Spontaneous formation of aorto-caval fistulae is rare, occurring only in 4% of all ruptured abdominal aneurysms, and spontaneous rupture of the inferior vena cava (IVC) associated with the unruptured abdominal aneurysm has not been previously found in the literature. A 79-year-old woman with abdominal pain and hemorrhagic shock, was found to have a leaking abdominal aortic aneurysm and was transferred to our hospital. Preoperative CT revealed a massive right retroperitoneal hematoma and an infrarenal large abdominal aortic aneurysm. At laparotomy, no leaking site was found in the aneurysm, but a 2-cm laceration in the wall of IVC was found. The injured site was closed with a patch while controlling bleeding with a balloon catheter. The patient recovered uneventfully and was discharged on the 17th postoperative day. The mechanism of spontaneous rupture of the IVC is unknown, but and may occur due to incidental and abrupt increase in venous pressure in a stenotic IVC.

We describe successful resection and anatomical revascularization in 2 men aged 75- and 50 who suffered from prolonged systemic infection. Blood culture was positive in both cases, Klebsiella pneumoniae and Staphylococcus aureus (MSSA), respectively. Case 1 was misdiagnosed as acute appendicitis and underwent laparotomy. Postoperative CT revealed leaking aneurysm. Case 2 was diagnosed correctly on screening CT. Bacterial culture of all surgical specimens proved negative. The postoperative course was fortunately uneventful. The early and accurate diagnosis of infected aneurysm is important to establish surgical strategy. Timing of surgical intervention is still difficult to determine for minimizing the risk of graft infection.

A 72-year-old woman, who had been treated for autoimmune hemolytic anemia with prednisolone and azathioprine since 2002, was found to have mild aortic stenosis in 1994. In December 2003, she suffered congestive heart failure, and was on temporary mechanical ventilation. In February 2004, the maximum pressure gradient between left ventricle and aorta increased to 115.8mmHg on echocardiographic examination. On April 6, aortic valve replacement was carried out with a 19mm bioprosthesis (Carpentier-Edwards PERIMOUNT^®, Edwards Lifesciences, Irvine, California). Preoperative prednisolone administration was continued until the day of the operation. Four packs of washed red blood cells were transfused intraoperatively and four packs of red blood cells were transfused postoperatively. Before transfusion, haptoglobin and water-soluble prednisolone were administrated to prevent hemolysis. Oral prednisolone and azathioprine were reestablished on the third postoperative day. Her postoperative course was uneventful and she did not suffer either infection or hemolysis. She was discharged on the 30th postoperative day.

Cardiac injury following blunt chest trauma requires immediate transportation, correct diagnosis and early surgical treatment. We present 2 cases of rare cardiac rupture, right auricular laceration and multiple ruptures of vena cava, respectively. Case 1: An 18-year-old male driver was transported to a local hospital in a state of shock immediately after a traffic accident. Chest CT demonstrated cardiac tamponade. After temporary hemodynamic improvement by pericardiocentesis, he was referred to our hospital. Since his blood pressure decreased below the measurable threshold in the ICU, he was transferred to the OR after emergency subxiphoid pericardial drainage. On opening the pericardium after full sternotomy, the right atrial appcndage laceration was found, about 1cm in length, and was sutured easily without cardiopulmonary bypass or any transfusion. Postoperative recovery was uneventful. Case 2: A 19-year-old male driver was directly transferred in an apneic shock state. Chest CT revealed cardiac tamponade. Full sternotomy was promptly carried out in the ICU after cardiopulmonary resuscitation (CPR) and subxiphoid pericardial drainage. Caval injury was found, 2cm in length, in both the superior vena cava (SVC) and intrapericardial inferior vena cava (IVC). His circulatory state was restored after the repair of these caval injuries without cardiopulmonary bypass; however, he died from severe brain damage postoperatively. In summary, blunt rupture of the right heart could be saved by prompt transport with airway assist, pericardial drainage, and proper surgery.