A 70-year-old man presented at a nearby hospital with dysphagia, hematemesis, and hemorrhage. After examination by magnetic resonance imaging and gastrointestinal fiberscopy, he was referred to our hospital on the suspicion of an aortoesophageal fistula due to a thoracic aortic aneurysm. Considering the degree of invasion and infection, we planned two operations but were compelled to perform three operations because of esophageal leakage. Aortoesophageal fistula due to thoracic aneurysms are usually fatal, with only 18 reported survivors in the past 22 years. The optimal treatment for this condition is not yet known. We report survival of the first case of aortoesophageal fistula due to thoracic aneurysm complicated by mediastinitis caused by esophageal leakage in which management by two operations was initially planned. From this case many possible strategies to manage aortoesophageal fistula due to thoracic aneurysms arose. Therefore, we report this case together with a review of the literature.

We report a case of severe aortic regurgitation due to deformation of the right coronary cusp which remained in a double-folded shape. A 76-year-old woman was admitted in August 2015 for the evaluation and treatment of dyspnea. She had no history of rheumatic fever, syphilis, endocarditis, or chest trauma. During physical examination, a grade IV/VI diastolic murmur was noted along the left sternal border. Her chest x-ray film showed marked cardiomegaly with interlobular pleural effusion (Vanishing tumor). An aortography revealed abnormally dilated proximal part of right coronary artery as well as severe aortic regurgitation. At operation, the ascending aorta was exposed through median sternotomy with the patient on total cardiopulmonary bypass. The left and non-coronary cusps were easily identified and noted to be normal. The right coronary cusp was recognized to be turned inside out and stayed in a double-folded shape, which made mal-coaptation of cusps and caused aortic regurgitation. The size of the right coronary cusp was larger than other two cusps. A very large right coronary ostium which occupied almost all of the sinus of Valsalva was confirmed. The aortic valve was excised and reconstructed with glutaraldehyde-treated autologous pericardium. She had an uneventful recovery and was discharged on POD 32. The mechanism of how right coronary cusp became disfigured was discussed. We think that the lesions of the sinus of Valsalva and proximal part of the RCA may have caused the double-folded right coronary cusp abnormality.

We describe a ruptured internal iliac artery aneurysm associated with sigmoid colon infarction. The patient was referred to our hospital complaining of lower abdominal pain. Computed tomography scan demonstrated a massive hematoma with a ruptured left internal iliac artery aneurysm. Hypovolemic shock prompted immediate laparotomy, endoaneurysmorrhaphy of the ruptured aneurysm, and resection of the recto-sigmoidal colon. During treatment for ruptured internal iliac aneurysm, we should consider potential colon infarction.

A 28-year-old woman with no underlying health issues was injured in a motorcycle accident and taken to our hospital by ambulance when she was 26 years old. Though she was diagnosed with multiple trauma, upon arrival at the hospital neither cardiac murmurs nor cardiac abnormalities on transthoracic echocardiography were detected. She was managed conservatively, and discharged on hospital day 16. She experienced dyspnea upon mild effort, and an early diastolic murmur appeared. She was again referred to our hospital, and diagnosed with severe aortic regurgitation. We scheduled an aortic valve replacement using an bioprosthetic valve because she intended to give birth. We also considered simultaneous aortic root enlargement as her aortic annulus was small. We performed the surgery 2 years after the initial motorcycle accident. Perioperatively, we noticed that her non-coronary cusp was torn. We converted the procedure to an aortic valve repair using an autologous pericardial patch. Her aortic regurgitation disappeared after the operation, and she was discharged on postoperative day 14. We successfully preserved the aortic valve cusps and avoided the need for anticoagulant therapy.

We describe our surgical experience of inflammatory abdominal aortic aneurysm (IAAA) in a 54-year-old man. Computed tomography (CT) with contrast enhancement revealed an infrarenal abdominal aortic aneurysm with marked thickening of the aneurysmal wall (mantle core sign) and left hydronephrosis. The left ureteral stenting was performed. Preoperative laboratory findings showed high levels of serum IgG4. The IAAA was removed and replaced with a woven-Dacron graft in situ. Histological examination revealed the IgG4 positive plasma cell, and demonstrated IAAA associated with IgG4. The postoperative serum IgG4 was reduced, but remained high. The postoperative CT revealed new right hydronephrosis, and the ureteral stent was performed. The mantle sign reduced in CT scan after steroid therapy. IAAA with hydronephrosis seems to be associated with IgG4-related sclerosing disease. In this case, the levels of serum IgG4 seems to be a good index for treatment efficacy.

The number of operations performed for cardiovascular disease has increased since recent improvements in diagnostic and the therapeutic technology have led to a remarkable increase in the life expectancy of patients with Marfan syndrome. On the other hand, operative procedures can be difficult when patients have complications of connective tissue abnormalities such as thoracic deformities, lung diseases and ophthalmic lesions. Although recent surgical outcomes have improved, those of secondary surgery are more difficult. We describe aortic root replacement to treat perivalvular leakage after aortic valve replacement in a patient with Marfan syndrome with a severe thoracic deformity.

The UBE woven 150cc WYK graft is a non-sealed graft that became available commercially in January 2005, and does not need to be preclotted before implantation. Subjects in this study comprised 50 patients with abdominal aortic aneurysms or common iliac arterial aneurysms, who received prosthetic Y grafts in our institution. Subjects were divided into 2 groups: the U group (n=26), with implantation of the UBE graft, and the I group (n=24) who received implantation of an INTERGARD^TM woven Y graft. Intraoperative bleeding, inflammatory response and duration of postoperative hospitalization were evaluated in each group. Significant differences were noted between C-reactive protein levels, frequency of recurrence of fever and duration of postoperative hospitalization. No differences were noted between intraoperative bleeding and time. The UBE woven 150cc WYK graft, compared with the INTERGARD^TM woven Y graft, required no extra time for implantation and appeared to offer advantages such reduced immunoreaction after surgery. However, follow-up for sufficient late-phase evaluation of the grafts is required.