A 55-year-old man was admitted to our hospital with angina pectoris. Coronary angiography revealed that the left anterior descending artery (LAD) originated from the proximal right coronary artery (RCA) which arose from the right coronary sinus of Valsalva, while the circumflex artery (CX) arose from the left coronary sinus of Valsalva. Multiple coronary lesions included total obstruction at the proximal RCA after branching the LAD, 75% stenosis at the origin of the LAD, and 90% stenosis at the proximal CX. These lesions were revascularized with the left interthoracic artery to the LAD, the radial artery to the RCA, and a couple of saphenous vein grafts to the CX. Postoperative angiography confirmed patency of all grafts. Anomalous coronary artery is found to be 0.62-0.83% by angiography. A rare anomalous coronary artery is documented in this article, which has been reported to be 4.4% of all anomalous coronary arteries.

A 71-year-old man was admitted complaining of abdominal pain. Contrast enhanced CT scan showed bilateral inflammatory common iliac artery aneurysms and encasement of bilateral ureters with perianeurysmal fibrosis. Drip infusion pyelography (DIP) showed bilateral hydronephrosis. After insertion of ureteral stents, Y-graft replacement and bilateral ureterolysis were performed successfully in spite of adhesion of the ureters to the aneurysmal wall. Postoperative DIP showed good passage in ureters and improvement of hydronephrosis. We would like to emphasize the usefulness of preoperative ureteral stenting for identification and mobilization of ureters.

The purpose of this study was to review our experience in the treatment of active endocarditis and identify determinants of early outcome. Sixty-nine patients (mean age 47.3 years, range 5 months to 88 years) underwent surgery for active endocarditis. Native valve endocarditis was present in 59 (85.5%) and prosthetic valve endocarditis in 10 (14.9%). The aortic valve was infected in 26 (37.7%), the mitral valve in 24 (34.8%), both aortic and mitral valves in 13 (18.8%), and the tricuspid in 3 (4.3%). Paravalvular abscess was identified in 22 (31.9%). Streptococci (27.5%) and Staphylococci (23.3%) were the most common pathogens, but the pathogen was not identified in 36.2%. Hospital death occurred in 13 (18.8%), and causes of deaths included cardiac failure in 6 and sepsis in 5. There were 2 late deaths, and the causes of death were cerebral infarction and renal dysfunction. Univariate analysis indicated that older age (p=0.02), New York Heart Association class III or IV (p=0.02), a preoperatively unidentified pathogen (p=0.02) and concomitant operation for abscess and fistula (p=0.04) were significant risk factors in hospital mortality. Prosthetic valve infection was a relative risk factor in hospita mortality (p=0.11). Multivariate analysis revealed that NYHA III-IV(p=0.02, odds ratio=18.1, 95% CI=1.49-220.1) and a preoperatively unidentified pathogen (p=0.02, odds ratio=7.45, 95% CI=1.44-38.5) were independent predictors of hospital mortality. To reduce hospital mortality in active endocarditis, early surgical intervention is recommended before the involvement of heart failure, particularly when the pathogen is not identified.

Higher incidence of spinal cord injury has been reported in total aortic arch replacement using a stented elephant trunk compared with the conventional one, perhaps due to embolism of atheromatous plaque to the spinal cord arteries. We report a case with delayed-onset lower spinal cord injury after replacement of the aortic arch and the descending thoracic aorta using a stented elephant trunk. A 69-year-old man who had a history of abdominal aortic aneurysm repair using a Y-graft and untreated Crawford's type II thoracoabdominal aortic aneurysm underwent replacement of the aortic arch and the descending thoracic aorta using a stented elephant trunk. He developed weakness of the lower extremities 4 days after the operation. Since a preoperative computed tomography demonstrated thrombus and atheroma in the aneurysm, atheromatous plaque that can cause embolization of the spinal cord arteries was suspected to be responsible for spinal cord injury. As this technique is mostly applied to patients with severe atheromatous aortic disease, embolization of the intercostal arteries or other main branches caused by manipulation of a stent graft must be avoided.

We report a case with Crawford type III thoracoabdominal aortic aneurysm associated with occlusion/stenosis of the visceral and the iliac arteries necessitating surgical repair. The patient was a 54-year-old man. His visceral arteries were obstructed except the left renal artery which was stenotic. His iliac arterial system was also completely occluded except the patent left common and internal iliac arteries. The blood flow of his visceral organs and lower extremities depended on the collateral vessels from the left internal iliac artery. We successfully performed thoracoabdominal aortic aneurysm repair concomitant with reconstruction of the visceral arteries and the femoral arteries using partial cardiopulmonary bypass between the left internal iliac artery and the left femoral vein. It is important to select appropriate adjuncts and surgical options for patients with thoracoabdominal aortic aneurysms that involve visceral/iliac arteries.

A 20-year-old woman had intermittent fever frequently since dental therapy one year previously. Two months previously Takayasu's arteritis had been diagnosed and she had been given 30mg/day prednisolone. She then developed subarachnoid hemorrhage, left arm pain/cataplexy, purpura, sight disturbance, and sepsis caused by Serratia. Finally she felt chest pain and a left Subclavian artery pseudoaneurysm was detected out. Therefore she was transferred to our service for emergency surgery. Preoperative angiography demonstrated post-stenosis aneurysm in the right common carotid artery, left common carotid artery aneurysm, and saccular pseudoaneurysm in the left subclavian artery that suggested impending rupture. The operation was performed through a left upper partial sternotomy extended to the left supraclavicular space. The left subclavian artery was ligated proximal to the aneurysm and distal portion was also ligated through a subclavicular approach. The postoperative course was uneventful. No ischemic sign has been seen in her left arm one year after operation and left/right brachial artery pressure index has improved to 0.80. The patient currently takes steroids and remains healthy without signs of expansion of bilateral carotid artery aneurysms.

We reported a successful emergency operation for ruptured juxtarenal abdominal aortic aneurysm via an extended retroperitoneal approach. A 70-year-old man with a history of distal gastrectomy and pancreatoduodenectomy complained of epigastric pain and was transferred to our emergency room in a state of shock. Computed tomograpy demonstrated a ruptured juxtarenal abdominal aortic aneurysm and massive intraperitoneal hematoma. We performed emergency graft replacement through an extended retroperitoneal approach in order to control the aorta quickly, safely, and reliably. This approach is a useful option in the emergency treatment of ruptured juxtarenal abdominal aortic aneurysm.

A 70-year-old man was given emergency admission with severe back pain. Computer tomography revealed type-B acute aortic dissection with a distal aortic arch aneurysm which was 69mm in diameter. The dissection extended from the distal portion of the aneurysm to right external iliac artery, and the false lumen was patent. The right renal artery arose from the false lumen. He was treated conservatively according to the guidelines of AHA, and later we performed total arch replacement electively for the aortic arch aneurysm. Distal anastomosis was applied using the elephant trunk method for reconstruction of only the true lumen. Postoperative computer tomography showed the false lumen was closed in the descending thoracic aorta, but patent below the level of the celiac artery. He was discharged without any complications. Cases of acute aortic dissection coexisting with atherosclerotic thoracic aortic aneurysm are rare. However, with the increase of the elderly population, vascular diseases will become more complicated. Strategy for therapy and operation should be considered carefully especially in such cases with multiple vascular diseases.

Since January, 1981 to December, 1990, eight patients (one male, 7 female) of Stanford A type aortic dissection underwent surgical treatments with deep hypothermic circulatory arrest. The average was age 59.6 years (range 50 to 72 years). All of them were diagnosed with UCG and/or CT before operation. Two cases had already been in shock state due to cardiac tamponade. Three cases had aortic insufficiency and one had neurological deficit. After median sternotomy, right atrial-femoral artery bypass was established. Right atrium was incised and coronary sinus was cannulated. Then retrograde coronary infusion of cardioplegic solution was employed at a continuous flow rate of 20ml/kg/hr. The mean rectal temperature was 19.6°C and the mean circulatory arrest time was 35.5min (22-58min). Two of eight cases died, because of DIC followed by necrotizing enteritis at 28th postoperative day, and prolonged shock state before operation. The rest were all survived without any neurological deficits. There were no severe complications related to deep hypothermia. We concluded that deep hypothermic arrest is safe and simple method, allows good inspection of operative field and makes it easier to repair the dissected aorta.