The diagnosis of ruptured dissecting limited abdominal aortic aneurysm was made in four cases. The sex ratio (M/F) was 1/3, and mean age was 63.5 years (from 53 to 78yr). Only one of these cases die due to intraoperative bleeding. Other three cases were discharged from our hospital. Intraluminal proximal anastomosis after fixed dissected aortic wall due to mattress suture and end to end anastomosis with reinforcement by Teflon felt were good results. The one case who was anastomosed simple intraluminal method has pseudoaneurysm in the proximal portion. It is important to diagnose preoperatively dissection and to make end to end anastomosis with Teflon felt.

A 60-year-old man with impending rupture of abdominal aortic aneurysm was transferred to our hospital. The patient entered a state of shock because of rupture during a CT scan examination. Emergency in site reconstruction with a dacron Y-graft was performed. There was massive intraperitoneal bleeding but no apparent abscess formation around the aneurysm. No drain was placed. A subcutaneous abscess that developed postoperatively was cured by open drainage and local antibiotic administration. Culture from both the aortic wall and the subcutaneous abscess revealed Salmonella infection. After subsequent intravenous antibiotic therapy for 45 days, the patient was discharged without any evidence of remaining infection.

Left ventricular thrombus is a complication of left ventricular dysfunction, including acute myocardial infarction, cardiomyopathy, and severe valvular heart disease. Surgical removal should be considered when a thrombus is mobile, when thromboembolism occurs, and when cardiac function has the potential to improve. Two patients with left ventricular thrombus underwent totally thoracoscopic transatrial thrombectomy. A thrombus developed in the apex of the left ventricle after acute myocardial infarction in one patient (Case 1) and during treatment for congestive heart failure in the other (Case 2). The minimally-invasive transatrial approach requires no sternotomy or left ventriculotomy and is thus particularly beneficial for treating left ventricular dysfunction. Moreover, totally endoscopic surgery confers the advantage of a deep and narrow visual field. Therefore, we consider that this strategy is highly effective for treating left ventricular thrombus.

The patient was a 61-year-old woman. In April 2005, she suffered a cerebral infarction and became paralyzed on the right side. In June 2005, a stent graft was placed to treat significant stenosis of the right coronary artery. Computed tomography (CT) in October 2006 revealed widespread patent aortic dissection in both the true and false lumens, extending from the origin of the ascending aorta to the three arch branches and both femoral arteries. Preoperative coronary angiography also showed occlusion of the left anterior descending branch. As a result of these findings, widespread Stanford type A chronic aortic dissection with coronary artery disease was diagnosed, and surgery was performed in February 2007. Brachiocephalic artery dissection and severe stenosis of the right subclavian artery were present, and the left common carotid artery and left subclavian artery were also dissected distally. In addition, both the true and false lumens were patent distal to the aortic arch, with the major abdominal branch bifurcating from both lumens and the dissection extending to the femoral artery, requiring cannulation of both lumens. During surgery, extracorporeal circulation was established by means of blood removal from the right atrium, transapical aortic cannulation, and cannulation of both luminens of the left femoral artery, in an effort to prevent malperfusion due to hypothermia. For revascularization, a Y-shaped artificial blood vessel was used to reconstruct the three arch branches first (the arch-first technique), after which an I-shaped artificial blood vessel was used to form anastomoses distally with both lumens, ensuring perfusion to the false lumen. The proximal anastomosis was then formed, and finally, a single coronary artery bypass graft (CABG) branch was performed using a great saphenous vein graft. No postoperative complications were encountered, and CT showed good blood flow through both luminens below the graft and aortic arch. The patient was discharged from hospital and returned home in an anbulatory condition independently 18 days postoperatively. In this case of widespread type A chronic aortic dissection, the cannulation site was selected and the order of reconstruction and methods of anastomosis were carefully chosen to avoid cardiac malperfusion during arch replacement, resulting in a good outcome.

A free-floating ball thrombus in the left atrium is a rare occurrence. Few patients who developed a ball thrombus after mitral valve replacement have been reported. Our patient was a 58-year-old man who had undergone mitral valve replacement in 1981. Since bleeding gastric cancer had been diagnosed anticoagulant therapy had been 4 days before admission. On admission, echocardiography revealed a large thrombus in the left appendage. First, he underwent total gastrectomy for gastric cancer. After the operation, he developed aspiration pneumonia, and was intubated. We observed that a large thrombus had moved from the left appendage to the left atrium. Emergency operation was successfull.

A 58-year-old man was admitted with pulsatile abdominal mass with fever and dull pain. Abdominal aortic aneurysm with left hydronephrosis due to obstruction of the left ureter was diagnosed by CT scanning. Aortic valve replacement was performed ten years previously for aortic regurgitation and recently his cardiac function deteriorated. On the 5th day after admission he suddenly suffered from hemorrhagic shock with massive melena. Emergency laparotomy was performed and ruptured abdominal aortic aneurysm was observed penetrating to the sigmoid colon with perianeurysmal abscess. The abdominal aorta was excluded and closed using two-layer sutures just below the renal artery, and bilateral common iliac arteries were also closed. The aneurysmal sac and the sigmoid colon were removed as a whole, and colostomy was made according to Hartmann's procedure. Permanent right axillo-bifemoral bypass graftiny was made to avoid infectious complications of the vascular graft. A successful vascular reconstruction was done without any complication of graft infection, however he died of cardiac failure due to dilated cardiomyopathy after 4 months postoperatively. We reported a successfully treated abdominal aortic aneurysm extending to the sigmoid colon with hemorrhagic schok.

We present a rare case of mitral stenosis with bilateral pulmonary arteriovenous fistulae (PAVF). A 55-year-old female who complained of dyspnea did not have pulmonary hypertension. She underwent successfully mitral valve replacement with an artificial valve 2 months after transcatheter coil embolization for PAVF. The combination with mitral valve replacement and transcatheter embolization is regarded as a useful procedure for mitral valve disease associated with PAVF.

Between 1984 and 1994, 58 patients underwent operations for type A aortic dissection. A sutureless ringed intraluminal graft was used in 9 of the 58 cases. The patients ranged from 47 to 74 years old (mean, 60.4 years). Six patients were discharged from the hospital and three patients died. The operative mortality rate for the 9 patients was 33.3% and for the other 49 patients it was 20.4%. Post-operative aortograms revealed a remaining false lumen in 5 of the 6 discharged patients. The result of the operation with the sutureless ringed intraluminal graft was not satisfactory. Therefore, we prefer to resect and replace the dissected aorta using the prosthetic graft rather than repair with the sutureless ringed intraluminal graft.

An 81-year-old woman with severe chest pain was admitted to our hospital. Computed tomography showed aortic dilation and a non-enhanced crescentic area in the ascending aortic wall, indicating a DeBakey type-II aortic dissection with thrombus. The ascending aorta was replaced with an impregnated knitted Dacron graft. Fresh clotted hematoma was found in the dissected ascending aortic wall, and the intimal surface was involved with a local atherosclerotic ulcer penetrating the media. Operative findings were compatible with intramural hematoma due to penetrating atherosclerotic ulcer described by Stanson et al. In the literature most penetrating atherosclerotic ulcers are located in the descending aorta, thus this case is rare.

A 62-year-old woman was admitted for chest and back pains. She was found to have thrombosed type A aortic dissection by enhanced computed tomography. Since she had no clinical symptoms after her admission, she was discharged. Forty days after the admission, she returned with acute renal failure and ischemia of both lower extremities. Occlusion of the abdominal aorta was diagnosed and emergency axillobifemoral bypass was performed. Her renal function and the ischemia of both lower extremities improved dramatically and she was discharged 30 days after the operation. Axillobifemoral bypass is one of the most effective and least invasive operations in such cases.