We report a case of a dissecting brachiocephalic artery aneurysm that developed at the anastomotic site following surgery for acute aortic dissection ; and which was successfully treated by stent grafting. The patient, a 62-year-old man, had undergone total arch replacement for an acute Stanford type A aortic dissection that accompanied dissection of the brachiocephalic artery. In the early postoperative period, he complained of dull pain in the right arm and fatigue on exertion. The blood pressure in the patient's right arm was found to be significantly lower than in the left. Enhanced computed tomography (CT) performed 1 month postoperatively revealed leakage at the anastomotic site of the brachiocephalic artery, leading to the formation of a false lumen and the creation of a dissecting aneurysm with a maximum short diameter of 30 mm. No re-entry was seen, and the greatly expanded false lumen was exerting pressure on the true lumen, causing ischemia of the arm. Enhanced CT performed 3 months postoperatively showed that the maximum short diameter of the aneurysm had increased to 35 mm. Because ischemic symptoms of the arm were also present, surgery was considered to be indicated, and stent grafting was performed. A stent graft was inserted via the right axillary artery and positioned to close the entry to the false lumen of the dissecting aneurysm. Symptoms resolved without any complications, and the patient was discharged 7 days after the surgery. The false lumen of the dissecting aneurysm completely disappeared, and no complications have developed during the 3-year interval since stent grafting. In this patient, stent grafting enabled minimally invasive closure of the entry to the dissecting aneurysm that had developed at the anastomosis site. We conclude that stent grafting is very useful for treating dissecting aneurysms caused by anastomotic leakage and without re-entry, as seen in this case.

Cardiovascular surgery in situs inversus totalis (SIT) is unusual. We report a case of coronary artery bypass grafting (CABG) in SIT. A 67-year-old man with unstable angina pectoris was admitted to our hospital. Coronary arteriography demonstrated three-vessel disease in the mirror-image heart. CABG with 4 distal anastomosis was carried out with conventional methods. Careful observation based on complete understanding for preoperative images could minimize operative difficulties caused by mirror-image heart.

We report a case of graft infection long after femorofemoral crossover bypas grafting (FFBG), first presenting as septic distal emboli without any infective signs in the groin. A 71-year-old man who had undergone FFBG visited our hospital because of sudden pain in his right foot. No infective signs were found in the graft route from physical examination. However, computed tomography demonstrated perigraft fluid and graft thrombi. Graft excision and extra-anatomic revascularization were successfully done. Light micrography showed Staphylococcus aureus extensively infiltrating in the expanded polytetrafluoroethylene graft wall.

Simultaneous pulmonary trunk and ascending aortic aneurysms are very rare, and the role of surgery in this entity is not well defined. We report a rare case of aneurysm of both the pulmonary trunk and the ascending aorta, associated with pulmonary and aortic valve insufficiency in a 17-year-old boy. Cardiac disease had been diagnosed at the age of 5, and at that time, pulmonary and aortic valve insufficiency were found by ultrasound cardiography (UCG). At regular follow-up, both cardiac valve regurgitation and the dilatation of the aneurysm gradually increased. A recent computed tomographic scan revealed that the ascending aortic aneurysm was 55 mm and the pulmonary trunk aneurysm was 60 mm. A UCG also showed severe aortic valve regurgitation and moderate pulmonary valve regurgitation with no pulmonary hypertension. Surgical repair was performed successfully. The aortic valve was replaced with a mechanical valve. The dilated ascending aortic aneurysm was excised and replaced with a Dacron graft. The pulmonary trunk aneurysm was incised longitudinally. The pulmonary valve was tricuspid, and no organic leaflets change was observed. Pulmonary valvuloplasty by commissure plication of the prolapsed cusps was performed. A large portion of the anterior pulmonary aneurysm wall was excised and plicated to reduce the radius diameter. The pathology of the aneurysm wall showed infiltration of inflammatory cells in the tunica media, fragmentation and decrease of elastic fiber, loss of muscular tissue, and increase in collagen fibers. No cystic medial necrosis was observed in the pathologic specimen. The postoperative course was uneventful, and there were no adverse events or complications at 2 years follow-up. The following image study revealed the normal size of the great vessels.

A university hospital plays roles as a specific functional hospital and as a teaching hospital in primary care because most medical school graduates receive basic clinical training in this area. An important objective of primary care education for all residents is the initial treatment of patients with first-to third-level emergencies. We examined the number of patients, the level of emergency (first, second, and third level) and the diagnoses that each resident encountered. Subjects included 29 residents (3 in the first year, 4 in the second year, and 2 in the third year) who had undergone clinical training for 3 months in the department of emergency medicine at the Saga Medical School Hospital which treats 7, 000 to 8, 000 patients per year with first-to third-level emergencies. Residents were involved with 214.6 emergency cases, which included approximately 59 types of first-level emergency, 31 types of second-level emergency, and 15 types of third-level emergencies. These results were largely compatible with the Objectives of Postgraduate Basic Clinical Training proposed by the Japan Society for Medical Education. These results show that university hospitals as specific functional hospitals should accept numerous emergency patients and that residents must receive clinical training in emergency medicine to achieve the objectives of primary care education.

A 15-year-old girl who had undergone a tracheostomy 4 years earlier because of holoprosencephaly and severe mental and physical disabilities had tracheo-innominate artery fistula with sudden-onset bleeding after endotracheal suctioning. Due to respiratory and circulatory instability, VIABAHN® was implanted in the brachiocephalic artery, and the patient was discharged on postoperative day 33. Three months later, rebleeding from the tracheostomy site was observed, and the patient was transported to our hospital. Although the bleeding stopped spontaneously on arrival, the patient experienced multiple bleeding episodes after admission. Therefore, transection of brachiocephalic artery was performed, after which the patient was discharged on postoperative day 20. Tracheo-innominate artery fistula is a rare complication that occurs after tracheostomy, but it is associated with a poor prognosis, and has a mortality rate of 100% if left untreated. Our case suggests that endovascular treatment using VIABAHN® for tracheo-innominate artery fistula is useful for temporary hemostasis.