We performed 6 revascularization procedures in 5 patients after removing aneurysms of the superficialized brachial artery. The patients were 2 men and 3 women with an age range of 52 to 73 years. Their periods of hemodialysis ranged from 1 to 10 years. The aneurysms included 3 unruptured aneurysms, 1 ruptured aneurysm at the anastomosis site of an arteriovenous fistula and 1 ruptured infected aneurysm. Three procedures with interposed techniques for aneurysms and 3 brachial-urnal bypasses through the ulnar side roots of the elbow were performed with saphenous vein grafts (SVG) for revascularization. Two interposed SVGs closed after operation angiographically. In contrast, all brachial-ulnar bypass SVGs remained patent. One patient of the 2 graft occlusion patients had a ruptured infected aneurysm, and the other patient had exercised his elbow joint actively after operation. In conclusion, brachial-ulnar bypass through the ulnar side roots in the elbow is an effective revascularization technique for patients who exercise the elbow joint after operation or who have infected aneurysms.

A 72-year-old woman complaining of orthopnea was admitted with cardiogenic shock. Her systolic blood pressure was only 66mmHg and electrocardiogram showed high lateral myocardial infarction. Transthoracic echocardiogram showed severe mitral regurgitation and disruption of the anterolateral papillary muscle. After orotracheal intubation and intraaortic balloon pumping (IABP), coronary angiogram was performed and an occlusion of the entrance of circumflex artery (#11) was diagnosed. Percutaneous coronary intervention was done successfully and emergency mitral valve replacement was performed using a St. Jude Medical prosthetic valve preserving the posterior mitral valve leaflet and mitral apparatus. Her postoperative recovery was entirely uneventful and she was followed up as an outpatient. Acute anterolateral papillary muscle rupture is a rare complication of acute myocardial infarction (AMI), although left coronary artery disease is associated with it and immediate recanalization is an important issue to rescue the patient.

Retroperitoneal lymphocele is a very rare complication of abdominal aortic aneurysm repair. An abdominal aortic aneurysm 5cm in diameter was repaired with the retroperitoneal approach in a 70-year-old man. On the 17th postoperative day, mild abdominal distention was reported and a fever of 38°C had developed. A computed tomography scan demonstrated massive fluid collection in the retroperitoneal cavity. Total parenteral nutrition with complete fasting was initiated. A pigtail catheter was inserted into the cavity, and 1, 000ml of milky, odorless, alkaline and sterile fluid was drained. Subsequently, a retroperitoneal lymphocele following abdominal aortic surgery was diagnosed. The leaking lymph tract was ligated because the lymphocele did not improve with long term drainage. Administration of ice cream through the nasogastric tube was used to detect the leaking lymph tract, and we ligated the leaking lymph tract completely. We believe that surgical repair is an alternative strategy when conservative treatments, i. e., fasting, intravenous hyperallimentation and drainage are not effective.

A 78-year-old woman who had undergone an axillobifemoral artery bypass with a prosthetic graft for Leriche syndrome presented 1 month later with cough and fever. A clinical examination revealed obvious redness in the right groin. Routine laboratory tests uncovered inflammation and methicillin-sensitive-Staphylococcus aureus was cultured from blood samples. Mitral valve vegetations were identified by echocardiography, and after a diagnosis of infective endocarditis, specific intravenous antibiotics were immediately administered. One month later, CT revealed a large pseudoaneurysm of the posterior left ventricular wall that had not been present at the time of admission. Transesophageal echocardiography and magnetic resonance imaging showed an aneurysmal cavity arising from the wall just below the posterior mitral valve leaflet. The patient agreed to undergo cardiac surgery due to the high likelihood that the pseudoaneurysm would rupture. The mitral annulus and leaflet were normal at surgery. We resected the posterior leaflet, closed the cavity using a Xenomedica patch, and reconstructed the leaflet. We did not remove the pseudoaneurysm using an extracardiac approach because the likelihood of damaging the coronary arteries and the coronary sinus was quite high. The postoperative course was uneventful. At follow-up 1 year later, the patient was afebrile and both CT and echocardiography showed that the cavity was completely filled by the thrombus. The imaging findings were useful in determining the surgical approach.

Background : This study was performed to evaluate surgical outcomes after cardiovascular surgery (including urgent surgery) in patients 85 or older. Methods : A retrospective analysis was performed on 39 patients (mean age, 86.3 years ; age range, 85-90 years) who underwent total arch replacement (n=4), ascending aorta replacement (n=4), descending aorta replacement (n=1), aortic valve replacement (AVR ; n=13), mitral valve replacement or valvuloplasty (n=3), coronary artery bypass grafting (CABG ; n=9), CABG+AVR (n=4), tumor resection (n=1) between June 2008 and December 2012 at Dokkyo Medical University Hospital. Results : Six hospital deaths occurred. One patient died due to bleeding from a ruptured descending thoracic aortic aneurysm, and another patient died due to gastrointestinal perforation from non-occlusive mesenteric ischemia (NOMI) after urgent AVR. The other deaths were related to various complications, including lung cancer, cholecystitis, myocardial infarction, and Takotsubo cardiomyopathy, during the postoperative period. Overall 30-day mortality was 2.6%, hospital mortality was 12.8%, duration of hospital stay after surgery was 41.3 days, duration of intensive care unit (ICU) stay was 3.8 days and ventilator time was 49.1 h. Twenty patients underwent elective surgery, and 19 patients underwent urgent surgery. The two groups had similar preoperative characteristics, except for the number of patients with aortic disease. No significant difference was evident in hospital mortality (26.3% vs. 5%, p=0.065) or 30-day mortality (0% vs. 5.3%, p=0.3) when comparing the two groups. However, the duration of hospital stay (58.9 days vs. 27.5 days, p=0.049), ICU stay (6.74 days vs. 1.05 days, p=0.002) and ventilator time (89.9 h vs. 8.2 h, p=0.006) was significantly longer in the urgent surgery group than in the elective surgery group. Fourteen patients (70%) in the elective surgery group and four patients (21.1%) in the urgent surgery group were able to be discharged from the hospital to their homes within 30 days after surgery. These data demonstrated that cardiovascular surgery in patients 85 years of age or older was associated with satisfactory outcomes, and outcomes associated with elective surgery were even better than those associated with urgent surgery. Conclusions : Therefore, advanced age does not represent a contraindication of conventional cardiovascular surgery. Rather, the decision for surgery should take the patient's preoperative condition, the severity of concurrent medical disease, the wishes of the patient, and the predicted functional outcomes into account.

Patient: A 74-year-old man. Previous history: Total arch replacement for thoracic aortic aneurysm at 72 years old. History of current condition: The patient presented at a local otolaryngology clinic complaining of hoarseness of the voice. Left vocal cord paralysis was present, and as he had previously undergone thoracic vascular graft replacement, he was referred to our department. Further investigation with computed tomography (CT) revealed air in the mediastinum, and he was admitted for treatment of mediastinitis. Post-admission course: Upper gastrointestinal endoscopy revealed esophageal ulceration. After antibiotic treatment, thoracic subtotal esophagectomy via right thoracotomy, esophagostomy, and gastrostomy were performed on admission day 39. Vascular graft infection was also suspected, and antibiotic treatment was therefore continued. As some improvement in inflammatory response was evident, antibiotic treatment was discontinued and the patient's condition was monitored, but fever developed on day 107, and CT again revealed air in the mediastinum. Bronchoscopy revealed a broncho-mediastinal fistula in the left main bronchus. On day 110, repeated total arch replacement using a vascular graft, omentoplasty, and left main bronchus repair were performed via left thoracotomy. Esophageal reconstruction was left for later surgery, but follow-up CT on day 160 again revealed air in the mediastinum. Bronchoscopy was performed the same day and revealed a broncho-mediastinal fistula in the left main bronchus, located on distally from the previous fistula. This fistula was surgically closed on day 173. The subsequent course was favorable, and antethoracic esophageal reconstruction by jejunal elevation was performed on day 233. The patient was able to start eating on day 244, and was discharged in an improved condition on day 250.

Valsalva sinus aneurysm (VSA) is a rare disease, especially that of Konno classification Type IV. When VSA ruptures, the patient has uncontrollable congestive heart failure because of massive left-right shunt. We encountered two cases with ruptured VSA of the right atrium. Case 1 : A 71-years-old man with a ruptured noncoronary VAS complained of dyspnea on effort. He underwent surgical treatment consisting of aneurysm resection and patch closure with Hemashield after medical treatment for congestive heart failure. He progressed well after operation and was discharged on the 14th postoperative day in stable condition. Case 2 : A 41-year-old man had heard systolic murmur. We diagnosed VSA rupture with echocardiography. He was symptomless but his left ventricle diastolic diameter was dilatated and Qp/Qs was 2.0 by blood gas sampling. He underwent elective surgical treatment consisting of aneurysm resection and patch closure with Hemashield. He was discharged on the 14th postoperative day in stable condition.