Thromboexclusion method for thoracic aortic aneurysm was studied in 10 patients who had dissecting aneurysm in 7 and atherosclerotic aneurysm in 3. The aortic aneurysms extended from the left subclavian artery to the diaphragma or more widely. The operations were extraanatomic bypass and permanent aortic clamp proximal to the aneurysm in 9, and proximal and distal to the aneuysm in one. The follow up periods were 14 days to 80 months. Eight patients survived more than 3 months and 5 of them had thromboexclusion of aneurysm to the diaphragma. One with the aneurysms of incomplete thromboexclusion resulted in aneurysmal rupture 28 months after operation, and recovered by additional clamp distal to the aneurysm. Another had aneurysmal rupture, and died 63 months after operation. A patient had the penetration of the clamp to the pulmonary artery, and died 12 months after operation. Temporary paraplegia occurred in a patient 15 months after operation. Two patients developed constipation without ileus. Any difference of blood pressure between upper and lower extremities was not recognized, and no patient had deterioration of renal function. Indication of this method should be strictly selected, and careful follow up study is mandatory.

Recently, arterial keton body ratio (AKBR) has attracted attention as a new indicator of liver function which is in equibilium with the ratio between oxidized and reduced forms of free nicotinamide-adenine dinucleotides (free NAD⁺/NADH ration) in the mitochondria. There are few reports on whether AKBR contributes to the hepatic energy charge in the open heart surgery with extra corporeal circulation (ECC) or not. This study was undertaken to clarify the contribution of AKBR to the hepatic energy charge during ECC and the relationship between AKBR and hepatic blood flow. AKBR was determined before, during and after ECC in the open heart surgery for 14 patients. Furthermore, the blood flow in hepatic artery, portal vein and liver microcirculation was measured before, during and after ECC in canine models. Finally, the pulsatile perfusion was performed in canine models and compared with the conventional non-pulsatile perfusion for the blood flow and AKBR. In clinical cases, AKBR was decreased in all cases during the ECC. AKBR which was measured at 2 or 3hr after weaning from the ECC was negatively correlated to the total perfusion time with -0.57 as the correlation coefficient. Six patients who were on the ECC over 180min did not show a good recovery of the AKBR after weaning from the ECC. Especially, three patients presented a clinical picture of acute hepatic failure with jaundice, elevation of the serum levels of transaminase and direct hyperbililubinemia, but only one showed hypoglycemia. These patients showed no improvement in clinical data and AKBR. The patient with improved AKBR recovered clinically. In our experiment, the blood flow in the hepatic artery, portal vein was measured by electromagnetic blood flow meter and the liver microcirculation was measured by laserdoppler flowmeter. The blood flow was decreased remakably in the non-pulsatile group at all sites of measurement: it recovered after ECC in hepatic artery and portal vein, but liver microcirculation did not improve well. AKBR was decreased during ECC and did not recover after ECC in the non-pulsatile perfusion. When the pulsatile perfusion was performed, liver circulation was maintained well, and AKBR recovered well after ECC. The above results suggest that AKBR reflects the liver microcirculation and pulsatile perfusion is beneficial to the liver microcirculation. Pulsatile circulation, however, involves several problems, hemolysis, the decrease of platelets, and so on, but these problems have been improved gradually. We think that the pulsatile perfusion will be used in clinical operations to maintain the good hepatic circulation.