This report documents a case of three-channeled aortic dissection. The diagnosis of dissecting aneurysm was made by chest X-P and CT to 70-year-old man, with a chief complaint of back pain. Aortogram showed aortic aneurysm (DeBakey type IIIb), which had an entry at distal of the beginning of the left subclavian artery. Though we had given a pressure control therapy, the patient died on the 5th day of the admission. At autopsy, a new dissection was found in the chronic dissecting outer wall, forming three channeled dissection and rupture was there. Three-channeled dissection is very rare, only 8 cases including ours have been reported so far. From this case, we learned it very difficult to diagnose and treat it.

We studied the effects of granulocytic elastase (GEL) and fibronectin (FN) on the coagulation and fibrinolytic system when using cardiopulmonary bypass (CPB). Blood sampling was performed before CPB (Pre), just after CPB (Post) the 1st postoperative day (PD1) and the second postoperative day (PD2). Laboratory parameters were GEL, FN, fibrinogen (Fib), prothrombin time (PT), fibrin degradation products (FDP), D dimer (D-D), α2 plasmin inhibitor plasmin complex (PIC) and antithrombin III (AT III). The level of GEL was highest and that of FN was lowest at Post. The levels of Fib, PT and AT III were lowest and that of PIC was highest just after CPB. The levels of FDP and D-D were highest on PD1. The levels of GEL and D-D correlated just after CPB and on PD1 and PD2. The level of GEL correlated with that of PIC on PD1. These results demonstrated that the level of FN decreased with CPB. And it was expected that CPB time affected the level of GEL. The levels of GEL affects D-D and PIC which are fibrinolysic factors particularly related to secondary fibrinolysis.

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as an option in patients with failure of retrograde access to the pancreatic duct (PD) because of difficulty in cannulation or surgically altered anatomy. This article provides a comprehensive review of the techniques and outcomes of EUS-PD, especially EUS-guided pancreatic transmural stenting. The clinical data derived from a total of 401 patients were reviewed in which the overall technical and clinical success rates were 339/401 (85%, range 63%–100%) and 328/372 (88%, range 76%–100%), respectively. Short-term adverse events occurred in 25% (102/401) of the cases, which included abdominal pain (n=45), acute pancreatitis (n=17), bleeding (n=10), and issues associated with pancreatic juice leakage such as perigastric or peripancreatic fluid collection (n=9). In conclusion, although EUS-PD remains a challenging procedure with a high risk of adverse events such as pancreatic juice leakage, perforation, and severe acute pancreatitis, the procedure seems to be a promising alternative for PD drainage in patients with altered anatomy or unsuccessful endoscopic retrograde pancreatography.

A Case of abdominal aortic occlusion caused by acute aortic dissection (DeBakey's type III b) is reported. A 59-year-old woman was admitted with sudden onset back pain and sensory disturbance of bilateral lower extremities. The pulsations of bilateral femoral arteries were absent. CT and aortogram revealed dissection of the thoracic descending aorta and infrarenal aortic occlusion. Since ischemic change had progressed, bilateral axillofemoral bypass was performed for limb salvage, and the symptoms improved rapidly. Axillofemoral bypass is an easy and safe procedure even in the acute phase of aortic dissection. It provides fast reperfusion, and so is considered to be useful to preventing myonephrotic metabolic syndrome MNMS.

In the postoperative treatment of ruptured abdominal aortic aneurysm surgery, the relationship between intra-abdominal pressure (IAP) and the clinical course is not been clearly understood. From April 2000 to January 2003, we treated 109 cases of abdominal aortic aneurysm surgery (non-rupture 71 cases, rupture 38 cases) and measured intra-abdominal pressure in 30 of the ruptured cases which we analyzed in this study. The patients were divided into 2 groups. The H-group included 12 patients with maximum IAP equal to or higher than 20mmHg, and the L-group included 18 patients with a maximum IAP less than 20mmHg. Clinical characteristics were compared between the 2 groups. The mean age was 79.3±7.6yr in the H-group and 70.7±10.1yr in the L-group (p=0.019). Preoperative shock was diagnosed in 83.3% of the H-group patients, and 61.1% of the L-group patients the (p=0.26). Postoperative maximum values of intra-abdominal pressure were 22.3±2.0mmHg in the H-group, and 15.4±2.4mmHg in the L-group. Duration of intubation was 87.7±110.0h in the H-group, and 25.1±29.2h in the L-group (p=0.04). Food intake was started 14.4±11.2d after surgery in the H-group, and 8.5±4.8d after surgery in the L-group (p=0.094). The length of ICU stay was 6.7±6.5d in the H-group, and 2.9±2.1d in the L-group (p=0.033). Length of hospital stay after surgery was 54.1±25.8d in the H-group, and 25.2±6.8d in the L-group (p=0.001). Complications occurred in 8 cases out of 11 surviving cases (73%) in the H-group, and in 3 cases out of 17 surviving cases (18%) in the L-group (p=0.0024). Complication in the H-group included acute renal failure, paralytic ileus, respiratory failure, abdominal wall dehiscence, and acute arterial occlusion, and that in the L-group included acute renal failure, upper limb paresis, and lower limb paresis. Monitoring of intra-abdominal pressure was considered beneficial to recognize complication and decide therapeutic strategy after ruptured aortic aneurysm surgery.

There were 16 patients who developed acute renal failure (ARF) follwing cardiovascular operation using extracorporeal circulation. They were treated by either CPD or CAVH because their ARF were resistant to medical treatment. These patients were divided into three groups according to their treatment; 7 patients treated by CPD (Group A), 5 patients treated both CPD and CAVH (Group B), 4 patients treated by CAVH (Group C). The survival rate was 33% in Group A, 20% in Group B, and 0% in Group C. The prognosis of the each group was poor. CPD and CAVH were effective to control the concentration of serum potasium and water removing. But CPD and CAVH were not very effective to control the concentrations of serum creatinine and blood urea nitrogen. There were three patients who developed low proteinemia which was one of the side effects of CPD. Seven of nine patients treated by CAVH, developed bleeding. The side effects of CAVH were seemed to be more severe than those of CPD.