A 59-year-old female case with cardiac tamponade due to rupture of the coronary arteriovenous fistula is described. Preoperative coronary arteriography showed bilateral coronary-pulmonary fistulae not associated with significant atherosclerotic stenosis. On opening the pericardium after establishing F-F bypass, the pericardial sac contained 300 grams of partially clotted blood. There was subepicardial hematoma along the area of the left anterior descending artery and the left circumflex artery without any other abnormal findings of the heart. The operation consisted of hemostasis with several mattress sutures along the left anterior descending artery and the left circumflex artery, closure of multiple fistulous openings from within the pulmonary artery, and ligation of abnormal dilated vessels originating from bilateral coronary arteries. The coronary arterio-venous fistula with aneurysmal dilatation should be operated on aggressively, whether symptomatic or asymptomatic, to prevent the rupture of fistulae.

A 42-year-old man with Budd-Chiari syndrome was admitted to our institute for reoperation. The patient had undergone a cavoatrial bypass 9 years previously, but early occlusion of the bypass graft was suspected as there was reappearance of dilated abdominal veins. Preoperative cavography showed occlusion of the bypass graft and well-developed collateral veins. The patient underwent direct reconstruction with endo-venectomy and patch angioplasty of the obstructed vena cava and hepatic veins using a ringed ePTFE graft. The markedly dilated tortuous subcutaneous veins of abdominal wall disappeared immediately after reoperation. Postoperative cavography showed the patency of the IVC and three hepatic veins, IVC-right atrium mean pressure gradient decreased from 16mmHg to 6.5mmHg. Direct reconstruction should be the first choice in surgical treatment for Budd-Chiari syndrome, and is also useful as a reoperative procedure.