Seven patients underwent surgical repair of the distal aortic arch aneurysm from January 1990 to October 1997. They were 5 men and 2 women ranging from 63 to 78 years of age (mean, 72.7 years). All patients were operated with a median sternotomy only. There was one operative death, which was ruptured case. However, there were no major complications in non-ruptured cases. This retrospective study suggests that it is possible to repair the distal aortic arch aneurysm through a median sternotomy approach alone, when 1) descending aorta originates with normal size just distal to sacciform aneurysm, 2) the maximum diameter of the aneurysm is over 70mm and 3) distal involvement of the aneurysm does not extend beyond the bifurcation of the trachea. It is useful to retract descending aorta proximally by three threads with pledget for distal anastomosis in inclusion technique.

Hybrid revascularization by MIDCAB and stent was performed in a 70-year-old man for reperfusion in the treatment of graft stenosis after CABG. The right SVG, which supplied coronary blood flow, was immediately under the median incision site, and was approached safely by the present method. After intervention, bleeding in the left thoracic cavity occurred, but this was treated conservatively. During intervention after cardiac surgery, transient heparinization of blood was performed for prevention of coagulation. Since strong anticoagulative treatment was continued thereafter, the patient was easily bled. Therefore, it appeared preferable to take time after cardiac operation or insert an indwelling drainage tube into the pleural cavity to monitor hemorrhage. The present method appears useful for patients undergoing re-operation or of high risk.

A 76-year-old man was admitted to our hospital because of sudden upper abdominal pain and shock status. The patient had undergone Miles' procedure with a colostomy on the left lower abdomen due to rectal cancer at the age of 70 years. CT scans revealed a thoracoabdominal aortic aneurysm. In view of the clinical findings, ruptured aneurysm requiring emergent operation was diagnosed. A left spiral skin incision was made, keeping away from the colostomy. An extraperitoneal approach was selected. The thoracoabdominal aorta was replaced with an artificial graft under partial extracorporeal circulation with femoral arterial and venous cannulation. The postoperative course was uneventful. No paraplegia occurred in spite of no reconstruction of the intercostal arteries due to severe atherosclerotic changes of the aortic wall. The fact that bleeding due to ruptured aneurysm was localized in the extrapleural and extrapritoneal spaces seemed to be an advantageous factor for the success in this case.

Direct coronary artery reimplantation to the aorta and mitral valve repair were successfully performed in a 29-year-old female with Bland-White-Garland syndrome (BWG syndrome). Under cardiopulmonary bypass, the main pulmonary artery was completely transected and the left coronary artery was excised with a cuff of pulmonary artery wall. Then the left coronary artery was directly anastomosed to the ascending aorta. Mitral regurgitation was repaired with valvulo-annuloplasty. The post operative course was excellent.

A 44-year-old man was given a diagnosis of severe ischemic heart disease and Leriche's syndrome. He had critical ischemia in the lower extremities and ischemic gangrene in a toe of the left foot. We planned a one-stage operation for these fatal diseases. To prevent irreversible ischemia of the lower limbs after mobilization of internal thoracic arteries or during extracorporeal circulation, we performed aorto-ilio femoral bypass grafting with extra-peritoneal approach first. Then conventional coronary artery bypass grafting was carried out for three coronary arteries with bilateral internal thoracic arteries (ITAs) and the saphenous vein. The postoperative course was uneventful.

Patient 1 was a 62-year-old woman who had been treated for hypertension for three years. Stanford A type acute aortic dissection occurred accompanied by right coronary ischemia. CABG and graft replacement of the ascending aorta were performed 8 hours after the onset of coronary ischemia, but after cardiopulmonary bypass the patient could not be weaned from the RVAD because of right ventricular infarction. On the 8th day after operation, she died due to right heart failure. Patient 2 was a 72-year-old male. Stanford A acute aortic dissection occurred and right coronary ischemia appeared during UCG examination in the ICU. CABG and graft replacement of the ascending aorta and the aortic arch were carried out less than 1 hour from the onset of coronary ischemia. The postoperative course was satisfactory and uncomplicated. If the dissection extends to the aortic root, it is important to monitor the ECG carefully to detect myocardial ischemic changes. In cases with coronary ischemia, early operation and CABG are mandatory.

A 47-year-old woman complained of dyspnea on exertion. Ultrasonic cardiography revealed coronary sinus type atrial septal defect. At operation, the drainage veins to the left atrium from the coronary arteries were observed but no anomalies of the vena cave or any other veins were observed. The defect was closed with a pericardial patch under cardiopulmonary bypass. The post-operative course was uneventful. Coronary arteriography performed on the 14th post operative day confirmed that the coronary veins drained individually into the corresponding atria. Unroofed coronary sinus is rare and difficult to diagnose prior to operation. Ultrasonic cardiography and coronary arteriography are considered useful for preoperative diagnosis.

The patient was a 52-year-old man with a history of antiphospholipid syndrome (APS), renal dysfunction and myasthenia gravis (MG). On May 2, 1998, he had sudden chest pain while sleeping. Enhanced computed tomography revealed acute aortic dissection (DeBakey type I). We performed emergency graft replacement of the ascending aorta and the aortic arch under extracorporeal circulation. Because of perioperative anuria, we used peritoneal dialysis (PD) just after the operation. Two days after the operation, we performed re-intubation nine hours after the extubation of the tracheal tube, and performed re-extubation three days later. For a while, his postoperative course was uneventful, but because of gradual worsening of APS, we administered more prednisolone, but 74 days after the operation, he died of multiple organ failure caused by an opportunistic infection, sepsis, and disseminated intravascular coagulation. This was very rare case of acute aortic dissection with MG and APS. After administration of more glucocorticoids, it is important to be wary of opportunistic infections.

The patient was a 63-year-old man with a history of multiple mononeuritis with hypergammaglobulinemia since 1980. The symptoms gradually worsened, and he had been bed-ridden since 1992. On February 28, 1997, he had sudden dyspnea after defecation. Echocardiography demonstrated a large thrombus in the right atrium and the right ventricle. Enhanced chest computed tomography revealed thrombi in the bilateral pulmonary arteries. The patient was considered to have acute pulmonary thromboembolism, and an emergency operation was indicated. Thrombectomy was performed under extracorporeal circulation through a median sternotomy. No thrombi were found in the right atrium or the right ventricle, and thrombi in the bilateral pulmonary arteries were removed completely. Four days after the operation, a Greenfield filter was implanted in the vena cava inferior because venography detected a thrombus in the right common iliac vein. The postoperative course was uneventful. No pulmonary rethromboembolisms were noticed after the operation. The long duration of being bed-ridden seemed to be the chief cause of thrombosis in the deep veins, and hyperviscosity due to hypergammaglobulinemia may have caused hyperthrombogenicity.