For the purpose of reducing blood loss and blood transfusion, 100 cases of acute aortic dissection treated at this department were studied, focusing on surgery for aortic dissection and coagulation factors, fibrinogen in particular. In cases of aortic dissection, fibrinogen decreased at the acute stage, and showed concentrations significantly lower in Stanford Type A than in Stanford Type B, in extensive dissection (DeBakey Type I or Type III retrograde dissection) than in limited dissection (DeBakey Type II), and in open false lumen type than in closed false lumen type. In the assessment of 34 cases of acute Stanford Type A aortic dissection operated on within 24h of onset, it was found that a marked prolongation of activated clotting time (ACT≥1, 000s) during cardiopulmonary bypass causes an increase in blood transfusion. When ACT was maintained for 400s or longer, to inhibit the marked prolongation of ACT, by changing at any time the dose of heparin during cardiopulmonary bypass by 50-250units/kg on the basis of the preoperative fibrinogen level, instead of fixing it at 300units/kg, ACT decreased significantly, and was controlled at appropriate levels despite the low concentration of fibrinogen. As fibrinogen can be measured in the hospital, and the result obtained in a short time, it is considered to play an important role in controlling ACT to determine the dose of heparin based on its concentration.

From January 1, 1999 through December 31, 2001, 152 cases of aortic dissection (77 cases of Stanford Type A and 75 Type B) were treated in our department. Among those cases, 25 patients (10 Type A (13.0%) and 15 Type B (20.0%)) were accompanied by atherosclerotic aneurysm. The mean age of onset of those cases was 71.4±9.8 years. Because those patients were older, it is necessary to pay attention to decide on treatment strategy and surgical procedure. In order to prevent atherosclerotic plaque being pumped into the brain vessel, we devised the following surgical procedure and perfusion method of cardiopulmonary bypass as follows; 1. In cases of retrograde perfusion from the femoral artery through the aneurysm, we usually pump the blood more slowly and gently than the antegrade perfusion. 2. We reduce the perfusion pressure after the heart beat changes to ventricular fibrillation. 3. After distal anastomosis of the vascular prosthesis, the blood is pumped from its perfusion branch. An initial tear was located in the spindle-shaped aneurysm in 3 cases (2.0%). Of 11 cases that aortic dissection was in contact with the atherosclerotic aneurysm, 2 cases of saccular shaped aneurysm terminated the dissection. In the 9 cases of spindle shaped aneurysm, however, the dissection involved the aneurysm, suggesting that the effect of aneurysm on the dissection depended on the aneurysmal shape. When the dissection coexists with aneurysm in different portions of the aorta, re-dissection may extend into the aneurysm. Therefore, careful decision making on the timing of surgery is necessary for abdominal aortic aneurysm complicated with aortic dissection, even when treating conservatively.

Patients with Stanford A acute aortic dissection who were treated within 48h of onset in our institution between January 1, 1999 to December 31, 2001 were divided into those younger than 70 years and those 70 years or older to compare the results of surgical and conservative therapies and the cause of death. The total number of patients was 74, the age was 33 to 88 years (66.5±11.9 years), and the ratio of men to women was 39:35. Atherosclerotic aortic aneurysm was concurrently observed in 21.1% in those 70 years or older, which was significantly higher than 5.6% in those younger than 70 years. Of 36 patients younger than 70 years, 27 (75.0%) were saved, compared with 18 of 38 patients (47.4%) 70 years or older. Surgical therapy was performed on 46 patients, 62.2%. The percentage of patients who underwent surgery was 69.4% in those younger than 70 years and 55.3% in those 70 years or older with no significant differences. Operative death occurred in 9 of 21 patients (42.9%) 70 years or older, which was significantly higher than the 12.0% (3 of 25) in those younger than 70 years. For 28 patients who did not receive surgical treatment, death occurred in 6 of 11 patients (54.5%) younger than 70 years compared with 10 of 17 (58.8%) 70 years or older with no significant difference: both rates were higher than 50% and 9 patients died of rupture during operative preparation. Since elderly people have a high risk for various complications and have poor operative results, it is important to carefully determine the therapeutic strategy, select a simple operative technique and conduct the operation as soon as possible.

Three cases of aortic dissection involving abdominal aortic aneurysms are reported. Two of the 3 cases died from intestinal necrosis. In one of them, the abdominal aortic aneurysm ruptured following aortic dissection. Fenestration was not performed at the proximal anastomosis in the operation, and it is thought that this resulted in occurrence of intestinal necrosis due to superior mesenteric artery obstruction. In the other non-survivor, aortic fenestration and graft replacement were performed. However, he died from descending-sigmoid colon necrosis due to internal iliac artery obstruction. An autopsy demonstrated no problem that with the graft anastomosis. The successful case of aortic fenestration and graft replacement had no postoperative complications. Since the aortic wall is fragile in acute aortic dissection, it is advisable that operation be conducted 1 month after the onset except in cases of aortic rupture and malperfusion syndrome. Fenestration, which is usually safe in chronic dissection, should be performed and it is desirable to fenestrate the aortic wall if possible even in acute dissection.

An 85-year-old man was admitted complaining of chest pain. The ECG showed ST depression in leads II, III, _aV_F, V₃-V₆ and Q wave in leads I, _aV_L with elevation in ST segments. An emergency coronary angiography revealed 75% stenosis in the left main trunk, 75-90% stenosis in the left anterior descending artery, total occlusion in the acute marginal branch, 75% stenosis in the left circumflex artery, and 75% stenosis in the right coronary artery. He was treated medically, because he was old and his hemodynamics were stable. About 39h later, he lost consciousness suddenly and was shown to have cardiogenic shock. Echocardiogram revealed pericardial effusion. Percutaneous drainage was performed, resulting in improved blood pressure and level of consciousness. He was transferred to Okaya Enrei Hospital and received emergency surgery for subacute LVFWR. A sutureless repair and coronary bypass was performed under cardiopulmonary bypass and cardiac arrest. He experienced no major complication and was discharged 40 days after surgery. It is concluded that the sutureless technique allowed for a shorter operation time and concomitant coronary bypass successfully prevented pseudoaneurysm and improved cardiac function. A higher quality operation is possible by using a combination of on-pump, cardiac arrest, coronary bypass and left ventricle repair with the sutureless technique in such cases in which treatment is needed for cardiac arrest as in the above example. This method contributed to an improved prognosis.

We report the efficacy of catheter-directed thrombolysis (CDT) for acute deep vein thrombosis. Between January 2003 and August 2004, 20 patients were treated with CDT for occlusive femoral, ilio-femoral and vena caval thrombosis, for less than 2 weeks from onset. Average age was 56.4 years (range 30-78 years), 11 patients were male, and the duration of leg symptoms was 4.4 days (range 1-12 days). Routine temporary inferior vena caval filters were used, and a multi-lumen catheter was inserted from the popliteal vein. Urokinase was used via the catheter by the combination drip infusion method and pulse-spray method. All patients received heparin and stasis of venous flow was prevented with intermittent pneumatic compression. If thrombus remained, mechanical thrombolysis was necessary. Metallic stents were implanted for iliac vein compression syndrome and organized thrombus. Venographic severity score (VS score) and extremity circumference were used to evaluate the effects of treatment. The duration of the treatment was 5.0±0.28 days (range 2-9 days) and the total dosage of urokinase was 1, 025, 000±57, 000 units (range 360, 000-1, 680, 000 unit). One (5%) iliac vein compression syndrome and two (10%) organized thrombi were treated by implanted metallic stents. Giant thrombi was captured by temporary inferior vena caval filters in two patients, but there was no pulmonary embolism. Two patients had thrombophilia, one was antiphospholipid syndrome and one was protein S deficiency. There was an early recurrence in one patient and re-CDT was needed. The VS score deteriorated to 6.2±2.5 (post CDT) significantly (p<0.0001) from 26.2±6.3 (pre CDT). CDT for acute deep vein thrombosis was effective and its early outcome was acceptable.

1) 34, 9 and 57% of the 5th year medical students participating in clinical clerkship training program agreed on the need for selecting palliative therapy, death with dignity, and euthanasia, respectively, in response to a terminal stage of malignancy.
2) 60% of medical students supported the organ transplant legislations, but only 23% actually carried an organ donor card. 26% of the surveyed students supported the Japan Society of Obstetrics and Gynecology's attitude towards preimplantation diagnosis.
3) It was pointed out that they had better educated about bioethics.

Cystic adventitial disease of the popliteal artery is a rare cause of lower extremity occlusive disease. We report 2 cases of this disease. Two male patients aged 27 and 59 year old complaining of intermittent claudication visited our vascular service. Angiography showed a smooth sharp defect of the popliteal artery. Postcontrast computed tomography (CT) scanning and magnetic resonance image (MRI) showed a cystic lesion around the popliteal artery. One patient underwent resection of the cyst, which in the other patient endscopic surgery was performed with the aid of intravascular ultrasonograpy and intravascular endscope. Fifty three cases of this disease have been reported in Japan so far. These patients included 45 men and 8 women with a mean age of 47.7, ranging from 19 to 76 years old. Chief complaints were commonly intermittent claudication and sensory disturbance. In all cases, angiography revealed a smooth sharp defect. Recently 3D-CT scan, ultrasonography and magnetic resonance angiography (MRA) also are accurate for cystic lesions around the popliteal artery and these new technologies easily distinguish such cases from arteriosclerosis obliterans, Buerger disease and popliteal entrapment syndrome. Treatment consist resection of the cyst, in 27 cases reconstruction of the popliteal artery using a saphenous vein graft or artificial graft in 19 cases, percutaneus aspiration under the guide of CT and endscopy in 2 cases and 1 with spontaneous resolution, was seen in 1 case. In conclusion, we encountered 2 cases of cystic adventitial disease of the popliteal artery. 3D-CT scan, ultrasonography and MRA were useful for preoperative diagnosis and evaluation of postoperative condition.

A case of pseudoaneurysm of the external iliac artery after a total hip arthroplasty is reported. A 48-year-old man had undergone a total left hip arthroplasty 5 years previously. Acute arterial occlusion (AAO) of the left lower extremity occurred 3 times. AAO was due to pseudoaneurysm of the external iliac artery, which was detected by rotating digital subtraction angiography (DAS). Aneurysmectomy and reconstruction were carried out. Rotating DSA was useful for the diagnosis of this unusual case of pseudoaneurysm of the external iliac artery after a total hip arthroplasty is unusual.

We encountered a recurrent suprarenal abdominal aortic aneurysm (AAA) patient with coronary artery disease and hyperlipidemia after repair of infrareanal AAA. A 72-year-old woman complaining of an abdominal throbbing mass was admitted. Computed tomography (CT) and aortography revealed infrarenal AAA which was totally removed and Dacron graft was replaced. The patient was followed as an outpatient. At the time of initial graft replacement there was no remarkable aneurysmal change in suprarenal abdominal aorta. Five years after the initial operation, a suprarenal AAA 5cm in diameter was detected by ultra sonographic examination. CT scan and aortography confirmed suprarenal AAA involving the celiac trunk of the supramesenteric artery and renal artery. Redo AAA operation with reconstruction of these branches was performed under V-A bypass support in a thoracoabdominal approach. Slight renal and liver dysfunction occurred postoperatively. However, serum creatine GOT and GPT values normalized by the ninth postoperative day. Postoperative aortography revealed patency of all branches.