An 81-year-old man complaining of back pain was admitted. Computed tomographic scan revealed an aortic arch aneurysm and an abnormal retroesophageal artery. It was believed to be an aberrant right subclavian artery. The diagnosis was confirmed by angiogram. Although there was no evidence of rupture, his back pain prompted us to perform emergency surgery. Through median sternotomy using a cardiopulmonary bypass, systemic hypothermia and selective cerebral perfusion, total arch replacement was done. There was evidence of impending rupture, which was probably the cause of his back pain. The proximal portion of the aberrant right subclavian artery was severely calcified, so the right subclavian artery was reconstructed. It was anastomosed with one branch of the arch graft which passed the anterior of the trachea. The postoperative course was uneventful. We believe median sternotomy was a proper approach for such a situation.

A 74-year-old woman presented with a pulsatile mass and pain in the right mid-thigh. Angiography demonstrated a ruptured solitary aneurysm at the superficial femoral artery (SFA), 45mm in diameter. The operation consisted of replacement of the aneurysm with a saphenous vein bypass grafting to the SFA. The pathological examination of the resected arterial wall revealed degenerative changes due to cystic medial necrosis. In the literature, there has been no report, as far as we know, on true aneurysm of the superficial femoral artery caused by cystic medial necrosis. Therefore, it is considered that our case is a very rare presentation of aneurysm with this particular etiology which occurred in the peripheral artery of a lower extremity.

Dacron grafts have made great progress and the material has become almost perfect recently. However, we encountered a rare case of a late-graft complication. A 34-year-old man was operated on for coarctation of the aorta in July 1982. Left subclavian artery-descending aortic bypass was performed using a Cooley double velour knitted graft. Eighteen years later, the patient was admitted to our hospital with an abnormal shadow in his chest X-ray. Angiography and computed tomography demonstrated a non-anastomotic aneurysm of the graft. Under cardiopulmonary bypass and deep hypothermic circulatory arrest, reoperation with a woven Dacron graft was successfully performed. This case suggests that it is important to follow up patients with implanted Dacron arterial prostheses because of the potential for rupture.

Gelatin-resorcin-formalin (GRF) glue has been widely used in repair of dissected aortic wall tissue, and the use of GRF glue has been reported to significantly reduce mortality from this surgical emergency. On the other hand, various late complications possibly due to GRF glue have also been reported. We performed reoperations after total arch replacement for acute type A aortic dissection using GRF glue in 2 cases. In case 1, total arch replacement was performed 3 years ago. Pseudoaneurysms of the aortic root and brachiocephalic artery and redissection of the descending aorta were revealed by subsequent computed tomography (CT). Partial graft replacement for these 3 sites were performed with open distal anastomosis and right common carotid artery perfusion. In case 2, total arch replacement was performed 5 years previously. Redissection of the aortic root was revealed by CT, and ultrasound cardiography revealed severe aortic regurgitation and severe mitral valve insufficiency. A modified Bentall procedure and mitral valve replacement were performed. In these 2 cases, the sites of redissection and pseudoaneurysm were identified as the sites of use of GRF glue at the first operation. We suspected that the use of GRF glue is associated with a certain amount of risk of redissection and pseudoaneurysm. Such patients should be carefully followed for years after surgery. It is necessary to use appropriate surgical and glue application techniques to obtain the desired effect of the glue.

Mediastinitis following graft replacement of the ascending and total arch aorta is a fatal complication of cardiac surgery. When graft infection is suspected, one choice of treatment is to remove the infected prosthesis and replace it with a new one. However such a procedure seems to be very risky. We report 2 successfully treated cases of mediastinitis following graft replacement of the ascending and total arch aorta. In one case, we treated with primary sternal closure after debridement and omental flap implant. In another case, the wound was left open and irrigation with iodine solution was undertaken for 6 days. The sternum was closed with pectoralis major muscle flap implantation. When graft infection is not suspected, primary sternal closure with implantation of tissue flaps is recommended. When graft infection is strongly suspected, we prefer secondary sternal closure after open irrigation.

A 44-year-old man underwent total arch replacement for acute type A aortic dissection. He was treated postoperatively in the intensive care unit for acute renal failure and respiratory failure. Although recovery of organ functions was seen, an unexpected fall in platelet count (PLT) occurred abruptly on postoperative day (POD) 7. The patient was treated with gabexate mesilate and platelet transfusion because disseminated intravascular coagulation (DIC) was initially suspected. Nevertheless, PLT dropped rapidly below 1.0×10⁴/μl. We suspected heparin-induced thrombocytopenia (HIT) and stopped all heparin administration including flush solution for pressure monitoring lines. The platelet factor 4-reactive HIT antibody test was performed and we began to give intravenous argatroban, 60mg/day. However, PLT did not increase at all. Multiple organ failure developed and metabolic acidosis deteriorated rapidly resulting in death on POD 15. HIT antibody was positive on POD 13 and a definitive diagnosed of HIT was made. For those patients treated with heparin continuously or repeatedly, HIT may occur and increase the mortality risk if the diagnosis is delayed.

We describe a case of cardiac surgery for a patient with CD36 deficiency. A 56-year old man had progressive dyspnea on effort for 1 year. On admission, echocardiography revealed severe aortic valve regurgitation. He required medical treatment for heart failure, and subsequently elective aortic valve replacement was planned. Pre-operative cardiac scintigraphy (¹²³I-BMIPP) showed total defect of myocardial uptake. CD 36 deficiency was diagnosed based on the characteristic findings. CD 36 deficiency could cause transfusion related complication by donor blood transfusion. We prepared 1,200 ml autologous blood preoperatively in a two week period. The operation was performed successfully without donor blood transfusion. He was discharged uneventfully.

A 75-year-old man, who had undergone aortic valve and ascending aorta replacement at the age of 73 years, was admitted to our hospital with one week of fever. Blood culture showed growth of Streptococcus bovis and echocardiography showed vegetation on the prosthetic valve. Although antibiotic treatment was commenced, he complained of abdominal pain, and computed tomography showed a superior mesenteric artery embolism. The abdominal pain improved with fasting, but echocardiography showed another vegetation, and re-aortic valve replacement was performed to prevent embolism recurrence. When he resumed eating postoperatively, he again complained of abdominal pain and computed tomography showed mesenteric ischemia. The necrotic intestine was extensively resected and he recovered successfully. A superior mesenteric artery should be revascularized to 2/11 prevent perioperative mesenteric ischemia when cardiac surgery complicated by acute superior mesenteric artery embolism is performed.

We report a case of surgical treatment for pseudoaneurysm 19 years after aortic root replacement. The patient was a 57-year-old female who had undergone aortic root replacement (Piehler procedure) in another hospital due to acute Stanford A type aortic dissection in 1988, and was then followed up at another hospital. However, a low density area around the artificial graft was pointed out on computed tomography (CT) in 2001, which increased to 60mm in size by November, 2006. She was then referred to our hospital for a redo operation. Pseudoaneurysm of the anastomosis and mitral regurgitation (MR) was diagnosed by the examination of the CT, angiography, etc., and we performed ascending aorta and aortic arch replacement, and mitral valve replacement (MVR) in April, 2007. A slight hemorrhage were found at the anastomosis of the artificial graft-artificial graft. Deterioration of the artificial graft or deterioration of the suture was suspected as the cause of the slight hemorrhage from the anastomosis a long period after the operation. In this case, loosening of the suture string was revealed, so the latter was more strongly suspected.

A 56-year-old man was admitted to our institution with sudden onset of severe chest pain and ischemia of the lower extremities on February 24, 2007. An enhanced computed tomography scan showed acute Stanford type A aortic dissection. Electrocardiography showed ST segment elevation in leads V_1-4 and a transthoracic echocardiogram revealed antero-septal wall akinesis. The patient was given a diagnosis of acute myocardial infarction (AMI) caused by left main trunk dissection (LMT) due to acute aortic dissection. Coronary angiography (CAG) showed severe stenosis in the LMT with poor distal run-off. For this reason, after we implanted a stent in the left main coronary trunk to maintain coronary blood flow, we performed total aortic arch replacement, coronary artery bypass grafting (SVG-LAD #8), and F-F cross-over bypass. Removal of the implanted stent from the LMT during the operation was simple. Postoperative CAG showed a patent SVG and intact LMT. Because preoperative PCI is still controversial for acute aortic dissection with AMI, either more immediate surgery or preoperative PCI (bridge stent to surgery) in the left main coronary artery is mandatory. Implantation of an LMT stent, as a bridge to surgery, is an effective strategy for acute type A aortic dissection with LMT occlusion before surgical repair.