We encountered a case of femoro-popliteal bypass using the in situ saphenous vein bypass procedure employing a new valvulotome and technique of angioscopically assisted valvulotomy. The new combined angioscope and valvulotome system for the in situ saphenous vein bypass grafting is safe and effective for resection of valve leaflets and to avoid valvulotome-induced injury in comparison with blind retrograde valvulotomy, and allows minimal skin incision through identification of venous tributaries by angioscopic guidance. Further detailed clinical observation may be needed for the evaluation of the long-term benefits of this maneuver.

The purpose of this study was to evaluate the efficacy of early rehabilitation starting on the day after cardiac surgery. In the early rehabilitation program, introduced from November 2006, we adopted an original video program about hospitalization and daily multi-specialist conference in the ICU. We divided 179 patients who underwent elective cardiac operation from June 2004 to September 2007 (mean age 65.4 years old, 51 women, 91 CABG, 53 valve procedures and 35 other procedure) into group A (the initial rehabilitation group : n=73) and group B (the early rehabilitation group : n=106). There were no significant differences in patient profile (age, gender, operation time etc.) between the two groups. The mean postoperative day of starting cardiac rehabilitation was 4.3+/-1.6 days in group A and 1.5+/-1.0 days in group B (p<0.01). The mean achievement period of all walking distances in group B was significantly shorter than in group A as follows, 50 m : group A 5.4+/-2.2 vs. group B 3.1+/-1.5 days (p<0.01), 100 m : group A 6.9+/-3.1 vs. group B 4.9+/-2.2 days (p<0.01), 200 m : group A 8.5+/-3.9 vs. group B 6.5+/-2.5 days (p<0.01), 300 m : group A 10.2+/-3.9 vs. group B 8.1+/-2.9 days (p<0.01), 500 m : group A 14.5+/-6.1 vs. group B 11.9+/-3.8 days (p<0.05). Approximately 90 per cent of patients in group B could walk by themselves on leaving the ICU. There were no major complications throughout rehabilitation. The mean hospital stay was 31.0+/-11.2 days for group A and 25.9+/-7.4 days for the group B, with a statistically significant difference (p=0.03). In a questionnaire survey at discharge, 91.0 per cent of patients in group B answered that early rehabilitation was most gratifying. In conclusion, early rehabilitation after cardiac surgery is effective for early recovery of ADL and leads to shorter hospital stay. We think both preoperative education and daily conferences are indispensable for safe and effective early rehabilitation programs.

From January 1982 to August 1993, 23 cues of advanced renal cell carcinoma with tumor thrombus in the inferior vena cava (IVC) were treated surgically. In terms of clinical stage, 12 cases were in stage III and 11 cases were in stage IV. The 23 cases were divided into three groups according to the location of the tumor thrombus in the IVC. In two cases, the tumor thrombus extended to near the right atrium or the hepatic vein, and in six cases, the thrombus extended to the hepatic IVC. All these tumor thrombus with invasion to the IVC wall were removed under partial cardiopulmonary bypass. In 15 cases, tumor thrombus were limited to near the junction of the renal vein, which were removed by balloon catheter or finger after clamping of proximal and distal side of IVC and renal vein. Direct suture of the IVC wall in 12, patch repair with EPTFE in 10 and graft replacement with EPTFE graft in 1 were performed. Eight patients who had distant metastasis, regional lymph node metastasis and extracapsular invasion died within one year, but 4 patients were alive more than four years. Survival rate at three years and five years according to the Kaplan-Meier method was 37.5% and 18.8%, respectively. In conclusion 1) partial cardiopulmonary bypass was useful and could control bleeding when tumor thrombus in the IVC extended to the junction of the hepatic vein or right atrium. 2) long term survival cases were recognized in cases with no distant metastasis, no regional lymph node metastasis and no extracapsular tumor invasion. 3) nephrectomy associated with tumor thrombectomy in the IVC was valuable on the basis of long-term prognosis.

Direct observation of the intravascular atherosclerotic change provides many diagnostic information and supports successful vascular surgery. Angioscopic inspections were performed in the 23 patients who underwent laser angioplasty for the peripheral arteries and 7 patients with aorto-coronary bypass surgery in this study. Useful images could be obtained in 19 (83%) of 23 observations in the peripheral arteries, and the successful rates of angioscopic observation were influenced by the diameter and the degree of kinking of each vessel. On the other hand, intraoperative observation of coronary artery with angioscope could be performed easily in all cases. From these findings, intraoperative application of angioscopy was considered to be useful procedure for the cardiovascular surgery.

A 62-year-old man, who had been given a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP), was admitted to our hospital for an operation for abdominal aortic aneurysm (AAA). Preoperative coronary angiography revealed severe triple vessel disease, and we chose to treat this first. The platelet count on his first admission was 2.1×10⁴/μl and preoperative immunoglobulin infusion was introduced for 5 days. Off-pump coronary artery bypass grafting (OPCAB) was performed safely with platelet transfusion, and he was discharged on the 14th postoperative day. Thirty-eight days later, graft replacement of AAA was performed with preoperative immunoglobulin infusion and no platelet transfusion, and he was discharged at the 11th postoperative day. Preoperative immunoglobulin infusion therapy and selection of OPCAB were useful to prevent perioperative bleeding complications. This is the first report of staged cardiac and aortic surgery in a patient with ITP.

A successfully treated case of a 73-year-old man with mycotic aneurysm of the iliac artery combined with psoas abscess was reported. The operation consisted of débridement of the infected arterial wall with arterial reconstruction using autologous reversed superficial femoral vein and wrapping the graft and filling the defects with omentum. Streptococcus pneumoniae was grown from the psoas abscess culture. He had peritonitis by gangrenous cholecystitis postoperatively and underwent reexploration for correction of the peritonitis. After his second operation, the postoperative course was uneventful. He is doing well 18 months postoperatively. Venous morbidity after superficial femoral vein harvest is minimal. In situ reconstruction with autogenous deep leg veins is a successful option in patients with mycotic aneurysms.

A 45-year-old man underwent total arch replacement for acute type A aortic dissection. Vital signs during the operation remained stable, but sinus tachycardia was recognized about 7h postoperatively, followed by a high level of PaCO₂, low level of PaO₂ and metabolic acidosis. Then, blood pressure decreased, accompanied rapid elevation of body temperature to 39.7°C. Body temperature was decreased gradually by cooling the whole body, however, coma, anuria and hypoxemia persisted. A diagnosis of malignant hyperthermia was made and Dantrolene was administered. However, the patient died of multiple organ failure 7 days postoperatively. The serum level of CPK increased to 12, 446IU/l and serum myoglobin elevated to a very high level (36, 500ng/ml) 2 days postoperatively. Although, it is very rare for malignant hyperthermia to develop after open-heart surgery, physicians must keep this disease in mind if sudden hyperthermia of unknown origin is demonstrated.

A 74-year-old man was admitted to our hospital to undergo an operation for distal aortic arch aneurysm with chronic aortic dissection. The first operation was attempted through left lateral thoracotomy. Since the aorta had a severely calcified false lumen, conventional aortic replacement was considered to entail greater risk and graft replacement was given up. As an another option, endovascular stent grafting via the aortic arch through median sternotomy was selected as a second operation. Deep hypothermic circulatory arrest with selective cerebral perfusion was used during delivery and deployment of the stented graft through the aortotomy site. The distal stented graft was deployed into the true lumen at the ninth thoracic vertebral level. Neither endoleaks nor complications were observed. Postoperative computed tomography showed complete thrombosis of the distal aortic arch aneurysm and the false lumen. The postoperative course was uneventful. Transaortic endovascular stent grafting is an effective and less invasive treatment for aortic arch aneurysms with severely calcified aorta.

A 73-year-old man was admitted to the hospital on March 31, 2000 because of nonsustained ventricular tachycardia (VT). In 1983, he was diagnosed as having apical hypertrophic cardiomyopathy (APH). Electrocardiograms showed high amplitude of R waves and giant negative T waves (GNT), and left ventriculography (LVG) revealed spade like configuration. He stopped medication without leave six months after the diagnosis. The latest ECG showed a decrease in amplitude of R waves, no signs of GNT, ST elevation in precordial leads, and an increase in QRS duration. LVG demonstrated midventricular obstruction, apical aneurysm, and the intraventricular pressure gradient in systolic phase was 56 mm Hg. No stenotic lesion was observed in coronary arteriography. Early diastolic paradoxic flow from the apical chamber toward the outflow of the left ventricle was detected by pulsed Doppler echocardiography. VT was successfully treated with beta-blocker and amiodarone, but he needed hospital treatment again one month later because of congestive heart failure. During the follow-up of APH, the decrease in amplitude of R waves and disappeasance of GNT, ST elevation, and the increase in QRS duration in electrocardiograms, and the detection of early diastolic paradoxic flow by echocardiography could be the predictors of developing apical aneurysm and/or left ventricular dysfunction.

A 71-year-old man who had undergone repair of a ruptured abdominal aortic aneurysm with a tube graft 3 months ago was transferred from another hospital with an Aortoenteric Fistula (AEF) for surgical treatment. Computed tomographic (CT) angiography revealed pseudoaneurysm formation at the proximal anastomotic site. Waiting for the elective operation, he developed massive hematemesis with shock. Endovascular stent-graft repair was emergently performed because of high risk for conventional open surgery. Gastrointestinal bleeding was successfully controlled. The psuedoaneurysm disappeared, which was confirmed by postoperative CT angiography. At 1-year follow-up, he has shown no clinical and radiographic evidence of recurrent infection or bleeding. For the case with shock, Endovascular repair could be a bridge to open surgery because it is fast and minimally invasive. Endovascular repair of AEF is technically feasible and may be the definitive treatment in selected patients without signs of infection and gastrointestinal bleeding.