A 69-year-old man developed abdominal aortic aneurysm (AAA) during treatment for chronic renal failure at another hospital. On admission, CT revealed infrarenal AAA associated with horseshoe kidney. The aneurysm was exposed through a transperitoneal approach, and aortoiliac reconstruction was performed preserving the renal isthmus. Two accessory renal arteries were reconstructed. Postoperatively, both reconstructed arteries were patent on angiography, and postoperative renal function was not impaired. In surgery for AAA with horseshoe kidney, preservation or reconstruction of renal feeding arteries is important to maintain renal function.

A 41-year-old woman was admitted suffering from chest pain and dyspnea. We performed an emergency operation under a diagnosis of type A acute aortic dissection combined with type B chronic 3-channeled dissection on CT scan. The ascending aorta was replaced with woven Dacron graft under deep hypothermic circulatory arrest. Atrial inflow for cardiopulmonary bypass was initiated only through the femoral artery because the right axillary artery was stenotic. Neither cystic medial necrosis nor aortitis were recognized in pathological examination of the ascending aorta. Postoperative recovery was smooth and uneventful. Three-channeled aortic dissection tends to enlarge the false lumen, and has a high risk of rupture compared with the more common 2-channeled aortic dissection, therefore careful follow-up is needed in this patient. When acute type A dissection is complicated with 3-channeled chronic dissection, it is important to preoperatively assess the route of visceral blood supply, and to carefully select the cannulation site of extracorporeal circulation to prevent malperfusion.

A 68-year-old woman with multiple gastric ulcers was admitted to our hospital due to post-prandial abdominal pain. Multirow detector computed tomography (MDCT) showed severe stenoses of both the celiac trunk and superior mesenteric artery (SMA) ; therefore, we decided to operate based on the presumed diagnosis of abdominal angina. We bypassed the stenoses using a saphenous vein graft from the right external iliac artery to the SMA, distal to the stenosis. The patient was symptom-free postoperatively. In summary, this case of abdominal angina was accurately evaluated preoperatively with MDCT and the flow meter^®. Thereafter, a focal stenosis in the superior mesenteric artery was successfully treated with an external iliac-SMA bypass using a saphenous vein graft.

A 76-year-old man was admitted with a diagnosis of mitral valve regurgitation and angina pectoris. Cardiac catheterization demonstrated grade III mitral valve regurgitation with elevated pulmonary pressure and stenosis in the LAD. Severe stenosis in the left internal carotid artery and multiple cerebral infarctions were also recognized. Mitral valve repair with coronary artery bypass was performed at one month after the left carotid endarterectomy. The ascending aorta contained fragile atheroma, so an arterial cannula was inserted into the graft anastomosed to the right axillary artery. Mitral valve repair with coronary artery bypass was performed under moderately hypothermic ventricular fibrillation. Air embolism in the right coronary artery was recognized during systemic rewarming. Mitral valve repair with coronary artery bypass was performed safely under moderately hypothermic ventricular fibrillation in this case of an atherosclerotic ascending aorta. Axillary artery cannulation is useful to avoid cerebral complications in such cases. The de-airing procedure should be completed before the initiation of the heart beating.

A 70-year-old woman was admitted to our hospital complaining of upper abdominal pain. Computed tomography revealed a 6-cm tumor next to the inferior vena cava (IVC). Venography revealed obstruction of the IVC, and venous return was via collateral circulations. Right nephrectomy and tumor resection of the middle part of the IVC was performed. The left renal vein, which was invaded by tumor, was divided without venous reconstruction. Pathological diagnosis was leiomyosarcoma. Postoperatively hemodialysis was needed for a month, but maintenance hemodialysis was avoided. Leiomyosarcoma of the middle part of the IVC sometimes invades bilateral kidneys, and sometimes it is not possible to reconstruct the renal vein. It is important to recognize collateral circulation by preoperative angiography, and to protect such circulation during operation.

We present a case of successful mitral valve repair in a 38-year-old woman with Marfan's syndrome. Prolapse in a redundant billowing posterior mitral leaflet caused severe mitral valve regurgitation. Only slight dilatation of the sinus Valsalva and grade I aortic regurgitation were recognized. At operation, prolapsed portions seen on both sides of the middle scallop were quadrangularly resected. The sliding leaflet technique reduced the height of the posterior mitral leaflet to prevent systolic anterior motion of the mitral valve, which could be expected to occur after the operation. The anterior extremities of the Carpentier-Edwards annuloplasty ring were bent upward to accommodate the shape of the anterior mitral leaflet. Mitral valve regurgitation disappeared postoperatively, and she is now doing well 3 years after the operation. In general, isolated mitral valve regurgitation appears in relatively young patients with Marfan's syndrome, and these patients are at high risk of developing aortic dissection and aortic regurgitation. Therefore, mitral valve repair should be performed to improve the quality of life after the operation, and to reduce the risk of bleeding, which may be a lethal complication in aortic surgery.

A 72-year-old woman suffered sudden back pain 42 days after ascending aortic replacement for retrograde acute type A aortic dissection. Computed tomography (CT) revealed type B aortic dissection and a stenotic true lumen at the abdominal aorta. The celiac artery and the superior mesenteric artery (SMA) branched from the true lumen, but bilateral renal arteries were not found by DSA. Infrarenal abdominal aortic fenestration was performed at 6th day from onset, because of progressive renal dysfunction. Intestinal ischemia was not confirmed by laparotomy. After the Infrarenal aorta was clamped and transected, the proximal intima was resected in a U-shape. The proximal stump which was reinforced with teflon felt was anastomosed to an 18mm woven graft. Distal anastomosis was carried to the true lumen was carried out with closure of the false lumen. Regaining flow into the collapsed true lumen was observed by epiaortic echography. Postoperatively, continuous hemofiltration was required for several days until renal dysfunction was improved. CT showed reasonable expansion of the true lumen, and no findings of visceral ischemia except for partial infarction of the left kidney. DSA revealed that bilateral renal arteries were perfused from the true lumen through the fenestration. Neither aortic dilatation nor new ischemia have been recognized, but further close observation is necessary.

A 24-year-old man was transferred to our hospital because of traumatic rupture of the thoracic aorta suffered in a traffic accident. On admission, he had recovered from shock and was alert. Chest CT showed massive hematoma around the total extent of the descending aora and the intimal flap at the diatal descending aorta. We performed an emergency operation. Through left thoracotomy, we found dilatation of the descending aorta. Epiaortic echo revealed that the aortic intima was completely transecred between Th 10 and Th 11. The pseudoaneurysm was replaced with a Hemashield vascular graft under partial cardiopulmonary bypass. The intercostal artery was preserved. His postoperative course was uneventful and paraplegia was not seen. We reported a rare case of traumatic rupture of the distal descending thoracic aorta above the diaphragm followed by successful surgical treatment.

The survival rate of patients with cardiac rupture due to a blunt trauma is low, therefore it is necessary to have a well-defined diagnostic and treatment plan in order to improve the survival rate. In 8 such patients transthoracic echocardiograms at the time of arrival at our hospital showed pericardial effusion with cardiac tamponade in all patients. The mean time between suffering the injury and arriving at the hospital was 186±185min, and the mean time between arrival and being brought to the operating room was 82±49min. Preoperative pericardial drainage was performed in 2 patients, and percutaneous cardiopulmonary support system was used in 2 patients. The rupture site was in the right atrium in 3 patients, the right atrium-inferior vena cava in 1 patient, the right ventricle in 2 patients, the left atrium in 1 patient, and the left ventricle in 1 patient. Extracorporeal circulation was used in 4 patients, and the injured site was repaired. We were thus able to save the lives of 6 of the 8 patients (survival rate 75%). Transthoracic echocardiography was easy to perform and effective for making an accurate diagnosis. Many such patients tend to have multiple traumas, but, if the patient is in a state of shock due to cardiac tamponade, the patient should be moved immediately to the operating room. It is important to provide circulatory maintenance until surgery, and pericardial drainage and PCPS are also effective additional treatment modalities.