A 47-year-old man with active aortic valve endocarditis underwent direct closure of a paraannular abscess and valve replacement. Methicillin-resistant Staphylococcus aureus was isolated from his blood culture preoperatively. Because of a postoperative paravalvular leak (PVL) and an echo-free space suggesting a residual cavity, he was reoperated for patch closure of the aneurysm and prosthetic valve replacement. However, the PVL and paraannular cavity were still observed after the 2nd surgery. At the 3rd operation, prosthetic valve detachment along one fourth of its circumference was confirmed, and the cavity was fully opened. A patch was used to cover the pseudoaneurysm and was placed under the orifice of the left coronary artery. This patch repair of the cavity was accomplished, followed by prosthetic valve replacement in situ. Trivial PVL was identified after the operation, and a diagnosis of intravascular mechanical hemolysis was made. Clinical examination revealed partial detachment of the prosthetic valve resulting in a significant PVL and paraannular pseudoaneurysm. Because of unremitting hemolysis and the increased PVL, the patient underwent a 4th repair. Inspection showed that the prosthetic valve was partially detached and the defect was opened at the upper edge. The orifice of the aneurysmal was covered, and valve replacement was performed in the supraannular position using 3 U-stays, which were passed through both the aortic wall and the patch, followed by ascending aortic graft replacement. In the case of aortic valve endocarditis with paraannular involvement, radical debridement and complete reconstruction of the left ventriculoaortic discontinuity without tension are required.

A 43-year-old woman underwent aortic valve replacement for aortic regurgitation causing aortitis syndrome. The postoperative course had been uneventful and inflammation was controlled by steroid therapy. She developed a moderate degree of dyspnea with cardiomegaly. Two years after the first aorta valve replacement (AVR), severe aortic regurgitation was observed on both echocardiography and aortography. Dehiscence of the prosthetic valve was suspected and an emergency operation was performed. To secure the reimplanted prosthetic valve, we applied the technique of passing felt-pledgeted sutures through the aortic wall in the vicinity to the right coronary cusp and the noncoronary cusp and others through the left coronary cusp with everting mattress sutures. The postoperative course of the second AVR has been uneventful for two months. Since prosthetic valve detachment can occur even if inflammation of aortitis is well controlled, strict management of inflammation is recommended for a prolonged period to prevent reccurence of aortitis and subsequent valve dehiscence.

Four patients, 13 to 53 years old, with congenital venous malformation including Klippel-Trenaunay syndrome underwent surgical treatment followed by sclerotherapy. They developed marked dilatation of varicose veins with spots, and complained of pain, dullness, and bleeding. Two patients also had hypertrophy of the diseased leg. Phlebography and color Doppler ultrasonography were performed in all patients to precisely determine the abnormal vein and incompetent communicating veins which were then resected and/or ligated with minimal skin incision. In two patients, additional ligation of incompetent communicating veins was necessary. One to two weeks after surgical therapy, sclerotherapy was performed with 1-2% polidocanol. Symptoms improved after treatment, even in a patient with claudication before operation. Surgical therapy for congenital venous malformation was feasible and satisfactory, with the aid of meticulous identification of abnormal veins and communicating veins by not only phlebography but color Doppler ultrasonography.

This is a case of an 81-year-old male who underwent stent-graft (SG) placement for type B aortic dissection at the age of 79. Two and a half years after the surgery, he was diagnosed with SG infection. Although he was scheduled for SG removal and the in-situ replacement of the descending aorta, he had difficulty maintaining oxygenation under single lung ventilation and detaching the severe adhesion of the aneurysm to the lung; therefore, only the aneurysm sac was opened, and abscess drainage was performed. The continuous irrigation and drainage of the aneurysm sac were performed, but the infection did not improve. On the 6th day after the surgery, the aortic aneurysm in the lung adhesion area was left untreated, and an extra-anatomical bypass was performed from the distal aortic arch to the anterior position of the pulmonary hilum, anastomosing with the abdominal aorta. All SGs were removed, the abscess and intima of the aortic aneurysm were extensively excised, and the remaining cavity was filled with omentum. The infection rapidly improved after the surgery, and he was discharged on the 52nd day after admission. Fortunately, the infection did not recur for 2 years since the surgery. This procedure is useful as an option for surgical reconstruction for stent graft infection for which in-situ descending aorta replacement is difficult.