The excellent long term-patency rates achieved using the internal thoracic arteries (ITAs) have expanded the variety of graft arrangements of these conduits for multivessel coronary revascularization. We encountered 2 patients who underwent multivessel coronary artery bypass, by using these terminal branches of the left ITA effectively. In both patients, LITAs were taken down using the skeletonization technique with a harmonic scalpel. One patient had 2 grafts using the off-pump technique with the Y-composite grafts constructed by the main LITA trunk and LITA terminal branch, which were anastomosed with the left anterior descending branch (LAD) and diagonal branch (D₁), respectively. The other patient had 6 grafts under on-pump cardiac arrest, including the natural LITA terminal branches which were anastomosed with the LAD and D₁. Postoperative multidetector computed tomography (MDCT) revealed excellent long-term patent grafts in both patients. In conclusion, the terminal branches of the ITA, if of suitable size and length, could be used effectively to construct a Y-anastomosis for the coronary arteries, when consideration for the size of the target coronaries and native-coronary blood flow competition.

We report a case of total aortic arch replacement for ruptured aortic arch aneurysm in an oldest-old person. The patient was a 92-year-old woman with hypertension, who had normal daily activity. She consulted another hospital because of hemoptysis. A chest roentgen exam showed an outpouching of the first left arch. In our hospital, chest computed tomography revealed a saccular thoracic aortic aneurysm, 43mm in maximum diameter, which seemed to be the cause of hemoptysis. The patient and her family wanted to have operation. While waiting for the operation, she coughed up a large amount of blood and suffered respiratory failure, requiring a mechanical respirator. Two days later, in the operation room, she coughed up a large amount of blood again and suffered long term hypoxygenation. Though she underwent total aortic arch replacement, she developed septic shock with MRSA pneumonia. However, she was weaned from ventilatory support on the 24th postoperative day. On the 86th postoperative day, ambulatory was possible. She had no ischemic cerebral damage. In extensively elderly patients, careful attention must be paid to decide an the indications for highly invasive surgery such as total aortic arch replacement.

We performed redo off-pump coronary artery bypass (OPCAB) through a left thoracotomy using a PAS·Port system for proximal vein graft anastomoses for a patient with symptomatic ischemia in the left circumflex system. A 60-year-old man underwent OPCAB (LITA-LAD, RA-4PD) 7 years previously. Coronary angiography revealed a remarkable lesion in the left circumflex system, but the left internal thoracic artery graft (ITAG) and the radial artery graft (RAG) were patent. OPCAB was performed through a left thoracotomy to avoid injury to the patent grafts. With the heart beating, a saphenous vein graft (SVG) was anastomosed sequentially from the descending aorta to the first and second obtuse marginary arteries. Avoiding descending aortic clamping, a proximal anastomosis was made using the PAS·Port system and the SVG was routed anterior to the pulmonary hilum. The postoperative course was uneventful and he was discharged on the 22nd postoperative day. Cardiac CT showed patent SVG and adequate proximal anastomosis. In this case OPCAB through left thoracotomy was effective. The selection of the graft inflow source and bypass routes according to the individual patient is essential for the success of the procedure.

No abstract available.
Aged ; Drug Resistance, Bacterial ; Humans ; Imipenem/pharmacology/therapeutic use ; Klebsiella Infections/diagnosis/drug therapy/*microbiology ; Klebsiella pneumoniae/drug effects/isolation & purification/*physiology ; Male ; Microbial Sensitivity Tests ; Phenotype ; Sepsis/diagnosis/drug therapy/*microbiology ; Thienamycins/pharmacology/therapeutic use