Late acute type A aortic dissection after coronary artery bypass grafting (CABG) is rare, and only a few cases have been published in the literature. It is important to treat cases of living graft during reoperation. We report a successful surgical treatment in a case of late acute type A aortic dissection after CABG. A 68-year-old man underwent a triple CABG (to the left anterior descending artery with left internal thoracic artery, to the left circumflex artery with left radial artery, and to the right coronary artery with right gastroepiploic artery) beating heart procedure using a centrifugal pump and pulmonary assist with closed circuit due to unstable angina pectoris in December 2007 and had presented with sudden anterior chest pain, and was found to have an ascending aortic dissection (type A) on enhanced computed tomography in May, 2009. We performed ascending artery replacement, paying special attention to the living graft performed through a median sternotomy. The postoperative course was uneventful and he was discharged on the 22nd postoperative day.

Thoracic aorta injury caused by blunt chest trauma is often fatal. A 26-year-old male with bilateral pneumohemothorax and disruption of the thoracic descending aorta due to a traffic accident was referred to our hospital. The chest X-ray film and CT scanning showed neither mediastinal widening nor periaortic hematoma. Three weeks after admission, aortography revealed flap formation at the aortic isthmus. Two months after trauma, we replaced the injured aorta with a vascular prosthesis using a centrifugal pump. Pathological examination showed separation of a medial layer of the aorta. His postoperative course was uneventful.

A 58-year-old woman, had received a transvenous permanent pacemaker was the subject of this study. Cervical phlegmon, induced by gastroduodenoscopy infected the tract of the transvenous pacemaker lead inserted into the left subclavian vein by the puncture method. Local management was unsuccessful, and consequently, microbial endocarditis developed with tricuspid valve vegetation. Removal of the entire system under cardiopulmonary bypass successfully eliminated the infection. It is neccesary that pacemaker patients undergoing procedures that may be associated with infections receive prophylactic antibiotics before such procedures. Patients with pacemaker infections should undergo aggressive total removal of the pacemaker system at an early stage of infection, particularly in cases with bacteremia.

We report a 78-year-old man who had an impending ruptured atherosclerotic arch aneurysm combined with chronic dissecting ascending aortic aneurysm. The patient underwent a graft replacement of the ascending aorta and aortic arch using the elephant trunk method with the aid of profound hypothermia and continuous retrograde cerebral perfusion. Cerebral blood velocity was measured with transcranial Doppler (TCD) during operation. The TCD flow pattern after weaning of cardiopulmonary bypass indicated a state of brain edema. Therefore it is important in extensive retrograde cerebral perfusion to control the perfusion pressure and prevent destruction of the blood brain barrier aggressively. Pharmacological intervention could improve the safety of retrograde cerebral perfusion. Postoperative diagnostic images showed that the part of the distal anastomosis around the elephant trunk was not surrounded with thrombus. At this stage, it is not necessary to perform next extensive aortic replacement. It is important to consider the occurrence of complication, who using elephant trunk method, including paraplegia, thromboembolism, kinking of prothesis.

A 39-year-old woman with Marfan's syndrome was referred with a symptom of exertional dyspnea, had mitral valve regurgitation, annuloaortic ectasia with aortic valve regurgitation and Stanford B type chronic aortic dissection. She was successfully treated with a one-stage operation, consisting of aortic root replacement with the Carrel patch method, mitral valve replacement and extended replacement of the thoracic aorta (ascending, arch and thoracic descending aorta), through median sternotomy and left antero-axillary thoracotomy. This operation was performed under hypothermic circulatory arrest with continuous retrograde cerebral perfusion. The postoperative course was uneventful. Although the operation may include complicated procedures, it is important to perform a sufficient operation corresponding to the patient's condition and lesions, employing the most advanced surgical techniques, such as circulatory arrest, myocardial protection and so on.