The patient was a 70-year-old woman with severe aortic stenosis and familial hyperlipidemia which was diagnosed in 1994. The patient was admitted as an emergency case due to syncope in 2002. According to ultrasound cardiography (UCG), the pressure gradient of the aortic valve was 120.7mmHg, and the diameter of the aortic valve annulus was 16.7mm. Computed tomography showed porcelain aorta from the annulus of aortic valve to the ascending aorta. On cardiac catheterization, the pressure gradient was 96mmHg, AVA was 0.4cm², and the ejection fraction was 38.7%. Since these findings suggested that conventional AVR was difficult, thoracotomy was performed at the left 5th intercostal level, and apicoaortic valved conduit (valved graft: SJM19HP, Intergard 22mm+Medtronic apical LV connector) was implanted. Postoperative cine MRI showed that most of the cardiac output (87%, 3.29l/min) flowed through the conduit, with the flow via the aortic valve accounting for 13%, 0.51l/min. This surgical procedure can be an effective alternative when conventional AVR is difficult.

A 16-year-old high school boy experienced intermittent claudication of his left lower limb during boxing training. Physical examination revealed a cold left foot and diminished pulse. A 64-row multi-slice CT (MSCT) demonstrated lateral shift and severe stenosis of the left popliteal artery due to malposition of the medial head of the gastrocnemius muscle. A diagnosis of popliteal artery entrapment syndrome (Delaney type II) was established and a surgical correction was planned. During surgery, since the artery was found to be compressed but not occluded, we simply released the popliteal artery by division of the medial head of the gastrocnemius and abnormal flips of muscle. The postoperative ankle brachial pressure index rose from “not measurable” to 1.22. MSCT was useful to characterize this anomaly by expressing the precise anatomical relation of muscle, bone and artery, which was a good guide for an appropriate surgical intervention.

A 71-year-old man had sudden onset of left lower limb swelling and consulted an orthopedic surgeon 14 days later. Venous echography demonstrated compression of the left iliac vein and the thrombus of the common iliac vein. After emergency admission, conservative therapy was given for 7 days, but the symptoms did not sufficiently diminish and a thrombus was also present. We therefore performed femoro-iliac cross-over vein bypass using a 10mm ringed ePTFE graft. Symptoms were completely improved and the graft was shown to be patent by echography after 3 months.

A 62-year old man was referred to our hospital with endocarditis. Although the infection was improved by antibiotic therapy, he underwent surgery because of severe aortic and mitral valve regurgitation. Preoperative computed tomography revealed a pseudoaneurysm of 20 mm in diameter at the posterior wall of the ascending aorta. The non-coronary cusp was infected and there was a punched-out pseudoaneurysm at the ascending aorta adjacent to the sino-tubular junction. After resection of the aortic wall and the aortic valve, a modified Bentall operation with a composite graft and mitral valve plasty was performed. Postoperative whole body computed tomography revealed no other pseudoaneurysms. In case of endocarditis, we have to consider the possibility of aneurysm formation throughout the body.

The patient was a 68-year-old woman with chief complaints of severe lumbago, left lateral abdominal pain and high fever. Computer tomography (CT) at a local hospital showed a left psoas abscess and a low density area around the terminal aorta. Blood tests indicated a high inflammatory response and MSSA was detected in a blood culture. Control of the infection was first attempted with antibiotics, but CT showed a pseudoaneurysm at the terminal aorta, and therefore she was transferred to our hospital. We diagnosed infected abdominal aortic and left common iliac aneurysms complicated by an MSSA psoas abscess, and performed extra-anatomic reconstruction with axillo-bifemoral bypass, aneurysmectomy and omentopexy in the psoas abscess cavity. Because of massive intestinal edema and mesentery, we attempted temporary abdominal closure with the vacuum-assisted closure (VAC) technique, and finally succeeded in closing without abdominal infection in the 6th operation, 42 days after the first operation. Infected abdominal aortic aneurysm complicated by psoas abscess is extremely rare and life threatening. The VAC technique is very effective not only in avoiding abdominal compartment syndrome but also in avoiding abdominal infection.

A case is described of the staged surgical repair of thoracic aortic aneurysm after revascularization of single functioning ischemic kidney of a 68 year old man. A hitological evaluation of renal function was obtained before renal revascularization, which encouraging us to perform the repair of thoracic aortic aneurysm with less risk of post-surgical acute renal failure. In case of single ischemic kidney, renal revascularization should be preceded to other major surgeries in order to prevent renal shut down.

Between 1970 and October, 1992, 120 cases of abdominal aortic aneurysms (AAA) were treated for surgical repair. Thirteen of these cases (11%) were performed with simultaneous repair for coexistent visceral vascular diseases and other intestinal organ diseases. Another 9 patients (7.5%) were treated with coronary revascularization for combined ischemic heart disease. Six of these cases received both operations during the same hospital stay. Our surgical strategy for coexistent AAA and ischemic coronary artery disease is basically a staged operation. Coronary revascularization should precede AAA repair. Operative mortality was 1.1 percent for elective AAA repair. Long-term survival was 78% for elective surgery with a mean follow-up of 51 months, and 52% for emergency surgery with a mean follow-up of 46 months. Major risks for late death were malignant neoplasms and ischemic coronary artery disease. Survival rate of the 9 patients with successful concomitant coronary revascularization and AAA repair was 89% after 51 months of mean follow-up. We conclude that re-evaluation for coexistent ischemic heart disease is the most important point for management before and after AAA repair.

Among the 203 cases of aortic valvular surgery, we experienced 8 cases of acute coronary insufficiency during the early postsurgical period. Five cases suffered from right coronary insufficiency. The other 2 cases had left coronary failure, and the remaining case had both. The main symptom of right coronary failure was right ventricular dysfunction, resulting in inability to wean from cardiopulmonary bypass in 3 cases, and left ventricular dysfunction due to inferior myocardial infarction in 2 cases. On the other hand, the main symptom of left coronary insufficiency was acute left ventricular pump failure with a broad anteroseptal infarction, and cardiac arrest occurred in the other 2. All patients receiving an emergency coronary artery bypass graft survived. Two cases expired due to thromboembolism in the interposed graft to the left coronary ostium in Cabrol's or Piehler's procedures. In the 6 survivors we could not detect any recent coronary lesions by postsurgical coronary cineangiography. We suggest that the pathophysiology of this phenomenon was coronary artery spasm and a lack of coronary reserve capacity in severe left ventricular hypertrophy of aortic valvular disease combined with diastolic dysfunction. Prompt coronary artery bypass grafting and a careful myocardial protection using retrograde cardioplegic solutions might save patients in this critical condition and an appropriate decision on the surgical indications for aortic valvular surgery is necessary before the occurrence of left ventricular diastolic dysfunction and demand ischemia.

A 55-year-old man was admitted with a thoracic aortic aneurysm causing wheezing. Computed tomography and angiography revealed a large distal aortic saccular aneurysm, occupying the retrotracheal space and compressing the trachea. There has been only one report of this type of aneurysm. This patient needed emergency intubation because of severe dyspnea caused by premedication for surgery. Replacement of the distal arch was performed via left posterolateral thoracotomy. Profound hypothermia was used during open proximal anastomosis, which helped to make this procedure safe and simple. This patient recovered uneventfully.

This study evaluated factors influencing residual aortic regurgitation (AR) after valve re-suspension surgery for acute type A aortic dissection. From January 1996 through December 2002, 63 patients were treated for acute type A dissection at our institution. Among these 63 patients, pre-and postoperative echocardiograms were available in 38 patients who underwent surgery combined with native aortic valve re-suspension. These 38 patients were divided into 2 groups according to the postoperative AR grade, i. e.: AR group: AR grade≥II (n=6), no-AR group: AR grade≤I (n=32). The severity of pre and postoperative AR was assessed by transthoracic or transesophageal echocardiography. The preoperative diameters of mid ascending aorta and sinotubular junction, and the percentage of the circumference of the dissection at the sinotubular junction level was measured by enhanced CT scan. Preoperative patient backgrounds were similar in both groups. The preoperative AR grade in the AR group was significantly greater than that of the no-AR group (2.25±1.17: 0.69±0.91, p<0.001). The tear was more frequently located in the ascending aorta in the AR group than in the no-AR group (66.7%: 37.5%, p<0.05). The percentage of circumference of the dissection at the sinotubular junction level did not affect the preoperative AR grade, but it did show a tendency to influence the severity of postoperative AR, though the difference was not significant. Three patients (7.9%) had AR grade III at the time of discharge, but did not clinically require further surgical intervention. Preoperative significant AR and the location of the tear in the ascending aorta are associated with postoperative residual AR after aortic valve re-suspension. The percentage of circumference of the dissection at the sinotubular junction level might influence the severity of postoperative AR.