A 48-year-old man was admitted with shortness of breath. He had been given a diagnosis of ankylosing spondylitis by an orthopedic surgeon 20 years previously. A grade III/VI to-and-fro murmur was audible at the left sternal border. Echocardiography revealed moderate to severe aortic regurgitation with annular dilatation. He had also suffered complained rigidity of the neck muscles and back pain for 20 years. He underwent aortic root replacement and his postoperative course was uneventful. Aortic valve regurgitation with ankylosing spondylitis in Japan has been seldom reported, compared with European or American. We discuss surgical problems and the management of these lesions are discussed.

A 62-year-old man presented with a chief complaint of swelling of the left lower extremity. Idiopathic retroperitoneal fibrosis had been diagnosed 6 years previously. Enhanced computed tomography demonstrated occlusion of the left common iliac vein, but without deep vein thrombosis, and a thick dense fibrous layer around the abdominal aorta and in front of the sacrum. After we administered steroid and anticoagulant therapy, remission of the swelling of the left lower extremity was obtained. Presently steroids are being gradually tapered, and he has remained free of recurrence of the swelling of his left lower extremity.

We report a rare case of cystic adventitial disease of the popliteal artery causing intermittent claudication. About 2 months previously, a 21-year-old man had sudden intermittent claudication in the left leg. The left-sided ankle brachial pressure index (ABI) at rest was 0.66. Computed tomography revealed that the arterial occlusion was segmentally caused by cystic lesions. A cystic adventitial lesion of the popliteal artery, measuring 9 cm in diameter, was surgically removed and reconstruction was performed with a saphenous vein graft. Postoperatively the left ABI improved to 1.01, and his symptoms disappeared. The histopathological diagnosis was cystic adventitial disease and the cysts were in the adventitia. The postoperative course was uneventful and he has been without recurrence for 14 months.

A 65-year-old man was referred to our service complaining of intermittent claudication of his left leg. During preoperative examinations, he was found to have bilateral isolated internal iliac artery aneurysms. As it was strongly suspected that ischemic colitis or gluteal ischemia would be caused if his bilateral internal iliac arteries were ligated during aneurysm surgery, his right internal iliac artery was reconstructed using a prosthetic graft. His postoperative course was uneventful. As aneurysm of the internal iliac artery is rare, there are few reports about reconstruction of the internal iliac artery. Technical details and pitfalls of internal iliac artery aneurysm surgery were discussed.

From January 1982 to August 1993, 23 cues of advanced renal cell carcinoma with tumor thrombus in the inferior vena cava (IVC) were treated surgically. In terms of clinical stage, 12 cases were in stage III and 11 cases were in stage IV. The 23 cases were divided into three groups according to the location of the tumor thrombus in the IVC. In two cases, the tumor thrombus extended to near the right atrium or the hepatic vein, and in six cases, the thrombus extended to the hepatic IVC. All these tumor thrombus with invasion to the IVC wall were removed under partial cardiopulmonary bypass. In 15 cases, tumor thrombus were limited to near the junction of the renal vein, which were removed by balloon catheter or finger after clamping of proximal and distal side of IVC and renal vein. Direct suture of the IVC wall in 12, patch repair with EPTFE in 10 and graft replacement with EPTFE graft in 1 were performed. Eight patients who had distant metastasis, regional lymph node metastasis and extracapsular invasion died within one year, but 4 patients were alive more than four years. Survival rate at three years and five years according to the Kaplan-Meier method was 37.5% and 18.8%, respectively. In conclusion 1) partial cardiopulmonary bypass was useful and could control bleeding when tumor thrombus in the IVC extended to the junction of the hepatic vein or right atrium. 2) long term survival cases were recognized in cases with no distant metastasis, no regional lymph node metastasis and no extracapsular tumor invasion. 3) nephrectomy associated with tumor thrombectomy in the IVC was valuable on the basis of long-term prognosis.

A 68-year-old woman with distal arch aortic aneurysm was admitted. Preoperative magnetic resonance angiography revealed occlusion of the right middle cerebral artery. Single photon emission computed tomography showed decreased cerebral blood flow at rest and decreased reactivity to acetazolamide in the right temporal lobe. At first, a superficial temporal artery to middle cerebral artery anastomosis was made by neurosurgeons. Improvement of both the cerebral blood flow and the reactivity to acetazolamide was confirmed by single photon emission computed tomography 18 days after the operation. Twenty-two days after the operation, a total arch replacement was performed. The postoperative course was uneventful without any neurological complication.