Idiopathic hypereosinophilic syndrome (IHES) is a rare systemic disease, but frequently associated with the eosinophil-infiltrated end organ (cardiac, hematologic, cutaneous, neurologic, pulmonary, splenic and thromboembolic) failure. Mechanical valve replacement for valvular heart disease in cases of IHES has the potential of thromboembolic accidents in the early post-operative period, even though the strict anti-coagulant therapy was performed. We reported a younger IHES case with congestive heart failure due to severe mitral regurgitation who underwent mitral valve repair instead of replacement. In this case, only the lateral scallop of the posterior mitral leaflet was involved with endocarditis due to the eosinophyl infiltration, with no other symptoms, i.e., initial hyperplasia and thrombus in the left ventricle that were detected in the most cases with IHES endocarditis. Mitral annuloplasty with the complete ring was simply performed because of the presence of sufficient intact anterior leaflet. The eosinophil count had been strictly controlled with imatinib mesilate in addition to the anti-coagulant therapy, and any thromboembolic event had been detected post operatively. In case of valvular heart disease due to IHES endocarditis, valve repair should be firstly attempt and imatinib mesilate is very useful and effective for preventing from post-operative thromboembolic accidents in FIP1L1-PDGFRα gene positive cases.

Three cases of aortic arch aneurysm complicated by aberrant right subclavian artery (ARSA) are reported. Two patients underwent emergent operations with diagnosis of a Stanford type A acute dissection and a ruptured distal arch aneurysm. The third patient underwent an elective operation under a diagnosis of distal arch aneurysm and right subclavian artery aneurysm. In all cases, deep hypothermic circulatory arrest with retrograde cerebral perfusion through median sternotomy was applied. The first patient with acute aortic dissection underwent total arch replacement and elephant trunk installation into the descending aorta. No ARSA was recognized. The other 2 patients underwent distal arch replacement with reconstruction of bilateral subclavian arteries. The in-situ reconstruction of the ARSA was performed in one patient and bypass grafting from the ascending aorta was done in the other patient. There were 2 hospital deaths. The postoperative angiogram of the first patient showed that the ARSA was occluded. One other patient needed a tracheostomy because of pulmonary complications and he died of asphyxia. The last patient died of esophageal perforation secondary to pressure necrosis.

Rupture of the posterior wall of the left ventricle is rare but it is one of the fatal complications which can follow mitral valve replacement (MVR). Of 216 MVR patients, including 51 who had double valve replacements, we have had four patients (1.9%) with this complication. The rupture occurred on the table in one patient and about 40 to 90min after entering ICU in the others. All the ruptures were repaired under cardiopulmonary bypass and cardioplegic arrest. The site of rupture was type I in two cases and type II in the other two. Two patients expired. One patient who had been repaired in the operating room died from multiple organ failure after a stormy course of two week's duration, and one who had been repaired in ICU died from uncontrollable hemorrhage. In the remaining two patients, one with a type I and one with a type II rupture, successful treatment in ICU was achieved by suturing an equine pericardial patch to the normal endocardium and mitral ring over the entire area of laceration through endocardial site after removal of the valve prosthesis in the first place, and then wrapping the area of epicardial laceration with another equine patch. In order to reduce mortality in patients with left ventricular rupture, repair from inside of the heart using an equine patch described above was very effective, and the preparation to perform the operation immediately after the onset of rupture in ICU is an important consideration as well.

Two patients with an aorto-iliac arteriovenous fistula as a complication of abdominal aortic aneurysms were presented. Both patients showed pulsating abdominal mass, and swelling of unilateral leg. The fistula was preoperatively diagnosed in one and in another it was suspected intraoperatively by careful palpation of continuous thrill on the aneurysm. Successful surgical management was accomplished in both patients. Awareness of this clinical entities is necessary to manage this rare complication in abdominal aortic aneurysm surgery.

Arterial reconstructions for iliac artery obstruction (IAO) were performed in 81 patients (70 males and 11 females) with arteriosclerosis obliterans (80) and thromboangiitis obliterans (1) from January 1979 to January 1991. Ages ranged from 36 to 79 with a median age of 63.4. Aortofemoral bypass (AF-B) was performed in 46 cases (including 21 Y graft patients), thromboendarterectomy (TEA) in 11, femoro-femoral cross-over bypass (FF-B) in 26 and axillo-femoral bypass (AXF-B) in 2. No patients in the AF-B, TEA or AXF-B group showed postoperative early occlusion, while two in the FF-B group had early occlusion. The bypass flow measured intra-operatively using an electro-magnetic flowmeter was 50-1, 100 (average 382) ml/min in the AF-B, 190-500 (331) ml/min in the TEA, 90-650 (219) ml/min in the FF-B, and 200ml/min in the AXF-B group. Two patients died; one from ischemic colitis and the other from myonephropathic metabolic syndrome. The long-term cumulative patency rates at 1, 2 and 5 years were 100, 96, and 96% in the AF-B, 100, 100, and 100% in the TEA, and 90, 84, 63% in the FF-B group, respectively. The two AXF-B cases had good patency one year and three years postoperatively. AF-B should be recommended for aorto-iliac obstruction even in high risk patients as long as severe heart disease is absent, because of the long-term patency rate. An additional bypass to the popliteal region should be performed, if bypass flow to the distal region is low.

Two cases of ruptured abdominal aortic aneurysm (AAA) treated with retroperitoneal approach are presented. Case 1 was a 73-year-old man with an infrarenal AAA of 44mm in diameter, and case 2 was a 73-year-old man with a 54mm pseudoaneurysm after graft replacement for AAA. Both patients had a history of previous laparotomy and their aneurysms had ruptured into only the right retroperitoneal space. A left retroperitoneal approach permitted wide and rapid exposure of the aorta with minimal damage to the intestines and respiratory function. Their postoperative courses were uneventful.

Infectious arterial aneurysm in a rare condition with a high mortality because of rapid aneurysmal growth and subsequent rupture. We encountered 3 cases of arterial aneurysm due to Salmonella infection. We evaluated there 3 cases and an additional 14 cases reported in the Japanese literature. Eleven patients with Salmonella infection had bacteremia. The incidence of bacteremia in patients with Salmonella infection was more frequent than that in patients with other bacillary infections. The location of the aneurysm was the abdominal aorta in 14. Rupture or impending rupture of the aneurysm was identified in 12. Fifteen patients underwent operation including in situ reconstruction in 9 and extra-anatomic bypass in 6. Among 15 patients who underwent an operation, 14 survived. These data suggest that accurate preoperative diagnosis, long-term antibiotic therapy, and immediate surgical intervention are essential for effective treatment of arterial aneurysm due to Salmonella infection.

A 73-year-old man who had undergone Y-grafting suffered from septicemia. A culture of arterial blood yielded Bacteroides fragilis. Computed tomography showed abscess and gas around the prosthetic graft. Under a diagnosis of a prosthetic graft infection caused by Bacteroides fragilis, removal of the infected graft, extra-anatomic bypass and omental grafting were performed 13 days after the first operation. After intensive treatment, he recovered and was discharged on the 45th day postoperatively.

A 71-year-old woman who had Takayasu's disease underwent Y-grafting, bypass grafting between the abdominal aorta and left renal artery with 8mm ePTFE graft and right nephrectomy for infrarenal abdominal aortic aneurysm and renovascular hypertension (RVH). Four years after the first operation, the bypass graft became occluded and hypertension was exacerbated. Magnetic resonance angiography revealed that the left renal artery was supplied by the collateral arteries. We performed replacement of the thoracoabdominal aorta and reconstruction of the left renal artery using the saphenous vein. Postoperatively serum creatinine level decreased and hypertension was controllable. She was discharged from the hospital and has been well for three years.

A 52-year-old man who had liver cirrhosis sufferred ruptured thoraco-abdominal aortic aneurysm. This patient was classified as having Child's class B liver cirrhosis preoperatively. The thoracoabdominal aorta was successfully replaced with reconstruction of the renal arteries, superior mesenteric artery, celiac artery, and 10th intercostal artery. Omentopexy was added. As persistent ascites continued postoperatively, peritoneovenous shunting was performed on the 29th postoperative day. Ascites disappeared and 20 days later the patient was discharged from hospital and has been well for two years.