The elephant trunk procedure is used to close the false lumen of the distal aorta in the surgical treatment for aortic dissection. We examined the state of the false lumen thrombus and measured the diameter of the aortic dissection, using postoperative digital subtraction angiography and computed tomographic scanning. We performed the elephant trunk procedure in 24 cases in the period, between January 1995 to December 1999. Total aortic arch replacement was performed in Stanford type A dissection, and descending aorta replacement was performed in Stanford type B dissection. In all patients, thrombotic closure around the elephant trunk graft was confirmed. Thromboexclusion of the false lumen of the descending aorta was observed in 18 cases (75.0%). The secondary operation may be unnecessary, because there was a tendency towards reduction of the diameter of dissecting aorta. These data revealed that this procedure was effective. In 6 cases (25.0%), residual dissection was recognized in the thoracoabdominal aorta, but there was no case of expansion requiring further operation. Nevertheless, careful follow-up is necessary, because aneurysms could expand in the future.

The left IMA graft to the LAD showed a string sign with no antegrade flow in an asymptomatic 67-year-old man 3 years after the operation. The LAD lesion had regressed from 95% stenosis to less than 50% during this period. Exercise electrocardiographic and thallium 201 myocardial scintigraphic examinations revealed no ischemia in the LAD region. When the LAD was temporarily occluded by a PICA balloon, the anterograde flow from the IMA to the LAD could be demonstrated by angiography. The IMA graft in no flow situation has maintained anatomical patency for 3 years after the operation.

A case of coronary subclavian steal following coronary artery bypass grafting (CABG) using the internal thoracic artery (ITA) in the presence of the stenosis of the left subclavian artery (SCA) is reported. The patient was a 70-year-old woman who developed recurrent angina about one year and three months after CABG with an ITA to LAD, and then underwent postoperative coronary arteriography. Angiograms revealed retrograde flow through the ITA to the left SCA and severe stenosis of the origin of the left SCA. Restoration of antegrade flow througn a left ITA graft to the coronary artery was achieved by balloon angioplasty to the stenosis of SCA. This procedure resulted in resolution of symptoms. The coronary subclavian steal is an infrequent, but very important complication after CABG with an ITA, and should be kept in mind in this mode of CABG.

Aortitis is an inflammatory arteriopathy that often progresses to obliteration of multiple large arteries. Surgical treatment for obstructive lesions due to aortitis syndrome therefore is difficult in many cases. The patient was a 23-year-old female who at the age of 19 had been diagnosed as aortitis syndrome with cerebral vessel involvement, and she subsequently received steroids. She increasingly experienced syncopal attacks, and was indicated for surgical treatment. Angiography revealed obstruction of the left common carotid and left subclavian arteries, and severe stenosis of the right common carotid and right vertebral arteries. She underwent bilateral ascending aorta-carotid artery bypass operation with 7mm ring-supported EPTFE grafts. After the operation she developed clinical signs of temporary brain damage due to hyperperfusion syndrome, but she now completely recovered and maintains a good clinical condition.

We report a case with successful surgical resection for a leiomyoma with an extension into the right atrium from the pelvic vein. The patient was a 54-year-old woman who presented with syncope in 1989. She had had a history of resection of a uterine leiomyoma 10 years previously. Preoperative angiograms showed a long tumor with an extension into the right atrium through the inferior vena cava originating from the right internal iliac vein. The diagnosis of intravenous leiomyomatosis was made. The operation was performed through a median sterno-laparotomy using cardiopulmonary bypass with successful results. Histologic sections showed a benign leiomyoma. To our knowledge, 20 cases of resection of intravenous leiomyomatosis with the use of extracorporeal circulation have been reported in the literature. This rare condition was discussed with the review of the literature.

We studied the incidence of associated ischemic heart disease (IHD) among 143 consecutive patients (male 118, female 25, mean age 68.5±6.9 years) operated upon for abdominal aortic aneurysm (AAA), excluding ruptured aneurysms. The screening of IHD was routinely performed by using dipyridamole thallium scintigraphy, and when it was positive, the lesion was further confirmed by selective coronary angiography. More than 50% luminal stenosis of the major coronary arteries was judged positive for IHD. Sixty-two patients (43%) with AAA were simultaneously afflicated with IHD. We also compared the 62 AAA patients with IHD with the remaining 81 AAA patients in this series. The patients with IHD had higher incidences of risk factors such as diabetes mellitus (p=0.0031) and hyperlipidemia (p=0.0029) than those without IHD. Five patients were operated on for AAA after coronary artery bypass grafting (CABG), 11 were operated on for AAA and IHD (CABG) simultaneously, 10 were operated on after PTCA, thirty-two patients underwent elective surgery for AAA and four had emergency procedures due to impending rupture of AAA with continuous infusion of nitroglycerin with or without diltiazem. There was no significant difference in surgical mortality between AAA patients with IHD and those without IHD (3%vs2%), and no cardiac death in this series. When both AAA and IHD are severe enough to warrant surgical treatments at the earliest opportunity, we recommend concomitant operations for AAA and IHD (CABG) since these have been performed quite successfully in our series.

Infectious arterial aneurysm in a rare condition with a high mortality because of rapid aneurysmal growth and subsequent rupture. We encountered 3 cases of arterial aneurysm due to Salmonella infection. We evaluated there 3 cases and an additional 14 cases reported in the Japanese literature. Eleven patients with Salmonella infection had bacteremia. The incidence of bacteremia in patients with Salmonella infection was more frequent than that in patients with other bacillary infections. The location of the aneurysm was the abdominal aorta in 14. Rupture or impending rupture of the aneurysm was identified in 12. Fifteen patients underwent operation including in situ reconstruction in 9 and extra-anatomic bypass in 6. Among 15 patients who underwent an operation, 14 survived. These data suggest that accurate preoperative diagnosis, long-term antibiotic therapy, and immediate surgical intervention are essential for effective treatment of arterial aneurysm due to Salmonella infection.

A 73-year-old man who had undergone Y-grafting suffered from septicemia. A culture of arterial blood yielded Bacteroides fragilis. Computed tomography showed abscess and gas around the prosthetic graft. Under a diagnosis of a prosthetic graft infection caused by Bacteroides fragilis, removal of the infected graft, extra-anatomic bypass and omental grafting were performed 13 days after the first operation. After intensive treatment, he recovered and was discharged on the 45th day postoperatively.

A 71-year-old woman who had Takayasu's disease underwent Y-grafting, bypass grafting between the abdominal aorta and left renal artery with 8mm ePTFE graft and right nephrectomy for infrarenal abdominal aortic aneurysm and renovascular hypertension (RVH). Four years after the first operation, the bypass graft became occluded and hypertension was exacerbated. Magnetic resonance angiography revealed that the left renal artery was supplied by the collateral arteries. We performed replacement of the thoracoabdominal aorta and reconstruction of the left renal artery using the saphenous vein. Postoperatively serum creatinine level decreased and hypertension was controllable. She was discharged from the hospital and has been well for three years.

A 52-year-old man who had liver cirrhosis sufferred ruptured thoraco-abdominal aortic aneurysm. This patient was classified as having Child's class B liver cirrhosis preoperatively. The thoracoabdominal aorta was successfully replaced with reconstruction of the renal arteries, superior mesenteric artery, celiac artery, and 10th intercostal artery. Omentopexy was added. As persistent ascites continued postoperatively, peritoneovenous shunting was performed on the 29th postoperative day. Ascites disappeared and 20 days later the patient was discharged from hospital and has been well for two years.