We report a case of successfully treated mesenteric ischemia following emergency endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA). A 79-year-old man, who had received hemodialysis for 5 years for diabetic nephropathy, presented with sudden onset abdominal pain. Contrast-enhanced computed tomography revealed an rAAA with a 60-mm diameter in the infrarenal abdominal aorta. Emergency EVAR was performed. After completion of stent graft placement, intraoperative angiogram revealed serious imaging delay of the superior mesenteric artery. An emergency saphenous vein bypass was performed from the right external iliac artery to the ileocolic artery. The postoperative course was uneventful, and there has been no evidence of endoleak or enlargement of aneurysm diameter during the follow-up period of 2 years.

Non-occlusive mesenteric ischemia (NOMI) is a rare but often fatal event following cardiac surgery. Early diagnosis of NOMI is difficult because the related abdominal symptoms are not very specific. From April 1999 to September 2003, 1,040 patients underwent cardiac surgery, among whom 5 patients who underwent angiography were given a diagnosis of NOMI. A catheter was used for immediate intra-arterial infusion of 500μg prostaglandin E1 into the superior mesenteric artery over a period of 30min. Prior to angiography, all patients had cutis marmorata and elevated serum lactate levels. Three patients showed peritoneal signs and therefore underwent laparotomy. Of the 5 patients, 4 survived. In conclusion, if mesenteric ischemia is suspected, selective angiography must be performed as soon as possible for diagnosis and treatment. Additionally, the presence of other findings such as cutis marmorata and elevated serum lactate levels proved to be useful in the early diagnosis of NOMI.

An 83-year-old woman with unstable angina pectoris underwent percutaneous coronary intervention (PCI) of the left circumflex artery, and her condition improved. However, on the eighth day after PCI, she went into a stated shock, and echocardiogram confirmed a large amount of pericardial effusion. Pericardiocentesis was immediately performed, and bloody pericardial effusion was drained. Cardiac rupture was suspected, although the cause was unknown. Emergency sternotomy was performed, and blow out type cardiac rupture in the center of a thumb-sized infarction was found at the area of the obtuse marginal branch. The ruptured left ventricular wall was successfully closed with 2 mattress sutures because the infarcted area was relatively small. Postoperative course was good, and she was discharged on the 25th postoperative day. In this case, the cause of cardiac rupture was thought to be a small branch of the left circumflex artery, which was occluded during PCI. This is one of the rare but important mechanisms of cardiac tamponade after PCI.

The use of axillofemoral bypass grafts (AxFG) has became a widely accepted treatment for high-risk patients with aortoiliac occlusive disease. On the other hand, AxFG has been associated with a variety of complications in the upper extremity. A symptom of upper extremity thromboembolism after AxFG occlusion is reported as axillofemoral bypass graft stump syndrome (AxFSS). We report the case of a 55-year-old man with repeated AxFSS after an AxFG occlusion. He underwent brachial artery exploration and embolectomy. Angiograms showed an embolus floating in the axillary artery, which originated from the occluded graft stump. The stump was obliterated with a metallic stent introduced through the same arteriotomy made for the embolectomy. The endovascular treatment of AxFSS is minimally invasive and is an effective modality in this condition.

After vascular surgical procedures, complications of the wounds in the groin region may sometimes lead to prosthetic graft infections or prolonged hospital stays. While some wounds heal completely during re-suture and VAC therapy, healing of other wounds that involve refractory graft infection, lymphorrhea, or a dead space, is extremely difficult. We performed tissue coverage using a Sartorius muscle flap for such difficult cases. The muscle is twisted onto itself to fill the dead space with some blood supply. Tissue coverage using a Sartorius muscle flap with adequate blood flow was effective in improving lymphorrhea and infection. We report four such cases where complications in the groin region were managed using a Sartorius muscle flap for wounded coverage.

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.

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.

We present a case of redo aortic valve replacement (AVR) in a 71-year-old man with a Lillehei-Kaster valve implanted 42 years prior. The patient initially underwent AVR and open mitral commissurotomy procedures for aortic regurgitation complicated with mitral stenosis in 1978 at the age of 29. Thereafter, he was followed at our outpatient clinic and treated without anticoagulant therapy for the initial two decades of the postoperative period. During the long-term follow-up, the mean pressure gradient remained between 40 and 60 mmHg and there were no adverse events noted before occurrence of heart failure triggered by tachycardia and pneumonia. Following improvement of heart failure, redo AVR was performed. There was no structural damage, thrombosis, or Lillehei-Kaster valve opening restrictions, though severe pannus growth on the left ventricle side was observed, which was thought to be the cause of the increased pressure gradient. This is the first known report of redo AVR after many years in a patient who underwent Lillehei-Kaster valve implantation. Furthermore, no other study has noted findings regarding pressure gradient change during the long-term follow-up period in such cases.

A 61 year old woman who had been receiving treatment for ulcerative colitis for 14 years complained of respiratory discomfort on exertion and was diagnosed with severe mitral regurgitation due to mitral valve prolapse. Minimally invasive mitral valvuloplasty with right mini-thoracotomy was performed in our facility. Laboratory findings showed elevated levels of serum creatine kinase (CK) and CK-MB immediately after surgery. In addition to elevated levels of myocardial enzymes, ST depression was seen in an electrocardiogram on postoperative day 2 ; therefore, we suspected myocardial ischemia during the surgery. Despite the persistently elevated levels of myocardial enzymes, coronary angiography showed no significant abnormalities. Because of the possibility of false CK elevation, we performed CK electrophoresis, which revealed the presence of macro-CK type 1. CK-MB activity is often falsely elevated when determined by immune-inhibition in macro-CK patients, and that leads to the suspicion of myocardial ischemia. We considered that it may be highly difficult to identify macro-CK in a patient after cardiovascular surgery owing to elevated levels of myocardial enzymes in most such patients.