A 68-year-old woman with a sudden onset of back pain was brought to our hospital by ambulance. Computed tomography (CT) showed Stanford type A (DeBakey type II) acute aortic dissection, left hemothorax, and hematoma extending along the pulmonary artery ; therefore, the patient underwent emergency operation. We performed a median sternotomy. Pericardial effusion was not observed ; however, a hematoma was found around the ascending aorta. Preoperative CT showed left hemothorax, but pleural effusion was not observed in the left pleural cavity. The left hemothorax, which was detected on preoperative CT, was diagnosed as an extrapleural hematoma. The dissection entry site was located at the proximal aortic arch ; therefore, ascending aorta-hemiarch replacement was performed. After weaning from cardiopulmonary bypass, the patient experienced sudden airway bleeding. The bleeding was attributed to the hematoma extending along the pulmonary artery. Here, we have reported a rare case of Stanford type A acute aortic dissection with the left extrapleural hematoma and lung hemorrhage.

A 29-year-old man with high fever and chest pain was admitted to our hospital. He had undergone aortic valve replacement 1 month before admission to our hospital. Since computed tomography revealed a pseudoaneurysm in the ascending aorta, he underwent an emergency operation. An occlusion catheter was inserted into the ascending aorta via the left femoral artery, in preparation for pseudoaneurysm rupture. Cardiopulmonary bypass was established with inflow via the right femoral artery and the right axillary artery, and with vacuum-assisted venous drainage via the right femoral vein. After core cooling, we performed resternotomy. The pseudoaneurysm ruptured while we were exfoliating the adhesion around the aorta. We inflated the occlusion catheter in the ascending aorta and controlled the bleeding. We continued core cooling and ventricular fibrillation occurred at 30°C. Subsequently, we induced circulatory arrest, and selective cerebral perfusion was initiated. We inflated the occlusion catheter in the descending aorta and initiated systemic circulation with inflow via the right femoral artery. The origin of the pseudoaneurysm was the region of cannulation in the previous operation. Therefore, we replaced the ascending aorta and performed omentopexy. In this case we reported the use of a strategy involving cardiopulmonary bypass for a pseudoaneurysm in the ascending aorta.

Osteochondromas, or exostoses, are the most frequent benign bone tumors. Although many osteochondromas are asymptomatic, they are sometimes responsible for vascular complications, most often associated with the popliteal artery. Here, we present a rare case of pseudo-aneurysm of the popliteal artery secondary to an osteochondroma of the femur in a 48-year-old woman. During surgery, a pseudo-aneurysm developed from a 1-mm hole in the anterior aspect of the popliteal artery, which was closely related to the protrusion of the femoral osteochondroma. The surface of the osteochondroma was quite sharp, rigid and firm. It was removed completely through the lumen of the aneurysm. A short segment of the popliteal artery, including the hole, was resected with an end-to-end anastomosis. The postoperative course was uneventful, and the patient recovered completely. The precise pathogenesis of pseudo-aneurysmal formation is still unknown. We speculate that local compression of the popliteal artery by a spiky osteochondroma can stretch the vessel and lead to rupture of the artery by continuous friction. Considering the potential risk of this vascular complication, shonld be closely monitered patients with osteochondroma of the femur.

We report a case of 10-year-old woman with aortitis syndrome who had a graft dehiscence at the site of proximal anastomosis 8 months after aortic root replacement. Because she suffered severe chest compression and ST depression was demonstrated on 12 lead ECG, she was admitted on a suspicion of vasospasmic angina. However, transesophageal echocardiogram and CT showed an echo-free space around the previous operated aortic composite graft, so we concluded that a proximal graft dehiscence and bleeding around it was the cause of her severely deteriorated circulatory condition, and emergency redo aortic replacement was planned. After deep hypothermic circulatory arrest was accomplished, selective cerebral perfusion was performed following re-sternotomy. Previous composite graft was detached at the site of proximal anastomosis, and the aortic annulus was friable and edematous. Redo aortic replacement successful. Laboratory findings revealed uncontrollable aortitis syndrome as the etiologic factor of graft dehiscence. Postoperatively, she was complicated with cerebral infarction due to a stuck valve. She was discharged at 56 postoperative day.

Objective : Although an endoleak is the most common complication after endovascular abdominal aortic aneurysm repair (EVAR), the proper and noninvasive method for the detection of endoleaks is not established. The purpose of this study is to investigate whether plasma levels of D-dimer and fibrin degradation product (FDP) could be predictors of endoleaks after EVAR. Methods : Between June 2011 and January 2014, 65 consecutive patients underwent EVAR at our institution. We evaluated 55 patients excluding 10 patients pre-existing conditions such as aortic dissection, arterial or venous thrombosis, conversion to open surgery, and difficulties in making outpatient visits. Enhanced computed tomography (CT) examination was performed during 12 months after EVAR. Persistent endoleaks and maximum aneurysmal diameter were evaluated at each follow-up time. Patients were divided into groups according to CT findings at 12 months after EVAR. There were 26 patients with endoleaks vs. 29 non-endoleak patients, 34 with unchanged aneurysm findings vs. 21 with shrinkage. No patient showed aneurysmal enlargement. Plasma levels of D-dimer, FDP, counts of platelet, prothrombin time (PT), and activated partial thromboplastin time (APTT) were also measured at the time of CT examinations. Results : There was no operative death and no major complication. Endoleaks in all patients were identified as type II. None of them required re-intervention. In the endoleak group, plasma levels of D-dimer and FDP were significantly higher than in the non-endoleak group in each postoperative period. In addition, postoperative counts of platelet were significantly lower in the endoleak group. PT and APTT test results showed no significant difference in the two groups. In the unchanged aneurysm group, postoperative D-dimer and FDP tended to be higher compared with the shrinkage group. Postoperative counts of platelet also tended to be lower in the unchanged group. There were no differences in PT and APTT test results. Conclusion : Plasma levels of D-dimer and FDP are potentially useful predictors of endoleaks after EVAR.

The patient, a 71-year-old man, was admitted to our department with fever from unknown causes. Ultrasonic examination of the abdominal regions revealed abnormal multiple low-density echo legions (that could be) associated with splenomegaly. For diagnostic purposes, splenic puncture was performed with the aid of an ultra-sound imaging device. Pale yellow-green pus was obtained from the lesions. Based on this finding, we made a diagnosis on the case as multiple abscess of the splean. The patient underwent intensive chemotherapy. However, he dontinued to have a high fever. On the ninth day from hospitalization, splenectomy was performed. Since then, his fever has subsided. Abscess of the spleen is a rare disease. It is generally classified into two types: one is a multiple type, and the other, a solitary type. Multiple splenic abscess mostly occurs as one of the abnormal conditions during the course of a primary disease, which is often severe. Our case, however, did not exhibit any sign of a primary disease.

Introduction: The regional palliative care support center (PCSC) has set the following palliative care goals for correction of misunderstanding and prejudice of the general community against palliative care, home care and home death of cancer patients: practice palliative care early after diagnosis, educate the community to understand palliative care and build a regional palliative care cooperation system. Method: This study reviewed four years (2009-2012) of data from the PCSC. Outcome data of the patients were collected during outpatient care, inpatient care, and in-home care that were supported by the PCSC. The PCSC managed palliative care based on patient conditions and symptoms in the early stage after diagnosis. The PCSC worked to spread the idea and importance of palliative care to the general community and health care professionals of the region, and also worked to promote the regional palliative care cooperation. Result: These efforts led to an increase in the number of first center visit of patients, especially introduction patients, and an extension of the period of treatments of both tumor department and palliative care department. These outcomes resulted in an increase in the rate of in-home care transitions, the length of in-home care and the number of deaths at home. These results suggest that the place of appropriate medical and caregiving treatments and the place of death are converting into home gradually from hospital.

A 14-year-old women who had a history of aortic root replacement at 7 years old admitted our hospital due to dilatation of aortic arch aneurysm. Loeys-Dietz syndrome was diagnosed when she was 10 years old. Computed tomography showed 70 mm proximal arch aneurysm. Operative findings revealed brachiocephalic artery and left common carotid artery branched from aneurysm. Partial arch replacement was performed and distal anastomosis was made between left common carotid artery and left subclavian artery. Close observation by CT regularly is necessary and undergo aortic repair not to miss the timing of surgery.

A 56- year-old woman visited our hospital complaining of right hypochondralgia. X-ray and endoscopic examinations revealed Borrmann 2 type gastric cancer in the anterior wall of an upper part of the stomach. Ultrasonography showed an echogenic mass in the suprarenal area. The mass which had septal formation within it, was about the same in density as fat on computerized tomography, and was hypovascular fed by the right inferior adrenal artery on angiography. These findings suggested that the mass might be adrenal myelolipoma. After total gastrectomy and right adrenectomy were done, histopathological study confirmed that the case is adrenal myelolipoma associated with Borrmann 2 type gastric cancer. In Japanese literature, only 54 cases of surgically resected adrenal myelolipoma have been reported, and this is the second case of adrenal myelolipoma associated with gastric cancer.

Tracheo-innominate artery fistula is a rare complication after tracheostomy, but sometimes presents with fatal bleeding. A 10-year-old girl presented with massive bleeding from a tracheostomy that she underwent for prolonged respiratory failure caused by sequelae of mumps encephalitis. Tracheo-innominate artery fistula, complicated by tracheostomy was diagnosed, and she was transferred to our institution. Under general anesthesia, she underwent transection of the innominate artery to exclude the tracheo-innominate artery fistula via median sternotomy. Her postoperative course was uneventful without recurrent bleeding or infection. Considering the risk of tracheo-innominate artery fistula, careful observation is necessary to prevent catastrophic bleeding in patients with mechanical respiratory support via tracheostomy.