Leg edema following the harvest of great saphenous vein (SV) is sometimes recognized after coronary artery bypass surgery (CABG). Maximum venous outflow (MVO) is one of the parameters of leg venous function which is measured by straingauge plethysmography. To clarify the mechanism of the development of leg edema after CABG, we measured the perioperative MVO. Six patients had leg edema afer CABG (group I), 4 patients had no edema after CABG (group II). Six patients without edema after cardiac surgery, apart from CABG, were selected as controls (group III). The MVO of both legs was measured before and after the operation. In group I, venous echo or venography of the leg, or both, were performed after the operation. The MVO of legs from which SV had been harvested in group I decreased from 35.0±13.6 (ml/min/ 100ml tissue) to 23.9±7.6 (p=0.04) after the operation, but did not differ from the MVO of the contralateral leg. The preoperative MVO of legs from which SV had been harvested in group I was slightly higher than the legs of other groups. There was no significant change of MVO in group II or III after surgery. No deep vein thrombosis was shown in group I by venous echo and venography. Left ventricular ejection fraction, blood cell count and serum chemistry indicated no changes in any of the three groups after the operation except for the hemoglobin level in group I. These results suggested that the leg which had edema had a relatively high MVO before the operation. This MVO significantly decreased to the level of leg from which SV had not been harvested after the operation, and the edema appeared. In conclusion, postoperative edema in the leg from which SV was harvested was the result of a decrease in venous function due to removal of the SV. SV which causes leg edema might play the greater part of the venous return than others and the total function of the venous return was higher than normal at the point of preoperation.

A 72-year-old woman was admitted as an emergency case to our hospital because of chest oppression. She had a history of admission due to the same symptoms about 9 months previously. Her chest computed tomography showed a dissection of the ascending aorta (DeBakey type II). We suspected an acute aortic dissection and an emergency operation with CPB was performed. The ascending aorta was markedly enlarged, but the dissected adventitia did not appear weakened. Moreover, there was no bloody pericardial effusion which is specific to acute aortic dissection. When the pseudo-lumen was exposed, a firm intimal flap and single entry hole were recognized. The chronic phase of aortic dissection was finally diagnosed. Then the dissected adventitia and intimal flap were removed and a patch graft aortoplasty with a tailored 26mm gelatin-impregnated knitted Dacron vascular graft was employed because the residual aortic wall was normal in size and consisting. Her postoperative course was uneventful and there was no evidence of recurrence of aortic dissection or enlargement 2 years after the operation. We conclude that patch aortoplasty for repair of chronic aortic dissection can be effective when the range of dissection is restricted and to residual aortic wall is normal.

Sinus of Valsalva aneurysm is a rare cardiac disorder, and reports of its origin among in the left sinus are scarce. This report describes a 38-year-old man with an isolated extracardiac unruptured aneurysm of the left sinus of Valsalva. The patient presented with chest pain due to compression of the main trunk of the left coronary artery by the aneurysm. The aneurysm was resected, and the aortic root was reconstructed using the Bentall procedure. Concomitantly, coronary artery bypass grafting (LITA-LAD) was added. Postoperative native coronary flow was fully restored, and his anginal symptoms disappeared despite occlusion of the additional LITA-LAD anastomosis. This type of case would be considered to not require concomitant CABG, since the cause of the coronary artery stricture was compression by an aneurysm in the left sinus of Valsalva.

A 72-year-old man presented with chief complaints of back pain. Medical workup discovered infrarenal abdominal aortic aneurysm (AAA) with Stanford type B acute aortic dissection on CT. The dissection originated distal to the left subclavian artery and extended to the right commom iliac artery. All visceral arteries branched from the false lumen. The maximum diameter of the thoracic aneurysm was 4.8cm and that of the abdominal aneurysm was 6.5cm. Multiple renal infarcts were noted and the right kidney function was decreased. Initial surgery was performed 3 months after presentation using a graft technique. Advanced atherosclerosis and dissection were noted in the aneurysm making the arterial wall quite vulnerable. Hemorrhage was extensive and hemostasis difficult in the defective arterial wall. The patient became unstable so the aneurysm was closed and the surgical procedure was changed to right axillo-bifemoral bypass rather than the original surgical plan of anatomic reconstruction of the AAA. The patient tolerated the procedure well. We report a rare case of acute aortic dissection which extended through the AAA.

There is an impression among cardiothoracic surgeons that the technique of profound hypothermic circulatory arrest (PHCA) is associated with an increased bleeding tendency compared to conventional bypass surgery. In addition to the recognized factors contributing to the hemorrhagic tendency seen in moderate hypothermic cardiopulmonary bypass (CPB), it is likely that the lower temperature utilized in PHCA may exacerbate platelet dysfunction. In this report, platelet counts and functions at the same cardiopulmonary bypass time were compared in human PHCA surgery (hypothermia group, n=16) and moderate hypothermic cardiopulmonary bypass surgery (control group, n=20). Mean platelet count corrected by hematocrit in the hypothermia group at 2h of CPB was significantly lower than in the control group (3.7×10⁴μl vs. 11.4×10⁴/μl, p<0.0001). In the hypothermia group, there were significant increases in the percentage of GMP-140 (P-selectin)-positive platelets (11.8% vs. 8.3%, p=0.0091) at 1h of CPB, and also in microparticles (24.8% vs. 10.5%, p<0.0001) and aggregated platelets (3.4% vs. 1.4%, p=0.0058) at 2h of CPB. Profound hypothermic circulatory arrest used in surgery for aortic arch aneurysm or dissection may cause irreversible platelet dysfunction and contribute to hemorrhagic tendency during the surgery. To minimize platelet dysfunction during CPB, the lowest blood temperature should be maintained above 15°C.

We report a rare case of acute type A aortic dissection in a patient with rheumatoid arthritis (RA) being treated with tacrolimus. The patient was a 77-year-old woman, who had received implantation of 6 artificial joints and was treated with 3 mg/day of tacrolimus and 10 mg/day of prednisolone. Tacrolimus, one of the immunosuppressive drugs for severe RA, had been applied to her to reduce the amount of prednisolone. An emergency surgery was performed successfully and 20 mg/day of prednisolone was administered for RA instead of her preoperative regimen. Such simplification of RA medication was actually useful to us for managing her difficult postoperative care. Respiratory insufficiency with persistent preural effusion was regulated by non-invasive positive pressure ventilation (NPPV) and pleural drainage. Disuse syndrome was treated with enteral nutrition and rehabilitation. Such care was also useful for her recovery.

Aortoduodenal fistula is rare complication of nonoperative abdominal aortic aneurysm. We successfully treated a case of primary aortoenteric fistula associated with Behcet's Disease with two surgical intervention. The patient was 41 years old man. He admitted to our hospital because of severe shock due to enormous gastrointestinal hemorrhage. Emergency laparotomy revealed the inflammatory abdominalaneurysm ruptured into the duodenum. As the saccular aneurysm was densely adherent with duodenum and retoroperitoneum, graft replacement was abandoned. Primary closure of the perforated area of duodenum and the neck of aneurysm were performed. Axillofemoral bypass restored blood flow of the lower extremities. Three month after the operation, aortoduodenal fistula recurred. On the second operation, abdominal aorta was divided through retroperitoneal approach. However, primary closure of the enteric perforation with graft replacement of the aorta is considered as the first choice of the surgical treatment for aortoenteric fistula. In a case of difficult condition such as this patient with severe shock or retroperitoneal fibrosis, repair of the duodenum wall and division of the abdominal aorta with axillofemoral bypass is an alternative method of choice.

Thirty-nine years old woman had a severe renovascular hyper-tension with Takayasu's arteritis Her left renal artery stenosis was treated with percutaneous transluminal angioplasty (PTA) three times. Six months after the third PTA, the left renal artery was occluded, and left renal failure occurred. Aorto-renal bypass surgery with a prosthetic graft was performed. Blood pressure dropped to normal range, and left renal function began to recover. Although PTA is an effective method in the treatment of renovascular hypertension, an incidence of restenosis after PTA is higher in Takayasu's arteritis rather than atherosclerotic lesions. Five months after renal revascularization, hypertension recurred in this case. However the aorto-renal bypass graft was patent accompanied by no symptoms. This aorto-renal bypass surgery can be considered effective in this condition.

Causative factors for thrombi formation in left atria of 38 patients with mitral stenosis who underwent mitral valve surgery (open mitral commissurotomy or mitral valve replacement) alone or in combination with other procedures were studied. There were 9 cases of left atrial thrombosis (LAT). Left atrial diameter was increased in LAT(+) group (6.1±1.6cm) compared with LAT(-) group (4.6±0.7cm). There was significant difference in the left atrial diameter between the two groups of patients (p<0.01). Cardiac output was decreased in LAT(+) group (3.04±0.74l/min) compared with LAT(-) group (3.99±1.07l/min). Cardiac output of LAT (-) group was significantly larger than that of LAT(+) group (p<0.05). Mean transition time of blood through left atrium (MTT_LA) was calculated using left atrial volume and cardiac output. In LAT (+) group, MTT_LA was significantly increased (6.2±3.9sec) compared with LAT(-) group (2.9±1.6sec). It is considered that, in mitral stenosis, prolongation of MTT_LA is one of the risk factors for thrombi formation in the left atrium.

This is a case report of a 57-year-old woman with high aortic occlusion (HAO) who had acute symptoms of severe ischemia of the lower extremities and the intrapelvic organs. Generally, HAO is a chronic ischemic disease of the lower extremities and the intrapelvic organs; therefore, acute HAO is relatively rare. Acute thrombotic occlusion of a major collateral artery might be the cause of acute HAO. Laser Doppler flowmetry of the sigmoid colon was useful to evaluate the ischemia of intrapelvic organs. Thrombectomy of the juxtarenal portion with the suprarenal aortic cross clamp was performed within four minutes, then the clamp was moved to the infrarenal portion. The remaining occluded aorta was replaced with a Y-shaped knitted Dacron graft. She had no symptoms after the surgery except renovascular hypertension. Seventy five percent stenosis of the right renal artery was exacerbated to 99%. Vascular clamping of the right renal artery might have been the cause of severe stenosis. Percutaneous transluminal renal angioplasty was successfully performed after the surgery. Aggressive renal artery reconstruction during surgery is recommended in cases with moderate or severe renal artery stenosis.