We successfully treated a case of extra-anatomical revascularization using an extrathoracic approach for what is called subclavian steal syndrome, and we describe the operative method. A 65-year-old man with dizziness was examined by digital subtraction assessment and given a diagnosis of subclavian steal syndrome by occlusion of left subclavian artery. He was relatively young for his age with good general condition, and no lesion were detected in aortic arch branches and cerebral arteries except for left subclavian artery. Therefore we performed left common carotid artery-subclavian artery bypass using a prosthetic graft. The preoperative symptoms and difference in blood pressure among arteries of the upper limbs disappeared, and he was discharged 15 days after surgery.

A case of successful surgical revascularization for mid-aortic syndrome is reported, with discussion of the operative method. A 10-year-old boy with headache and vomiting was admitted to our hospital for excessive hypertension. A diagnosis of mid-aortic syndrome with severe stenosis of abdominal aorta and stenosis or occlusion of bilateral renal arteries was made. His hypertension did not respond to conservative treatment. Therefore we performed aorto-aorta bypass using a prosthetic graft and revascularization of the bilateral renal arteries. The preoperative symptoms disappeared, his blood pressure became controllable, and he was discharged on the 21st day after surgery. At present, he attends school and has a normal blood pressure without hypotensive medication.

A 73-year-old man suddenly felt severe back pain. Computed tomography showed acute type B dissection. The false lumen existed from the distal arch to the right common femoral artery and was patent. The true lumen was severely compressed by the false lumen and his right leg was cold. In spite of limb ischemia, we started conservative therapy because he had severe airway stenosis due to obesity and obstructive sleep apnea syndrome (OSAS) and we thought surgical intervention very risky. We thought OSAS also involved a risk of high blood pressure and started continuous positive airway pressure. His blood pressure went down along with the improvement of respiratory conditon. After 12 days from the onset he evacuated bloody stool and gastrointestinal fiberscopy revealed giant gastric ulcer bleeding. Platelet counts and prothrombin time began to increase 2 days later. Computed tomography 14 days after onset showed a patent false lumen and severely compressed true lumen. Computed tomography 39 days after onset showed thrombosis of the false lumen and considerable dilatation of the true lumen. Hypercoagulability after bleeding from gastric ulcer and treatment of OSAS were important in this successful conservative therapy.

Obstructive sleep apnea syndrome (OSAS) has symptoms such as severe snoring, apneic attack, and daytime hypersomnia due to repeated obstruction of the upper respiratory tract during sleep. The mortality rate due to cardiovascular complications in severe OSAS. We reported 5 cases of OSAS among the acute aortic dissection cases we treated. They were 2 cases of DeBakey I (cases 1, 2) and 3 cases of III b (cases 3, 4, 5). Organ ischemia was recognized in 4 among 5 cases of dissection combined with OSAS. There was 1 case of renal ischemia (case 1), 2 cases of limb ischemia (cases 3, 4), 1 case of visceral and spinal ischemia (case 5). Case 4 was III b type dissection with severely compressed true lumen and limb ischemia. The false lumen occluded by combining antihypertensive therapy and continuous positive airway pressure used to OSAS. Case 5 also had a severely compressed true lumen, and visceral ischemia 4 days after the onset. Angiography showed a severly compressed orifice of the true lumen of the celiac artery and superior mesentric artery due to the occluded false lumen. We placed a stent into the orifice of celiac artery transluminally and then patient recovered. There were many dangerous situations such as organ ischemia, and severely compressed true lumen among the cases of dissection combined with OSAS. Marked changes of intrathoracic pressure in apneic attacks may place stress on the thoracic aorta.

We encountered a case of ruptured penetrating atherosclerotic ulcer (PAU) that previously had focal ulceration. A 82-year-old man was followed on a diagnosis of distal arch true aneurysm with a diameter of 4.5cm on CT examination. He was admitted with sudden onset of back pain, but he had experienced no previous symptom. CT scan showed a ruptured penetrating atherosclerotic ulcer, therefore we performed emergency replacement of the thoracic descending aorta. The postoperative course was good. CT scan showed the thoracic descending aorta had focal ulceration with a width of 11mm and depth of 7mm at 6 months, however the width was 11mm and the depth was 11mm 1 month before rupture of the PAU. This suggested progression of the focal ulceration caused the PAU rupture.

Acute aortic dissection is a formidable disease because of complications such as rupture or visceral ischemia. Early diagnosis of these conditions is essential. The patient was a 40-year-old woman with acute type B aortic dissection, suspected to have Marfan syndrome. We first treated her with medical therapy, but 5 days later she suffered from repeated abdominal angina. This was thought to be probably predictive of malperfusion, so we decided to perform an operation. We maintained an elevated blood pressure (about 140mmHg), used heparin and Prostaglandin E₁ for the prevention of angina, until total aortic arch replacement and open stent grafting was performed. She has been doing well since.

A 61-year-old man who had hypertension and renal dysfunction (serum creatinine : 1.5-2.0 mg/dl) was referred to our hospital for an abnormal shadow on chest roentgenogram. Chest CT scan with contrast revealed a distal aortic arch aneurysm (maximum diameter 52 mm) and left subclavian artery aneurysm (maximum diameter 30 mm). For the surgical treatment of the aneurysms, left hemi-collar incision and left subclavian incision followed by median sternotomy were performed. After the left subclavian artery was secured distal to the aneurysm, a ringed dacron graft was anastomosed with the distal left subclavian artery. Cardiopulmonary bypass was commenced, and selective cerebral perfusion was instituted at 25°C. The aorta was transected at the origin of the left common carotid artery. A 30 mm stent graft (length 13 cm) was inserted and was fixed on the transected aorta using 4-0 Prolene continuous suture. Then a branched dacron graft was sewn onto the transected aorta and the stent graft. The left common carotid artery and the brachiocephalic artery were anastomosed onto side branches of the graft. The left subclavian artery was reconstructed by anastomosing the ringed bypass graft onto one of the side branches. The left subclavian artery was ligated between the aneurysm and the origin of the vertebral artery, thereby interposing the subclavian artery aneurysm. After proximal anastomosis was done and the heart was reperfused, the patient was weaned from cardiopulmonary bypass. The patient was discharged without any major complication. Two years after the operation, the patient is doing well and there is no evidence of aneurysmal dilatation or endoleak. In conclusion, frozen elephant trunk technique provides an alternative to conventional graft replacement, resulting in complete exclusion of these aneurysms in a single stage. However, long-term follow up is warranted in order to ensure the durability of the stent graft.

An 81-year-old-woman was successfully treated with simultaneous minimally invasive direct coronary artery bypass (MIDCAB) and colectomy. The patient complained of effort angina and tarry stool and had a combination of Bormann type II transverse colon cancer with oozing bleeding and long segmental stenosis of the left anterior descending coronary artery (LAD). Angiography suggested that the anastomotic site on the LAD extramusclarly presented on the tortours LAD. We therefore carried out one-stage operation of MIDCAB and colectomy. First, MIDCAB to the LAD using the left internal thoracic artery was performed via left anterior thoracotomy. After closing the left thoracic wall, we carried out transverse colectomy with lymph node resection via upper median laparotomy. The total operation time was 3hr 30min, 2hr 10min for MIDCAB and 1hr 20min for Colectomy respectively. Postoperative coronary angiography showed good patency of the LITA. The resected colon specimen showed moderately differentiated adenocarcinoma: ss, n1, Po, Mo stage 3a. She was discharged 15 days after the operation.

A 68-year-old man was admitted to our hospital with dyspnea and general fatigue. At first, pulmonary embolism was diagnosed by electrocardiography and pulmonary scintigram. X-ray CT scans and echocardiography revealed a tumor occupying the right atrial cavity. To prevent further pulmonary embolism, he underwent tumor resection. In surgery, two venous drainage cannulas were inserted directly to the superior vena cava and to the inferior vena cava via the right femoral vein, in order to avoid the direct contact with the right atrium prior to institution of extra-corporeal circulation. The tumor was carefully removed together with the atrial wall around the site where the tumor originated. A pathological study showed that the specimens were myxoma in the right atrium. His post-operative course has been uneventful until now, however, long-term observation with respect to the metastasis and/or recurrence of this tumor will be carried out.

The patient was a 37 year-old man. We diagnosed Loeys-Dietz syndrome based on his physical characteristics that were widely spaced eyes and brachycephaly etc. Since he developed De Bakey III b aortic dissection 3 months later, he needed surgical repair for saccular-shaped distal arch aortic aneurysm. We performed total aortic arch replacement for the aneurysm and valve-sparing aortic root reconstruction for dilatation of the Valsalva sinus. Furthermore we performed the frozen elephant trunk technique for residual aortic dissection at the same time. After 18 months from the operation, we were able to recognize by computed tomography that the false lumen of the aorta next to the stent graft was thrombosed and absorbed and finally disappeared. The stent graft treatment for patients with connective tissue disease might be an effective method and deserves more attention.