Three cases of aortic dissection involving abdominal aortic aneurysms are reported. Two of the 3 cases died from intestinal necrosis. In one of them, the abdominal aortic aneurysm ruptured following aortic dissection. Fenestration was not performed at the proximal anastomosis in the operation, and it is thought that this resulted in occurrence of intestinal necrosis due to superior mesenteric artery obstruction. In the other non-survivor, aortic fenestration and graft replacement were performed. However, he died from descending-sigmoid colon necrosis due to internal iliac artery obstruction. An autopsy demonstrated no problem that with the graft anastomosis. The successful case of aortic fenestration and graft replacement had no postoperative complications. Since the aortic wall is fragile in acute aortic dissection, it is advisable that operation be conducted 1 month after the onset except in cases of aortic rupture and malperfusion syndrome. Fenestration, which is usually safe in chronic dissection, should be performed and it is desirable to fenestrate the aortic wall if possible even in acute dissection.

Ten patients after coronary artery bypass grafting had reoperatinons and eight patients underwent postoperative PTCA at Nihon University Hospital from 1970 to July 1991. The difference of age between the reoperation group and the postoperative PTCA group is not significant. Most patients of the reoperation group and all of the PTCA group were male. Symptoms of the patients who required again surgical treatment or PTCA were almost reattack of angina and many cases were complicated by the coronary risk factors, particularly uncontrolled hypercholesterolemia and smoking. The bypass numbers of the reoperation group in the first operation were 2.1 and those of the PTCA group were 3.5. The difference of them was statistically significant (p<0.05). The period from the primary operation to the second treatment also showed statistically significant difference between two groups (p<0.05) (reoperation group: 81.8 months, PTCA group: 55.7 months). In the reoperation group, there were two operative deaths, two late deaths (not caused by heart disease), and the others remained asymptomatic. In PTCA group, no one had died, but four patients repeated attacks of chest pain after PTCA (mean interval 2.3 months), and two of them underwent re-PTCA. For a symptomatic case whose native coronary arteries or vein grafts show progressive stenosis and who have undergone PTCA, reoperation is recommendable as an effective treatment to relieve the symptom.

A 66-year-old woman with aortic stenosis and idiopathic thrombocytopenic purpura (ITP) underwent concomitant splenectomy and aortic valve replacement (AVR). High-dose trans-venous gamma-globulin therapy (400mg/kg/day) was performed for five days before surgery. The number of platelet, which was 6.0×10⁴/mm³ on admission slighty increased to 7.0×10⁴/mm³ before surgery. The aortic valve was replaced by an ATS 19mm prosthesis using cardiopulmonary bypass. Platelets were transfused postoperatively. Perioperative hemorrhage was moderate, and the postoperative course was uneventful. This was the second case we treated by concomitant cardiac surgery and splenectomy. It was safely performed after high-dose trans-venous gamma-globulin therapy.

A 63-year-old man suffered from type A acute aortic dissection associated with descending thoracic aortic aneurysm and coronary stenosis. He was treated surgically 49 days after onset of acute aortic dissection. Deep hypothermic selective cerebral perfusion was carried out for brain protection. It revealed the aneurysm, 51mm in diameter, located just distal to the aortic arch, and an intimal tear of the dissection located posterior wall of aneurysm. The total arch was replaced with 24mm vascular graft and CABG (LITA-to-seg. 8) was carried out. The postoperative course was uneventful and he was discharged on the 18th postoperative day.