Case 1 was a 48-year-old mother who was under observation for Marfan syndrome and thoracic aortic dilation. She was brought to the hospital with chest pain, and a CT scan revealed acute aortic dissection (Stanford A). Aortic incompetence was also observed, and an emergency Bentall procedure was performed. Case 2, her daughter, was a 26 years old and 39 weeks pregnant. She did not meet the diagnostic criteria for Marfan syndrome. She experienced severe back pain on the same day that her mother was admitted for aortic dissection. Because the patient did not agree to the use of a contrast agent due to concern about its effect on the fetus, emergency cesarean section was performed. Subsequently, a CT scan performed on the patient showed acute aortic dissection (Stanford B). Accordingly, antihypertensive therapy was commenced. In both cases, the patients were discharged after they recovered. Although case 2 did not meet criteria for Marfan syndrome, because of the hereditary disposition, we strongly suspect this was a Marfan syndrome pregnancy. This type of case is included in the case literature on cesarean and vigilant perinatal care is thought to be necessary.

We report 2 patients with unilateral pulmonary edema after heart surgery who were successfully treated using venovenous extracorporeal membrane oxygenation (VV ECMO). Case 1 : A 35-year-old woman presented with dyspnea. Echocardiography showed severe mitral regurgitation (MR) and tricuspid regurgitation (TR) and therefore, mitral valve plasty (MVP) and tricuspid annular plasty (TAP) were performed via right thoracotomy. After weaning from cardiopulmonary bypass, respiratory failure occurred with expectoration of foamy sputum and it was difficult to maintain oxygenation. Therefore, we performed VV ECMO to maintain oxygenation. A chest X-ray film after surgery showed ipsilateral pulmonary edema. After weaning from VV ECMO, deep venous thrombosis occurred and therefore we inserted an IVC filter. Case 2 : A 67-year-old man, who had previously received aortic valve replacement experienced dyspnea and visited our hospital. Echocardiography showed an aortic root abscess, and therefore Bentall operation was performed. After weaning from cardiopulmonary bypass, oxygenation was difficult to maintain, and therefore we performed VV ECMO. A chest X-ray film post operatively showed right ipsilateral pulmonary edema. The patient was weaned from VV ECMO 5 days post operatively and was discharged 60 days post operatively. We believe that VV ECMO can be beneficial for patients with respiratory failure after heart surgery, but complications related to this approach such as DVT should also be considered.

A 3-month-old girl of univentricular heart of left ventricular type with atresia of left atrioventricular valve (LAVV) and coarctation of the aorta (Co/AO) is presented. UCG and angiography revealed concordant AV connection with straddling RAVV with transposed great arteries [SDDT]. The following pressures (in mmHg) were noted on catheterization: RA mean 1 (a=3, v=1), LA mean 12 (a=17, v=14), LV 84/0/8, Ao 81/41, and PA 74/39. Patent foramen ovale (PFO) was restrictive and balloon atrioseptostomy was not feasible. Blalock-Hanlon atrial septectomy (8×6mm), subclavian flap aortoplasy (SFA) and pulmonary arterial banding were performed simultaneously under bilateral thoracotomy. Acute renal failure occurred after surgery and the girl required peritoneal dialysis for 5 days. At 6 months after surgery, girl is doing well. There will be a predictable fall in pulmonary vascular resistance after atrial septectomy and SFA with a ligation of PDA may result transient increase in systemic resistance. Therefore, atrial septectomy and SFA in conjunction with pulmonary arterial banding should be done simultaneously.

We report a rare case with infection of a stent-graft. A 82-year-old man, who had undergone endovascular stent grafting to repair the descending aortic aneurysm 2 years previously, was admitted with high-grade fever. The blood culture detected methicillin-resistant Staphylococcus aureus (MRSA). Endoleak due to stent-graft infection was diagnosed and operation for synthetic graft replacement was performed. The synthetic graft was infiltrated in Rifampicin prior to the graft replacement to prevent re-infection. Additionally, the graft was covered with the greater omentum. He was discharged on the 45th day after surgery without any problems. One year follow-up showed no sign of re-infection of the graft.

A 49-year-old woman was found to have unruptured Valsalva's sinus aneurysm. All of the sinuses were involved in the anuerysmal dilatation and the aortic valve was intact with no aortic insufficiency. Aortic root reconstruction surgery (root remodeling operation) was successfully performed and the histopathology of the aortic wall showed healed aortitis. Her postoperative course was uneventful. Valve-Sparing surgery can be one option, even in cases with aortitis.

A 79-year-old woman had received implantation of a pace maker for sick sinus syndrome at age 64 and tricuspid valve annuloplasty and Maze at age 68. Furthermore, she underwent tricuspid valve and mitral valve replacement with a bioprosthesis because of tricuspid valve and mitral valve regurgitation at age 73. She was referred to our institution for congestive heart failure in November 2005, because her bioprostheses at the mitral and tricuspid positions had shown significant regurgitation due to the degeneration of the prostheses, which required rereplacement. Because 1) surgical treatment of the heart had been performed twice in the past, 2) the general condition was not good owing to cirrhosis and hypothyroidism and 3) the durability of bioprostheses is short, we performed mitral valve re-replacement by using the “valve-on-valve” technique for reducing the invasion of surgical therapy. She had a satisfactory postoperative course. The “valve-on-valve” technique is a useful option for the re-replacement of bioprosthesis because it obviates the need for removing the sewing ring of the previous bioprosthesis.

We presented here 2 cases of rare nonvascular tumor involving the aorta. Case 1: A 69-year-old woman. She presented leg edema and dyspnea on admission. Computed tomography revealed abdominal aortic aneurysm perforating left common iliac vein. Abdominal aortic aneurysm replacement and fistula closure were done on an emergency basis. Immunohistologic examination revealed that malignant mesothelioma invaded the aortic wall. Case 2: A 47-year-old woman presented with dyspnea. Enhanced computed tomography revealed rupture of the descending aortic aneurysm (saccular type). Aortic replacement was done on an emergency basis. One year after the operation, computed tomography revealed a giant mass (160×70mm) surrounding the descending thoracic aorta. On biopsy, malignant schwannoma was found to invade the descending aorta. Sometimes nonvascular tumors form aneurysms. So we should be careful in diagnosis before operation.

We report a patient who underwent an operation for an infectious abdominal aortic aneurysm 10 months after intravesical bacillus Calmette-Guerin therapy. A 68-year-old man had previous gastrectomy for early gastric cancer and intravesical BCG therapy for early stage urinary bladder cancer. His follow up CT scan revealed an abdominal aorta pseudoaneurysm. We performed aneurysmectomy, omentopexy and bilateral axillo-femoral bypass. The culture of an abscess in the aneurysm identified Mycobacterium bovis. The patients improved clinically with antituberculosis agents after operation. Intravesical bacillus Calmette-Guerin therapy is effective in the treatment of early stage urinary bladder cancer. Although this treatment is generally considered safe, serious complications including vascular complications have been reported.

Background/Aims: Immune checkpoint blockade has recently been reported to be effective in treating microsatellite instability (MSI)-high tumors. Therefore, sufficient sampling of histological specimens is necessary in cases of unresectable pancreatic cancer (UR-PC). This multicenter study investigated the efficacy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) using a Franseen needle for MSI evaluation in patients with UR-PC. Methods: A total of 89 patients with UR-PC who underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or EUS-FNB using 22-G needles at three hospitals in Japan (2018–2021) were enrolled. Fifty-six of these patients (FNB 23 and FNA 33) were followed up or evaluated for MSI. Patient characteristics, UR-PC data, and procedural outcomes were compared between patients who underwent EUS-FNB and those who underwent EUS-FNA. Results: No significant difference in terms of sufficient tissue acquisition for histology was observed between patients who underwent EUS-FNB and those who underwent EUS-FNA. MSI evaluation was possible significantly more with tissue samples obtained using EUS-FNB than with tissue samples obtained using EUS-FNA (82.6% [19/23] vs. 45.5% [15/33], respectively; p<0.01). In the multivariate analysis, EUS-FNB was the only significant factor influencing the possibility of MSI evaluation. Conclusions EUS-FNB using a Franseen needle is desirable for ensuring sufficient tissue acquisition for MSI evaluation.

Endurance exercises, such as cycling or running, are useful for reducing arterial stiffness. However, individuals with a low physical fitness level, or patients suffering from leg diseases with pain, are unable to perform such moderate-intensity lower-limb exercises for long periods of time. The aim of this study was to evaluate the effects of acute cycling with Electrical muscle stimulation (EMS) on the brachial to ankle pulse wave velocity (ba-PWV). Ten healthy adult men performed 3 sessions, as follows of 20 min: cycling at 50% VO2max (C), cycling at an intensity of 50%VO2max subtracted from VO2 during EMS (LC), and cycling at the intensity of the LC trial while also being combined with EMS (LC+E). The ba-PWV was measured before and after each exercise. In addition, the femoral artery blood flow (BF) was measured in eight healthy adult men before and after exercise using an ultrasound imaging system. In the C and LC+E trials, the ba-PWV significantly decreased immediately after the exercise session, whereas the ba-PWV did not significantly change following the LC trial in any session. Compared with the baseline, the femoral artery BF values significantly increased after all trials. In the C and LC+E trials, the femoral artery BF was significantly greater than that in the LC trial. Acute endurance low-intensity cycling with EMS results in a reduction in the arterial stiffness which is similar to that with moderate-intensity exercise.