Primary abdominal aortic dissection occurs infrequently. We experienced aortic dissection originating at the level of the right renal artery, for which graft replacement and reconstruction of the aorta and also the celiac, superior mesenteric and both renal arteries were performed. A 44-year-old woman with severe back pain was admitted to our hospital. CT and aortogram revealed primary abdominal aortic dissection. The abdominal aorta was replaced with a trunk prosthetic graft, to which were connected smaller grafts for the four abdominal visceral and also lumbar arteries. The intercostal artery was preserved by a diagonal trasection at the upper end of the graft site. To prevent ischemia of the visceral organs, we used a selective perfusion technique to the superior mesenteric artery and both renal arteries. The postoperative course was uneventful. The postoperative aortogram demonstrated good patency and function of the trunk graft and reconstructed visceral arteries

We present a rare case of tuberculous thoracic aneurysm which ruptured into the lung. A 66-year-old woman who has been treated for lung tuberculosis and spondylocace was referred to our hospital for treatment of a descending thoracic aneurym confirmed by enhanced CT scan. On the 6th hospital day, she had massive hemoptysis and her systolic pressure dropped to 70mmHg. Emergency operation was performed under an F-F bypass. The saccular aneurysm was excised and surrounding infected tissue was debrided. UBE graft was inserted in situ and totally covered with omentum. The pathological diagnosis of the specimen was tuberculous aortic aneurysm. The postoperative course was uneventful. Good reconstruction and omental vessels around the replaced graft were revealed by postoperative angiogram. Two years later she is well. The omental covering of the replaced graft was a useful method for preventing graft infection.

A 59-year-old female case with cardiac tamponade due to rupture of the coronary arteriovenous fistula is described. Preoperative coronary arteriography showed bilateral coronary-pulmonary fistulae not associated with significant atherosclerotic stenosis. On opening the pericardium after establishing F-F bypass, the pericardial sac contained 300 grams of partially clotted blood. There was subepicardial hematoma along the area of the left anterior descending artery and the left circumflex artery without any other abnormal findings of the heart. The operation consisted of hemostasis with several mattress sutures along the left anterior descending artery and the left circumflex artery, closure of multiple fistulous openings from within the pulmonary artery, and ligation of abnormal dilated vessels originating from bilateral coronary arteries. The coronary arterio-venous fistula with aneurysmal dilatation should be operated on aggressively, whether symptomatic or asymptomatic, to prevent the rupture of fistulae.

A case of ruptured dissecting aortic aneurysm (DeBakey IIIa) involving a right-sided aortic arch is reported. A 54-year-old man was admitted to our hospital with a complaint of severe back pain. Roentgenogram and enhanced computed tomography of the chest revealed a right-sided aortic arch, right descending thoracic aorta and right pleural effusion. Thoracocentesis of the right thoracic cavity revealed bloody fluid. The ruptured dissecting aortic aneurysm was suspected. The enhanced CT of the chest revealed leakage of the contrast medium at the level of the bifurcation of the trachea so aortography wasn't performed. There was a 2cm intimal tear in the descending aorta. Resection and grafting of the aneurysm via right thoracotomy was performed. The patient made an uneventful recovery and was discharged 4 weeks later. It is pointed out that the operative method and/or decision of the method of approach for the aneurysm involving a right arch are difficult because of the aberrant left subclavian artery and/or tortuous descending thoracic aorta. Impeccable judgement is needed for emergency operation of ruptured dissecting aneurysms like the present case.

A 42-year-old man with Budd-Chiari syndrome was admitted to our institute for reoperation. The patient had undergone a cavoatrial bypass 9 years previously, but early occlusion of the bypass graft was suspected as there was reappearance of dilated abdominal veins. Preoperative cavography showed occlusion of the bypass graft and well-developed collateral veins. The patient underwent direct reconstruction with endo-venectomy and patch angioplasty of the obstructed vena cava and hepatic veins using a ringed ePTFE graft. The markedly dilated tortuous subcutaneous veins of abdominal wall disappeared immediately after reoperation. Postoperative cavography showed the patency of the IVC and three hepatic veins, IVC-right atrium mean pressure gradient decreased from 16mmHg to 6.5mmHg. Direct reconstruction should be the first choice in surgical treatment for Budd-Chiari syndrome, and is also useful as a reoperative procedure.

Introduction: Long-term cardiac hypertrophy causes heart failure. One of the mechanisms of this transition from hypertrophy to heart failure is collapse of hypoxic response and angiogenesis. Heat shock protein 27 (HSP27) was found to act as an anti-apoptotic protein and its phosphorylation is responsible for the protection of cells against heat stress. HSP27 has been reported to regulate p53 expression, which contributes to down-regulate angiogenic factors through hypoxia inducible factor-1α(HIF-1α). We have reported that thermal therapy, namely Waon therapy, improves cardiac and vascular function in patients with chronic heart failure. However, the effect of this therapy on cardiac hypertrophy due to pressure overload is unknown. The purpose of this study is to investigate the effects and mechanisms of thermal therapy (Waon therapy) on the transition from cardiac hypertrophy to heart failure after pressure overload. Methods: Cardiac hypertrophy was induced by transverse aortic constriction (TAC) in C57BL/6 mice. At 2 weeks after TAC, all mice were examined by echocardiography and showed left ventricular hypertrophy. Then, mice were randomly divided into thermal therapy or untreated group. Thermal therapy group received thermal therapy using an experimental far infrared ray dry sauna, which elevates the core temperature by 1 degree Celsius for 30 minutes, daily for 4 weeks. Sham operated mice were used as control. At 6 weeks after TAC, we measured body weight, heart rate and blood pressure before sacrifice, and eviscerated heart and leg muscle. Western blot analysis of p53, phosphorylated HSP27, HIF-1α and vascular endothelial growth factor (VEGF) was performed using extracted protein form heart. Results: At 6 weeks after TAC, body weight, heart rate and blood pressure did not differ in three groups. Echocardiography showed that left ventricular fractional shortening of thermal therapy group was significantly larger than that of untreated group (Sham vs. Untreated vs. Thermal; 50.0±1.7 vs. 36.7±1.3 vs. 46.2±0.5, P<0.01, n=6 each). Heart weight/tibia length ratio of thermal therapy group was significantly smaller than that of untreated group (6.7±0.1 vs. 9.7±0.5 vs. 7.9±0.2, P<0.01, n=9 each). Western blot showed that thermal therapy increased phosphorylation of HSP27 and reduced p53. Thermal therapy also increased HIF-1α and VEGF at 6 weeks after TAC. Capillary/myofiber ratio was larger in thermal therapy group than that in untreated group (1.71±0.05 vs. 2.04±0.04 vs. 2.41±0.10, P<0.01, n=4 each). Conclusion: Thermal therapy, namely Waon therapy, prevented the transition from cardiac hypertrophy to heart failure induced by pressure overload in mice. As the mechanism, thermal therapy amplified the phosphorylation of HSP27 and inhibited p53, increased HIF-1α and VEGF, and then increased angiogenesis.

A 78-year-old woman with abnormal shadows on computed tomography (CT) was given a diagnosis of right-sided aortic arch and Kommerell diverticulum (KD), accompanied by aberrant left subclavian artery. Although no symptoms were observed, the maximum diameter of the aneurysm was 63 mm, and surgical intervention was chosen because of the possibility of rupture. At first, a 4-branched blood vessel prosthesis with a side branch was anastomosed to the ascending aorta. Next, after reconstructing the cervical branches, a Conformable GORE® TAG® (W.L. Gore and Associates, 34 mm×200 mm) was inserted from the side branch and expanded in the range of Zones 0 to Th 7. Finally, ALSA coil embolization was performed. She was discharged on postoperative day 36, and at her 2-year follow-up, she was doing well, with shrinkage of Kommerell diverticulum.