A 71-year-old man with an abnormal shadow on chest x-ray was given a diagnosis of Kommerell's diverticulum involving the right-sided aortic arch with mirror image branching. Furthermore, mild funnel chest had been seen on CT scan more than 10 years earlier. The patient was followed up because there were no symptoms ; the Kommerell's diverticulum expanded to reach 63 mm in diameter. To eliminate the risk of rupture, we performed thoracic endovascular aortic repair (TEVAR) with a commercially available device, consisting of bypass grafting of the supra-aortic branches. The patient was discharged from the hospital in good clinical condition, with no signs of endoleak and currently shows no indications of device migration. We thus concluded that debranching TEVAR for Kommerell's diverticulum with right-sided aortic arch is minimally invasive, safe, and effective. Availability of this device that has a new performance feature is expected to improve treatment results and lead to advances in minimally invasive endovascular repair.

We report an 85-year-old woman with rupture of aneurysm of the descending thoracic aorta into the left lung. She was admitted with sudden onset back pain and hemoptysis. Emergency operation was performed to replace the ruptured descending thoracic aorta, and lower lobectomy of left lung. The left lobectomy ensured that hematoma was not left in lung, although it decreased respiratory function after operation. In addition, it decreased bleeding and operating time compared to segmental resection. She was discharged without contracting an infection in the lung or graft, although she needed tracheotomy for a time. We suggest that the lower lobectomy of lung was an important factor in saving this elderly patient with rupture of an aneurysm into the left lung.

We report a 78-year-old man who had an impending ruptured atherosclerotic arch aneurysm combined with chronic dissecting ascending aortic aneurysm. The patient underwent a graft replacement of the ascending aorta and aortic arch using the elephant trunk method with the aid of profound hypothermia and continuous retrograde cerebral perfusion. Cerebral blood velocity was measured with transcranial Doppler (TCD) during operation. The TCD flow pattern after weaning of cardiopulmonary bypass indicated a state of brain edema. Therefore it is important in extensive retrograde cerebral perfusion to control the perfusion pressure and prevent destruction of the blood brain barrier aggressively. Pharmacological intervention could improve the safety of retrograde cerebral perfusion. Postoperative diagnostic images showed that the part of the distal anastomosis around the elephant trunk was not surrounded with thrombus. At this stage, it is not necessary to perform next extensive aortic replacement. It is important to consider the occurrence of complication, who using elephant trunk method, including paraplegia, thromboembolism, kinking of prothesis.

From January of 1987 to December 1992, twelve patients (7 males and 5 females, mean age, 52.8 years) underwent emergency surgery for DeBakey type I acute aortic dissection. The surgical procedure was resection of the initial intimal tear and replacement of the ascending aorta (four patients underwent hemiarch replacement). Operative mortality was 41.7% (5/12). Three died in the operating room due to heart failure (2) and uncontrollable bleeding (1). Another two early deaths resulted from extension of the residual false lumen. All surviving patients each had a patent double-channeled aorta and aneurysmal dilatation of the false lumen was noted in 3 patients. There were two late deaths, one due to rupture of the residual false lumen and the other, to stroke during re-operation for enlargement of the residual false lumen. It is apparent from these results that in type I acute aortic dissection extensive operation such as total arch replacement is necessary.

The purpose of this study was to examine the responses of cerebral blood flow and metabolism to changes in arterial carbon dioxide tension during moderate hypothermic cardiopulmonary bypass in patients with cerebrovascular disease undergoing open heart surgery. Computed tomography scan (CT) and single photon emission computed tomography (SPECT) were performed preoperatively for 17 patients. The patients were categorized according to their CT and SPECT findings. Ten patients were included in the normal group, 7 patients were included in the CVD group. Blood flow velocity in the middle cerebral artery (MCAv) was measured by means of transcranial Doppler ultrasonography at two different arterial carbon dioxide tensions (at a high PaCO₂ of 45-50mmHg, at a low PaCO₂ of 30-35mmHg, uncorrected for body temperature) during moderate steady-state hypothermic cardiopulmonary bypass. Simultaneously cerebral oxygen consumption was estimated by relating the arteriovenous oxygen content difference to flow velocity (D-CMRO₂). MCAv and D-CMRO₂ were expressed as percentages of the values determined at 30 minutes before cardiopulmonary bypass. In the normal group, a PaCO₂ of 47.4±2.5mmHg (mean±SD) was associated with an MCAv of 99.4±17.8% and a D-CMRO₂ of 53.4±25.5%, while a PaCO₂ of 33.7±1.3mmHg was associated with an MCAv of 64.3±18.1% and a D-CMRO₂ of 53.5±26.2%. In the CVD group, a PaCO₂ of 49.1±4.2mmHg was associated with an MCAv of 81.4±22.3% and a D-CMRO₂ of 34.0±19.4%, while a PaCO₂ of 33.6±1.3mmHg was associated with an MCAv of 54.7±23.8% and a D-CMRO₂ of 49.0±19.4%. We conclude that in patients with cerebrovascular disease cerebral blood flow is changed in response to changes in arterial dioxide tension during moderate hypothermic cardiopulmonary bypass, however a high PaCO₂ depresses cerebral oxygen consumption because hypercarbia may cause potentially harmful redistribution of regional cerebral blood flow away from marginally-perfused to otherwise well-perfused areas.

We investigated the effects of rewarming speed on cerebral circulation and oxygen metabolism during cardiopulmonary bypass (CPB). Twenty-four adult patients who had undergone open heart surgery with moderately hypothermic CPB were divided into two groups. In the slow rewarming group (group S), the rates of increase of blood temperature were under 0.1°C/min. In the rapid rewarming group (group R), they were more than 0.1°C/min. Mean blood flow velocity in the middle cerebral artery (mean MCAv) was measured by transcranial Doppler ultrasonography, and the index of cerebral oxygen consumption was evaluated by Doppler-estimated cerebral metabolic rate for oxygen (D-CMRO₂). The change of oxyhemoglobin level in the brain (Oxy Hb) was monitored by near-infrared spectroscopy. In group S, mean MCAv and D-CMRO₂ changed in a parallel manner following the changes of the rectal temperature throughout the periods, and mean MCAv was always higher than D-CMRO₂. In group R, however, the rate of increase of D-CMRO₂ was more rapid than that in group S from the beginning of rewarming, and D-CMRO₂ exceeded the level of mean MCAv just before termination of CPB. In addition, Oxy Hb in group R showed more rapid changes than that of group S. In conclusion, rapid rewarming during CPB may cause the disruption of cerebral flow-metabolism coupling.

We report a case of aneurysm localized to the noncoronary sinus of Valsalva with moderate aortic regurgitation (AR). The patient was a 49-year-old woman who had been suspected to have some kind of connective tissue disorders. She underwent an aortic root remodeling procedure to replace the isolated, unruptured and extracardiac aneurysm and the ascending aorta. Postoperative angiogram showed no aneurysm and improved AR. This procedure was able to preserve her own aortic valve and normal sinuses of Valsalva and enable her to obtain better quality of life, although progression of the enlargement of the aorta or AR requires careful follow-up.

A 67-year-old man was referred to our department for surgical treatment of ischemic cardiomyopathy. Chest X-ray showed cardiomegaly with a cardiothoracic ratio of 62% and pulmonary congestion. CAG revealed multiple obstructive lesions in the left coronary artery system. LVG and UCG showed ventricular dilatation and dysfunction. ECG showed complete left bundle branch block with a QRS duration of 180ms. He underwent autologous bone marrow cell implantation and biventricular pacing concomitant with coronary artery bypass grafting. He is doing well after 15 months without any complications. Combination with therapeutic angiogenesis and cardiac resynchronization therapy may contribute to the development of new regenerative strategy for patients with severe ischemic cardiomyopathy.

An 85-year-old man being treated for idiopathic interstitial pneumonia underwent chest CT 6 months prior to the current admission and was diagnosed as having an expanding saccular aneurysm of the aortic arch. Due to the patient's advanced age and the anatomical position of the aneurysm, it was difficult to perform total aortic arch replacement or hybrid arch repair with a commercially available device. After ethical approval had been obtained from the institutional review board, a commercially available stent graft (Relay Plus®) was fenestrated with a 12-mm hole. Under general anesthesia, bypass grafting was performed between the bilateral axillary arteries and the right common carotid artery with a T-shaped ring-supported e-PTFE prosthesis. The fenestrated stent graft was advanced through the left femoral artery and deployed with the device fenestration located at the bifurcation of the brachiocephalic artery. Then, a branched stent graft was deployed through the right common carotid artery in a retrograde manner between the brachiocephalic artery and the ascending aorta through the fenestration to complete the procedure. The patient had an uneventful postoperative course, with no detectable endoleak on postoperative digital subtraction angiography. The current technique, involving the use of an easy-to-make device，is effective for endovascular aneurysm repair, especially when a proximal neck needs to be created in the ascending aorta.