recovery was uneventful. The patient was discharged from the hospital with no symptoms. The diagnosis of papillary fibroelastoma (PFE) was confirmed on histologic examination. PFE is a well-known tumor that usually arises on the heart valves. Although, historically, this tumor has incidentally been discovered at necropsy, clinical case reports have recently increased. However, the vast majority of clinically reported PFEs were the cases of the left side of the heart, for which the operative indication is quite definite because of serious complications such as cerebral or myocardial infarction caused by this tumor, irrespective of size. On the contrary, only a small number (17 cases) of the right heart PFEs have been reported in the literature and its operative indications are unclear. Review with regard to the operative indications for the right heart PFEs was made based on the total of 18 cases including our patient.

Cardiac injury following blunt chest trauma requires immediate transportation, correct diagnosis and early surgical treatment. We present 2 cases of rare cardiac rupture, right auricular laceration and multiple ruptures of vena cava, respectively. Case 1: An 18-year-old male driver was transported to a local hospital in a state of shock immediately after a traffic accident. Chest CT demonstrated cardiac tamponade. After temporary hemodynamic improvement by pericardiocentesis, he was referred to our hospital. Since his blood pressure decreased below the measurable threshold in the ICU, he was transferred to the OR after emergency subxiphoid pericardial drainage. On opening the pericardium after full sternotomy, the right atrial appcndage laceration was found, about 1cm in length, and was sutured easily without cardiopulmonary bypass or any transfusion. Postoperative recovery was uneventful. Case 2: A 19-year-old male driver was directly transferred in an apneic shock state. Chest CT revealed cardiac tamponade. Full sternotomy was promptly carried out in the ICU after cardiopulmonary resuscitation (CPR) and subxiphoid pericardial drainage. Caval injury was found, 2cm in length, in both the superior vena cava (SVC) and intrapericardial inferior vena cava (IVC). His circulatory state was restored after the repair of these caval injuries without cardiopulmonary bypass; however, he died from severe brain damage postoperatively. In summary, blunt rupture of the right heart could be saved by prompt transport with airway assist, pericardial drainage, and proper surgery.